Managing the worker who still has problems after 1-3 months
A worker with LBP who is still having difficulty in returning to normal occupational duties at 1-3 months has a 10-40 per cent risk of still being absent at 1 year. By the time 6 months has passed, the risk is higher still. Thus a need exists to identify workers off work with LBP before chronic- ity sets in. Intervention after 4 weeks is more effective than treatment received much later, and a system should be established to identify absence of this degree.
At the subacute stage an active rehabilitation programme is needed. There is some empirical evidence that intervention can work,26-28 and guidelines from NICE advocate a proactive approach in which employers and doctors are encouraged to consider referral to a physiotherapist or rehabilitation specialist, psychological interventions such as small group cognitive-behavioural therapy, education in a ‘back school, the appointment of a case manager, or intensive multidisciplinary treatment.29 The evidence from larger and better conducted randomized controlled trials (RCTs) is less strong and benefits seems to be small30 with uncertainty about cost-effectiveness.
Nonetheless, it has been suggested20 that certain elements are essential and that effective rehabilitation programmes should:
- ? Include a progressive increase in the amount of exercise to build physical fitness (the precise type of exercise being less critical).
- ? Be based on behavioural principles of pain management.
- ? Advise on overcoming fear-avoidance and dependency behaviours (more than the biomedical injury model).
- ? Involve stakeholders in the workplace.
NICE has further suggested that GPs should ‘consider offering’ an exercise programme, or course of manual therapy or acupuncture; and, in the event of major psychological distress, an 8-week combined physical and psychological treatment programme, including a cognitive-behavioural approach.31 However, effect sizes, at least for some of these interventions, are likely to be small.30