Keys to Understanding Spine-Related Disability
Highlight from the 2nd Annual Spine 10 x 25 Summit: Technology Update
During the 2nd Annual Spine 10 x 25 Summit: Technology Update, Robert Barth, PhD, discussed three sets of key references he believes critical to changing our understanding of disability. Two sources presented were published guidelines: the American Medical Association Guides to the Evaluation of Work Ability and Return to Work, and the American College of Occupational and Environmental Medicine’s Occupational Medicine Guidelines (ACOEM Guidelines). The third reference was a group of population-based efforts worldwide that reveal the impact of public health campaigns on disability behaviors.
Dr. Barth described population-based efforts over the past two decades intended to decrease the incidence of long-term disability in Norway, Canada, Scotland and Australia. Campaigns specifically addressed back pain as the leading cause of disability claims. Dr. Barth focused on a large-scale Australian campaign that was conducted over three years as “rich” in significant findings. Aus $10 million (US $7.6 million) was spent on public outreach via television, radio and print advertising, as well as physician guidelines and a widely-distributed self-care book, The Back Book. The Australian campaign “was the most extensive and the most impressive in terms of results,” Dr. Barth reported.
The public information efforts targeted three main messages: back pain is not a serious problem, activity is more beneficial than rest for recovery, and patients must take ownership of their recovery. Resulting individual attitudes and behaviors were assessed by telephone and postal surveys, comparison with a control group, and analyses of workers’ compensation claims. The Australian campaign produced measurable changes in population attitudes and reported behavior, with “significant reduction in workers’ compensation claims for back pain, and significant reduction in days away from work for back pain,” Dr. Barth said.
Dr. Barth also discussed the American Medical Association Guides to the Evaluation of Work Ability and Return to Work. With the US experiencing a disability epidemic that takes millions of people out of the workforce, Dr. Barth pointed out that the emphasis of the AMA Guides is on return to work. “Although work is becoming less physically demanding and dangerous, and healthcare continues to improve, the rate of disability claims is increasing faster than population growth,” he said.
According to Dr. Barth, the Guides recommends patients stay in the work environment, if at all possible, during recovery from physical injury. Physician gatekeepers are encouraged to keep patients at work, to encourage activity, and to base any work restriction orders on objective medical findings, not on patient preference or subjective reports of pain. Dr. Barth summed up his overview of the Guides in a quote from the text itself: “There is no science to support the need for activity restrictions in patients with lumbar disc herniations or low back pain, and limitations may, in fact, impede the patient’s return to work and foster disability unnecessarily.”
The chapter on disability prevention in the 2011 ACOEM Guidelines, co-authored by Dr. Barth, was the final reference presented. “Cornerstones of Disability Prevention and Management” identifies some key points of general misconception. “Most notably, there is little relationship between objectively verifiable health problems and vocational disability. Disability is driven more by social and psychological issues than by medical issues.”
The ACOEM Guidelines suggest investigating psychological factors for low back pain patients who don’t progress as expected. Psychological evaluation and treatment is recommended on the condition that it will expedite functional recovery. Short-term, evidence-based techniques such as cognitive-behavioral therapy are emphasized for their proven effectiveness in lowering risk of long-term disability.
These published guidelines and practical initiatives seek to educate all parties in the disability system about the risks, pitfalls and successes in disability prevention. Patients are encouraged to be active participants, and to take responsibility for their recovery. Healthcare providers must shift away from medicalizing nonmedical problems, and “choose the diagnostic and therapeutic methods that are most effective at restoring function, shortening the period of disruption, and maximizing cost effectiveness,” noted Dr. Barth.