February 11, 2004

A new prescription for back pain

I have long suspected that the way this country treats back pain for work-related injuries is not only ineffective, it's actually destructive. I have seen countless back claims degenerate into permanent and total disability following surgery. We are now beginning to see data that bears this out. In an article with profound implications for employers, insurers and workers with lower back pain, New York Times (free registration required) reporter Gina Kolata demonstrates the futility and the ineffectiveness of our current approach to back pain. The data calls for a transformation of the treatment paradigm itself.

Here's the way it works now: A worker suffers a lower back strain. He's in a lot of pain. He goes for an MRI, which reveals a herniated disc. The insurer assumes that the herniation is work related, the condition is compensable and treatment begins. Perhaps surgery is performed. However, a number of studies have suggested that in 85% of the cases it is impossible to say why a person's back hurts. Beyond that, many studies have found that abnormal disks are usually inherited, with no links to occupation, sports injuries, or weak muscles. So the use of the MRI to confirm compensability is indeed questionable.

Then there is the issue of treatment. Studies confirm that there is little evidence that aggressive treatment is in any way helpful to the patient. One doctor quoted in the article says, "Maybe you are better off not going to a doctor." Under the current system, if the employee is lucky, neither the treatment nor the surgery will permanently disable him and, eventually, he will return to work. The irony is that in most cases, doing nothing at all would be equally or even more effective than treating the injury with conventional medicine!

So what is the new treatment paradigm? In the view of Dr. James N. Weinstein, a professor of orthopedics and editor in chief of Spine, we should teach people to live with pain, to put aside the fear that any motion will aggravate their injury. This is a concept that many Americans have trouble accepting. If we experience pain, we seek an immediate cure. For back injuries, this approach just doesn't work. We have to learn that "hurt doesn't mean harm." There will be pain for a while. During the natural recovery process, treatment should focus on "functional restoration:" That means working on training, strength, flexibility and endurance. And let's not forget to offer the needed counseling that addresses fears of reinjury, anxiety, and depression.

Which brings me back to the employer's best tool for fostering an active (but not necessarily pain free) recovery: Modified duty. Once we recognize that the vast majority of back injuries resolve themselves in a few months, with little or no treatment required, the need for proactive employers to help injured employees through the process - and the pain - becomes paramount. By providing modified duty, we give injured employees a reason for getting up in the morning and a place to go. We give them meaningful tasks, which help take their minds off the pain. Above all, we help them maintain their identities as productive workers. This is by far the most effective and the least expensive approach to lower back injuries. As with so many other workers compensation issues, proactive management is the best solution.

Also see: Study shows active recovery fosters return to work



The NY Times article by Gina Kolata has several serious problems. It quotes two of the biggest foes of ergonomics protections -- Stanley Bigos and Norton Hadler -- to perpetuate the myth that we don't know what causes back injuries and we can therefore do nothing to pervent them.

Yet all the good science shows strong links between back pain and work that requires heavy lifting.

You could read the OSHA ergonomics standard hearing testimony for scientific and first-person accounts, but I'll just cite the comprehensive 1997 NIOSH review of ergonomics studies, "There is strong evidence that low-back disorders are associated with work-related lifting and forceful movements." The National Academy of Sciences came to a similar conclusion in two studies. There is equally good evidence that ergonomic improvements can prevent those injuries.

Why otherwise do we see such high rates of MSDs among poultry processing workers and significantly elevated rates of back injuries among nursing home workers? A survey of BLS data in the 1990's showed that muculoskeletal disorders account for 26% of the general population and 46 percent of injuries to nursing home employees. Do people with inherited back problems just naturally gravitate toward those jobs?

Giving valuable newspaper space to those who have an ideological axe to grind against regulatory prevention of back injuries does not service to NY Times readers and Workers Comp Insider shouldn't be snowed by them either.

Thanks for your comment, your links, and your thoughtful perspective, Jordan.

You won't get an argument from me about the high proportion of back injuries associated with certain types of work. I've worked with a number of nursing home and hospital workers and seen the difference that good mechanical lifts, ergonomic aids, and other prevention programs can make in terms of curtailing MSDs.

I can't speak for my colleague who made this post, but what I found worth consideration in the article is not whether back injuries exist or whether they are work-related, because quite clearly many are; the discussion that I found of interest is what the best treatment path is to ensure optimal recovery. Is the increasingly common surgery-intensive approach effective, or is a less aggressive path of active, gradual, functional recovery effective? (Of course, there may be no single answer since much would hinge on the nature of actual injury itself.) Yet in our experience, we have seen time and again how a supportive employer can foster a recovery through the adoption of safe modified duty programs.

Clearly, whatever our differences in perspective on this article, we would not disagree on the importance preventing injuries in the first place. The weekly toll should be mandatory Monday morning reading in boardrooms everywhere. Again, thanks for your comments and the important work you do carrying the safety message at Confined Space.

Thanks for the kind words.

I'm not a doctor. As far as I'm concerned, the least invasive the treatment, the better for the patient, as well as for the "bottom line."

"Active, gradual, functional recovery" sounds great, as long as it doesn't mean sending people with back injuries right back into the same conditions that caused the injury in the first place -- which is all too often the practice.

Keep up the good work.

There should be TWO strong preventive efforts in workplaces:
1. preventing injuries and illnesses
2. preventing needless disability and life/vocational disruption

One of the "sick" aspects of our occupational health and safety system in the US is that sometimes when we see hard-hearted or irresponsible employers with weak safety programs, we sometimes inadvertently or even overtly ENCOURAGE ongoing disability in workers because that increases the evidence against the employer: "Look how bad this employer is, causing all these long-term disabling injuries." This particular scenario is extremely likely when lawyers get involved, since their income is directly proportional to the "victim's" misery.

The sad part is that the worker is now being victimized by BOTH sides (the employer and the "advocate") and has become an unwitting actor in a social justice "passion play."

The problem is that it's the worker's whole life that is being disrupted, but the other participants are simply using him or her to earn their livings and further their political or personal agendas.

What the worker needs (as a human being engaged in living life, not as "Exhibit A" of employer injustice) is to figure out how to best handle the actual set of circumstances they find themselves in, and get life back to normal as soon as possible.

This bilateral abuse of workers really really makes me mad and sad.

Another comment: this situation reminds me of my experience during the early days of "Women's Liberation." During the period when I was looking at all the circumstances of my life through the lens of "we women have been used and abused," it was impossible to work out an intimate relationship. When I focused on "righting the wrongs done to me and my sisters", I was wary and prickly and bickering all the time. True intimacy and contentment only became possible when I realized that I had drop this "big picture historical backdrop" point of view in order to live my own life happily -- to figure out what worked for ME and HIM within our own actual skills, abilities, values and comfort zones.

I hope this perspective is useful to you.

Jennifer Christian, MD, MPH
President, Chief Medical Officer
Webility Corporation

Thanks for your comments, Dr. Christian. It is the "preventing disabilty" aspect of this article that most interested me.
With your women's liberation anecdote, you also make a good point about finger pointing that can get in the way of a positive solution. (Of course, that's not to say that some finger pointing shouldn't be in order when there are instances of egregious disregard for safety.) But often, it gets back to communication and trust - workers comp woes are often organizational symptoms of larger employer-employee problems.


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This page contains a single entry by Jon Coppelman published on February 11, 2004 6:32 PM.

Mandatory English at the workplace? was the previous entry in this blog.

Ergo tips - workstation ergonomic design is the next entry in this blog.

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