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.

Active rehabilitation

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