A Non-Surgical Intervention Protocol For Occupational Back Injuries
Will Decrease Fiscal and Manpower Losses to the Workforce
Dr. Howard W. Fisher, B.Sc. B.Ed. D.C. 103 Shelborne Avenue
Toronto, Ontario, M5N 1Z2 [email protected]
Introduction
Low back pain is one of the foremost causes of disability, decreased ability for physical activity and economic loss in the industrialized world.1 The introduction of a fully integrated intervention modelfor occupational back pain can be shown to be not only cost beneficial for the workers’ compensation boards and insurers but will significantly reduce days lost to work by injured workers.
Over the past several decades, countless studies have related the fiscal impact of low back pain. Back injuries are statistically one of the most common and costly work-related disorders in America. Herniated discs are responsible for back pain in about 40% of low back pain sufferers.2 3 4 One-hundred and sixty (160) of every one hundred thousand (100,000) adults in the United States undergo surgery for herniated discs annually.5 Low-back pain specifically affects 1,000,000 workers annually and is responsible for more lost workdays than any other musculoskeletal injury. More than twenty-five percent of all compensation claims involve back injuries with an economic cost of billions of dollars to industry, with no consideration whatsoever of the pain, suffering and impact upon quality of life. In the United States alone the cost of therapy and disability payments for low back pain related injury are between $50 and $100 billion per year.6 7
Most workers with back injury return to work quickly. The minority who do not and are absent from work for more than six months, and account for the majority of associated costs and health care: as much as ninety-seven per cent of the total.8 9 10 11 12
1
Lee CR, Kim JY, Hong YS, et al. Comparison of disability duration of lumbar intervertebral disc disorders among types of insurance in Korea. Industrial Health . 2005;43:647-55.
2
Frymoyer, JW, and Cats-Baril, WL. An overview of the incidence and costs of low back pain. Orthop. Clin. North. Am. 1991:263-271.
3
Cypress BK. Characteristics of physician visits for back symptoms: a national perspective. Am. J. Public Health. 1983;73:389-395
4
Deyo RA, Tsui-wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the united states. Spine. 1987 12:264-268.
5
Anderson, GBJ, Weinstein JN. Disc herniation [editorial]. Spine. 1996; 21(Suppl. 24):1S.
6
Frymoyer JW, Cats-Baril WL. An overview of the incidences and costs of low back pain. Orthop Clin North Am. 1991; 22:263-271.
7
University of Minnesota Environmental Health Sciences. PuBH 5120: Injury Prevention Spring Semester 2004. http://enhs.umn.edu/2004injuryprevent/back/backinjury.html.
8
Hazard RG, Haugh LD, Reid S, et al. Early Prediction of Chronic Disability After Occupational Low Back Injury. Spine. 1996;21(8):945-951.
13 14
The average cost of a low-back associated workers’ compensation claim is approximately $8,500 USD. This is more than double the cost of the average injury compensation claim. In 7% of the low back claims, the duration of disability was longer than one year, and these accounted for 75% of the costs and 84% of the total disability days.15
While there has been a concentrated effort to reduce and prevent low back injuries in the workplace, statistically it remains as the major cause of disability and financial burden on the healthcare system. Preventive and educational strategies have been instituted with moderate, but insignificant, results in the prevention of low back problems.16 Due to ever-increasing costs related to back injuries, many companies have started occupational safety programs, including ergonomic changes to the workplace. Unfortunately these preventive changes have not lead to a decrease in these injuries and investigators have postulated that the programs may not be implemented in a broad spectrum manner because of: an attempt by employers to avoid a negative image, the fear of government regulation, preconceived perceptions that risk assessment is ineffective, or unfamiliarity of the benefits of preventive intervention.17
A National Academy of Sciences study indicated that musculoskeletal injuries are expected to further increase as a result of the shifting ergonomics of the workplace, the baby-boomer influence (aging of the population), and the changing occupational demographic of women finding employment in the material handling and computer-related sectors.18
Current Protocols
9
Loisel P, Lemaire J, Poitras S, Durand MJ, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occup Environ Med. 2002;59:807-815.
10
Abenhaim L, Suissa S. Importance of economic burden of occupational back pain: A study of 2500 cases representative of Quebec. J occup Med. 1987;22:670-4.
11
Lee P. The economic impact of musculoskeletal disorders. Qual Life Res. 1994;3(Suppl):S85-S91.
12
Spitzer WO, Leblanc FE, Dupuis M, et al. Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians. Report of the Quebec Task Force on Spinal Disorders. Spine. 1987;12(Suppl):S1-S59.
13
Webster BS, Snook SH. The cost of 1989 workers’ compensation low back pain claims. Spine. 1994;19:1111-6.
14
Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers’ compensation low back pain claims. J Occup Environ Med. 1997;39:937-45.
15
Hashemi L, Webster BS, Clancy EA, Volinn E. Length of disability and cost of workers’ compensation low back pain claims. J Occup Environ Med. 1997;39:937-45.
16
Hazard RG, Reid S, Haugh LD, et al. A Controlled Trial of an Educational Pamphlet to Prevent Disability After Occupational Low Back Injury. Spine. 2000;25(11):1419-1423.
17
Melhorn JM, Gardner P. Prevention of Musculoskeletal Disorders in the Workplace. Clinical Orthopedics and Related Research. 2004; 1(419): 285-296.
18
National Academy of Sciences. Work Related Musculoskeletal Disorders: Report, Workshop Summary, and Workshop Papers. Washington, DC: National Academy of Sciences, National Research Council, Institute of Medicine; 1999:1-240.
Sadly, the current diagnostic protocol for occupational disc-related injuries virtually predetermines a negligible return to the workplace for these patients. A discal injury is one that, as a rule, will not respond to current palliative forms of treatment. The initial evaluation by the examining physician leads to a prescription of bed rest, an anti-inflammatory, analgesic regimen and a wait-and-see attitude for cessation of pain and symptomatology. Without a positive outcome, the patient is then referred for a course of physiotherapy lasting one to three months. By removing a worker from the workplace for therapy for only three months there is only a fifty per cent (50%) chance of them returning to work by fifteen months from the date of injury.19
Once again without a positive response from the therapy, the injured worker is referred to a specialist. This can take from one to three months before the specialist can see the patient, and sometimes even longer. The responsible specialist will then order diagnostic imaging, most likely an MRI, and this can take from one to three months. The results of the imaging will then dictate the next steps. If a surgical procedure is necessary, the scheduling can take from two weeks to several months, and the subsequent recovery and rehabilitation a minimum of three to six months. Lumbar fusion remains the surgical procedure of choice and less than ideal clinical results are obtained by a major proportion of patients. The costs to the health care system (workers’ compensation or insurer) at this point are now far in excess of $100,000. There is a direct correlation between the length of time that an injured worker has been out of the workplace and the probability of their return to work.20
Statistics indicate that any injured worker who has not returned to work by twelve months has only a two per cent (2%) probability of returning to work by fifteen months.21 There has not been a published study that indicates that average length of disability and loss of work for occupationally caused disc pathologies, however the general consensus suggests that these injuries, in particular, are the most difficult to resolve and have the least success in total recovery. This is where the serious complications arise as disc-related injuries generally present with radiating pain and radiating pain has been determined to be an indicator of the prediction of a chronic disability.22 According to the United States Bureau of Labor Statistics workers absent for more than six months due to work related injury have only a fifty-per cent (50%) probability of returning to work. Workers absent for more than one year have a twenty-five per cent (25%) chance of returning to work and those absent for two years have a negligible chance of ever returning to work.23 24
19
Crook J, Moldofsky H. The probability of recovery and return to work from work disability as a function of time. Qual Life Res (Suppl 1). 1994;3: S97-S109.
20
Rehak D. When An Employee Is Injured Time is Of the Essence. Hughston Health Alert. 2004; Vol. 16 No. 1: 1.
21
Letz G, Christian JH, Tierman SM. Disability prevention and management. In: Current occupational and environmental medicine. 3rd ed., Ladou J, ed. McGraw Hill. Singapore. 2004; 21-35.
22
Turner JA, Franklin G, Fulton-Kehoe D, Egan K,et al. Prediction of chronic disability in work-related musculoskeletal disorders: a prospective, population-based study. BMC Musculoskelet Disord. 2004;5:14. Published online 2004 May 24. doi: 10.1186/1471-2474-5-14.
23
Rehak D. When An Employee Is Injured Time is Of the Essence. Hughston Health Alert. 2004; Vol. 16 No. 1: 1.
In consideration of the limited effects of preventive programs and awareness campaigns in the workplace,25 a number of researchers have proposed an intervention protocol directed at those workers who are at risk of a longer duration disability.26 27 28 Post-injury intervention programs are focused on the return of the disabled worker and expediting his return to work as soon as possible,29 and have demonstrated a statistically significant increase in the rate of return to the workplace of low back patients.30 31 32
Post-injury interventions consist of occupational medicine interventions, ergonomic interventions, clinical rehabilitations and rehabilitative interventions. These interventions (the Sherbrooke model)33 have been initiated from a minimum of six weeks past the date of injury (occupational intervention), continued with a clinical intervention at eight weeks (a visit to a back pain medical specialist and back care school) and a rehabilitative intervention at twelve weeks.34 One such study found that the intervention model returned injured subjects back to their usual employment 2.4 times faster than those with no interventions.35
Another study evaluated a two-year multidisciplinary early intervention pilot program for the nurses at a large teaching hospital who had injured their backs. The study compared rehabilitative outcomes and costs before and after the introduction of the intervention program. The results indicated that the ratesof back injuries and lost-time back injuries decreased by 23%and 43%, respectively, on the ‘intervention’ wards, while these parameters increasedon the ‘control wards’. Combined expenditure was 32% lower per injury and 34% lower per lost-time injury for those in the ‘intervention’ group compared to their counterparts on the ‘control’ wards. This study indicated that an
24
US Department of Labor. Industry Injury and Illness Data 2002. www.bls.gov/iif/oshsum.htm.
25
University of Minnesota Environmental Health Sciences. PuBH 5120: Injury Prevention Spring Semester 2004. http://enhs.umn.edu/2004injuryprevent/back/backinjury.html.
26
Frank JW, Brooker AS, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine. 1996; 21: 2918-29.
27
Linton SJ. The socioeconomic impact of chronic back pain: is anyone benefiting? Pain. 1998; 75: 163-68.
28
Spitzer WO. Low back pain in the workplace: attainable benefits not attained. Br J Ind Med. 1993; 50: 385-8.
29
Cats-Baril W, Frymoyer J. The economics of spinal disorders. In: Frymoyer JW, Ducker TB, Hadler NM, et al, eds. The adult spine. Principles and practice. New York. Raven Press. 1991.
30
Loisel P, Abenhaim L, Durand P, et al. A population-based, randomized clinical trial on back pain management. Spine. 1997; 22: 2911-18.
31
Turk D. Efficacy of multidisciplinary pain centers at a crossroad: a practical and conceptual reappraisal. Seattle WA. IASP Press. 1996: 257-73.
32
Yassi A, Tate R, Cooper JE, Snow C, Vallentyne S, Khokhar JB. Early intervention for back-injured nurses at a large canadian tertiary care hospital—an evaluation of the effectiveness and cost benefits of a two-year pilot project. Occup Med 1995;45:209–14.
33
Loisel P, Durand P, Abenhaim L et al. Management of occupational back pain. The Sherbrooke model. Results of a pilot and feasibility study. Occup Environ Med. 1994; 51:597-602.
34
Loisel P, Abenhaim L, Durand P, Esdaile JM, et al. A population-based, randomized clinical trial on back pain management. Spine. 1997; 22:2911-18.
35
intervention program reduced the incidence and timelost due to back injuries and was cost-beneficial when compared to the current paradigm.36
The use of the back pain medical specialist was used to rule out discopathies or tumors, more serious injuries. The prompt use of diagnostic imaging to rule out the significant pathologies can play a key role in the etiology of incident-related low back pain. In a follow-up cost evaluation study, it was noted that injuries to the intervertebral disc generate significantly increased costs compared to other back injury cases.37 Since approximately twenty-five per cent of the back injury cases account for the majority of the compensation and insurer costs and days lost from work, one might assume that a large proportion of these are disc-related.
For many years it was believed that the source of both localized and radiating pain in disc-related injuries was solely from the pressure on the neurological components in the neural foramina or spinal canal from the herniated nuclear material, however researchers have determined that not to be the only cause. Investigators have shown that herniated discal material will induce an inflammatory response in the spinal cord and surrounding areas causing pain.38 39 40 As a result of these concomitant potential causes of nociception (pain), it becomes imperative for any comprehensive therapeutic regimen to be successful for treating discopathies to involve some mechanism for resorption or removal of discal material.
TABLE I
PROBABILITY OF RETURNING TO WORK FROM A LOW BACK INJURY TIME AWAY FROM JOB DUE TO
LOW BACK INJURY
PERCENTAGE CHANCE OF RETURNING TO WORK
3 MONTHS 50% OF RETURNING IN 15 MONTHS
6 MONTHS 50% OF RETURNING EVER
12 MONTHS 2% OF RETURNING IN 15 MONTHS,
25% OF RETURNING TO WORK EVER
24 MONTHS (<2%)NEGLIBLE CHANCE OF
RETURNING EVER
36
Yassi A, Tate R, Cooper JE, Snow C, Vallentyne S, Khokhar JB. Early intervention for back-injured nurses at a large canadian tertiary care hospital—an evaluation of the effectiveness and cost benefits of a two-year pilot project. Occup Med.1995;45:209–14.
37
Loisel P, Lemaire J, Poitras S, Durand MJ, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occup Environ Med. 2002;59:807-815.
38
Takahashi H, Suguro T, Okazima Y, et al. Inflammatory cytokines in the herniated disc of the lumbar spine. Spine. Jan 15 1996;21(2):218-24.
39
Bobechko W P, Hirsch C. Auto-Immune response to nucleus pulposus in the rabbit. J Bone Joint Surg Br. 1965; Aug;47:574-80.
40
Haro H, Shinomiya K, Komori H, et al. Upregulated Expression of Chemokines in Herniated Nucleus Pulposus Resorption.Spine. July 1996; 21(14):1647-1652.
Instituting A New Protocol
In the last ten years, technological advances in the field of non-surgical spinal decompression have presented another option that will offer an alternative solution to these highly costly cases. Non-surgical spinal decompression therapy, through the use of a device capable of generating a dynamic vector, can reduce intradiscal pressure to -150 millimeters of mercury (-150mm. Hg.).41 By reducing the pressure on the neurological components and herniated discal nuclear material, spinal decompression will allow re-absorption of the nuclear material, healing, and a decrease in the inflammation and pain to take place.42 This technique has been proven to be significantly effective to treat the pain and physiological effects of disc-related disorders such as bulging, herniation and degeneration.43 44 Further studies have shown non-surgical spinal decompression to have an efficiency rate of eighty-six per cent (86%) of subjects previously thought to need surgical intervention. 45 46
A non-surgical spinal decompression table is designed with a split between the upper and lower section to eliminate frictional resistance between the patient and the table and to allow the ability to exercise more control over the dynamic vector that creates the axial distraction which results in the decompression forces that are applied to the lumbar or cervical spine. The equipment applies predetermined distractive forces calibrated by biofeedback sensors (17 times per second) and is based on a logarithmic progression in a gradually increasing manner. These controlled vectors are designed to achieve distraction of the vertebral bodies without eliciting the sympathetic reflex muscular reaction inherent to traction devices. Empirical evidence has shown that approximately twenty visits over a six week period will achieve the projected results.
With the establishment of the efficacy of this new therapeutic regimen in conjunction with the proven results of various forms of interventions, the logical proposal for optimum benefits would be to combine them. This strategy would decrease the costs to the health care system and return disc-related injured workers back to the workforce. The intervention could be conducted at approximately six weeks in cases of non-responsive back injuries and would involve diagnostic imaging capable of revealing discopathies, although according some researchers, “clinical symptoms and findings remain the most important basis for diagnosis”.47 Since these vertebral unit injuries are
41
Ramos G, Martin W. Effects of vertebral axial decompression on intradiscal pressure. J of Neurosurgery. 1994;81: 350-353.
42
Tilaro F. An overview of vertebral axial decompression. Canadian Journal of Clinical Medicine. 1998; vol. 5 no.1.
43
Gose E, Naguszewski W, Naguszewski R. Vertebral axial decompression for pain associated with herniated or degenerated discs or facet syndrome: An outcome study. J Neurological Research. 1998;20: 186-190.
44
Tilaro F, Miskovich D. The effects of vertebral axial decompression on sensory nerve dysfunction. Canadian Journal of Clinical Medicine . 1999;vol 6. no. 1:2-7.
45
Gionis TA, Groteke E. Spinal decompression. Orthopedic Technology Review. 2003; vol 5-6.
46
Shealy CN, Leroy P. New concepts in back pain management: decompression reduction, and
stabilization. In: Weiner R, ed. Pain Management: A Practical Guide for Clinicians. Boca Raton, Fla: St Lucie Press; 1998: 239–257.
47
among those that keep workers out of the workplace for the longest duration and present the system with the highest costs, treatment with a regimen of non-surgical spinal decompression will decrease time lost from work and money spent.
Conclusion
It is a documented fact that a limitednumber of cases were responsible for most of the long term disabilitycosts, in accordance with occupational back pain epidemiology. From a review of the literature, it is apparent that back injuries sustained in the workplace are a major cause of morbidity and expense to worker’s compensation boards.48 49 Intervention programs have been demonstrated to be effective for returning injured workers to the workplace and saving money for both compensation boards and disability insurers alike.50 Occupational trauma may also be the precipitating factor in a number of degenerative and traumatic (disc-related) disorders but by interceding in the established protocols with a new, highly successful paradigm, the health care professionals may be able to expedite an earlier return to the workforce and indeed prevent unnecessary disability payments to the injured worker who has subsequently returned to work.
48
Spengler DM, Bigos SJ, Martin NA et al. Back Injuries in industry: a retrospective study: 1. Overview and cost analysis. Spine 1986; 11:241-245.
49
Spitzer WO. Magnitude of the problem. Spine. 1987; 12(Suppl): 12-5.
50
Loisel P, Lemaire J, Poitras, et al. Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six-year follow up study. Occup Environ Med 2002;59:807–15.
