1. Spine 10 x 25 Initiative, Research Summit July 18 th, 2015 Matthew Smuck, MD Chief, Physical Medicine & Rehabilitation Associate Professor, Department of Orthopaedics Stanford University Etiology of Spine-Related Disability: Occupational Factors

2. DISCLOSURES Cytonics - Research support ($ - paid to institution) Lumo BodyTech - Advisor (stock options) BlueJay Mobile Health - Advisor (stock options) Vivametrica - Founder (20% owner) State Farm Auto Insurance - Consultant & Expert Witness ($ - hourly) ISIS - Board of Directors ($ - travel/honoraria) The Spine Journal - Executive Editorial Board ($ - travel)

3. I NTRODUCTION Occupational Factors -Back Pain Risk -Disability Risk Perspectives Prevention Opportunities Spine-Related Disability http://www.spine.foundation

4. O CCUPATIONAL F ACTORS Specific tasks associated with back pain -Heavy lifting -Frequent bending/twisting -Awkward postures -Whole body vibration -Prolonged sitting Back injury claims highest in manual labor professions -Construction -Delivery -Manufacturing -Nursing Spine-Related Disability 1.Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA. 2007;297:1594–6. [PubMed: 17426279] 2.Gregg CD, McIntosh G, Hall H, Hoffman CW. Prognostic factors associated with low back pain outcomes. J Prim Health Care. 2014;6:23–30. [PubMed: 24624408] 3.Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ. 2010;340:c1035. [PubMed: 20234040]

5. O CCUPATIONAL F ACTORS Prevalence rates similar between countries Injury claim rates vary between countries -Cultural influences – Japan vs USA -Financial influences – Compensation -Psychological influences – Follows unemployment rates Spine-Related Disability 1.Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA. 2007;297:1594–6. [PubMed: 17426279] 2.Volinn E, Nishikitani M, Volinn W, Nakamura Y, Yano E. Back pain claim rates in Japan and the United States: framing the puzzle. Spine (Phila Pa 1976). 2005 Mar 15;30(6):697- 704. PMID: 15770188

6. O CCUPATIONAL F ACTORS Risk factors for chronicity and recurrence (varied proof) -Lack of decision-making freedom -Low workplace social support -Return to work expectations -Salary inadequacy -Low prospects for promotion/development -Monotony Spine-Related Disability 1.Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA. 2007;297:1594–6. [PubMed: 17426279] 2.Gregg CD, McIntosh G, Hall H, Hoffman CW. Prognostic factors associated with low back pain outcomes. J Prim Health Care. 2014;6:23–30. [PubMed: 24624408] 3.Sultan T. Al-Otaibi. Prevention of occupational Back Pain. J Family Community Med. 2015. PMCID: PMC4415130

7. O CCUPATIONAL F ACTORS Risk factors for chronicity and recurrence (varied proof) -Lack of decision-making freedom -Low workplace social support -Return to work expectations -Salary inadequacy -Low prospects for promotion/development -Monotony Job Dissatisfaction Spine-Related Disability 1.Hadler NM, Tait RC, Chibnall JT. Back pain in the workplace. JAMA. 2007;297:1594–6. [PubMed: 17426279] 2.Gregg CD, McIntosh G, Hall H, Hoffman CW. Prognostic factors associated with low back pain outcomes. J Prim Health Care. 2014;6:23–30. [PubMed: 24624408] 3.Sultan T. Al-Otaibi. Prevention of occupational Back Pain. J Family Community Med. 2015. PMCID: PMC4415130

8. HIGH JOB DEMANDS (Physical or Psychological) Increased risk of injury Reduced recovery Occupational Factors S PINE D ISABILITY http://www.brainpickings.org/2013/02/01/which-came-first-the-chicken-or-the-egg/

9. P ERSPECTIVES Spine-Related Disability Risks for Disability Duration Effect Size -Age (1.30) -Sitting >75% (1.38) -Heavy work (1.40) -Dissatisfaction (1.40) -Vibration (1.67) -Obesity (1.68) -Driving >75% (1.82) -Social isolation (2.13) -Severe depression (2.47) -General health (2.78) Risks factors for Back Pain Odds -Prior back pain10x -Morbid obesity 4x -Heavy lifting 4x -Poor posture 2x 1.Steenstra IA, Verbeek JH, Heymans MW, Bongers PM. Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature. Occup Environ Med. 2005 Dec;62(12):851-60. PMID: 16299094

10. HIGH JOB DEMANDS (Physical or Psychological) Increased risk of injury Reduced recovery Occupational Factors S PINE D ISABILITY “P REVENTION IS BETTER THAN CURE ” E RASMUS Secondary & Tertiary Prevention Primary Prevention

11. O CCUPATIONAL F ACTORS Primary Prevention Opportunities -Standardized assessment of job satisfaction “T HE PAY IS GOOD, AND I CAN WALK TO WORK.” J OHN F. K ENNEDY Spine-Related Disability

12. O CCUPATIONAL F ACTORS Secondary Prevention Opportunities -Performance measures Spine-Related Disability

13. O CCUPATIONAL F ACTORS Tertiary Prevention Opportunities -Workplace involvement improves return to work rates “E VERY NOTABLE WORK IS AT FIRST IMPOSSIBLE.” T HOMAS C ARLYLE Spine-Related Disability

14. Thank You! Matthew Smuck, MD Chief, Physical Medicine & Rehabilitation Associate Professor, Orthopaedic Surgery Stanford University msmuck@stanford.edu