Prevention and Treatment of Work-related Low Back Pain (LBP): What works? Dr P. Paul F.M. Kuijer, p.p.kuijer@amc.nl Assistant Professor and Consultant for Work-Related MSDs Academic Medical Centre (AMC) Coronel Institute of Occupational Health, Netherlands Center for Occupational Diseases People and Work Outpatient Clinic Amsterdam, the Netherlands Prevention occupational diseases & Optimizing work participation

Academic Medical Center Amsterdam, the Netherlands Academic Medical Center Amin Khan and I, just around the corner ;-)

Curious: what countries are online? Where are you? Curious: what countries are online?

7 Topics Nothing as practical as a good theory: start with the Disease First Approach What are work-related and personal risk factors for LBP? Training courses in lifting technique: waste of time and money? Pre-employment selection of strong women: less LBP? Have an ounce of prevention: hard data versus gut feeling Work-directed care: Distressed, Immobilized, or Lacking Employer Support? A good threesome talk and ergonomics: that works!

Program Lecture, 30 minutes Questions / Remarks, 30 minutes Part I Prevention Part II Treatment Questions / Remarks, 30 minutes

Low Back Pain: world wide largest disability problem 16% (14%-18%) ↑ 0.19% / year http://vizhub.healthdata.org/gbd-compare

Low Back Pain: years lived with disability http://vizhub.healthdata.org/gbd-compare/

Work disability: Lifestyle or Work? Many common diseases are directly linked to lifestyle factors, but these are generally not the conditions that keep people out of work. Instead, common mental health problems and musculoskeletal disorders are the major causes of sickness absence and worklessness due to ill-health. This is compounded by a lack of appropriate and timely diagnosis and intervention. 8

Case definition of ‘non-specific low-back pain’: Part I Prevention Case definition of ‘non-specific low-back pain’: Pain in the lower back region lasting at least 24 hours without any demonstrable physical cause.

… received a call of the manager operations … … truck drivers handling packed goods repeatedly complaint about the heaviness of the work and low back pain. Can you arrange for us a safe lifting training? In addition we want to select the most appropriate employees. How strong, how tall, and how old should my male employees be?

Disease first approach!

Simple cause-effect model Work as a truck driver of packed goods? Physical activities: lifting, kneeling, pushing, … Posture Movement Applied forces Workload Workrelated MSD Specific MSD Exposure criteria Is there evidence? Physical capacity Ability to recover Low Back Pain!

Lots of medical evidence…

Multidisciplinary practice guideline 50 Occupational Physicians

www.occupationaldiseases.nl/datafiles/LowerBackPain.pdf

http://www.emutom.eu/ in Spanish & English

Low Back Pain due to work? A1 Does worker handle objects > 15kg during > 10% of working day? Yes, score 7 & go to B No, go to A2 A2 Does worker handle objects > 5kg during > 2x per min for total of >2 hours per working day, or objects >25 kg >1x per working day? Yes, score 4 No, score 0 A: Lifting and/or carrying B1 Does worker work with trunk bend and/or twisted > 40° for >1/2 hour per working day? Yes, score 7 & go to C No, go to B2 B2 Does worker work with trunk bend and/or twisted > 20° for > 2 hours per working day? Yes, score 5 No, score 0 4 B: Frequent bending / twisting of trunk 7 C1 Has worker been exposed to average vibration levels > 1m/s2 per working day for >5 yr? Yes, score 5 No, go to C2 C2 Is worker exposed to average vibration levels > 0,5m/s2 per working day? Yes, score 3 No, score 0 C: Whole body vibration 14. Checklist including exposure definitions for the RF and corresponding scores voorbeeld…………………………(worker lifts >25 kg more than once a day……………scores for other RF 5 and 3 resp.; total score corresponding to the exposure profile of this particular worker is 12) 11 Total score (0-19)

11 52 47 44 The probability is 44% that the individual’s non-specific LBP is due to work-related risk factors (attributable fraction)

Name of your presentation

Remember the call of the manager operations… … truck drivers handling packed goods repeatedly complaint about the heaviness of the work and low back pain. Can you arrange for us a safe lifting training? In addition we want to select the most appropriate employees. How strong, how tall, and how old should my male employees be?

What works to prevent LBP? Safe lifting training? Pre-employment medical examination?

Gut feeling versus hard data Freely available at aoemj.biomedcentral.com/articles/10.1186/2052-4374-26-16, and thanks to the Dutch Ministry of Social Affairs and Employment Name of your presentation

Do not train lifting technique - 1 Highest level of evidence Training of employees in safe lifting behaviour can theoretically result in a reduction of the biomechanical load on the back of 5% -10%. There is no evidence the learned behaviour can be performed in practice. A2 Lavender 2000; A2 Daltroy 1993; B Hess 2007

Do not train lifting technique - 2 Highest level of evidence There is no evidence available for the effectiveness of training in lifting technique for preventing back pain or back pain-related disability or treating back pain.  A1 Martimo 2006: A1 Verbeek 2011 Cochrane Work Reviews http://work.cochrane.org/

The findings from their study of more than 18,000 workers suggest that training courses for handling heavy items – which are often mandatory for employers and workers – could be a waste of time and money…. Name of your presentation

Cochrane Work: Martimo 2006, Verbeek 2011 Never forget: Do not mind stoop or squat Cochrane Work: Martimo 2006, Verbeek 2011

No pre-employment medical examinations Low level of evidence There is no reason to assume that women or juveniles have an increased risk of low back pain due to lifting than men or adults. D Habib 2012 A1 Griffith 2011

What works: reduce the horizontal lifting distance Highest level of evidence: ‘Aids to reduce the horizontal lifting distance or friction in patients transfers or while lifting objects like bridgeboards, rods, gliding sheets of rolling floors can reduce the load on the low back’

Sector specific solutions Effective intervention unloading Engineering firm PCM rolling floor® Verschoof S et al. Appl Ergon 2005; 36(5):595-600

In the near future: exoskeletons ‘Personal lift assist devices are promising interventions in reducing the load on the low back. However, more research is needed to evaluate the effects on the longer term.’

Take home messages - I: skate on thick ice Establish whether work matters: the disease first approach! Proven (in)effective interventions: No: instruction and training in lifting technique, back belts or non-specific pre-employment medical examination Yes: improve lifting height, use lifting devises, or other production methods Use a multidisciplinary practice guidelines: One message for all - clinicians, health & safety professionals, employers, and workers”

Part II Treatment

Prognosis LBP Reassure: Stay active: walking, standing, cycling Pain & Disability: ↓ 50% after 4 weeks 8 out of 10: back at work Inform: 7 out of 10 a next episode (that’s life) Stay active: walking, standing, cycling Always check: Patient expectations regarding pain, work disability and sick leave → unfavourable …. 2006 Guideline Low Back Complaints Netherlands Society of Occupational Medicine

LBP: Distressed, Immobilized, or Lacking Employer Support? Reme SE J Occup Rehabil. 2012

LBP patients with unfavourable prognosis

Time contingent integrated care

This works… 88 days 208 days Lambeek LC,.et al. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. BMJ. 2010 Nov 30;341:c6414. doi: 10.1136/bmj.c64

… despite no effect on pain!

Take home messages - II: Again, skate on thick ice LBP has a favourable prognosis! Check patient expectations regarding pain, work disability and return to work LBP: Distressed, Immobilized, or Lacking Employer Support Effective work-directed care: Discuss ergonomic measures together with worker, employers and caretaker Time contingent graded activity

Questions or Remarks