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Integrated Care for Low Back Pain: Focus on Gain
Abstract & Commentary
By Nancy J. Selfridge, MD. Dr. Selfridge is Associate Professor, Integrated Medicine, Ross University School of Medicine, Freeport, Grand Bahama; she reports no financial relationship to this field of study.
Synopsis: Integrated care consisting of a graded activity program and a workplace intervention was shown to reduce duration of time off work as a primary outcome, compared to usual care. Functional status in private life as a secondary outcome was also better in the integrated care group. Intensity of pain as a secondary outcome remained the same in both groups.
Source: Lambeek LC, et al. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ 2010;340:c1035; doi:10.1136/bmj.c1035
In this study from the Netherlands, researchers evaluated the effectiveness of an integrated care program compared to usual care in shortening duration of time off work. Participants in this study were adults, ages 18-65, who had been off work for at least 12 weeks due to low back pain. Baseline data were collected on patients, including two prognostic factors: duration of sick leave and characteristics of the job. Patients were then randomized to two groups: integrated care (n = 66) and usual care (n = 68).
Integrated care was coordinated by an occupational medicine physician, who, with the patient and other members of the integrated care team, set a proposed and mutually agreed upon date for full return to work. Care consisted of a graded exercise program (otherwise not defined) following a functional capacity assessment and including a cognitive behavioral component to reduce fear of movement; and a workplace intervention including observation of the workplace and involvement of patient, supervisor, and occupational therapist to discuss and implement solutions to obstacles for returning to work.
Usual care group patients received "usual treatment" from medical specialists, occupational physicians, general practitioners, and/or allied health professionals.
Primary outcome was return to work, defined as duration of sick leave and was self-reported by diary, collected every month, and corroborated with data on sick leave from the occupational health service. Secondary outcomes were pain intensity (scored using a visual analog scale) and general functional status using the Roland disability questionnaire, a check list of statements about the effect of low back pain on elements of one's daily activity and well being. Both questionnaires were administered at baseline and after 3, 6, 9, and 12 months. Data collection for the primary outcome was complete for 93% of patients at 12 months and for the secondary outcomes was complete for 87% of patients at 12 months.
Of the 66 patients allocated to the integrated care group, 61 completed the treatment. Twelve patients received only two elements of the integrated care (occupational management plus graded activity or workplace intervention).
Patients and care providers were not blind to treatments. However, care providers were not involved in measuring outcomes and the analysis of data was blinded.
Data results were compared in both intention-to-treat and per-protocol analyses.
At the 12-month follow-up, the median number of sick leave days from the day of randomization was 82 in the integrated care group compared with 175 in the usual care group, a significant difference (P = 0.003). Functional status improved more in the integrated care group (P = 0.01), but there was no difference in pain improvement between the two groups.
Back pain is one of the most common medical complaints in the United States and the economic burden of this problem is unquestionably profound. A rather small percentage of patients with low back pain are responsible for the lion's share of this burden, heavily due to disability and absence from work.
The authors admit a limitation of the study in not being able to blind the patients or the therapists to the interventions. Further, it is not certain which components of the integrated care yielded greatest benefit. Interestingly, previous research on subacute back pain by the authors of this study comparing the effectiveness of the integrative care components concluded that only workplace intervention was effective at reducing sick leave.1 A recent systematic review concurred that physical conditioning programs have uncertain effectiveness in reducing sick leave time.2 Thus, it would appear that a workplace intervention may be of paramount importance in reducing time off work for low back pain patients. One can also wonder about the impact on sick time of establishing a return to work date in mutual agreement with the patient early in the course of treatment, one of the main responsibilities of the clinical occupational physician in the integrated care protocol here.
Risk factors for the onset of back pain do include some work-related items: physically strenuous work, sedentary work, psychologically strenuous work, and job dissatisfaction.3 Keeping this in mind, the present study does not help delineate what precise workplace interventions are operant in producing favorable results. It would be interesting to know if patients who responded favorably with this intervention experienced greater job satisfaction or sense of control at work or had any of these risk factors modulated in the intervention, as the workplace intervention described in this study focused on "removing obstacles" to return to work, never a "one size fits all" proposition. Also, can the results obtained by these researchers in the Netherlands be generalized to an American population with different access to care, different systems of workers compensation and disability insurance, and possibly different "usual care"?
Participants in both arms of the study documented "additional treatments" consisting of physical therapies, manual therapies, and alternative therapies, which were not further defined. The usual care group had a much higher utilization of additional treatments and of specialty care, diagnostic testing, and inpatient or surgical care. These data suggest that most of what patients do to manage their low back pain may have limited effect on disability and pain and contributes a great deal to the overall cost of low back pain.
Pain improved equally in both groups over the duration of the study. Thus, this study supports a growing body of evidence that return to work as a treatment goal can and should exist for each patient separate from the goal of pain control and management.
1. Anema JR, et al. Multidisciplinary rehabilitation for sub acute low back pain: Graded activity or workplace intervention or both? A randomized controlled trial. Spine 2007;32:291-298.
2. Schaafsma F, et al. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev 2003;(1):CD001822.
3. Wheeler S, et al. Approach to the diagnosis and evaluation of low back pain in adults. In: Basow DS, ed. UpToDate. Waltham, MA: UpToDate; 2010.