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.