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View Full Version : The Rehabilitation of Low Back Pain; are we missing a goldenopportunity ?



dmcfarlane
06-08-2006, 03:54 PM
On the current evidence we could be saving billions on the rehabilitation of back injuries if we;
* combined rehabilitation programs with ergonomic interventions and
* put physical therapists and/or in control of rehabilitation programs
* encouraged exercises to increase the endurance and correct activation of the transversus abdominis and multifidus
* provided workers with a relevant bio-psychosocial education.

Over the last few years low back pain claims have cost billions; they cost New South Wales alone an estimated 700 million dollars a year (Browning, 2005); not to mention the human suffering. I hear that in the US there is a trend to place rehab coordination in the hands of "Claims Mangers".
Does anyone know of any "Claims Mangers" that use these strategies?

Here is a brief summary of the background. Combining rehabilitation programs with ergonomic interventions combined with a can halve the recovery time (according to Loisel et al, 1997) and rehab programs managed by physical therapists can also halve the recovery time (according to Lindstrom et al, 1992). Ergo it might be possible to combine these approaches and achieve an even faster recovery time. Loisel has shown that the management of back injury rehabilitation cases should be taken out of the hands of the medical profession (after an initial medical check) and placed in the hands of ergonomists (McGill, 2002). Certainly it is strong evidence for a combined rehab programs and ergonomic interventions for lower back pain. McGill has described a Canadian study that tested the efficacy of different model of management of sub-acute back pain for preventing prolonged disability found that ergomomic interventions were more successful than clinical interventions (Loisel et al, 1997). It looked at how the effectiveness of the following different treatment regimes;
* usual care,
* clinical intervention,
* ergonomic intervention, and
* full intervention (a combination of the previous two)

It determined how these affected the duration of absence from regular work compared the initial functional status and pain findings with those found after a follow-up a year later. The authors concluded that close association of occupational intervention to improve ergonomic factors combined with clinical care is of primary importance in impeding progression toward chronic low back pain. The full intervention group returned to work 2.41 times faster than the traditional care group, and they found that most of the difference was due to the occupational (OHS) intervention. Average return-to-work times were;
* 60 days for full intervention,
* 67 days for occupational only,
* 131 days for enhanced clinical only and
* 120.5 days for the traditional care only.

The workers were not assigned to a group until they had 4 weeks of absence from work. It is probable that an early intervention would have produced even better outcomes. In a follow-up study Loisel et al (2001) mention that they used a participatory ergonomics approach (i.e. one where ergonomists help the management to implement solutions that have been identified in consultation with the workers). In recent years there has been further evidence of the success of Loisel's "Sherbrooke approach";
* P. Loisel, L. Gosselin, P. Durand, J. Lemaire, Stephane Poitras and L. Abenhaim, (2001), "Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain", Applied Ergonomics, 32, pp 53-60.

* P Loisel, J Lemaire, S Poitras, M-J Durand, F Champagne, S Stock, B Diallo and C Tremblay, (2002), "Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study", Occupational and Environmental Medicine, 59:807-815

* Anema JR, Cuelenaere B, van der Beek AJ, Knol DL, de Vet HC, van Mechelen W., (2004), "The effectiveness of ergonomic interventions on return-to-work after low back pain; a prospective two year cohort study in six countries on low back pain patients sicklisted for 3-4 months.", Occup Environ Med. 2004 Apr;61(4):289-94.
Anema et al (2004) showed that it was possible replicate the success of the original Loisel approach (in Canada) in 6 other countries (Denmark, Germany, Israel, Sweden, the Netherlands and the United States).

The evidence from Sweden that suggests that (after an initial medical diagnosis; preferably by an orthopaedic specialist) the rehab process should be managed by physical therapists rather than general practitioners. A research project has studied the effects of a graded activity program that included measurements of functional capacity; a work-place visit and a supervised sub-maximal, gradually increased exercise program suited to the demands of the patient's work (Lindstrom et al, 1992). The patients in the activity group were given physical therapy (on average they had about 11 appointments with a therapist). They returned to work significantly earlier than did the patients in the control group. The average duration of sick leave attributable to LBP during the second follow-up year was 12.1 weeks for the activity group and 19.6 weeks for a control group.

The average duration of sick leave attributable to LBP during the second follow-up year was about half that for the control group. More recent research in the UK based on Lindstrom's techniques has confirmed that graded activity is particularly effective in reducing the number of days of absence from work because of low back pain (Staal et al, 2004). None of the authors appear to believe (as far as I can tell from their personal communications with me) that these various approaches are incompatible with each. The evidence certainly suggests that we ought to give some of them a go (preferably all of them).

Given that (a) ergonomic interventions combined with a rehab program can halve the recovery time (according to Loisel et al, 1997) and (b) rehab program managed by physical therapists can halve the recovery time (according to Lindstrom et al, 1992) it might be possible to combine these approaches and achieve an even faster recovery time.

Many of these studies are scant on details of the therapy techniques used. The current evidence-based model of spinal stabilization in Australia emphasizes the correct activation of the transversus abdominis and multifidus for increasing their endurance; however therapists using this approach have claimed many successes (Jemmett, 2003). It is entirely possible that this more modern approach might yield even better results than some of those undertaken in the past.

Recent research suggests that a short-term intervention including bio-psychosocial education, manual therapy and exercise is more effective than general advice on staying active and it leads to a more rapid improvement in function, mood, quality of life and general health (Wand et al, 2004). However if it is not provided soon enough these psychosocial benefits are not always achieved.

Regards,

David McFarlane

References

1. P Loisel, P Durand, L Abenhaim, L Gosselin, R Simard, J Turcotte and JM Esdaile, (1994), " Management of occupational back pain: the Sherbrooke model. Results of a pilot and feasibility study", Occupational
and Environmental Medicine, Vol 51, 597-602

2. P. Loisel, L. Abenhaim, P. Durand, J. Esdaile, S. Suissa, L. Gosselin, R Simard, J. Turcotte and J. Lemaire, (1997), "A population based randomized clinical trial on back pain management", Spine. Dec 15; 22,
(24), pp 2911-8. The abstract is on the web at;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9431627&itool=iconabstr&queryhl=5

3. S. McGill, (2002), "Low back disorders. Evidence based prevention and rehabilitation", (Human Kinetics, Leeds) page 163.

3. P. Loisel, L. Gosselin, P. Durand, J. Lemaire, Stephane Poitras and L. Abenhaim, (2001), "Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain",
Applied Ergonomics, 32, pp 53-60.

4. Anema JR, Cuelenaere B, van der Beek AJ, Knol DL, de Vet HC, van Mechelen W., (2004), "The effectiveness of ergonomic interventions on return-to-work after low back pain; a prospective two year cohort study in
six countries on low back pain patients sicklisted for 3-4 months.", Occup Environ Med. 2004 Apr;61(4):289-94. The abstract is on the web at;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15031385&itool=iconfft&query_hl=9

5. "BACK PAIN. GPs take the lead" (by Len Browning) National Safety June 2005 pages 33 to 35. See the last paragraph on page 35.

6. Lindstrom I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL., (1992), "The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an
operant-conditioning behavioral approach", Phys Ther. 1992 Apr;72(4):279-90 The abstract is on the web at;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1533941&query_hl=1

7. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B., ("Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group.", Spine. 2001 Feb 1;26, (3):262-9. see
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD002193/frame.html

8. Spitzer W, Leblanc F, Dupuis M, et al., (1987), "Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians. Report of the Quebec task force on spinal disorders," Spine 12, (supplement 7): S1-S59.

9. P. Finch, (1999), "Spinal pain - an Australian Perspective", Proceedings of the 13th World Congress of the International Federation of Physical Medicine and Rehabilitation", Washington, pages 243 - 246.

10. S. McGill, (2002), "Low back disorders. Evidence-based Prevention and Rehabilitation ", (Human Kinetics, Leeds), p 5.

11. B. Wand, C. Bird, J. McAuley, C. Doré, M. MacDowell, L. De Souza, (2004), "Early Intervention for the Management of Acute Low Back Pain A Single-Blind Randomized Controlled Trial of Biopsychosocial Education, Manual Therapy, and Exercise", Spine 29 (21):2350-2356. This paper can be found on the web at; http://www.medscape.com/viewarticle/492853

12. Lindstrom I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL., (1992), "The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach", Phys Ther. 1992 Apr;72(4):279-90. The abstract is on the web at; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1533941&query_hl=1

13. Staal JB, Hlobil H, Twisk JW, Smid T, Koke AJ, van Mechelen W.
"Graded activity for low back pain in occupational health care: a randomized, controlled trial.", Ann Intern Med. 2004 Jan 20;140(2):77-84.

14. Rick Jemmett, (2003), "Spinal Stabilization: The New Science of Back Pain", Rev. Edition, (Novont Health Publishing, Halifax), ISBN: 0-9688715-1-8, pages 115-123

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