Early Occupational Intervention for Chronic Low Back Pain Does Not Add to Benefits of Usual Care

Peer Reviewed

Patients with chronic low back pain (LBP) in physically demanding jobs at risk for sick leave did not benefit from early occupational-oriented intervention given as an add-on to comprehensive usual care in an open-label, parallel-group randomized controlled trial in the August 16 issue of PLOS Medicine.

construction worker with chronic low back painChronic low back pain is experienced by many workers whose jobs are physically demanding. Photo Source: 123RF.com.“The findings indicate that occupational elements may be integrated into usual care and do not necessarily have to be carried out by a specialist in occupational medicine,” explained lead author Bjarke B Hansen, MD, PhD, of The Parker Institute and Department of Occupational and Environmental Medicine, Copenhagen University Hospital, Denmark.

“This study again supports that most cases of back pain are self-limiting,” commented SpineUniverse editorial board member Santhosh A. Thomas, DO, MBA, who is Medical Director of the Center for Spine Health, Cleveland Clinic, Avon, OH. “Reassurance and education can play a big part in return to work and cost containment for low back pain.”

Study Rationale

“Research has shown that among sick-listed workers with chronic low back pain, interventions performed by an occupational specialist are superior at reducing disability and sick leave, compared with usual care in a primary or secondary healthcare setting,” Dr. Hansen said.

“However, comprehensive usual care enhanced with a clear explanation for the pain also seems to alter fear-avoidance behavior towards work and also seems to reduce sick leave and occupational medicine is often given as add-on to usual care,” Dr. Hansen told SpineUniverse. “Therefore, we tested the add-on effect of providing an early occupational-oriented intervention in addition to usual care.”

Study Methods

“Our study tested the benefit of a 3-month occupational intervention given as an add-on to a single hospital consultation, which included an explanation of the pain based on a clinical examination and magnetic resonance imaging (MRI), as well as simple instructions to stay active and continue working,” Dr. Hansen explained.

The study included 305 patients (99 women) with LBP and in physically demanding jobs who were seen at a single hospital consultation that included a thorough explanation of the pain based on clinical examination and MRI as well as recommendations to stay active and continue working. Half of the patients were randomized to occupational intervention (n=153) or no additional intervention (control group; n=152) and were followed for 6 months to determine how many sick leave days they took.

Sick Leave Days Similar in Both Groups

“No difference between groups was found for cumulative sick leave days (primary endpoint) at 6 months,” Dr. Hansen said. The mean number of sick days was 15.49 in the control group and 18.54 in the occupational intervention group (mean difference between groups, 3.50; P=0.422).

Both groups showed significant improvements in the following secondary outcomes with no significant difference in improvement between the groups: average pain score, disability, fear-avoidance beliefs about physical activities and work, and physical health-related quality of life.

“It is normal to have fear of worsening of pain and/or delayed resolution,” Dr. Thomas commented. “Most new onset of back pain will resolve without any complications. If a patient has red flags (eg, weight loss, leg pain, weakness, bowel and bladder issues, recent use of steroids, history of cancer, advancing age, history of spine fracture from minor trauma, or night pain), this would require additional work up. Back pain with leg pain is different than back pain alone, and may require more attention.”

When is MRI Needed to Help Explain Back Pain?

“We believe that an explanation for back pain given by a medical physician may alter fear-avoidance beliefs and behaviors and, thereby, increase the odds for work participation in patients with chronic LBP,” Dr. Hansen said. “Furthermore, a personalized explanation of the back pain based on MRI and a clinical examination may remove fear of severe conditions.”

“An MRI scan is not a recommended for routine examination in the diagnostics of non-specific low back pain and in the absence of ‘red flag’ symptoms, most guideline advocate for several weeks of conservative care without any diagnostic imaging,” Dr. Hansen added. “Studies have also indicated that liberal use of imaging in LBP may even worsen long-term outcomes in some patients.”

Dr. Thomas concurred that an MRI or CT scan may be needed if a patient has red flags. However, these types of advanced imaging can be deferred in most patients as “they do not show source of pain, but rather show anatomy,” Dr. Thomas said. “A good history and physical exam helps the most, and imaging should be done for confirmation of clinical suspicion, and for plans to perform invasive procedures.”

“Imaging of the spine has a high priority in the assessment of patients with low back pain, who seem to expect such procedures to be undertaken,” he said. “In this study, MRI was used to exclude fear for serious diagnoses in the patients (eg, cancer) and to highlight the benign nature of degenerative findings. We believe that MRI should never be performed without a proper explanation of the findings and a clinical examination.”

Dr. Hansen and Dr. Thomas have no relevant disclosures.

Updated on: 09/18/19
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Physical Therapy for Cervical Radiculopathy Linked to Improved Post-surgical Outcomes
Bjarke B. Hansen, MD, PhD
The Parker Institute
Department of Occupational and Environmental Medicine
Copenhagen University Hospital
Santhosh A. Thomas, DO, MBA
Medical Director, Center for Spine Health
Cleveland Clinic

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