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Section 10, Chapter 12: Work-focused Healthcare for Low Back Pain

Serena Bartys and Mette Jensen Stochkendahl

BACKGROUND

Work disability due to low back pain (LBP) is now a leading health concern, resulting in significant healthcare costs and welfare payments, causing more global disability than any other condition.1 In the United States (US) indirect costs of LBP are estimated to be more than US $50 billion per year, in the United Kingdom (UK) US $11 billion and in the Netherlands almost US $5 billion.2 The majority of these costs are accounted for by approximately 10 percent of patients who are considered complex because they develop persistent LBP and fall out of work.

This represents a significant challenge to the healthcare system. Therefore, early discussions about work with individuals with LBP are crucial in order to avoid lengthy sickness absence which results in fewer treatment gains and greater costs.3 For almost two decades, research has shown that personal and occupational psychosocial variables play a more important role in the course and recovery from LBP than spinal pathology.4-6 (Table 12-1 illustrates some commonly held “myths” about LBP and work). This research underpins current clinical guidance that encourages early self-management and a continuation, or early resumption of, normal activities including work.7

TABLE 12-1. Four commonly held “myths” about LBP and work
Myth 1) A full recovery/being pain free is needed before going back to work
False: Often, work has a therapeutic/beneficial effect in itself, even with physically demanding work. Maintaining contact with the workplace improves outcome.
Myth 2) Work is “all or nothing”
False:  In most contexts work modifications are available. These include a change in work hours, work space and aids, tasks, responsibilities, predictability, pace, workload or number of repetitions.
Myth 3) Back pain is caused by the work place and/or work characteristics
False: In most cases, it is not possible to determine causality and causal attributions to work are unhelpful.
Myth 4) Discussing work related issues is not the job/role of healthcare
False: All key stakeholders (including healthcare professionals) need to take responsibility for work participation through collaboration and communication.

Healthcare is often the first point of contact for individuals with LBP, and it may also be the gatekeeper to other systems such as welfare and compensation. Healthcare professionals (HCPs), therefore, are in a prime position to administer the latest evidence-based guidance. To date, however, there is only sparse and conflicting evidence demonstrating the successful implementation of guidelines and the resultant effects on improving rates of LBP disability.8

As the population (and workforce) ages and the healthcare burden increases, it is clear that widespread action is needed in order to address the societal and economic impacts caused by work loss due to LBP. In recognition of this, recent policy has called for healthcare to become more “work-focused.”9 Work-focused healthcare involves HCPs taking an interest in, and accepting responsibility for, addressing obstacles to work participation in the clinical encounter. This shift reflects the emerging evidence which suggests that, rather than focus solely on individual factors, the wider systems involved can contribute directly or indirectly to work disability due to LBP.10

Accepting that work-focused healthcare for LBP is required, however, does not diminish the challenge it presents. In order to highlight the complex interplay between the different aspects of healthcare for LBP and work participation, an evidence synthesis was undertaken.11 An abridged version of the study is presented here.

EVIDENCE STATEMENTS

Findings are presented in the form of evidence statements, which were produced using a grading system adapted from Waddell & Burton, 200612 (see Table 12-2). Each evidence statement was graded according to the nature and amount of relating evidence.

TABLE 12-2. Evidence grading system used to rate the strength of the evidence underlying the statements
EVIDENCE GRADE DEFINITION
*** Robust

includes good qualitative studies, evidence-based guidance, systematic reviews, reviews of multiple good studies, good original studies (e.g. cohort studies).

Generally consistent findings provided by (reviews of) multiple scientific studies.
** Adequate

includes weaker qualitative studies, narrative reviews with limited data, weaker original studies (e.g. cross-sectional studies, low number studies)

Generally consistent findings provided by (reviews of) few/and or lower quality scientific studies.
* Limited Based on limited data: a single scientific study, consensus, or inconsistent findings provided by (reviews of) multiple scientific studies.

 

Evidence Statement 1

  • There is robust evidence to suggest that a lack of work-focused healthcare (i.e., a failure by healthcare professionals (HCPs) to address work issues within the clinical encounter) is an obstacle to work participation.

Addressing work issues in the clinical encounter was defined as talking to the patient and the employer; posing questions and giving advice to the patient about work accommodation/date for return-to-work and prevention of re-injury; and referral to other relevant HCPs. All except one retrospective cohort study relating to this evidence statement concluded that addressing work participation as a part of the clinical encounter would have a positive effect—the study found, instead, that this effect disappeared when injury and workload characteristics were included in the analysis-model. Reasons for not addressing work issues were reported as HCPs don’t generally regard engagement in work issues within their professional remit and some of the reasons for this are proposed to include a lack of financial incentive, a lack of time and standard procedures/role clarity, and increasing job demands.

Some of the evidence indicated that HCPs do not adhere to guidelines and give advice to (over)rest and take an unnecessarily long time off work. One study suggested that this was because HCPs do not believe guidelines to be valid and true and, therefore, are unlikely to apply them. In this vein, it was also reported that HCPs’ distress about complexity in work disability management and their own misconceptions about working with LBP could be an indirect determinant for advising sickness absence and not engaging in work discussions. A seemingly important aspect was the difficulty HCPs reported with finding a balance between being a patient advocate and also gate-keeper of sickness absence certification. Many of the studies conducted in the countries where this kind of system is in place indicate that HCPs allow a high degree of patient influence on their decision making about sickness certification in order to preserve the patient-practitioner relationship.

Evidence Statement 2

  • There is robust evidence to suggest that a lack of communication and timely cooperation between HCPs and relevant stakeholders (e.g., employer, occupational therapist, compensatory system) is an obstacle to work participation.

In several different types of studies, a lack of communication or loss of contact between stakeholders, poor communication skills, or poorly communicated (and coordinated) activities in a return-to-work program among stakeholders, and unidirectional communication between stakeholders were specifically cited as negative influences on work participation.

According to some of the evidence, a lack of common goals, structural barriers between stakeholder practice, societal norms and HCPs desire to maintain the professional status quo, and HCPs being unaccustomed with involving others in their practice were proposed to act as barriers to communication. Poor communication was also identified as one of several workflow obstacles occurring when carrying out a new model designed to enhance cooperation. The evidence suggested that, by improving communication within a team of HCPs/relevant stakeholders, workflow obstacles could be addressed. Time delays from incorrect or slow procedures affecting other stakeholders were seemingly reduced, as well as addressing additional issues, such as conflicting demands from relevant stakeholders and lack of trust.

Where the effects of systematic cooperation between employer, occupational health service, and social insurance office have been tested, a significantly immediate and sustainable effect on work participation (6 years) was found in the intervention group compared to “treatment-as-usual” peers, but HCPs highlighted difficulties due to “LBP patients’ inexhaustible need for healthcare.” Despite a general consensus among the studies that HCP communication with relevant stakeholders is important, a question about the independent effects of HCP communication have been raised in an observational study.  The authors found that giving a patient a work-resumption date and providing guidance on how to prevent recurrence and re-injury were positively associated with an early return-to-work in this study, but this association became weaker upon adjusting for other variables (e.g., socio-demographic and job characteristics, pain duration and co-morbidity), highlighting the importance of other systemic factors.

Evidence Statement 3

  • There is adequate evidence to suggest that a lack of timely access to (suitable and satisfactory) healthcare is an obstacle to work participation.

Two of the studies relating to this evidence statement were based on workers’ perspectives, (one prospective survey and a retrospective case-note review) who cited geographic barriers to appropriate and timely care, and/or access issues related to workers’ “claimant status” (adding an extra administrative burden and reducing consultation time), and satisfaction in terms of perceived quality of healthcare. However, the prospective survey study reported that an injured workers’ satisfaction with their employer’s treatment of their disability claim was more important compared to satisfaction with HCPs. Healthcare provided by the employer was also reported to be important, because this can affect both the worker and the HCP, and it was suggested that not having access to health insurance providing easy access to healthcare through the employer is an obstacle to work participation.

DISCUSSION

There has been much progress at further understanding obstacles to recovery and work participation for patients with LBP, but treatment has largely been focused on targeting individual beliefs and behaviors. Until now, comment on the influence of wider systemic factors operating largely outside the individual’s perception and control has been mostly descriptive.10,13 The evidence outlined in this chapter highlights how the healthcare system has an equally important influence on work disability for those with LBP. Findings add further weight to this under-reported area and provide useful information to guide policy and practice.

From the evidence, it is clear that further resources are needed to assist HCPs to engage in work discussions with LBP patients, which can often be complex and challenging. For example, evidence shows that many individuals with LBP expect treatment to result in a significant reduction or complete removal of pain in order for it to be considered successful and for them to be able to work.14 These unrealistic expectations and misconceptions are a difficult issue for HCPs to manage, and often result in the use of practices that are not recommended or evidence-based, such as referral for imagery.8 It has also been shown that HCPs themselves have misconceptions about the work-health relationship15,16 (see Table 12-3). This has been put forward as one of the factors explaining non-adherence to current evidence-based clinical guidelines for LBP, a phenomenon that is found across several different countries.8 However, this study also supports the more nuanced and complex picture reported in other studies focusing on barriers to implementation of guidelines. It would seem that in order to address non-adherence to guidelines, multidimensional initiatives and implementation strategies such as decision support systems; multilevel educational strategies; reminder systems; clinical practice audits; and regulatory change such as incentives to increased communication would be beneficial. Actions to ease the administrative burden on HCPs and to improve certain issues like time pressure, and access to proper assessment tools and communication platforms would also be helpful.17

TABLE 12-3. “Work-focused” dialogue – Good Practice Guide
The following nine focus areas and questions are meant to be examples that may serve as a guide to initiating a “work-focused” dialogue with your LBP patient. The examples constitute questions and domains that are known to be predictive factors of a poor prognosis, but the list is not comprehensive, and it is not meant to be used as a standardized and validated questionnaire.
1. Pain
How much does your pain prevent you from doing everyday activities, including work?
Do you see this improving/remaining the same/getting worse?
2. Stress and depression
How has your mood and level of energy been the last couple of weeks?
How do you feel about work?
3. Support of family and friends
How much support do you get from your family and friends?
Do you feel this helps or hinders your ability to work?
4. Job satisfaction
How satisfied are you (normally) with your job?
How do you get along with your manager/colleagues?
5. Work place support
Do you feel your employer/manager/colleagues understands your situation?
Have you discussed workplace accommodations?
6. Work load
How would you describe your work load – physically, mentally, time-wise?
How confident do you feel in your ability to carry out your work duties?
7. Barriers to work
What would you like to change/what would it take to help you stay at/return to work?

Findings also highlight how the healthcare system acts as a crucial stakeholder among various other important systems (e.g., the workplace and compensation/insurance systems). Thus, removing procedures that increase stakeholder conflict also appears to be of key importance. Healthcare practices that are unhelpful for the return-to-work process are often further reinforced by compensation and welfare systems requiring a medical diagnosis for a condition that most often does not have a specific underlying pathology.18 In the evidence reviewed, HCPs described their cooperation with other stakeholders as unclear, scarce, and often initiated late in the process. It was reported that HCPs are generally not accustomed to initiating contact with other relevant stakeholders, and, therefore, it appears important to further promote a widespread understanding of the positive link between work and health amongst these stakeholders. Altering working procedures to include relevant incentives, mandatory engagement and cooperation with other stakeholders, as well as improving the transparency and consistency of the return-to-work process, is also required.

The other salient aspect revealed in this area of the evidence was “access to suitable/satisfactory healthcare,” i.e., having access to the right healthcare at the right time. There was adequate evidence to indicate that a lack of timely access to suitable healthcare has the potential to be an obstacle to work participation for those with LBP. The retrieved studies indicated that lack of access was due to simple geography or eligibility criteria related to “claimant status,” but a lack of health insurance through the employer was also highlighted. Affordability has been identified as significant gap in health system coverage, and it is a problematic barrier in the context of most social welfare systems where equal access to healthcare is an overriding goal and principle.19 Wider provision of workplace “onsite” healthcare has been promoted in an international policy review that emphasized the value of investing in appropriate employee healthcare.20 What is clear from the evidence presented here is that work participation is a multi-faceted process that involves the individual, health and work systems, and that work disability due to LBP must be conceptualized and understood within this systemic context.

CONCLUSIONS AND FURTHER RECOMMENDATIONS

In order that healthcare for LBP becomes more work-focused, supportive policy that will enable all key players to work together is required. In recognition of this, the UK government are attempting to influence a systemic and cultural shift in embedding work as a health outcome.9 In clinical practice, this would mean that employment would have to be considered in the treatment plan and advice provided to an individual. As a minimum, this would trigger work-focused health conversations at each contact with HCPs, resulting in consistent messaging across the system (see Table 12-3 for a “good practice” guide).

Embedding work as a health outcome in clinical practice would:

  • Highlight the importance of work in patient care and ensure it is considered and supported as part of a more holistic service addressing the biopsychosocial influences on LBP disability;
  • Stimulate the demand from the healthcare system for high quality occupational health provision, attracting more HCPs into multidisciplinary professions requiring the education curriculum of HCPs to become more work-focused; and
  • Enable a consolidation and standardization of data collection around work participation to facilitate future workforce planning and capacity requirements from a range of multi-disciplinary HCPs. These data would also facilitate a better understanding of what works for whom, and at what cost, to fill current evidence gaps and accurately inform healthcare commissioning.

PEARLS AND PITFALLS

  • The findings presented reflect evidence from employed populations only, which does not accurately represent all LBP populations. The principles around work-focused healthcare should apply to all, but it is acknowledged that provision of support may need to be different for unemployed populations.
  • Compared with a systematic review, the method of “best-evidence” synthesis inevitably involves a greater degree of subjective judgement. In order to minimize the risk of bias, the authors adhered to processes similarly applied in a systematic review, and described the process as explicitly as possible.
  • Where pragmatic answers are needed to guide international policy and practice, we assert that a broad and inclusive approach is needed. This is because work disability is a complex social issue.
  • The findings presented here focus on the barriers to implementation of work-focused healthcare, and as a result may appear to be skewed towards negative examples of healthcare practice.

SUGGESTED READING

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