Multifactorial Predictors of Work Status in Patients With Low Back Pain Identified
Commentary by Y. Raja Rampersaud, MD, FRCS(C) and Peter G. Whang, MD, FACS
People with chronic low back pain (LBP) not receiving workers compensation are more likely to be unemployed if they are depressed, smoke, have an ongoing legal or insurance claim, or have a high-chronicity risk, according to findings from a prospective observational study in The Spine Journal.
“The clinical implications [of the findings] are that LBP has to be assessed from a multidimensional perspective, including the societal impact,” said senior author Y. Raja Rampersaud, MD, FRCS(C), Spine Surgeon, Associate Professor in the Divisions of Orthopaedic and Neurosurgery at the University of Toronto in Ontario. “One tool or one questionnaire, would be ideal, but the heterogeneity of LBP makes that impossible.”
The study was designed to identify modifiable independent risk factors for negative work status in a non-workers compensation cohort of patients with LBP presenting for Inter-professional Spine Assessment and Education Clinics (ISAEC). Under the program primary care physicians refer patients with unmanageable LBP symptoms of >6 weeks to ISAEC for multidisciplinary assessment, multidimensional risk stratification and patient-specific education, facilitated self-management of symptoms, and shared-care management plan.
The study included 462 patients (mean age, 45 years; 52% female) with LBP for 6 weeks to 12 months. None of these patients had red flag conditions, established pain disorders, narcotic dependency, or were pregnant or less than 1 year postpartum.
At initial ISAEC consultation, no statistically significant differences were found between patients who were underemployed (ie, unemployed, modified work duty, or receiving disability; n=344) or employed (n=118) in terms of age, gender, body mass index, dominant pain pattern, LBP associated with injury, or duration of symptoms. Multivariate logistic regression identified the following independent risk factors for underemployment status at initial consultation: legal or insurance claim (odds ratio [OR], 2.77; P=0.04), depression (OR, 2.28; P=0.019), smoking, and higher scores on the STarT Back scale (indicating a high-chronicity risk) or Oswestry Disability Index (ODI).
Due to a publication error, the ORs for smoking (OR, 3.80; P<0.001), STarT Back Score (OR, 1.19 per integer increase, P=0.001) and ODI (OR, 1.05 per integer % increase, P<0.001) were not included in the results table (data provided by the authors).
Predictors of Change in Employment Status After 6 Months
A total of 178 of the overall group completed baseline and 6-month follow-up and had complete data sets. Of these patients, the underemployment rate did not change significantly during the study (25.5% at baseline and 22.9% at follow-up). Notably, 10.5% of patients who were employed at initial consultation were underemployed by 6 months. The only significant predictor of changing to underemployment status on bivariate analysis was an elevated baseline ODI score (P=0.0101).
In contrast, 41% of patients who were underemployed at baseline (16 of 39 patients) became employed after completing ISAEC. The absence of depression was a significant predictor of return to work in this subgroup (P=0.0001).
Assessing Risk Factors for Underemployment in Clinical Practice
“While there is certainly awareness of the multidimensional aspect of LBP, implementation into practice remains challenging,” Dr. Rampersaud said. “There are a variety of short screening tools (eg, the STarT Back) that enable simple assessment of risk factors that can be incorporated into clinical intake. However, simple questions that address the impact of an individual’s low back pain on home, play, and work life are critical to determining what is most important to the patient, and whether it is reasonably modifiable or not. We often assume it is just about managing pain, however, factors such as secondary depression impact well beyond pain.”
Peter G. Whang, MD, FACS
Associate Professor, Spine Service
Department of Orthopaedics and Rehabilitation
Yale University School of Medicine
New Haven, CT
When considering the deleterious effects that low back pain can have on our patients, it should come as no surprise that recalcitrant symptoms can lead to significant functional disability, and an inability to work is known to be a major driver of societal costs. The findings of this prospective observational study are therefore, quite important because the authors identify a number of modifiable risk factors that may affect employment status of patients with low back pain.
Specifically, depression and smoking were the two variables found to be associated with underemployment at the time of initial presentation; similarly, patients with higher baseline Oswestry Disability Index (ODI) scores more likely to leave the work force despite undergoing treatment for their low back pain. Taking into account these results, practitioners may find that initiating therapies specifically targeting these two conditions—depression and smoking—may lead to greater improvements in the clinical outcomes of patients with debilitating back pain. In addition, individuals with greater functional disability as reflected in their ODI scores may be at higher risk for developing chronic symptoms, and would presumably benefit from closer follow-up and access to more intensive forms of nonoperative care.
This investigation certainly has its limitations, including a relatively small sample size as well as questions regarding the applicability of its findings to all health systems since the data was obtained from a novel treatment program recently established in Canada that utilizes more integrated strategies to manage patients with low back pain. As the principle of value-based medicine becomes more important, it will be critical to further elucidate the effects of low back pain on employment status and other functional outcomes.
In the meantime, given the multifactorial nature of back pain and the current paucity of evidence-based guidelines and other validated paradigms for the treatment of this nearly ubiquitous condition, it is becoming increasingly clear that patients with low back pain may be best served by a therapeutic model emphasizing multidisciplinary care.