1. Prevention and Treatment of Work-related Low Back Pain (LBP): What works?
Dr P. Paul F.M. Kuijer,
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

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

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

4. 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!

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

6. Low Back Pain: world wide largest disability problem
16% (14%-18%)
↑ 0.19% / year

7. Low Back Pain: years lived with disability

8. 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

9. 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.

10. … 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?

11. Disease first approach!

12. 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!

13. Lots of medical evidence…

14. Multidisciplinary practice guideline
50 Occupational Physicians

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

17. 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)

18.
The probability is 44% that the individual’s non-specific LBP is due to work-related risk factors (attributable fraction)

19. Name of your presentation

20. 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?

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

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

24. 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

25. 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

26. 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

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

28. 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

29. 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’

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

31. 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.’

32. 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”

33. Part II Treatment

34. 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

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

37. LBP patients with unfavourable prognosis

38. Time contingent integrated care

39. 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: /bmj.c64

40. … despite no effect on pain!

41. 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

42. Questions or Remarks