Which Patients with Back Pain Will Return to Work?
Abstract & Commentary
By Allan J. Wilke, MD, Residency Program Director, Associate Professor of Family Medicine, University of Alabama at Birmingham School of Medicine—Huntsville Regional Medical Campus, Huntsville, AL
Dr. Wilke reports no financial relationship to this field of study.
Synopsis: Seven pieces of information can identify those patients most likely to successfully rehabilitate back pain.
Source: Dionne CE, et al. A clinical return-to-work rule for patients with back pain. CMAJ. 2005;172:1559-1567.
In an effort to develop a simple predictive tool to identify back pain patients at risk for prolonged absence from work, Dionne and associates prospectively identified primary care patients from 7 sites (4 emergency departments and 3 family medicine offices) in and around Quebec City. They included patients aged 18-64 years who presented with back pain and who had missed at least one day of work. The back pain had to be nonspecific, that is, pain that was not secondary to fracture, infection, tumor, or major neurologic deficit,1 the so-called “red flag” syndromes. They excluded patients who had reasons other than persistent back pain for not returning to work (for instance, pregnancy) and patients with neck pain only.
Dionne et al identified over 100 potential predictors of return to work after reviewing the literature and conducting focus groups. They included the usual demographic and socioeconomic data and other constructs such as health beliefs, symptoms of depression, use of alcohol or tobacco, weight of the medical file, current financial compensation for back pain, and physical demands of the job. Trained interviewers telephoned patients and inquired on use of services for back pain. These interviews occurred 3 weeks after the initial presentation, and again at 6 weeks, 12 weeks, 1 year, and 2 years.
The primary outcome was return to work, which Dionne et al rated in predefined degrees: “success,” “partial success,” “failure after attempt,” and “failure.” This categorization is based on a previous study.2 The last 2 categories were lumped together because the researchers concluded that they were clinically indistinguishable.
Eight hundred sixty patients had complete data sets. The average age was 39 years, the male: female ratio was 58:42, and 52% had a high school education or less. At 12 weeks, about 75% were in the success or partial success categories. At 2 years, 20% were still in the failure categories.
Seven predictors, measured at baseline, identified patients who were not in the success category. These included: patient’s expectation that he/she would not be back to normal work within 3 months; radiating pain; previous back surgery; intense pain (4 to 10 on a 10-point scale); frequent change of position because of back pain; irritability and bad temper; and difficulty sleeping. Only 5% of individuals who reported the absence of all of these 7 predictors were not back to work at 2 years.
Commentary
One of the things I do as a primary care physician that I dislike the most is filling out disability and return-to-work forms, especially when I’m asked to estimate when a worker might be able to come back. As clinical prediction rules go, this one is weak, but it does help identify patients who are going to do well. In the worst case scenario (your patient answers all seven questions in a glass-half-empty fashion), he or she would have a 44% chance of returning to work in good health by 2 years. These patients could be directed to more comprehensive services. Does anything work? Last year Internal Medicine Alert3 reviewed an article that showed that an exercise program of graded activity can return a patient to full employment faster than usual care.4 Considering the time and expense involved in treating low back pain (second only to upper respiratory problems as a reason for visits to a physician),1 any help would be appreciated.
References
1. Deyo RA, Weinstein JN. Low back pain. N Engl J Med. 2001;344:363-370.
2. Baldwin ML, et al. The error of using returns-to-work to measure the outcomes of health care. Am J Ind Med. 1996;29:632-641.
3. Wilke AJ. Tough Love for Low Back Pain. Internal Medicine Alert. 2004;26(6):42-44.
4. Staal JB, et al. Graded activity for low back pain in occupational health care: a randomized, controlled trial. Ann Intern Med. 2004;140:77-84.
Seven pieces of information can identify those patients most likely to successfully rehabilitate back pain.
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