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HSE
Health & Safety
Executive
Improved early pain management for
musculoskeletal disorders
Prepared by the Institute for Musculoskeletal
Research and Clinical Implementation
for the Health and Safety Executive 2005
RESEARCH REPORT 399
HSE
Health & Safety
Executive
Improved early pain management for
musculoskeletal disorders
Alan Breen DC PhD
Jennifer Langworthy MPhil
Jeffrey Bagust PhD
Institute for Musculoskeletal Research and
Clinical Implementation
AECC
Bournemouth
Dorset BH5 2DF
This report examines the usefulness of secondary intervention pain management techniques in helping
people with musculoskeletal disorders (MSD’s) to stay at work or get back to work in the early stages
of an episode. The methodology adopted was mainly that of narrative review to present the latest
evidence and authoritative evidence-based guidance addressing such measures and barriers to their
implementation. Care Pathways, consistent with our findings, are proposed.
The Pathways are for use in the first few weeks of an episode that threatens, or causes, work loss.
They are for employees, employers and (if necessary) health professionals, where the latter can
provide assessment and evidence-based intervention within one week of request. The evidence was
variable in quality across the spectrum of MSDs, with upper limb disorders in need of the greatest
development. As well as effective care for these disorders, we have taken into consideration their
natural history and barriers to positive outcome.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its
contents, including any opinions and/or conclusions expressed, are those of the authors alone and do
not necessarily reflect HSE policy.
HSE BOOKS
© Crown copyright 2005
First published 2005
All rights reserved. No part of this publication may be
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Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to [email protected]
ii
ACKNOWLEDGEMENTS
We are grateful to the following experts who gave generously of their time to provide critical
commentary on the care pathways contained in this report: Kim Burton, Nick Kendall, Bob
Mootz, Margarita Nordin, Jane Reeback, Inger Scheel, Linda Stone, Gordon Waddell, and Mary
Wyatt. We also wish to thank the Musculoskeletal Process of Care Collaboration: Dawn
Carnes, David Evans, Nadine Foster, Suzanne Parsons, Tamar Pincus, Martin Underwood, and
Steve Vogel for reviewing sections of the report and Clive Osmond for providing statistical
advice. None of the above bear any responsibility for what we have written.
iii
iv
CONTENTS
ACKNOWLEDGEMENTS
EXECUTIVE SUMMARY
iii
vii
1.
INTRODUCTION
1
2. RATIONALE FOR EARLY INTERVENTION
3
3.
CULTURE
AND PAIN
3.1
JOB
CULTURE
3.2
ETHNICITY
3.3
GENDER
5
5
5
7
4.
PAIN
PHYSIOLOGY
9
5.
PREDICTORS
OF OUTCOME
5.1 MUSCULOSKELETAL DISORDERS GENERALLY
5.2
BACK
PAIN
5.3
NECK
PAIN
5.4
UPPER
LIMB DISORDERS
11
11 11
13
14
SUMMARY OF CURRENT GUIDELINES, SUBSEQUENT REVIEWS
AND RESEARCH
6.1 GUIDELINES: MUSCULOSKELETAL DISORDERS
GENERALLY
6.2 BACK PAIN – GUIDELINES
6.3 BACK PAIN - SUBSEQUENT REVIEWS AND RESEARCH
6.4 NECK PAIN AND UPPER LIMB DISORDERS
– GUIDELINES
6.5 NECK PAIN AND UPPER LIMB DISORDERS
– SUBSEQUENT REVIEWS AND RESEARCH 6.6. OTHER MUSCULOSKELETAL DISORDERS
6.7. SUMMARY OF CURRENT THINKING
17 27 31 31 7.
PROSPECTS
FOR IMPROVED CARE
33
8. CARE PATHWAYS AND CLINICAL MANAGEMENT
8.1. THE GENERIC CARE PATHWAY
8.2. THE EMPLOYER PATHWAY
8.3. THE EMPLOYEE PATHWAY
8.4. HEALTH PROFESSIONAL PATHWAY
8.5. LINKS BETWEEN THE THREE PATHWAYS
37 37 38 38 39
39 6. v
17 17 21 22
9. EARLY INTERVENTIONS BY MUSCULOSKELETAL
PRACTITIONERS
9.1. TRADITIONAL CASE MIX AND INTERVENTIONS
9.2. PSYCHOSOCIAL CHARACTERISTICS OF PATIENTS
9.3.
ATTITUDES
TO ANALGESIA
9.4.
IMAGING
9.5.
REACTIVATION
9.6. GUIDELINE CONSISTENT ATTITUDES GENERALLY
9.7.
CO-MORBIDITY
9.8 PREVIOUS OCCUPATIONAL AND NHS USE OF MUSCULOSKELETAL PRACTITIONERS
9.9. A COMMON INTERVENTION PACKAGE
9.10. ACUTE
BACK PAIN
9.11. MANIPULATION, MOBILISATION AND SOFT TISSUE TECHNIQUES
9.12. ADVICE AND PSYCHOSOCIAL INTERVENTIONS
41 41
41 41 43
43
43
44 44
45 46 48
48 49 10. SUMMARY POINTS AND GENERAL RECOMMENDATIONS
10.1. EMPLOYERS
10.2. EMPLOYEES
10.3. HEALTH PROFESSIONALS 51
51
51
51 11.
53
APPENDIX 1: THE CARE PATHWAYS
APPENDIX 2: PAIN RELIEF INFORMATION
APPENDIX 3: THE ATTITUDES TO BACK PAIN SCALE
69
73
75 GLOSSARY (Professional bodies and health regulators with registers of
musculoskeletal practitioners)
77
REFERENCES
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EXECUTIVE SUMMARY
Purpose of the work
• The aim of this study was to establish the usefulness of early pain management
techniques in helping people, within the first 2 weeks of the onset of symptoms of
an MSD, to stay at work or get back to work by:
• presenting the latest evidence and authoritative evidence-based guidance
addressing these measures and barriers to their implementation
• proposing care pathways that are broadly consistent with the evidence.
The role of physiology, culture and ethnicity
• The main consideration in early pain management is to control pain while avoiding
withdrawal and inactivity. Job culture has more to do with this than ethnicity or
gender.
•
Negative neurophysiological interactions between pain and stress promote an
environment that can sustain disability and absenteeism, whereas continued activity
and involvement along with positive expectations oppose it.
Predictors of outcome
• Social isolation, dissatisfaction in the workplace and multiple co-morbidities
(especially musculoskeletal ones) are probably the most consistent psychosocial
factors associated (albeit usually only moderately) with the occurrence, duration of
absence and future disability from non-specific musculoskeletal disorders. A high
level of pain at the beginning of an episode is an important physical predictor.
However;
• Neck pain has a higher incidence and influence on work in women and in
people with previous significant injury.
• Combinations of physical load factors are implicated in tenosynovitis or
peritendonitis of the wrist or forearm, but imprecise measurement of exposure
makes this association undependable.
•
•
Most of these predictors are in the low to moderate range and are not necessarily
independent factors.
Interactions with other life factors, such as social inequality, mental disorders, nonwork activity and poor health may confound these associations.
Back pain – Evidence-based guidance and subsequent research
• The most recent and authoritative multidisciplinary evidence-based guidelines for
acute low back pain management are from Europe and Australia. These present
consistent messages that for work-related problems, early intervention should be a
collaborative approach that includes the employer in:
Assessment
• Diagnostic triage (Nonspecific conditions, serious pathology or root pain)
• Psychosocial assessment
• Reassessment
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Interventions for acute non-specific back pain (95% of cases)
•
Information, reassurance and advice to stay active
•
Adequate pain control
•
Manual therapy if not improving
•
Multiple interventions involving the workplace if no improvement
•
Temporary modified work if needed
• Recent reviews and research into early intervention for back pain emphasise the
importance of worker empowerment, biopsychosocial rehabilitation and the value
of combining guideline-recommended interventions.
Neck pain – Guidelines and subsequent research
• There is less evidence upon which to base care decisions for neck pain than for back
pain, and much less for upper limb disorders. The most authoritative recent
guidelines are from Australia, Sweden, Finland and the United States. An
additional US neck pain guideline is under development
•
For neck pain, current thinking, (albeit in a climate of largely inconclusive
evidence) supports a very similar approach to that found in back pain guidance.
Shoulder pain – Guidelines and subsequent research
• For shoulder pain, there is some support for combined interventions including
active exercises, stretching and hot and cold. There was tentative evidence for
ultrasound for calcific tendonitis but not for any other shoulder disorder.
Upper limb disorders – Guidelines and subsequent research
• For other upper limb disorders, current thinking focuses more on work
modifications and physical and mental reconditioning than on treatment, however,
there may sometimes be value in the following treatments for resistant problems:
•
Rotator cuff tendonitis – subacromial steroid injection
•
Lateral epicondyitis – topical NSAID
•
Carpal tunnel syndrome – individual exercises/keyboard adaptations
Prospects for improved clinical care
• NHS primary care, although at the forefront of the opportunity for early
intervention, is not generally well configured to implement the changes needed for
early evidence-based intervention on biopsychosocial principles.
•
•
Lack of awareness, inconsistent leadership, competing priorities and lack of
ongoing support and commitment are common employer barriers.
Musculoskeletal practitioners (chiropractors, osteopaths and musculoskeletal
physiotherapists) are well placed for early evidence-based intervention, but their
more traditional approaches may require modification.
Conclusion:
Latest evidence and current thinking supports the use of biopsychosocial assessment
and intervention in close proximity to work for improved early management of
musculoskeletal disorders. The employer and employee have the main roles in this and
musculoskeletal practitioners (chiropractors, osteopaths and musculoskeletal
physiotherapists) are the most accessible qualified health professionals to support them.
viii
RECOMMENDED CARE PATHWAYS FOR EARLY
MANAGEMENT OF MUSCULOSKELETAL DISORDERS
GENERIC CARE PATHWAY
Scope: Any new episode of any musculoskeletal pain that interferes with work
and lasts more than a day or two if severe, or up to a week if not severe.
Note: Over-reaction to mild or resolving episodes should be avoided.
STAGE 1: Within one week from onset:
Initial discussion, assessment and planned action with employer or their services
Activity modification considered
Involvement of health professional (if concerned)
STAGE 2: Within two weeks from onset
if not recovered:
Reassessment and revised action plan for recovery
Monitoring and amendment of staged recovery plan - together with employer and with
particular attention to activity and function (as distinct from pain alone)- until recovery
achieved.
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EMPLOYER PATHWAY
Employees need to be aware of the employer’s desire to help and their policy of
encouraging early discussion. The starting point for this is a key message to all
employees to the effect that; “If you are having problems working because of pain in
your back, neck, shoulders, arms or anywhere else, we want to help. Come in and talk
to us!”
Employers also need to be aware of who is off work and why. There needs to be a ‘case
manager’* at work who monitors progress, plus a standing group who address persistent
reasons for absence.
STAGE 1: Within one week from onset:
Initial discussion of the problem, its nature and planning initial action with the
employee (record notes for future monitoring)
Listening to the employee
Employee story and concerns, nature of problem, any associated problems or
unhappiness at work, level of job demands and of personal control at work. Whether off
work/having difficulty at work for non-work reasons, duration of current episode,
improving, worsening or fluctuating course, aggravating and relieving factors, other
health problems, employee beliefs and expectations about work in general, about
specific work issues and recovery.
Reassurance and information
Positive messages and assurance of value to organisation, commitment to overcoming
the problem and why it is best to remain at work if possible. Information giving (e.g.
Back Book), reasons to consult appropriate health professional (e.g. for pain control,
problem-solving, uncertainty or worry). Be willing to arrange temporary activity
modification, job rotation or job sharing. Do a risk assessment and reach agreement
on a plan for recovery that includes initial work-related changes. Arrange a follow-up
discussion.
STAGE 2: Within two weeks from onset if not recovered:
(Input from chiropractor, osteopath
or musculoskeletal physiotherapist if needed)
Review and if necessary amend work activity
modifications, again considering
job rotation or job sharing.
Monitor, review and modify the plan for recovery with employee (and health
professional if involved), with particular attention to activity and function, until full
recovery.
*This could be an occupational health practitioner, the personnel officer or the employer themselves, depending on
the size of the organisation.
x
EMPLOYEE PATHWAY
STAGE 1: Within one week of getting the problem (it’s best to get in early!)
Most muscle and joint problems are harmless and clear up on their own (– and of
course many have nothing to do with work or injury). If they need care, they respond
best to a plan for recovery that is started early. In these cases, good recovery is more
likely if you can control the pain, stay at work (even if you have some pain), and keep
active, perhaps with modified activities.
Tell your employer, line manager or human resources manager about the problem and
discuss the effect of your activities and work.
If you are worried, consider whether you should make an appointment to see a health
professional at work (if available), or a chiropractor, osteopath or musculoskeletal
physiotherapist in the community who can provide effective physical treatments, advise
you on what kind of changes to make to your activities and help you to manage your
condition*. Arrange a follow-up discussion with your employer or other manager
within the next week to check progress.
STAGE 2: If you have not recovered within two weeks of getting the problem:
Do not be discouraged! Make a plan to overcome the problem, using pain control and, if
necessary, modified activities at work and/or other treatment. Make this together with
your employer and (if applicable) the health professional you are seeing.
Check with these people regularly that the plan is working and that your activities at
work are increasing by stages. If not, reconsider your strategy together.
*You may have to pay for this.
xi
HEALTH PROFESSIONAL PATHWAY
(i.e. an occupational health practitioner at work or a chiropractor, osteopath or
musculoskeletal physiotherapist at work or outside of work)
STAGE 1: First attendance with the health professional
Assessment
Conduct diagnostic triage leading to a working diagnosis. Refer to secondary care if
serious pathology, systemic disorder or progressive neurological disorder is suspected.
If not, decide if there is a specific diagnosis (e.g. DeQuervain’s tenosynovitis) or if the
problem is non-specific. Assess for other health problems (including other
musculoskeletal disorders), psychological barriers (such as illness behaviour or low
mood) and social burdens (such as family pressures or poor housing). Become
conversant with the person’s job demands, personal control at work and non-work
activities. Check that they feel supported at work and that things are going well there
and at home.
Intervention
Provide reassurance, information, and pain control and agree an initial re-activation
strategy with time-limited, specific activity modifications to facilitate the person’s
presence at work. Seek agreement to involve (rather then simply inform) the employer
if necessary. Avoid unnecessarily attributing the problem to injury or mechanical
derangement, but for conditions where there is evidence of its effectiveness, consider
using manipulative treatment to reduce pain and disability early.
Initiate Care Plan
Plan for recovery, taking other health, work or social problems into consideration.
Agree staged re-activation with personalised and specific work-related activities with
employee and employer. Monitor recovery, with particular attention to activity and
function. Report your findings to the patient’s general practitioner.
STAGE 2: Within four weeks from first attendance (if still not recovered):
Review
Review and modify the plan for recovery of activity and function with the employer and
employee. Review the role of societal factors, general health, exercise and activity in
longer- term recovery and secondary prevention. If not recovering, consider initiating
an exercise program at work or other work-based intervention
xii
1. INTRODUCTION
The HSC and HSE have established a Musculoskeletal Disorders (MSD) Priority Programme as
a means of contributing to a 30% reduction in days lost from workplace injuries and workrelated ill-health by 2009-10. As part of the Priority Programme, a research agenda has been
developed, which includes as part of its continuous improvement, the aim; ‘To understand how
best to develop a culture of good practice including use of collaboration and partnership
working to ensure continuous improvement in tackling MSDs.
Musculoskeletal disorders (MSDs) and stress are the most commonly reported types of workrelated illness (HSE-Statistics, 2004), representing around three-quarters of cases. In 2001-2,
an estimated 1,108,000 people suffered a musculoskeletal disorder that they thought was caused
by or made worse by their current or past work. Although there is evidence of a decrease in the
incidence of musculoskeletal disorders since 2001-2, there has been no decrease in their
prevalence. The purpose of this report is twofold:
1. to present the latest evidence and authoritative evidence-based guidance addressing the
usefulness of secondary intervention pain management techniques in helping people
with MSDs to stay at work or get back to work, and
2. to propose Care Pathways consistent with that evidence.
The Care Pathways proposed are meant to be applicable to all employees, whether or not their
organisation has occupational health support. In addition, we will present some of the
contextual evidence relating to barriers to reducing current prevalence in terms of inherent
environmental risks and current health care practices and provision.
The quality of evidence and subsequent authority of evidence-based guidance on early pain
management for musculoskeletal disorders cannot be expected to be uniform. A small number
of high-impact, non-specific conditions (notably non-specific back pain) have been studied
more extensively than the many specific conditions that do not individually have as high an
influence on disability and work loss. This means that they will lag behind in the amount and
quality of evidence available in the literature. This report will present published authoritative
guidance, even where this evidence is lacking, but more for completeness than to support
recommendations for care.
1
2
2. RATIONALE FOR EARLY INTERVENTION
Why should early intervention be prioritised? Whether or not early intervention would produce
better outcomes is difficult to investigate. This is partly because groups being compared may
have unknown characteristics that affect outcome and partly because most musculoskeletal
episodes do not last long anyway. However, from the back pain evidence that dominates the
research in this area, two things are clear; first, return to work is much less likely if longer-term
absence has already occurred (Clinical Standards Advisory Group [CSAG], 1994) and secondly,
changes related to determinants of disability, quality of life and chronic disability can appear by
14 days after onset, supporting a policy of early assessment (Kovacs et al., 2004). Once pain
has become chronic, there are neurophysiological mechanisms, notably central sensitisation
(Melzack, 1999) and dorsal horn windup (Mannion and Woolft, 2000) that can perpetuate it.
Most episodes improve considerably within 1 month (Shekelle, 2003) and treatment alone does
not necessarily improve outcome beyond a condition’s natural history (Indahl et al., 1995). For
those who do not recover well, improvement in terms of pain, disability and return to work
seem to change little after 3 months (Pengel et al., 2003) by which time fear of returning to
previous activities can have increased (Grotle et al., 2004). Recovery then becomes more of a
challenge. For this reason, and in the light of ongoing research into factors that may predict a
poor outcome (Boersma and Linton, 2005), it seems sensible to act early and appropriately
when problems are first encountered (Linton, 2000), especially with high-risk patients (Valat,
2004). However, there is a considerable body of expert opinion, with continuing support from
recent research, that successful early intervention does not necessarily depend on treatment.
The following are examples:
• A study by the Department of Social and Family Affairs in the Republic of Ireland (Leech,
2004) reported a 40% reduction in acute low back pain claims progressing to long duration
when given early triage-type assessment and advice alone.
• A Scandinavian study of people attending chiropractors for low back pain found that they
were twice as likely to be pain free by the 4th visit if their pain episode was of less than 6
months’ duration (Leboeuf-Yde et al., 2004).
• Comparing strategies in two Canadian companies, Lemstra and Olszynski (2004) found that
if early intervention consisted of encouragement and reassurance at work, with modification
of duties, the incidence of injury claims, duration and costs were lower than if case
management passed to clinicians operating an early treatment intervention package.
• A 4.6-year follow-up survey of 300 injured workers in the US (Robinson et al., 2004) found
that pain intensity, disability status and health-related quality of life did not differ
significantly at follow-up between multi-disciplinary pain centre treatment and evaluation
only.
• A systematic review of determinants of disability following low back injury (Crook et al.,
2002) found that referral to clinics geared to occupational injuries within 30 days predicted
faster return to work.
These are examples of a new approach and meaning of rehabilitation, that include psychological
and social, as well as medical aspects. This involves including the use of practical
considerations and personal, emotional, societal and work-related factors to promote recovery
(Waddell and Burton, 2005). The scientific evidence about how best to intervene is improving
slowly, and there are many gaps in our knowledge about the effectiveness of specific
approaches. Current understanding of what predicts good and bad outcomes is founded on an
increasing number of better quality systematic reviews and prospective cohort studies, but these
do not necessarily reveal the risks in isolation. Reviews of the literature are limited by the
3
heterogeneity in interventions, patient populations, outcome measures and definition of what
constitutes a given condition and exposure to a given risk. For lack of good evidence to support
biomedical predictive factors, the early interventions currently recommended are more along
social and occupational lines. The only exception to this is the very small proportion of
sufferers with serious medical conditions.
This form of early intervention means continued activity, involvement and coping, promoted in
the first instance by family, friends and employers and, only if there is concern or no
improvement, by clinicians. It is focussed on reassurance and empowerment, to head off
negative beliefs and behaviours, withdrawal from activity and physical deconditioning (Vlaeyen
et al., 1995) (Fig 1). This combination of factors may apply when there is withdrawal from the
workplace (Severeijns et al., 2005).
Figure 1 Cognitive-behavioural model of fear of movement/(re)injury
Vlaeyen et al, 1995 (reproduced with kind permission of Elsevier, Netherlands)
4
3. CULTURE AND PAIN
3.1. JOB CULTURE
Industrial management styles and work practices have an influence on musculoskeletal
disability. Stress at work, pieceworking and poor working conditions are also linked to absence
due to these disorders. In the early management of musculoskeletal disorders, low job decision
latitude and dissatisfaction are important considerations in recovery (Table 1). This suggests
that innovative ways of enhancing workers’ range of opportunities to contribute, based on their
individual strengths, would be a helpful cultural shift in industry (Hague et al., 2001).
3.2. ETHNICITY
In the UK, ethnic minority groups represent almost 5% of the total population (IASP, 2002;
Lasch, 2002). A review of pain amongst ethnic minority groups of South Asian origin (Njobvu
et al., 1999) found a higher likelihood of visiting a general practitioner than in people of British
origins (although consultation rates vary considerably in different regions of the UK).
However, a second review of factors associated with protracted work absence from back pain
(Truchon and Fillion, 2000) did not support age, gender, ethnicity or education as predictors.
Fewer people in UK ethnic minorities are thought to present with musculoskeletal symptoms,
even though conditions like low back pain seem to be more prevalent in Pakistanis living in
England than in Pakistan (Njobvu et al., 1999). When Asian and African-Caribbean people do
seek help from UK primary care, pain may be less focussed to specific anatomical regions of the
body (Allison et al., 2002), making care sometimes more challenging.
In a subsequent qualitative study (Rogers and Allison, 2004), descriptions from a sample of
South Asians in Britain suggested less demarcation between pain located in specific parts of the
body and broader social and personal concerns. Help from family members was referred to
more than individual strategies of managing pain. Musculoskeletal pain in ethnic minorities
may also be associated with poorer housing and low income however (Njobvu et al., 1999).
Given the association between musculoskeletal pain and distress (Pincus et al., 2002), newer
arrivals may suffer this more than those who have had the time to become used to their new
country.
5
Table 1 Summary of recent reviews and research into predictors of absence, duration
of absence and future disability from musculoskeletal disorders
Occurrence of absence
Crook et al. (2002)
Back pain
(review)
Duration of absence
Future disability
older age
radiating pain
previous episode
job problems
functional disabilities
older age
radiating pain
low job satisfaction
widespread pain
previous episodes
Evans, Mayer &
Gatchel (2001)
Back pain
(cohort study)
non-work-related
health conditions
higher disability
greater job stability
Pincus et al. (2002)
Back pain (review)
distress
depression,
low mood
Steenstra (2004)
Back pain
(review)
specific LBP
higher disability
social isolation
older age
female gender
social dysfunction
heavier work
higher compensation
van den Heuvel
et al. (2004)
Back pain
(cohort study)
high disability
low co-worker support
low job satisfaction
Burton et al.
(2005)
MSDs
(cohort study)
Truchon & Fillion
(2000)
Back pain
(review)
psychosocial distress
low job satisfaction
lack of social support
attribution of problem to work
reduced control
adverse organisational climate
previous episodes
low job satisfaction
negative attitudes to LBP
radiating pain
negative coping
6
high disability
low co-worker support
low job satisfaction
3.3. GENDER
Gender-related cultural issues may also contribute important pain factors. In a primary care
qualitative study of women with musculoskeletal pain in Sweden (Johansson et al., 1999),
bodily symptoms signalled loss of control. The explanatory models referred to physical damage
and strain injuries, but were also psychological and self-blaming. The consequences of pain
were described as negative consequences for the women’s everyday lives that challenged their
self-perception as women. Participants' search and need for legitimization of their illness
experiences, and the expectations placed on doctors as legitimizing agents were evident. Pain
was expressed in terms of patients' gendered concerns and psychosocial circumstances. Gender
and other physical factors can also combine. For example, female asylum seekers may suffer
musculoskeletal pain related to dietary deficiency (de Torrente de la Jara et al., 2004).
One systematic review (Linton, 2000) found abuse to be a potentially significant factor in back
and neck pain in women. A further study (Hamberg et al., 1999) explored experiences of abuse
in a group of women suffering from long-term biomedically undefined long-term
musculoskeletal pain. The women gave hints of abuse before avowing it. An understanding
listener, who was expected to apprehend the hints, ask about abuse and confirm that it was valid
to talk about it, was described as a precondition for disclosure. The authors concluded that it is
important to explore woman abuse when investigating and treating musculoskeletal disorders,
but carers must consider carefully the danger involved.
7
8
4. PAIN PHYSIOLOGY Recent evidence supports a conceptual framework for understanding the relationship between
pain and stress. This crosses a number of clinical conditions (Melzack,1999), including the
group of musculoskeletal disorders considered here. Devereux et al (2004) found high job
stress to be an intermediate factor and perceived life stress to be a possible independent factor in
the development of musculoskeletal complaints.
The “neuromatrix theory of pain” extrapolates from the premise that pain is a multidimensional
experience. The body systems involved, principally i) the sensory nervous system, ii) the
cognitive and affective functions of the brain, iii) its neural modulating and inhibiting systems,
and iv) endocrine and other chemical effects, as well as the individual’s genetic makeup,
combine to influence recovery from painful experiences. In terms of the management of
musculoskeletal disorders, the neuromatrix theory suggests that there is a synergy between
musculoskeletal pain and emotional stress that can work against recovery. This supports the
rationale for early reduction of anxiety and distress as an integral part of rehabilitation (Waddell
and Burton, 2004). The main dimensions of the pain experience (Fig 2.) are the sensorydiscriminative (S), the affective-motivational (A) and the evaluative-cognitive (E). These are
influenced by somatosensory, limbic and thalamocortical components, which are accessible to
external intervention (or insult).
Figure 2 The Neuromatrix
Melzack, 1999 (reproduced with kind permission of Guilford Publications, New York)
For musculoskeletal disorders in the presence of stress, activity is thought to be a key element in
pathophysiological progression (Melzack, 1999). Broadly, a stress response that is protracted
and concurrent with musculoskeletal pain can cause sensitisation of the central nervous system
(Ursin and Eriksen, 2001) and could be a catalyst not only for ongoing symptoms, but for actual
muscle and bone destruction. The latter is largely related to cortisol output, which mobilises
glucose for rapid energy access, plus the release of cytokines (chemical pain stimuli) from tissue
9
strain or inflammation. Activity in the form of exercise takes up the glucose, inhibits cortisol
release and dilates blood vessels, reducing local cytokine concentrations and peripheral pain
stimuli. By contrast, prolonged inactivity in the presence of stress raises blood pressure,
narrows arteries, causes immuno-suppression, promotes tissue tenderness and sensitivity and
can cause anxiety and depression. The perpetuation of stress in this way has been termed an
adverse ‘neurosignature’ (Melzack, 1999), although evidence for these associations is not
entirely consistent. A systematic review of studies of the relationship between recovery from
physical and mental tasks and circulating levels of adrenaline and cortisol (Sluiter et al., 2000)
found no conclusive evidence of such a relationship in occupational settings (unlike in sports
settings). This may be because it only applies to some occupations.
Consistent with this, Harris (1999) proposed that even disorganised or inappropriate cortical
representations of proprioception, signalling incongruence between motor intention and actual
movement, can result in centrally-generated pain akin to that experienced in phantom limb pain.
This applies to musicians, writers and keyboard operators and may be amenable to activity
modification and retraining.
Depression and low mood are moderate predictors of chronicity in low back pain (Pincus et al.,
2002) and a recent population-based study (Chui et al., 2005) has linked this and poor sleep to a
reduced pain threshold. However, Lepine and Briley (2004) suggest that lack of clarity over the
effect of depression on existing pain, and of pain on existing depression, demands that treatment
of depressed people who also have pain must address the psychological, somatic and physical
symptoms to be optimal. This conclusion seems to sit well with the neuromatrix theory.
The neuromatrix concept also supports a rationale for combining reactivation with reassurance
in management and a possible link between severity of initial musculoskeletal pain and
persistent pain later (Dworkin and Portenoy, 1996). It may also help to explain the placebo
effect when expectations of positive outcome are generated. Tubach et al (2002) found that
positive expectations of recovery, along with social support at work, were associated with
earlier return to work and reduction in pain and functional capacity in people with acute low
back pain.
Vase et al (2005) also found that repeated placebo analgesia in people with irritable bowel
syndrome is associated with positive desires and expectations, but not with endogenous opioid
mechanisms, tending to confirm the potential of positive emotions in suppressing pain
(Rainville, 2004). The reverse effect has been observed in that the anticipation of pain evokes
increased activity in the primary somatosensory cortex of the brain (Porro et al., 2002). This
may partially explain the importance of pain-related fear and whether it is fear of pain or fear of
activity that is paramount in the prediction of poor outcome (Vlaeyen and Linton, 2000).
However, a recent study failed to find any predictive relationship between pain-related fear in
the early stages of a low-back episode (<3 weeks from onset) and the persistence of pain at 3, 6
and 12 months (Sieben et al., 2005).
A recent systematic review of studies examining beliefs and expectations of people with chronic
musculoskeletal pain and their primary care practitioners (Parsons et al., 2005) found evidence
that a desire by patients and carers alike to avoid dissonance in the doctor-patient relationship
was an important issue. This highlights the role and possible effects of this relationship on the
pain experience and its outcome (Dekkers, 1998).
10
5. PREDICTORS OF OUTCOME
5.1. MUSCULOSKELETAL DISORDERS GENERALLY
Burton et al (2005) conducted a large prospective study of employees in a pharmaceutical
company, measuring one psychological factor (distress) and 6 work-based psychosocial factors
at baseline, and their prediction of spells and length of spells of absence attributable to
musculoskeletal disorders 2 years afterwards.
For all musculoskeletal disorders, higher
proportions of those in manual work, and to a lesser extent older age and male gender, had
previously taken such sick leave. With the exception of home-work balance, mental stress and
attribution of back pain to individual factors, all psychosocial scores at baseline were modestly,
but significantly higher in those who subsequently took absence. Foremost among these were
job satisfaction, inevitability beliefs about low back pain, relationships at work and perceived
exertion. All 6 factors investigated (psychosocial distress, job satisfaction, lack of social
support, attribution of the problem to work, reduced control and adverse organisational climate)
had an association with the occurrence of work absence, (with modest odds ratios between 1.6
and 2.8). The duration of subsequent absence was not convincingly predicted by the presence of
psychological distress and any of the occupational psychosocial factors, with the exception of
older age. However, even this could be explained by interactions with other, undisclosed
factors, such as general health and previous episodes. The mean psychosocial score differences
in Burton et al’s study (2005), were much fewer, and less pronounced for neck pain and upper
limb disorders than for back pain, but lack of numbers taking sick time may have influenced
this.
For work-related musculoskeletal disability, there is only weak evidence for which
psychological factors constitute reliable predictors of poor recovery. Truchon (2001) suggests
that combinations of risk factors for poor outcome could comprise the strongest indicator that
recovery will be difficult. It therefore seems sensible to be aware of the range of
biopsychosocial factors that predominate in the more recent reviews as well as possibly
important combinations. The evidence base is not evenly developed for musculoskeletal
disorders. Spinal pain research leads in the improvement of methodologies, whilst for upper
limb pain syndromes case definitions are only just coming into use (Harrington et al., 1998).
Thus clinicians may see the evidence as inconclusive or untested (Ferlie et al., 1999) while
retaining substantial autonomy over their work practices. A safe approach to biopsychosocial
assessment and management might be alertness to the presence of combinations of important
factors and trying to work collaboratively with the main stakeholders in the process.
Acute episodes of musculoskeletal pain may also be recurrent ones and the recurrent nature of
the complaint may have important biopsychosocial predictors. A prospective cohort study from
the USA (Evans et al., 2001), comparing workers with recurrent and non-recurrent spine-related
injury claims, found that the recurrent group had a greater rate of non-work-related health
conditions, received higher disability payments, and had slightly greater job demands. This
group also had a greater rate of pre-injury Axis I psychiatric disorders, particularly substance
abuse/dependence disorders, than the NRI group. In addition, the recurrent group also had
greater job stability.
5.2. BACK PAIN
The UK lifetime and one year prevalence of a disabling episode of back pain is 58.3% and
36.1% respectively (Walsh et al., 1992). However, this does not accurately reflect the severity
of the episode, or its impact on work or the activities of daily living. Recent reviews of studies
11
into factors that predict new onsets or poor outcomes take either a psychological, psychosocial
or a biopsychosocial approach.
A systematic review of psychological predictors of future disability in people who have back
pain (Pincus et al., 2002) found these to be generally weak to moderate, with only distress,
depression and low mood supported by evidence as reasonable predictors. (Four of the 18
studies reviewed were work-related.) Psychological distress has been found to have high
sensitivity, but low specificity as a predictor of future functional limitations (Dionne et al.,
2005). However, a list of 7 factors (expectation of return to work, severity, radiating pain,
difficulty in getting comfortable, previous back surgery, self-assessed bad temper, disturbed
sleep) had better results for predicting success or partial success of return to work at 2 years
(Sensitivity 79.0%, Specificity 64.3%) (Dionne et al., 2005). Waxman et al (1998) found in a
population study, that those consulting for back pain of more than 3 months’ duration had a
greater than average depression score. One argument for early intervention is the desire to
avoid the onset of depression if it is not already a factor.
Hoogendoorn et al (2000) reviewed studies of psychological and social factors associated with
getting back pain. These are: low workplace support, low job satisfaction and low job decision
latitude. A subsequent systematic review of inception cohort studies of workers who were on
sick leave for less than 6 weeks (Steenstra et al., 2004) concluded that such factors as having a
history of low back pain, degree of job satisfaction, educational level, marital status, number of
dependents, smoking, working more than 8 hour shifts, type of occupation and size of company
do not influence the subsequent duration of sick leave. Instead, the psychosocial factors
predicting longer sick leave were: specific LBP (such as neurogenic claudication), higher
disability levels, radiating pain, more social isolation, older age, female gender, heavier work
and receiving higher compensation. Of these, only higher disability, social isolation and
radiating pain had high effects.
This is broadly consistent with a large prospective cohort study of prognostic factors for back
pain recurrence and sickness absence in a variety of worker types in the Netherlands (van den
Heuvel et al., 2004). This study also found high disability, low co-worker support and low job
satisfaction to be predictors of both recurrence and duration of sick leave, but none of these
predictors stand out. A prospective cohort study of 189 Dutch civil servants (Verbeek and van
der Beek, 1999) found that pain intensity at baseline was the best predictor of back pain at
follow-up.
A Canadian review and update of occupational disability following low back injuries (Crook et
al., 2002), was more or less consistent with the above, but included a number of demographic
and biological factors in the list of outcomes, as follows: for work-related outcomes, having
children at home, being older, having greater disability, having radiating or nerve root pain, and
having pain that is worse on standing and lying merit consideration as predictors of poor
outcome. Social isolation at work plus the level of disability of the episode suffered seem to be
among the stronger predictors of future problems and work absence. Even so, it must be borne
in mind that the risks (odds ratios) reported in these studies were not very high.
Truchon and Fillion (2000) carried out a narrative review of 18 studies of biopsychosocial
determinants of prolonged work absence from low back pain and proposed that previous history
of back problems, perceived inability to carry on with work and job dissatisfaction were
promising indicators. Negative attitudes and beliefs about back pain in the early stages were
also proposed as factors associated with prolonged absence, but not initial intensity of pain.
One small but carefully controlled inception cohort study (n=113) (Coste et al., 2004), included
only subjects with acute low back pain of less than 72 hrs duration and no episodes in the
12
previous 3 months. It examined the interactions between Health-Related Quality of Life (SF­
36), recovery and 11 biopsychosocial factors. Delayed recovery was associated with higher
baseline disability, lower SF-36 score and temporary compensation status. In the longer term,
low back pain only affected quality of life in foreign nationals, patients who already had comorbidities, had psychiatric disorders, were unemployed or were dissatisfied with their jobs.
Low supervisor support may be a precursor to job dissatisfaction. In a cross-sectional study of
young Belgian health care and distribution company workers in their first employment, Van
Nieuwenhuyse et al (2004) found that first-ever occupational back pain was also associated with
a combination of low psychological job demands and low supervisor support. This study also
sought physical risk factors and found 1) long periods of seated work, 2) more than 12 flexion
or rotation movements of the trunk per hour and 3) more than 3 years in a job involving lifting
more than 25kg at least once an hour, to be weak to moderate predictors of first-ever low back
pain at work.
5.3. NECK PAIN
Cote et al. (2004) conducted a large population-based prospective cohort study of the annual
incidence and course of disabling neck pain. The authors found a one-year incidence of only
0.6%, of which 36.5% of episodes resolved and a further 32.7% resolved within the year.
22.8% reported a recurrent episode. The incidence of disabling neck pain was 1.67 times higher
in women, in whom it was also 1.19 times more likely to persist and only 0.75 times as likely to
resolve as in men. In working populations, the risk may be higher. A prospective cohort study
found the 3-year incidence of neck/shoulder symptoms to be 24% and identified high job
demands as a weak, but significant risk factor (RR 2.1; CI:1.2-3.6) (van den Heuvel et al.,
2005).
Enthoven et al (2004) conducted a 5-year follow-up study of back and neck pain in primary care
and found that half of people have some clinically important level of pain and disability at that
interval, and are consuming health care for it.
A questionnaire study of 558 Austrian office and computer workers (Tilscher et al., 2005) also
concluded that women experience more severe headaches, neck pain and arm pain than men,
earlier in the course of work sessions and associated with fatigue. However, perceptions also
appear to have some influence on the development of neck pain. A study of VDU users
(Wahlstrom et al., 2003) found that those who had high job strain and perceived they had high
levels of muscular tension were more likely to develop neck pain at follow up. The pattern of
exacerbations and remissions of neck pain episodes seems to be similar to that of back pain
(Thomas et al., 1999).
There is some evidence for a relationship between the onset of neck pain and physical risk
factors such as posture and duration of sitting (Ariens et al, 2000) and psychosocial risk factors
such as high job demands, low control, support and job satisfaction (Ariens et al., 2001a; Ariens
et al., 2001b). These factors do not, however, predict work loss. There is also little evidence
linking pushing and pulling tasks to musculoskeletal disorders other than back pain (Hoozemans
et al., 1998).
A study by Hoving et al (2004) investigated perceived recovery, pain intensity and neck
dysfunction in 183 general practice patients with neck pain of at least 2 weeks duration, 7 and
52 weeks later. Only older age and concurrent back pain were consistent, if moderate,
predictors of these although previous trauma and previous neck pain were weak predictors. A
prospective study by Croft et al (2001) found that previous significant injury was an
independent and distinct risk factor for subsequent episodes.
13
The credibility of the term “whiplash injury” has been brought into serious doubt by lack of
objective evidence linking structural change to the development of chronic pain (Stovner, 1996),
despite reports of disc protrusions in small numbers of severe cases (Jonsson et al, 1994). This
may not have as high an impact on work loss as in work-related injuries. An Australian review
(Athanasou, 2005) found that return to work rates after “whiplash” and other motor vehicle
accidents were considerably higher than after back injuries and other work-related accidents.
5.4. UPPER LIMB DISORDERS
The number of named conditions involved, uncertainty over the criteria for their case
definitions, difficulty with quantification of exposure factors and lack of evidence for
independent risk factors are reasons why sufficient prospective studies predicting outcome and
treatment effects have been slow to appear. The problems of classification are formidable (Katz
et al., 2000) and the view from primary care is often for simpler models more aligned to the
back pain model until better prognostic information comes forward (Croft, 1999). Such is the
debate even about the ergonomic work-relatedness of these disorders that the importance of
exposure factors, especially relative to non-occupational causes is still in dispute (Punnett and
Wegman, 2004). These authors, however, concluded that the etiologic importance of
occupational ergonomic stressors for the occurrence of MSDs of the low back and upper
extremities has been demonstrated.
Meaningful case definition work has now been done and has begun to be used. Harrington et al.
(1998) have provided consensus-based case definitions for carpal tunnel syndrome,
tenosynovitis of the wrist, De Quervrain’s syndrome, adhesive capsulitis and tendonitis of the
shoulder and Helliwell et al. (2003a) have developed a classification system based on 30
variables for the same conditions, plus fibromyalgia and non-specific upper limb disorder.
An examination schedule has also been developed (Palmer et al., 2000). This tool is reported to
have high inter-observer agreement - but the occurrence of such symptoms may also vary
greatly according to exposure. Measurement of exposure has been found to be very imprecise
(Svendsen et al., 2005), making reliable risk information difficult to obtain and perhaps
accounting for the weak predictive associations of factors such as high job demands and low
social support.
Viikari-Juntura (1998) summarised the epidemiologic evidence of associations between
physical load and individual factors and disorders of the upper limb. Only associations with age
for rotator cuff tendonitis and vibration for carpal tunnel syndrome were considered to be
strongly supported by evidence. Combinations of physical work load factors have been
implicated in tenosynovitis or peritendinitis of the wrist or forearm and in carpal tunnel
syndrome. A large cohort study of unskilled workers doing continuous repetitive upper limb
work (Bonde et al., 2005) found no association between such activities and psychological stress
symptoms alone. The same research group (Bonde et al., 2003) had previously concluded that
in the course of recovery from shoulder tendonitis, physical workplace exposures and perceived
psychosocial job characteristics in the period preceding diagnosis seemed not to be important
prognostic factors.
For lateral epicondylitis, an inception cohort study by Waugh et al. (2004) found that women
and patients who report nerve symptoms are more likely to experience a poorer short-term
outcome after physiotherapist management. Work-related onsets, repetitive keyboarding jobs,
and cervical joint signs had a negative prognostic influence in women. A randomised trial of
general practice and physiotherapy versus information giving, advice to stay active and graded,
unsupervised exercise for this condition (Haahr and Andersen, 2003a) found that poor prognosis
14
at 1 yr follow-up was related to manual work and high baseline pain, whilst no relation was
found between the type of medical treatment given and prognosis. This may have implications
for the future management terms of a greater focus on interaction with the workplace regarding
job modification to reduce physical demands during recovery. The same authors also reported
on a general practice population (Haahr and Andersen, 2003b), where being a new case
suffering from tennis elbow was associated with having had to adopt non-neutral postures of
hands and arms, use of heavy hand held tools, and high physical strain. (The latter measured as
a combination of forceful work, non-neutral posture of hands and arms, and repetition.) Tennis
elbow among women was also associated with low social support at work.
The 3-year incidence of elbow/wrist/hand has been reported at 15% (van den Heuvel et al.,
2005), with high job demands (RR: 1.9; CI: 1.0-3.7) and low social support of co-workers (RR:
2.2; CI: 1.0-4.9) identified as weak but significant risk factors for first onset. Both factors had
interactions with stress symptoms. MacFarlane et al (2000) had previously found from a 2 year
population prospective cohort study, that psychological distress, aspects of illness behaviour,
and other somatic symptoms are important predictors of one-month prevalence of forearm pain
in addition to work related psychosocial and mechanical factors. Future pain was associated
with dissatisfaction with the support available from colleagues and supervisors and with
repetitive movements of the arm or wrist. A subsequent case-control study into the prevalence
of psychological factors in diffuse upper limb pain and the more focal problem of carpal tunnel
syndrome (White et al., 2003) found no differences between the two conditions but this study
did not include work-based factors.
Key messages:
• There are consistent and over-arching themes in the evidence about prediction of poor
outcome from work-related musculoskeletal disorders, but none that are strongly
associated with specific conditions. This evidence is less complete, for neck and upper
limb disorders than for back pain.
• High exposure to physical stressors, high job demands, multiple co-morbidities and
high psychosocial pressures, (the latter especially in relation to dissatisfaction and low
social support at work,) seem to be relevant factors. However, none of these are
particularly consistent across study populations.
• Improved early pain management should take account of the natural course and jobrelatedness (or otherwise) of conditions. Clinicians need to be aware and responsive to
psychosocial factors in their management.
15
16
6. SUMMARY OF CURRENT GUIDELINES, SUBSEQUENT
REVIEWS AND RESEARCH
6.1. GUIDELINES: MUSCULOSKELETAL DISORDERS GENERALLY
An Australian government guideline group (National Health and Medical Research Council
[NHMRC], 2003) developed a multidisciplinary, evidence-based national guideline that
addresses acute low back pain, acute thoracic spinal pain, acute neck pain, acute shoulder pain
and anterior knee pain. Its consensus panel also considered the key messages needed for the
management of acute musculoskeletal pain generally. (Note: this guideline considers ‘acute’ to
be the first 12 weeks of an episode.) These general messages are presented under the headings
of ‘Acute Pain Management’ and ‘Effective Communication’ and are paraphrased below:
Acute Pain Management:
•
Develop a management plan comprising:
• Case history and physical examination (ancillary assessment only if serious
condition suspected).
• Providing information, assurance and advice about resuming normal activity
and other options for pain management as needed (also mentioned under
‘Non-pharmacologic interventions’).
• Reassessing the pain and revising the management plan as required.
•
Pharmacologic interventions if required:
• Paracetamol or other simple analgesics, administered regularly if pain mild to
moderate.
• Non-steroidal anti-inflammatory medication (NSAID) if paracetamol
insufficient (unless contraindicated).
• Oral opioids (regular intervals in a short course) for severe musculoskeletal
pain.
• (Not recommended: anticonvulsants and antidepressants, routine use of
muscle relaxants.)
Effective Communication:
• Develop a management plan with the patient - avoiding jargon and alarming
labels.
• Provide adequate explanation to overcome inappropriate expectations, fears or
mistaken beliefs. Printed materials may be useful.
• Adapt communication to the patient’s needs and abilities and ensure
information has been understood.
These messages have considerable resonance with the other guidelines described in this report.
6.2. BACK PAIN - GUIDELINES
The most authoritative guidelines are for back pain. Collaboration between care providers,
employers and social care administrators is strongly recommended in order that the care
provider can propose activity modifications that will help people to recover. Incentives for the
key stakeholders to engage in this kind of collaboration is encouraged by the European Acute
Low Back Pain Guidelines (European Commission [EC], 2004a), but arrangements will vary
depending on whether or not there is a clinical occupational health service available and
whether the care provider is working in the NHS or private health sector.
17
For primary care providers, the European Commission Guidelines make 6 evidence-based
recommendations about assessment and 6 about interventions for people presenting with acute
back pain in the first 12 weeks of an episode (EC, 2004a).
Assessments for the diagnosis of acute non-specific low back pain
• Case history and brief examination should be carried out
• If history taking indicates serious spinal pathology or nerve root syndrome, carry out more
extensive physical examination including neurological screening when appropriate
• Undertake diagnostic triage at the first assessment as basis for management decisions
• Be aware of psychosocial factors, and review them in detail if there is no improvement
• Diagnostic imaging tests (including X-rays, CT and MRI) are not routinely indicated for
non-specific low back pain
• Reassess those patients who are not resolving within a few weeks after the first visit, or
those who are following a worsening course
Recommendations for the treatment of acute non-specific low back pain
• Give adequate information and reassure the patient
• Do not prescribe bed rest as a treatment
• Advise patients to stay active and continue normal daily activities including work if
possible
• Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals;
first choice paracetamol, second choice NSAIDs
• Consider (referral for) spinal manipulation for patients who are failing to return to normal
activities
• Multidisciplinary treatment programmes in occupational settings may be an option for
workers with sub-acute low back pain and sick leave for more than 4-8 weeks
(EC, 2004a)
The European Guidelines also remind us that the risks of individual attacks of low back pain are
higher where there is:
•
•
•
•
Heavy manual labour
Manual material handling
Awkward postures
Whole body vibration
18
They also provide key evidence based principles for back pain management in the occupational
health setting. For people who are in work, these are:
• Recognising that selection at recruitment will not reduce incidence significantly. For
example, there is no evidence that clinical examination or diagnostic tests such as X-rays are
valid predictors of future risk. Hence they have no place in routine pre-placement screening
or selection.
• Understanding that while ergonomic measures will bring some benefits there are no wellvalidated preventative techniques. This means that some incidents of back pain in any
workforce are inevitable.
• Ensuring that the need for an active approach to case management is understood by
employees and employers and planning for this in anticipation of future incidents. The
educational element in this would include a shared understanding that active management
reduces pain and disability and that return to work before the person is pain free will often be
the best way of speeding resolution of the discomfort.
• Securing a collaborative approach to case management with primary care providers as soon
as possible after an incident of back pain in order to plan an early and effective return to
work, with temporary modification to tasks or working arrangements if this is likely to
hasten recovery.
• Arranging access to rehabilitation for anyone who has been away from work for more than
four weeks.
The implications of this for primary care providers are:
• Giving a patient entitlement to absence from work because of non-specific back pain may
be essential in severe cases but should be avoided where possible as it is likely to delay
rather than hasten recovery.
• Where there is occupational health provision led by a clinical health professional the
provider of primary care is recommended to secure consent from the patient for an early
discussion with the occupational health practitioner to agree a shared plan for case
management. This should include arrangements for referral for rehabilitation if the pain
persists and for prevention of return to work within four weeks.
• Where there is no clinical occupational health service, the primary care provider is
recommended to review the options for collaboration on occupational aspects with the
patient and liaise as appropriate to ensure that the principles outlined above are followed, if
pain persists and prevents return to work.
These guidelines also provide evidence-based advice about prevention (EC, 2004b), not
exclusively with a view to preventing the episodes themselves (which is impractical given the
ubiquity of non-specific back pain), but the consequences of the episodes, such as disability,
work loss and the development of a chronic pain state. From the standpoint of secondary
prevention, therefore, its recommendations are shown below:
•
•
Physical exercise is recommended in the prevention of low back pain, in the prevention of
recurrence and for the prevention of recurrence of sick leave due to low back pain. There
is insufficient evidence to recommend for or against any specific type or intensity of
exercise.
Back schools based on traditional biomedical/biomechanical information, advice and
instruction are not recommended for prevention of low back pain. There is insufficient
evidence to recommend for or against psychosocial information delivered at the worksite,
19
•
•
•
•
•
•
but information oriented toward promoting activity and improving coping may promote a
positive shift in beliefs.
Lumbar supports or back belts are not recommended.
Shoe inserts/orthoses are not recommended. There is insufficient evidence to recommend
for or against in-soles, soft shoes, soft flooring or antifatigue mats.
Temporary modified work and ergonomic workplace adaptors can be recommended to
facilitate earlier return to work for workers sick listed due to low back pain.
There is insufficient consistent evidence to recommend physical ergonomics interventions
alone for prevention of low back pain. There is some evidence that, to be successful, a
physical ergonomics programme would need an organisational dimension and involvement
of the workers. There is insufficient evidence to specify precisely the useful content of
such interventions.
There is insufficient evidence to recommend stand-alone work organisational interventions,
yet such interventions could, in principle, enhance the effectiveness of physical ergonomics
programmes.
Whilst multidimensional interventions at the workplace can be recommended, it is not
possible to recommend which dimensions and in what balance.
Whilst the new European Acute Back Pain and Prevention Guidelines provide us with the most
recent, rigorous and widely agreed principles currently available, these are aimed at the
European Economic Area generally, and offer no particular context to UK health and
occupational scenarios. However, they do agree with another recently published national
evidence-based guideline from Australia on all acute musculoskeletal disorders (National Health
and Medical Research Council [NHMRC], 2003). This also recommends advising patients to
stay active, and providing explanatory material that can empower the patient, [for example, The
Back Book (Roland et al., 2002)]. Also common to both guidelines are adequate pain control
that using non-invasive methods, the avoidance of imaging in the absence of clear indications of
possible pathology and a care plan that is monitored and reviewed.
Prior to the European Commission Guidelines, UK Occupational Health Guidelines for the
Management of Low Back Pain at Work (Waddell and Burton, 2000) had already highlighted
important additional values that are commended to workers, employers and care providers in the
UK. Central to these is the recommendation to advise employers that:
“High job satisfaction and good industrial relations are the most important organisational
characteristics associated with low disability and sickness absence rates attributed to LBP”.
This is supported by messages contained in a four-page leaflet that urges a shared understanding
between workers, employers and health professionals of the principles, reminding employers
that:
• Consultation with workers/trade unions is important when developing measures to combat
back pain.
• Ensure that work activities are not making unreasonable physical demands.
• Explain that you want to help people recover and encourage early reporting of episodes.
• Talk with people who have back pain. Discuss whether their job needs to be adapted.
Consider solutions such as rest pauses, task rotation, handling aids and extra help from
colleagues.
• Make contact if people are absent and discuss solutions.
• Don’t insist on freedom from pain before someone resumes normal work.
• Keep a check on progress and be prepared to make further adjustments.
20
Workers are also advised that:
•
•
•
•
Back pain is common and does not necessarily signify damage.
Inactivity can make the problem worse.
Report back pain to your employer if it is causing problems at work.
Work together to overcome the obstacles.
This approach may appear somewhat idealistic and the limitations of occupational guidelines
for the management of low back pain have been noted by Staal et al (2003) in an international
review. These include lack of attention to organisational barriers and cost implications and are
considered further in Chapter 7. However, the main consensus points lie in the advocacy of
staying at work or a phased return to it with modified duties if necessary. Reviews and research
studies subsequent to these guidelines are gradually adding useful context to the
recommendations.
6.3. BACK PAIN - SUBSEQUENT REVIEWS AND RESEARCH
Striking a balance between physical and psychosocial approaches to a new back pain episode
can be difficult if it is uncertain which of these is contributing most to the problem. A recent
epidemiologic study of nurses (Smedley et al., 2005) found a weak, but significant association
between sudden onset back pain and specific patient handling tasks, whereas a gradual onset
was significantly associated with psychological symptoms. However, there is little else to guide
clinicians in categorising patients outside of a complete case history and assessment that
includes psychological and social factors as well as physical ones.
The scientific evidence on the effectiveness of physical activity programs at worksites is still
limited (Proper et al., 2002) and, judging from recent systematic reviews of the effect of
ergonomic interventions on returning to work and remaining at work (Elders et al., 2000;
Hoozemans et al., 1998), these may also need to go well beyond training in working methods.
Success in establishing a shared plan with the patient can depend on the degree of satisfaction
they feel about their treatment. A recent systematic review of 20 studies (Verbeek et al., 2004)
found that being included in the decision-making, with all the interpersonal requirements that
are needed for this, is a central factor.
The latest systematic review evidence of exercise therapy for non-specific low back pain
(Hayden et al., 2005) did not find it to be any more effective than no treatment in the early
stages, although a graded activity program subacute stage (6-12 weeks) may reduce
absenteeism. Physical conditioning programs that include a cognitive-behavioural approach,
plus intensive physical training (specific to the job or not) to improve aerobic capacity, muscle
strength and endurance, and coordination; that are in some way work-related; and are
supervised, seem to be effective in reducing the number of sick days for some workers with
chronic back pain, compared to usual care. However, there is no evidence of their efficacy for
acute back pain (Schonstein et al., 2002). Exercise therapy per se seems to have little or no role
in early intervention strategies for back pain.
A systematic review of multidisciplinary biopsychosocial rehabilitation in the management of
subacute back pain (4-12 weeks duration) (Karjalainen et al., 2001) found moderate evidence of
faster return to work, reduced sick leave and reduced subjective disability compared with usual
care. However, this is an expensive approach, involving combining clinical, psychological,
social and/or vocational interventions. However, a workplace visit did add to the effectiveness.
A recent randomised trial (Wand et al., 2004) compared patients with acute low back pain who
all received early intervention in the form of assessment and advice to stay active, but were
randomised to the presence or absence of biopsychosocial education, manual therapy and
21
exercise. The latter had significantly less disability at 6 week follow up although not at 6
months. This parallels another recent large trial in which patients with subacute and chronic
back pain were randomised to a package of care that included clinical assessment, advice to stay
active, plus manipulation and exercise by chiropractors, osteopaths and physiotherapists (UK
BEAM, 2004). This was compared with “active management” advice by a GP practice team,
including pain control, advice to stay active and the Back Book (Roland et al., 2002). This also
showed less disability in the manual therapy group with differences still detected at one year
follow-up.
6.4. NECK PAIN AND UPPER LIMB DISORDERS – GUIDELINES
Unlike for back pain, there are few national guidelines and no international consensus for neck
pain or upper limb disorders. However, multidisciplinary guidelines on the evidence-based
management of acute musculoskeletal pain have been developed in Australia (NHMRC, 2003)
and neck pain guidelines are currently being developed by a North American Neck Pain Task
Force, due to report by 2007
6.4.1. NECK PAIN
The Australian Guideline (NHMRC, 2003) gives comprehensive guidance for acute neck pain.
It suggests in its evidence review that most acute neck pain is non-specific, is most commonly
without known cause, and is commonly attributed to a whiplash accident. However, those who
get neck pain soon after such an accident are reported to be more likely to develop chronic neck
pain. Osteoarthritic change is not to be regarded as a cause or risk factor for chronicity. On the
other hand, psychosocial work-related factors are weakly, but consistently associated. These
conclusions are based on a relatively small number of surveys and other cohort-type studies and
may be tempered by future confirmatory work.
The Australian Guideline also makes several interspersed consensus and low-level evidencebased statements about case-history taking, physical examination, ancillary investigations and
appropriate terminology. These are aimed at improving diagnostic differentiation between
specific and non-specific acute neck pain and therefore have direct relevance to pain
management. The thinking is, if the condition is classified as non-specific, the clinician may
bypass the search for a cause and turn attention directly to management and prognosis (Raspe,
2002).
These statements are:
History:
• Attention should be paid to the intensity of pain because regardless of its cause, severe
pain is a prognostic risk factor for chronicity and patients with severe pain may require
special or more concerted interventions. (Consensus statement)
• The hallmarks of serious causes of acute neck pain are to be found in the nature and
mode of pain onset, its intensity and alerting features. (Consensus statement)
• Eliciting a history aids the identification of potentially threatening and serious causes of
acute neck pain and distinguishes them from non-threatening causes. (Consensus
statement)
Physical examination:
• Physical examination does not provide a patho-anatomic diagnosis of acute idiopathic
or whiplash-associated neck pain as clinical tests have poor reliability and lack validity.
(Evidence-based statement)
22
• Despite limitations, physical examination is an opportunity to identify features of
potentially serious conditions. (Consensus statement)
• Tenderness and restricted cervical range of movement correlate well with the presence
of neck pain, confirming a local cause for the pain. (Evidence statement)
Ancillary investigation:
• Plain radiography is not indicated for the investigation of acute neck pain in the absence
of a history of trauma, or in the absence of clinical features of a possible serious
disorder. (Evidence statement)
• In symptomatic patients with a history of trauma, radiography is indicated according to
the Canadian C-Spine Rule. (Decision algorithm for using X-rays to reveal trauma)
(Evidence statement)
• Computed tomography is indicated only when: plain films are positive, suspicious or
inadequate; plain films are normal but neurological signs or symptoms are present;
screening films suggest injury at the occiput to C2 levels; there is severe head injury;
there is severe injury with signs of lower cranial nerve injury, or pain and tenderness in
the sub-occipital region. (Consensus statement)
• Acute neck pain in conjunction with features alerting to the possibility of a serious
underlying conditions is an indication for magnetic resonance imaging. (Consensus
statement)
Terminology:
• Except for serious conditions, precise identification of the cause of neck pain is
unnecessary. (Consensus statement)
• Once serious causes have been recognised or excluded, terms to describe acute neck
pain can be either ‘acute idiopathic neck pain’ or ‘acute whiplash-associated neck pain’.
(Consensus statement)
The Australian guideline makes only evidence-based statements (but not recommendations)
about pain management approaches to acute neck pain. Four of these have evidence of benefit:
• Advice to Stay Active (Activation) – Encouraging resumption of normal activities and
movement of the neck is more effective compared to a collar and rest for acute neck
pain.
• Exercises – Gentle neck exercises commenced early post-injury are more effective
compared to rest and analgesia or information and a collar in acute neck pain. Exercises
performed at home are as effective for neck pain as tailored outpatient treatments at two
months and appear to be more effective at two years after treatment.
• Multi-modal Therapy – Multi-modal (combined treatments) inclusive of cervical
passive mobilisation in combination with specific exercise alone or specific exercise
with other modalities are more effective for acute neck pain in the short term compared
to rest, collar use and single modality approaches.
• Pulsed electromagnetic therapy (PEMT) – Pulsed electromagnetic therapy reduces pain
intensity compared to placebo in the short term but is no different to placebo at 12
weeks for acute neck pain.
The Guideline lists common interventions for which there is thought so far to be insufficient
evidence of effectiveness as single treatments. These are:
Acupuncture, Opioid analgesics, Simple analgesics (eg paracetamol), Cervical manipulation,
Cervical passive mobilisation, Electrotherapy, Gymnastics, Microbreaks (regular breaks from
computer work), Multi-disciplinary biopsychosocial rehabilitation, Muscle relaxants, Neck
school, Non-steroidal anti-inflammatory drugs, Patient education, Spray and stretch therapy,
23
Traction, Transcutaneous electrical nerve stimulation. Only for soft collars was there found
evidence of no benefit.
A number of Spanish neck pain guidelines were reviewed by a national group (Saturno et al.,
2003) and their quality found to be low. Where such guidelines do exist, they so far address
mainly physical treatments and not overall management strategies. However, there are echoes
of the recommendations found in the European Guidelines for Acute Low Back Pain (EC,
2004a) in the “Whiplash Book”, for patients, (Waddell et al., 2004) in terms of the need for
diagnostic triage, reassurance and the use of interventions that promote activity. Its main
themes are: reassurance that serious damage is very rare, rationale and suggestions for staying
active and at work, controlling pain, stress and tension, doing exercises, treatment in the form of
collars, heat and cold, manipulation, and traction. The evidence review from the Quebec Task
Force Guidelines for “whiplash”-associated disorders (Spitzer, 1995) underpins many of the
conclusions of subsequent guidelines.
The Swedish Council on Health Technology Assessment in Health Care (SBU, 2000) reviewed
the evidence on 15 common treatments for acute and chronic neck pain and concluded that it
was sparse. The Australian Guidelines reflect this and many of their recommendations are
consensus based and recommend advice to stay active, gentle neck exercises and ‘multi-modal’
treatment, including gentle passive mobilisation (NHMRC, 2003). The Swedish Guideline
found moderate evidence against surgery for acute herniated cervical disc and limited evidence
against traction and neck supports. There was also moderate evidence in favour of physical
exercise and of manual therapy, when the latter was used as part of a treatment program.
The NHS support organisation, Prodigy, has also recently published guidance for the
management of neck symptoms generally (Prodigy, 2004). These do address management
strategies, despite the lack of evidence.
6.4.2. NECK AND SHOULDER PAIN
Guidelines on neck and shoulder pain have also been developed by the Kaiser Foundation
Research Institute in the United States. These addressed a number of specific interventions,
although not management strategies, for a variety of musculoskeletal disorders, including acute
neck pain, calcific tendonitis of the shoulder and non-specific shoulder pain (PhiladelphiaPanel, 2001; Harris and Susman, 2002).
The interventions considered for shoulder pain were:
•
•
•
•
•
•
•
•
Ultrasound
Exercise
TENS
Massage
Thermotherapy
EMG biofeedback
Electrical stimulation
Combined rehabilitation modalities
And for neck pain additionally:
•
Exercise/neuromuscular re-education
•
Traction
The Guideline sought clinically important, as well as statistically important differences, but did
not specifically address acute pain states. It found insufficient evidence to make positive
24
recommendations about any of the above interventions other than ultrasound for calcific
tendonitis of the shoulder No interventions for acute neck pain were supported for lack of
evidence. There was also evidence of no benefit from traction.
6.4.3. SHOULDER PAIN
For acute shoulder pain, the Australian Guideline group (NHMRC, 2003) found only low levels
of evidence relating to case history taking, examination and imaging and their reliability and
predictive value. However, they did report evidence of short-term benefit for corticosteroid
injections, active exercises, NSAIDs, ultrasound and manual therapy when the latter is
combined with stretching, hot and cold and education.
The Dutch College of General Practitioners published a mono-disciplinary consensus guideline
on the management of shoulder complaints (Winters et al., 1999). This does not differentiate
between acute and chronic shoulder pain, is not oriented towards occupational issues and the
authors warn that its context may be specific to general practice in the Netherlands. It is aimed
at improving the clinical approach in a condition, from a general practice viewpoint, where pain
may be generated in other structures and pathophysiological processes. Accordingly, it gives
guidance on classification, diagnostic differentiation, and performance of case history and
examination, followed by management advice, paraphrased as follows:
Classification:
•
With or without limited passive range of motion
Diagnostic differentiation from:
• Nerve root syndromes
• Rheumatoid arthritis
• Polymyalgia rheumatica
•
Systemic disorders and general illness
Case history including considerations of:
• Location, restriction, neck complaints, onset, severity, sleep and function, aggravation
by movement or rest, previous episodes, treatment and its outcome
Examination:
• Pain location, active and passive abduction and passive external rotation - and if these
do not reproduce the pain, neck movement examination
•
Imaging usually unnecessary
Management:
• Information and advice (expect early recovery if of recent onset)
• Simple analgesics (paracetamol, NSAID)
• Corticosteroid injection if not improving within 2 weeks
• Activity modification (initial protection from aggravation followed by gradual reactivation) • Referral to physical therapy if not improving by 6 weeks
For calcific tendonitis of the shoulder, recent guidance from the National Institute for Clinical
Excellence (NICE, 2003) supports the use of extracorporeal shockwave lithotripsy. However,
80% of patients experienced significant pain from the procedure.
6.4.4 UPPER LIMB DISORDERS
The South African Compensation Commissioner’s Guidelines for Health Practitioners and
Employers (but not employees) to manage Work-Related Upper Limb Disorders (South African
Department of Labour, 2004) suggest that employees with symptoms of short duration, but are
still able to work, have the most to gain from educational interventions. Founded mainly on
25
expert opinion, these guidelines apply the European Agency for Safety and Health at Work
(1999) classification of physical origins of upper limb disorders as being based in tendon, bursa,
nerve, blood vessels and ‘other’; to conditions of the shoulder, elbow and upper extremity. For
elbow and upper extremity disorders, their recommendations cover:
Elbow:
•
•
•
•
Cubital tunnel syndrome
Lateral humeral epicondylitis (tennis elbow)
Medial humeral epicondylitis (golfer’s elbow)
Olecranon bursitis (beat elbow)
Forearm, wrist, hand and finger:
• Anterior and posterior interosseous syndrome
• Carpal tunnel syndrome
• De Quervrain’s tenosynovitis
• Guyon (ulnar) tunnel syndrome
• Intersection syndrome
• Pronator teres syndrome
• Radial tunnel syndrome
• Tendinosis/tenosynovitis of extensor/flexor tendons
• Trigger finger/thumb
• White finger (Reynaud’s syndrome, vibration syndrome)
The resulting Guideline advises a diagnostic process that links the above principles to the kind
of ergonomic activity involved in the worker’s job, such as consideration of the rapidity,
repetitiveness, force, posture and vibration involved, and their relationship to the activity
modification to be considered. The Guideline does not, however, address uncertainties in
relation to agreement on criteria for case definitions, in the quantification of exposure factors or
in the independence of the risk factors proposed. Nor does it consider non-work activities in the
assessment. However, it does recommend the consideration of psychosocial issues, especially
in the workplace and, importantly, the necessity for a care plan.
Employers are advised to:
• Heed concerns of workers and supervisors
• Gain better understanding of jobs and tasks
• Identify existing and potential hazards
• Determine underlying causes of hazards
Employers are also provided with a ‘Risk calculator’, (Kennedy, 2004) based on physical
exposure factors, but this does not consider psychosocial or non-work factors that may play a
role.
Health professionals are given a list of therapeutic options. However, these are mainly passive
treatments most of whose efficacy has not been established by evidence. These are:
A. Employee education
B. Anti-inflammatory strategies:
• Cryotherapy (ice)
• Non-steroidal anti-inflammatory drugs
• Electrotherapeutic modalities (physiotherapy)
26
• Infiltration with corticosteroids (dubious value)
C. Therapeutic strategies:
• Initial treatment may include rest
• Immobilise (splintage) – occupational therapy
• Mobilise (physiotherapy)
• Mobilise to appropriately strengthen muscles
• Education – good work habits, pacing, joint conversation and self-management
(occupational therapy)
D. Reasonable job accommodation:
• Temporary job change
• Workstation redesign
• Tool and equipment adaptation
• Job task modifications
• Retraining and reassessment
• Work schedule modifications
• Job enlargement
• Job rotation
E. Psychological evaluation:
F. Surgery (as last resort)
An important recommendation of this Guideline is for plans of action for surveillance for
WRULDs in workforces. These plans relate mainly to ergonomic assessments and prevention.
The Finnish Institute of Occupational Health (Viikari-Juntura, 1998) has recommended work
modifications (that are feasible) as a front line consideration in light of evidence of associations
between these and some physical load factors. This guideline also cautions against surgery for
carpal tunnel syndrome where gripping is a major task, because the grip strength itself may be
compromised by the surgery. Other physical treatments were found to be supported by case
studies only.
A review of occupational standards and guidelines for hand-arm vibration syndrome (Pelmear
and Leong, 2000) focuses on prevention based on workplace assessment, but not on early
intervention or secondary prevention.
6.5. NECK PAIN AND UPPER LIMB DISORDERS – SUBSEQUENT REVIEWS AND
RESEARCH
The evidence from randomised trials of interventions for neck pain and upper limb disorders
lags behind back pain by some way. For example, despite the fact that some guidelines
recommend manual therapy, a recent systematic review (Bronfort et al., 2004) concluded that
the evidence is still inconclusive for spinal manipulation or mobilisation for acute neck pain in
both the short and long terms, although Hurwitz et al (1996) had earlier interpreted the evidence
to suggest that these probably provide at least some short-term benefits. It may be that manual
therapy for neck pain is being too narrowly defined, or that there are important subgroups of
patients who will and will not benefit from these interventions.
27
Kjellman et al (1999) also extensively reviewed the trial literature on neck pain treatments and
found it unsatisfactory for drawing firm conclusions because of low methodological quality,
lack of follow-up and low number of trials.
6.5.1. Upper limb disorders
In a study and review of how physiotherapists and occupational health nurses can become more
effective in the treatment of people with upper limb disorders, Kupper et al (2004) found
insufficient good quality research to determine what best practice should comprise. This is
probably because evidence summarisation and synthesis for upper limb disorders is frustrated
by lack of uniformity in defining the conditions, the outcome measures used in trials, and by the
low number and quality of the trials themselves. Although greater uniformity in case definitions
has become possible (Harrington et al., 1998), they do not as yet seem to have been used to
support management guidelines.
Gam and Johanssen (1995) conducted a systematic review and meta-analysis of randomised
trials of ultrasound therapy for a variety of musculoskeletal disorders, including: lateral
epicondylitis (4 trials), bursitis of the shoulder (3 trials), scapulohumeral periarthritis (2 trials)
and tendonitis of the shoulder (1 trial). This review pooled the results of a number of studies
and found no advantage of ultrasound over sham ultrasound. Nevertheless, ultrasound remains
a recognised treatment based on clinical experience, which undoubtedly combines it with advice
about activity and work as well as other interventions.
6.5.2. Shoulder pain
A Cochrane review of common interventions for shoulder pain, which included NSAIDs, intraarticular or subacromial steroid injections, oral steroids, physiotherapy, manipulation under
anaesthesia, hydrodilatation and surgery (Green et al., 2004a), found 31 trials that met its
inclusion criteria. Owing to the diversity of outcome measures used and the small effect sizes in
individual trials (-1.4-3.0) the review was not able to offer conclusions about the effectiveness
of conservative management techniques for shoulder pain beyond the tentative one that
subacromial steroid injections were more beneficial than placebo for rotator cuff tendonitis.
A previous Cochrane review of interventions commonly used by physiotherapists (Green et al.,
2003) had found 21 usable trials, but did not differentiate between acute and chronic pain..
Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease
and longer term benefit with respect to function. Combining mobilisation with exercise resulted
in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy
was demonstrated to be more effective than placebo for adhesive capsulitis but not for rotator
cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in
improvement compared to placebo in pain in calcific tendinitis. There was no evidence of the
effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff
tendinitis. When compared to exercises, ultrasound was of no additional benefit over and above
exercise alone. There was some evidence that for rotator cuff disease, corticosteroid injections
are superior to ‘physiotherapy’ but no evidence that physiotherapy alone is of benefit for ‘frozen
shoulder’.
A further review of common treatments for rotator cuff tears (Ejnisman et al., 2003) reported
insufficient uniformity in describing the treatments to be able to draw any conclusions from the
research literature.
Mitchener et al’s (2004) subsequent systematic review of the effectiveness of rehabilitation of
subacromial impingement syndrome (SAIS) found that the limited evidence currently available
28
suggests that exercise and joint mobilizations are efficacious for patients with SAIS. Laser
therapy appears to be of benefit when used in isolation, but not in combination with therapeutic
exercise. Ultrasound is reported to be of no benefit, and acupuncture trials present equivocal
evidence. These authors concluded that the evidence is insufficient to support a guideline for
shoulder pain at present, but called for more and better research that could support one in the
future. A further systematic review of multidisciplinary biopsychosocial intervention for neck
and shoulder pain of any duration carries (Karjalainen et al., 2000) reported that compared with
other rehabilitation approaches, there is little evidence as yet of any advantage.
6.5.3. Lateral elbow pain
The most recent systematic review of physical interventions for work related upper extremity
disorders is by Verhagen et al (2003). Because of the wide variety of interventions used and the
few studies of reasonable quality, no conclusions could be drawn about manual therapy,
massage, multidisciplinary treatment, and energised splint.
A Cochrane review by Green et al (2004b) of injections and non-steroidal inflammatory drugs
(NSAID), both topical and oral, for lateral elbow pain (tennis elbow) included 14 trials with
some evidence of short-term effectiveness compared to placebo in all of these, but could offer
little insight into their relative benefits. There was limited evidence that topical NSAIDs are
more effective than placebo with respect to pain, but only in the short term. There was no
evidence that oral NSAID gives lasting benefit and they had significantly more gastrointestinal
effects. There was inconclusive evidence that injections may be more effective than oral
NSAID in the short term.
The US Agency for Healthcare Research and Quality (AHRQ, 2002) reviewed the evidence on
the diagnosis and treatment of: carpal tunnel syndrome, cubital tunnel syndrome, epicondylitis
and De Quervrain’s disease.
For epicondylitis, the review found:
Diagnosis
• insufficient evidence to support the use of any tests for epicondylitis
• insufficient evidence to support specific indications for surgery.
Interventions for epicondylitis:
Treatment (RCTs)
Control
• Laser therapy vs sham laser therapy (7 RCTs)
• Oral naproxen vs diflunisal (2 RCTs)
• Ultrasound vs phonophoresis of cortisone (2RCTs)
• Ultrasound vs sham ultrasound (3RCTs)
• Elbow brace (2 crossover studies)
• Acupuncture vs sham acupuncture (2RCTs)
• Oral NSAIDs vs steroid injection (2 RCTs)
• Topical DMSO vs placebo (1 RCT)
• Oral diclofenac vs placebo (1RCT)
• Topical diclofenac vs topical salicylate (1RCT)
• Injs of glucosamines (1RCT)
• Injs of Methylprednisolone vs Lidnocaine (1 RCT)
• Injs of Lidnocaine + triamcinolone vs lig. (1RCT)
• Injs of Methylprednisolone vs hydrocortisone (1RCT)
• Brace over several months vs ‘physiotherapy’ (1RCT)
29
Outcome
- no significant difference
- conflicting evidence
- no significant difference
- trend towards ultrasound
- no effect
- +ve at 2w for pn and global
- conflicting evidence
- trend to DMSO but skin irrit.
- + for pain only
- + ve but sl occas skin irrit
- +ve at 6m but site pain
- +ve for pain
- +ve
- no effect
- +ve for control (nonsig)
•
•
•
•
•
•
•
•
•
•
Brace +‘physiotherapy’ vs ‘physiotherapy’ (1RCT)
- +ve
Denervation vs denervation + decompression (1RCT) - +ve
Pulsed electromagnetic field vs sham (1RCT)
- no effect
Extracorporeal shock wave vs sham (1RCT)
- +ve
Steroid inj vs manipulation and friction (1RCT)
- +ve
Steroid inj vs brace/immobilisation (1RCT)
- +ve
Acupuncture vs steroid inj (1RCT)
- +ve but selection bias
TENS+phonophoresis vs ultrasound (1RCT)
- no difference
Physical therapy vs ultrasound (1RCT)
- no difference
Manipulation +home ex vs US+physio+ home ex(1RCT) - +ve
The review concluded, for all of the above comparisons, that there is insufficient evidence to
recommend any of the above interventions that have positive trial outcomes due to trial quality
or need for further replication.
6.5.4. Carpal and cubital tunnel syndromes and other upper extremity disorders
There were tentative conclusions in the Verhagen et al (2003) review in favour of individual
exercises and keyboard adaptations for people with carpal tunnel syndrome, but the benefit of
expensive ergonomic interventions in the workplace was not clearly demonstrated. A second
Cochrane review by Verdugo et al (2004) concluded only that surgery is significantly more
effective for more severe forms of carpal tunnel syndrome than is splinting.
The AHRQ (2002) reviewed 2 meta-analyses and a number of trials of physical interventions
for carpal tunnel syndrome. It mainly found only trends because of small sample sizes. (Studies
said to have had design difficulties have been omitted)
Interventions for carpal tunnel syndrome:
Treatment
Control
• Endoscopic vs open release (1 meta-analysis)
• No neurolysis vs neurolysis (1 meta-analysis)
• Oral tenoxicam+trichlormethiazide vs ? (1RCT)
• Carpal bone mobilisation vs ? (Unblinded RCT)
• Physical therapy vs home exercise (1RCT)
Outcome
- + for global improvement
- +ve trend
- no effect
- +ve trend
- +ve trend for return to work
For cubital tunnel syndrome, the AHRQ (2002) review found:
Interventions for carpal tunnel syndrome:
Treatment
Control
Outcome
• Medial epicondylectomy vs anterior transposition (1RCT)- +ve for pain and global, but
insufficient data to determine rates of surgical complications.
For De Quervrain’s disease, the AHRQ (2002) review found one study comparing corticosteroid
plus lidnocaine injection versus immobilisation splints, but concluded that design problems
prevented any conclusion.
A further randomised comparison of 268 computer operators with neck or upper limb pain to
taking short breaks, adding exercises to the breaks and to controls (van den Heuvel et al., 2003)
found no difference between groups in terms of sick leave or severity or frequency of the
complaints, although both productivity and reported recovery were higher in the intervention
groups.
30
6.5.5. Repetitive strain injury
The literature broadly acknowledges a lack of precise understanding of the term “repetitive
strain injury” (Stone, 1983; Browne et al., 1984) which has been contested in current thinking
(Hadler, 1999). A Cochrane review by Karjalainen et al (2000) found insufficient research to
draw any conclusion about multidisciplinary biopsychosocial rehabilitation for repetitive strain
injury.
6.6. OTHER MUSCULOSKELETAL DISORDERS
6.6.1. The Knee
A systematic review of conservative approaches for cruciate ligament, medial collateral
ligament and meniscal injuries (Thomson et al., 2002) found a wide-ranging spread of
approaches, but insufficient evidence to establish the relative effectiveness of any of them.
Deep transverse friction massage is a commonly used manual therapy procedure for tendon
problems, but there is little good evidence of its effectiveness. One Cochrane review (Brosseau
et al., (2001) of its use in treating pain due to iliotibial band friction syndrome found only one
small sample trial of low quality and could not draw any conclusions about this treatment.
6.6.2. The Ankle and Heel
Two Cochrane reviews addressed acute ankle sprains. The first (Kerkhoffs et al., 2002)
reviewed the trial evidence comparing immobilisation and functional treatment and concluded
tentatively that the latter is probably superior, especially in terms of time to return to work.
However, van der Windt et al (2002) found unacceptably small effects of ultrasound treatment
for acute ankle sprains. For plantar heel pain, although there is some limited evidence for the
effectiveness of corticosteroid injections for producing temporary relief (Crawford and
Thomson, 2003), there was insufficient evidence to address any other therapy.
6.7. SUMMARY OF CURRENT THINKING
6.7.1. Back Pain
There is strong consensus in the latest evidence-based guidelines (EC, 2004a) that absence from
work because of non-specific back pain is likely to delay, rather than hasten recovery. Many of
the national guidelines for acute low back pain that were considered in developing the European
ones (Koes et al., 2001) recommend a two-stage approach, which involves waiting until people
were failing to recover by 4 weeks from the onset of their problem to intervene. However,
failure to manage the episode optimally in its early stages by, if necessary, controlling pain,
modifying activities, acting on worsening symptoms or inappropriately using bed rest, may
inhibit recovery. This intervention need necessarily always involve a health professional, but
should be able to bring personal, social and occupational interventions into play (Waddell and
Burton, 2004).
When treatment is needed, there is also a growing level of support for multi-modal evidencebased interventions, combining the interventions recommended in current major guidelines.
This implies the need to have resources to provide these efficiently and without fragmenting
care across providers.
31
6.7.2. Neck pain and Upper Limb Disorders
Despite the improvement in case definitions (Harrington et al, 1998) there is a lack of
internationally agreed diagnostic criteria, and of randomised controlled trials of specific
interventions for specific conditions, as well as a belief that there is overlap, both in the nature
and effective management of a number of these disorders (Helliwell and Taylor, 2001; Waddell
and Burton, 2004). The evidence has also been thought to be insufficient to support
authoritative reviews of treatments for upper limb disorders (Hoving et al., 2001).
The literature, however, also recognises a strong parallel between neck and non-specific upper
limb disorders and their low back pain counterpart, especially in terms of the psychosocial
predictors of outcome. Current thinking favours applying what we also know from the back
pain evidence (Helliwell & Taylor, 2001; Helliwell, 2003b). It also draws a similar model to
the ‘neuromatrix theory’ (Melzack, 1999) to suggest that its multifactorial nature (Helliwell,
2003b), can be made up in any combination of physical, physiological and psychological
components – and can be therapeutically influenced by them. Figure 3 presents a schematic
form of guidance for this, which takes these factors into account. The model presented suggests
a multi-modal approach with options to overcome workplace factors with ergonomic
interventions and changes in work organisation; lack of control over working practices with
change in work organisation; pain with analgesia, distress with cognitive interventions and
education; muscle fatigue with training and exercise, and neuroplasticity with anti-epileptic
drugs. In a systematic review of return-to-work treatment programs that included all non­
specific musculoskeletal disorders, Meijer et al (2005) found that all effective treatment
programs consisted of such multiple components, the most prominent of which involve
conditioning the sufferer in terms of their knowledge, psychological state, physical state and
working conditions.
Figure 3 Possible approaches to treatment
Helliwell, 1999 (reproduced with kind permission of Elsevier, Philadelphia)
Key messages:
• Multi-modal interventions, including workplace adaptations, seem to hold out the best
promise for improving early pain management for musculoskeletal disorders.
• Clinical expertise, applied in collaboration with employees and employers may provide
improved early care if applied along evidence-based lines.
• The evidence can be expected to become more authoritative as time passes, making
radical departure from these principles inadvisable.
32
7. PROSPECTS FOR IMPROVED CARE To what extent is it practicable to use the evidence about the early stages of musculoskeletal
disorders to improve their early management? When a Clinical Standards Advisory Group
report on back pain (CSAG, 1994) recommended early access to evidence-based care and a shift
of resources to physical approaches in primary care, the initial response was one of poor
compliance (Little et al., 1996). Soon afterwards, concise national guidelines were developed
specifically for primary care and with a focus on preventing the slide into chronicity by patients
with acute back pain (Waddell et al., 1999). However, despite evidence of small changes in
general practitioner management, (Frankel et al., 1999), and the appearance of national referral
advice for acute back pain (NICE, 2001), inappropriate referral to secondary care for
musculoskeletal disorders in general seems to persist (Barnett et al., 1999; Sheehan, 2001)
coupled with negative feelings toward such patients on the part of some GPs (Chaudhary et al.,
2004).
Improving the management of these disorders in line with research evidence has been a slow
and difficult process. Although advocated in current primary care guidelines (Waddell et al.,
1999; EC, 2004b), assessment of non-medical obstacles to recovery is problematical and
frustrating for health care traditionalists. For work-related musculoskeletal disorders, the
British Society of Rehabilitation Medicine (BSRM, 2000) called for greater investment in
Vocational Rehabilitation, including the development of a National Service Framework for
services to those of working age. However, the NHS priorities reflected in the existing National
Service Frameworks do not include these disorders, which are currently linked to the Long
Term Conditions Framework (DH) and to the reduction of orthopaedic waiting lists. There is
evidence (Maddison et al., 2004) that such a scheme can be successful for this, but do not of
themselves necessarily provide early intervention before 4-6 weeks from GP referral, let alone
from onset of an episode.
This puts Primary Care Trusts and general practitioners in the forefront of the public sector
implementation of early intervention strategies. However, there is evidence that the
implementation and quality assurance of back pain guidelines in England and Wales has so far
been unsuccessful (Langworthy et al., 2005) where there has been little or no central funding for
implementation. Yet a media campaign alone can alter beliefs in a positive direction that is
retained years later (Buchbinder and Jolley, 2005).
Primary care low back pain research has come to refer to a ‘window of opportunity’ (Waddell et
al., 2003; Waddell and Burton, 2004) in these early stages, and it is clear that for the vast
majority of patients a biomedical approach is inadequate (Foster et al., 2003). However, to take
advantage of this, primary care would need to be committed, co-ordinated and adequately
resourced. However, consideration of the range of biopsychosocial factors involved does not fit
easily into the conventional medical model of disease (Engel, 1977; Bartys et al., 2000).
There is also evidence from the back pain literature that family doctors have difficulty with such
patients, who may not consult them until after private treatment has failed (Chaudhary et al.,
2004). GPs’ confidence in their own abilities to assess patients and supply evidence-based care
generally (Tomlin et al., 1999) and for back pain in particular is lacking and they can experience
extreme difficulties (Skelton et al., 1995; Schers et al., 2000), making this an important area for
improved education. However, presentations at conferences and seminars are insufficient to
change general practice (Davis et al., 1995) and general practitioners may consider the
implementation of evidence generally to be like fitting the square peg of research results into the
round hole of patients’ lives (Freeman and Sweeney, 2001). More practice-based interventions
33
and outreach visits requiring interaction and promoting ownership (Gabbay and le May, 2004)
will be needed for this. In the meantime, stress on GPs, demands on their time and the desire to
avoid conflict in the doctor-patient relationship have been found to be reasons why general
practitioners misuse the sickness certification system (Hussey et al., 2003).
Guidelines almost unanimously recommend that clinicians begin with diagnostic triage and a
biopsychosocial assessment (Koes et al., 2001). For primary care clinicians this can present a
challenge, perhaps because of the prevailing view that occupational, socioeconomic,
medicolegal and psychological factors are not amenable to effective intervention by family
practitioners (Valat, 2004). Unfortunately, diagnostic triage alone does little to predict either
future health-related quality of life (Horng et al., 2005) or work disability (Hunt et al., 2002)
leaving apparently little role for the general practitioner. A recent randomised controlled trial of
a brief psychosocial intervention by Dutch general practitioners in patients with subacute low
back pain (Jellema et al., 2005) found no effects of this intervention over usual care in a
subgroup of patients with higher fear avoidance and catastrophising questionnaire scores. This
is not surprising, since evidence that these are single strong predictors of poor outcome in the
first place is lacking (Pincus et al., 2002; Sieben et al, 2005). The wider spectrum of
biopsychosocial factors was not considered in the trial. This highlights the problem of
unidisciplinary approaches and failure in contemporary thinking to consider multiple
biopsychosocial factors.
Evidence-based early management of musculoskeletal disorders does not necessarily have a
clinical component. When it does, it requires competent screening for serious disease, a
functional assessment and a ready awareness of the major psychosocial factors for poor
outcome. Advice about exercise, activity modification and the provision of manual therapies
are generally available within a week from professionals qualified in chiropractic, osteopathy or
musculoskeletal physiotherapy. These professions are publicly regulated and the first two
generally work in the independent sector. Combined with the giving of accurate information
and advice about pain control and continuing normal activities (Abenhaim et al., 2000), this
approach has a good fit with current guidelines. However, attitudes to reactivation,
collaboration with other carers and promotion of patient independence may be variable in these
professionals and if they are isolated from the local health and occupational care systems this
can cause fragmentation and delays if first efforts are not effective (Pincus et al., 2005a). It may
also be important to determine these practitioners’ attitudes toward such factors as participants
in a care pathway.
However, there is readiness to approach, report and work with employers and a balance between
having all players onside and having too many limited players needs to be struck. If all players,
patient, employer and health professional, are following evidence-based principles, either within
or outside an occupational health facility, rapid access to these professionals could offer an
improved approach for those who need clinical help.
Evidence-based guidelines are useful, but often stop short of important considerations needed
for their implementation (van Tulder et al., 2004). The ones reviewed here are multidisciplinary
and guidelines for individual professions are less common. Although they may be better
implemented (Bekkering, 2004), there is a danger that they will digress from the evidence to
suit practice conventions. It has been suggested that future mono-disciplinary guidelines
should be adherent to a multidisciplinary parent to avoid this (Breen et al., 2005).
Guideline implementation has been shown to be sometimes more difficult in large
organisations. The US Army Medical Department, for example, developed an implementation
strategy for low back pain guidelines, broadly aligned to those discussed here (Farley et al.,
2004). This involved well-resourced programs both to build ‘local ownership’ and put in place
34
the clinical and administrative systems needed to ensure staff adherence. Even this level of
clinical accountability and resource did not produce the desired effect. The main barriers were
inconsistent leadership due to staff rotation, lack of ongoing support and competing policies and
priorities. The success that was achieved was attributed to the clarity and utility of the support
materials, the technical support that backed them up and the co-ordination of information
exchange.
These are familiar themes from other guideline implementation initiatives (Breen, 2003) and
highlight the need to acknowledge the professional dominance model in clinical behaviour
change (Ferlie et al., 1999). However, despite improved understanding of what is available to
help assess guideline implementation (Pagliari and Kahan 2003), the distinction between better
outcomes in terms of practitioner behaviour, patient benefits or reduced pressures on health,
occupational or social support systems is blurred (Grimshaw et al., 2004). This makes
generalisation about effectiveness of implementation strategies problematical.
Key messages:
• Implementation of evidence-based guidance, even if it holds out the promise of
substantial improvement in care, faces formidable organisational and stakeholder
barriers.
• Clarity, simplicity and improved access to early and informed decision-making
involving employee, employer and (if necessary) a health professional who is
committed to a collaborative approach, is necessary for improved early pain
management.
35
36
8. CARE PATHWAYS AND CLINICAL MANAGEMENT
Appendix 1 contains the Care Pathways recommended. These Pathways are for employers,
employees and health professionals and apply to any episode of any musculoskeletal pain that:
• interferes with work
• lasts more than a day or two if severe, or
• lasts up to a week if not severe
The rationale for them comes from the following conclusions drawn from the literature:
• Occasional work-related musculoskeletal discomfort can be regarded as normal, but action
should be taken if it is severe, persistent or distressing.
• Rehabilitation can start as soon as a problem is identified as non-resolving.
• The employer needs to know about and be supportive in the rehabilitation and secondary
prevention processes.
• If initial efforts to promote recovery are not showing promise within a week, reassessment
and review should take place.
• Health professionals should be able to supply expert assessment and evidence-based
interventions and work collaboratively with employers.
In compiling this report, simple, 2-stage pathways were developed and sent to 8 experts plus a
research collaboration group for critical review. Based on the feedback received, they then went
through 2 further refinements before being finalised.
The care pathways suggested constitute a direction to take and not a ‘quick fix’. They are also
not an invitation to over-react to mild or resolving episodes. They are meant to be consistent
with the Department of Work and Pensions’ Framework for Vocational Rehabilitation (VR),
focussing on early intervention and the pivotal role of the employer. Because, in most cases,
predictors of poor outcome are not related to any kind of serious disease process, but to
psychological and social factors, these are more likely, at the outset, to be within the power of
the employer and employee together to improve, without resorting to a health professional
(Irving et al., 2004). The Pathways offer a rationale and method for implementing VR in light of
accumulated research evidence, and expert opinion (Irving et al., 2004).
There are four Pathways; a Generic Care Pathway, which sets out the sequence common to all
three stakeholders, plus individual Pathways for Employers, Employees and Health
Professionals. They all operate in two stages in time, intended to resist the slide of events into
chronicity or recurrent problems. For the Generic, Employer and Employee pathways, these
stages are within one week from when the problem began with a follow-up within two weeks.
The Health Professional Pathway’s first stage occurs at the employee’s first attendance and the
second stage within four weeks thereafter.
8.1. THE GENERIC CARE PATHWAY
The process in Stage 1 depends on identifying, early, people having musculoskeletal problems
that will not resolve on their own and are threatening absence from the workplace. Employers
and employees can initiate together modification of at-work activities. However discussion
alone may identify obvious solutions. Discussion alone can improve communication channels
and lead to solutions that prevent future episodes (Linton and Bradley, 1996). Staying at work,
where activities can be planned, is central to this. In terms of long-term recovery, job retention
is better than going off work and then returning (DWP, 2004). The decision to involve a health
37
professional should be led by the employee and should occur if there is concern about time to
recovery or the seriousness of the problem.
Stage 2 is a follow-up of Stage 1 which should happen within two weeks of the onset of the
problem, if only to check that recovery has happened. If not, it is an opportunity to fine tune the
initial plan, which should be thought of in terms of activity and function and not pain alone.
This is a central principle. Some discomfort during recovery is normal and substantial reduction
in initial pain severity (low back pain) may be necessary to produce clinically meaningful
improvement in function if initial pain intensity is high (Turner et al., 2004). Some work
activity, however small, generally assists recovery to take place.
The Australian
musculoskeletal pain guidelines (NHMRC, 2003) and the European Acute Back Pain
Guidelines (EC, 2004a) both advocate reviewing and monitoring progress, which is not the
same as unlimited treatment sessions, and must be distinguished from hypervigilance.
8.2. THE EMPLOYER PATHWAY
Employers need a system for the identification and monitoring of employees in difficulty. The
initial discussion should be by a person for whom the employee has regard and trust. Most
employers do not have occupational health resources, and line managers may be too close to the
problem to help. Other options include human resources managers or the employers
themselves.
Stage 1 involves listening and assimilating the employee’s problem and discovering what their
proposed solution would be. This may be the cue to a prompt and collaborative solution. The
main messages should be optimistic and reflect moral support, controlling pain and staying
active and at work if possible. Reassurance, commitment to finding a solution and providing
information (e.g. The Back Book (Roland et al., 2002) or the Neck Book (Waddell et al., 2004)
are the key elements. This should be pragmatic and taken at face value. It is not the same as
counselling employees about their health. A time for the second discussion should be diarised
and should occur whether recovery has occurred or not. Lack of commitment on the part of
either party is probably the main obstacle to the success of Stage 1 and this might be reduced by
a well-circulated company policy or manifesto.
Stage 2 is a chance to discuss the prevention of a repetition of the problem, or about further
measures if it is not clearing up. If necessary, a chiropractor, osteopath or musculoskeletal
physiotherapist could be accessed to help. However, in many instances, just giving the
employee greater control of their work situation could be an essential part of recovery.
Refusing to accept the employee back at work until all symptoms have abated does not make
recurrence less likely. It can prolong disability and reduce the likelihood of recovery. Where
the problem does not originate in work, yet interferes with it, this also needs to be recognised.
Any health professional involved should be able to provide pain control and reactivation
strategies. Prolonged passive treatment with no improvement should be avoided in favour of a
multidisciplinary approach involving workplace changes. Monitoring and reassessment are
important roles of the health professional.
8.3. THE EMPLOYEE PATHWAY
The aim here is early recovery. The main requirement is reassurance and open discussion with
the employer. This should suggest a solution, often based on modified activities at and/or
outside of work. A health professional is only needed if there is concern, or failure of early
recovery. Only a tiny proportion of musculoskeletal problems underlie real threats to health.
Long-term disability is more likely to result from withdrawal into inactivity, whereas recovery
38
is more likely if some activity is maintained. Therefore, some semblance of normal activity, if
necessary with simple pain control measures such as over-the counter analgesics, is usually the
initial consideration. People who go off work are less likely to return than those who stay and
make changes (Verbeek et al., 2004).
8.3.1. Accessing musculoskeletal practitioners
Vocational Rehabilitation can be inhibited by signing off patients too readily (Irving et al.,
2004), taking a ‘wait and see approach’ and the lack of NHS provision for early intervention. If
a health professional outside of the employer’s occupational health provision is needed, the
main practitioners who can provide early intervention are chiropractors, osteopaths and
musculoskeletal physiotherapists. These professions are all regulated by statute like doctors and
dentists and can be accessed in the community directly (see glossary). Most are able to see
patients within one week. However, the NHS does not usually cover them (although examples
of this do exist) and employees and/or employers, may have to pay.
The problem should be monitored until it is gone, but the end of the episode does not mean the
end of the process. Consideration needs to be given to whether it is likely to come back and
prevention. Employees should consider whether some kind of lifestyle change, for example to
improve general fitness, or a change of job role is appropriate.
8.4. HEALTH PROFESSIONAL PATHWAY
The health professional consulted should have the time and competence to provide all the
assessments and interventions in the pathway, including physical treatments, with knowledge of
the evidence relating to them. Specific conditions (e.g. lateral epicondylitis) can be treated
according to biomechanical and tissue recovery principles, plus other evidence-based
interventions. All conditions should be managed under the principles of pain control and re­
activation with problem-solving and staged recovery linked to everyday tasks.
If the employee is off work for more than 2 weeks, GP certification may be needed, but the
Decision-maker in some DWP offices do accept certification by these musculoskeletlal
practitioners. If not, a report to the GP is necessary before this point. However, findings should
be reported to them at an appropriate point regardless of work absence. Monitoring of recovery
by the musculoskeletal practitioner may not involve treatment, but rather modification of the
patient’s own self-care, including exercise. Failure of recovery by 12 weeks from onset (CSAG,
1994; Waddell et al., 1999) should trigger a further bio-psychosocial reassessment and may lead
to greater emphasis on condition management and employer involvement. Evidence of a new
specific condition may require referral for investigation or for management by another health
care professional.
8.5. LINKS BETWEEN THE THREE PATHWAYS
An important link between these pathways is ongoing discussion between employer and
employee and the monitoring of recovery by the two parties. If a health professional is
consulted, their inclusion in discussions of any work-based recovery is likely to be necessary for
optimal results. The employer’s role in monitoring recovery is important. If recovery is
problematical, that role increases rather than recedes.
39
40
9. EARLY INTERVENTIONS BY MUSCULOSKELETAL
PRACTITIONERS
The Health Professional Pathway refers to obtaining early help from chiropractors, osteopaths
and musculoskeletal physiotherapists if there is concern about disability or early recovery from
a musculoskeletal disorder. Although chiropractors, and osteopaths and a minority of
physiotherapists offer a full range of manual treatments, there has traditionally been confusion
over terminology and what these other interventions are (Breen et al., 2000). However, there is
tentative evidence from all 3 professional groups that patients who seek their help early have
better outcomes than those who wait (Pringle, 1993; Leboeuf-Yde et al., 2004, Bekkering et al.,
2005).
9.1. TRADITIONAL CASE MIX AND INTERVENTIONS
Surveys from the 1980s and 90s (Burton, 1981; Pedersen, 1994) found that chiropractors and
osteopaths treat mainly low back pain (around 50% of their cases) and neck and arm pain
(around 30% of their cases). Most patients seek their help in the first month of an episode and
the vast majority can be offered an appointment within a week. Their main interventions at the
first visits are ergonomic advice (62%), social/emotional counselling (28%), and manual
therapies 95% (Pedersen, 1994). Physiotherapists traditionally evidence little use of
manipulation, fitness programs, and multidisciplinary efforts involving behavioural aspects of
treatment (Foster et al., 1999) in favour of various methods of electrotherapy. However, there
is awareness among physiotherapists of the need to change (Pinnington, 2001) and this is
undoubtedly now happening in those who specialise in musculoskeletal disorders.
9.2. PSYCHOSOCIAL CHARACTERISTICS OF PATIENTS
Levels of severity in secondary care rheumatology patients with back pain have been found to
be higher than in those of osteopaths and chiropractors (Gillies, et al. 1993). However, little is
known about the psychosocial characteristics of patients attending these practitioners. Given
the possible predictors of poor outcome it would be useful to know to what extent current
practice includes patients with psychosocial problems.
We are currently studying a cohort of first-time patients with a new episode of non-specific low
back pain at a chiropractic clinic in the South of England. Demographic, severity and workrelated data for these are shown in Table 2. The age, gender, duration of current episode in this
cohort are very similar to those in a previous osteopathic cohort studied in the North of England
(Burton et al., 1995). Only a small proportion were off work, but of those that were, just over
half had been off for over a week.
41
Table 2 Baseline characteristics of a cohort of new back pain patients at one
chiropractic clinic (n=101)
Mean age (SD)
42.9 (10.39)
%
Female
Current episode <4w duration
First ever episode
Previous episodes but lasting<1/2 of past year
Employed or self-employed
% who generally enjoy their work
Currently off work due to back pain
% off work >1 week
Severity (Deyo, 1988)
Back pain: mod-extreme bothersome past 1w
Leg pain: mod-extreme bothersome past 1w
Mod-extreme interference with normal work
Dissatisfied with current state of wellbeing
55
57
24
55
86
99
16
63
59
37
65
91
The baseline information gathered from these patients also included the following psychometric instruments, plus a disability scale (Deyo, 1988): The Fear-avoidance beliefs questionnaire (Waddell et al., 1993) Catastrophising (inevitability scale of the Back Beliefs Questionnaire) (Symonds et al., 1996) Anxiety and coping scales of the Coping Strategies Questionnaire) (Rosenthiel & Keefe, 1983) Distress (General Health Questionnaire 12) (Goldberg, 1978) Table 3 Psychometric and severity characteristics of a cohort of new back pain patients
at one chiropractic clinic (n=101)
Scale
Mean
raw
score
Mean
%
score
Higher score denotes:
FABQ Activity (min 0 max 24)
FABQ Work (min 0 max 42)
FABQ Total (min 0 max 66)
BBQ Inevitability (min 9 max 45)
Coping Strategies (anxiety) (min 0 max 36)
Coping Strategies (coping) (min 0 max 36)
GHQ (distress) (min 0 max 36)
Disability (cut down activity past 4w) (min 0 max 28)
Disability (cut down social past 4w) (min 0 max 28)
13.4
12.8
26.2
31.9
5.0
20.7
12.9
5.6
13.7
55.8
30.5
39.7
63.6
13.8
57.4
35.8
20.0
48.8
more fear-avoidant
more fear-avoidant
more fear-avoidant
less inevitability beliefs
high anxiety
high coping
high distress
high disability
high social impairment
The results in Table 3 suggest that these patients were more fear-avoidant about activity than
about work, but did not have high scores generally; that they were only moderately distressed
and not very anxious, despite moderate on-average social impairment and fairly high back pain
bothersomeness (see Table 2). These findings are broadly similar, where comparable, to a
cohort of osteopathic patients (Burton et al., 1995).
42
9.3. ATTITUDES TO ANALGESIA
The recommendation to use analgesics at the first visit for musculoskeletal pain has traditionally
been unusual for chiropractors (Pedersen, 1994), where this is reported to have been
recommended in only 3% of new patients. Recent qualitative work (Grundy and Vogel, 2005)
suggests that osteopaths too may have mixed feelings about ‘masking’ the pain. Furthermore,
the chiropractic, osteopathic and musculoskeletal physiotherapy professions do not generally
have prescribing rights, although the Health and Social Care Act (2001) holds provision for this.
However, adequate pain control is seen in virtually all evidence-based guidelines as an essential
option, to be used if necessary to allow reactivation in non-specific conditions and prevent a
chronic pain state developing.
The European Acute Back Pain Guidelines (EC, 2004a) recommend starting with paracetamol
as first line and NSAIDs as a second line and taking these at regular intervals to allow adequate
buildup in the blood stream. Despite evidence for the effectiveness of muscle relaxants,
(Schnitzer et al., 2004) the guidelines did not recommend them for acute back pain because of
the risk of dependency after even 1 week of use. The European guidelines also recommend
against using epidural steroids injections for acute low back pain.
Up to 4 grams per day of paracetamol, purchased from a pharmacy (BNF, 2004), and ibuprofen,
up to 1.2 grams per day, are recommended for acute back pain by Poole Hospital Pain Clinic
(Appendix 2). The importance of taking this medication at regular intervals is stressed, along
with continuing the full 4 gram per day paracetamol use for at least 72 hours. It is
recommended that ibuprofen, 400 mg 3 times a day after food can be added to paracetamol if
pain is not coming under control.
For severe pain, the Poole Hospital Pain Clinic guidance (Appendix 2) also recommends adding
10 mg of oral morphine (Oramorph) to this medication for 2 days as a maximum. However, a
prescription would be required for this and driving and the operation of machinery would not be
permitted.
9.4. IMAGING
Guidelines consistently recommend against the routine use of X-rays for acute episodes of
musculoskeletal pain and none of the 3 professions except UK chiropractors have traditionally
used them extensively. Their use by members of the British Chiropractic Association, dropped
from 71% of new and old patients in 1977 (Breen, 1977) to 22% in 2000 (Young and Breen,
2000), probably influenced by the RCGP’s Acute Back Pain Guidelines (Waddell et al., 1999).
9.5 REACTIVATION
There has also been concern about the 3 professions’ approaches to encouraging reactivation
and about the number of treatment sessions they may require. A trial comparing chiropractic
with hospital outpatient management for back pain (Meade et al, 1990), found that the
chiropractors tended to spread the same number of sessions of over a longer period in order to
monitor progress. This is consistent with current guidelines that recommend reassessment and
follow-up. However, the General Chiropractic and Osteopathic Councils’ codes of practice
(GCC, 2005b; GOsC, 2005) warn against promoting treatment dependence.
43
9.6. GUIDELINE CONSISTENT ATTITUDES GENERALLY
In order to establish a measure of guideline-consistent attitudes for the 3 UK professions, Pincus
et al (2005b) conducted a large qualitative study to determine the principal issues for them in
relation to following current guidelines. This has provided an ‘Attitudes to Back Pain Scale’ in
the form of questionnaire (Pincus, 2005c) (see Appendix 3) that can be used to enquire about
these. This scale determines practitioners’ attitudes to:
Personal interactions:
1. limiting the number of physical treatment sessions
2. willingness to engage psychological issues
3. interacting with other professionals in the care of the patient
4. recognising own limitations
Orientation towards treatment:
1. maintaining mobility and returning to/staying at work
2. restricting activity and vigilance over biomedical/structural systems
Use of this scale in a survey of 546 practitioners from all 3 professions (Pincus et al, 2005a),
found statistically significant differences in attitudes between them. Physiotherapists were more
inclined to limit treatment sessions than osteopaths, and chiropractors were the least amenable
to this. This was the only large effect. The other differences were that:
• Physiotherapists and chiropractors were more inclined towards engaging psychological
issues than osteopaths
• Physiotherapists perceived greater connection to the health care system than the other
two.
• Osteopaths reflected greater recognition of their own limitations than physiotherapists
(Comparisons with chiropractors were not significant).
• Physiotherapists were more concerned about patients returning to work and normal
activities.
• Physiotherapists were less concerned about underlying structural problems and
vigilance about them than the other two professions.
This is the first large-scale comparison that has been made between the 3 professions.
However, it only measures attitudes and not actual behaviour and some of the differences are
probably explained by the closer involvement of physiotherapists with the NHS and with being
employed as opposed to self-employed.
9.7. CO-MORBIDITY
The widespread use of complementary and alternative medical (CAM) practitioners in insured
schemes would be new in the UK. A recent study in the US, where this is more prevalent, (Lind
et al., 2005) found that for back pain, this involved more visits but lower costs than
conventional treatment. These patients also had less co-morbidity than those under
conventional care.
We have to date collected 2-year follow-up data on co-morbidity in the above ongoing study of
53 new patients of working age presenting to a chiropractic clinic in the South of England.
Twenty of these had other conditions (including musculoskeletal ones). Treatment sessions
44
beyond the first 6 weeks were received by 75% of these patients compared with 36% of those
without co-morbidities, but these differences did not reach statistical significance.
A large UK population survey (Ong et al., 2004) found that people who had attended
chiropractors and osteopaths for low back pain in the past 3 months had significant levels of
disability, but more were from non-manual occupations, with better general health, than those
who attended physiotherapists. It is not known whether better general health status was a result
of treatment or an initial presenting feature. However, the higher likelihood of workers with
non-specific low back pain and co-morbidity remaining work disabled (Nordin, 2002), may
make it advisable to consider additional professional development, at least for chiropractors and
osteopaths, if access to them for occupational musculoskeletal problems increases.
9.8. PREVIOUS OCCUPATIONAL AND NHS USE OF MUSCULOSKELETAL
PRACTITIONERS
Green (2000) surveyed 100 UK companies and 422 employees and found considerable interest,
but limited commitment to and knowledge of using osteopaths to prevent disability and work
loss. This was despite considerable previous involvement with them and largely related to
failure to keep accurate records of reasons for absenteeism and record previous experiences with
osteopathy for future evaluation. A similar survey by Hagen (1999) found that companies,
especially large ones, were interested in receiving help from chiropractors, especially in relation
to reducing sickness absence, but were generally uncertain about actual effectiveness.
9.8.1. Case study 1
A pilot study (Jay et al., 1998) following 32 workers in 3 public utilities companies with
back/leg or neck/arm pain over a 2-year period. Their care over this time by chiropractors was
paid for by their companies. Sickness costs dropped by 30% compared to the year before the
scheme and by a further 20% the following year.
9.8.2. Case study 2
Stanley et al (2001) studied the effects of providing physiotherapist-staffed back pain clinics in
general practices, where patients could receive care, on average, within 4 days of referral.
Among patients in work, (n=378) 53% did not take time off and of those who did, 29% went
back within a week. The authors calculated that the cost of providing such a service by
physiotherapists would be that of providing between 1.0 and 1.7 whole time equivalents per
100,000 head of population.
9.8.3. Case study 3
In 1995-6, the Wiltshire Health Commission mounted a pilot scheme to test the CSAG’s
recommendations about the management of acute back pain (CSAG, 1994), particularly in the
context of referral to chiropractors, osteopaths and musculoskeletal physiotherapists. Outcomes
for 344 patients with acute back pain were compared with 194 controls, with no significant
differences in age, gender, severity and previous work loss and who had been treated
conventionally over the previous 4 months (Scheurmier and Breen, 1998). The results are
summarised in Table 4.
45
Table 4 Outcomes in patients with acute back pain referred to chiropractors,
osteopaths and musculoskeletal physiotherapists compared to controls
Outcome
Study patients
Control patients
Wait for consultation (mean days)
Certified days in episode (mean)
Patients certified sick (%)
Advised to pursue normal activity (%)
Prescribed medication (%)
GP consultations in episode (mean)
7.4
23.8
52
52
46
1.9
24.8
44.2
73
33
59
2.4
The examples above come from the GP fund holding era of the late 1990s, when up to 20% of
chiropractors and osteopaths, and 60% of musculoskeletal physiotherapists sampled, were
providing services to the NHS (Langworthy et al, 2000). Since this era has passed, such
arrangements have become less common for chiropractors and osteopaths but, where available,
they are more formalised. For example:
9.8.4. Case study 4
NHS funded chiropractic has been provided continuously in Wilmslow; initially through GP
fundholding, but currently by the Salford Central Cheshire Primary Care Trusts (GCC, 2005).
The service has been audited and found: 90% of patients had at least 75% improvement after 4.05 visits. For every 22 patients referred, the service saves the NHS £10,000. 8 out of 10 patients waiting for orthopaedic appointments did not need them following care by
the chiropractors. 9.8.5. Case study 5
Nottingham City Primary Care Trust offers multidisciplinary service at the Waverly Health
Centre (GCC, 2005). This service includes chiropractic and is available to people who live in
the Hyson Green and Radford areas of Nottingham. It is called the ‘Impact’ team and receives
referral from over 20 GPs and other health professionals in the area and residents can also selfrefer. This service is currently undergoing evaluation, due to be completed in September 2005.
9.9. A COMMON INTERVENTION PACKAGE
A second major MRC back pain trial (UK BEAM, 2004) included osteopaths and
musculoskeletal physiotherapists. In preparation for this second trial, the 3 professions
collaborated to gain consensus about the treatment package for back pain that includes
manipulation, irrespective of the professional group that uses it. The trial compared this with
active management by a GP and with an exercise package of care. This treatment package was
developed by the Trial Working Party (Harvey et al., 2003), and agreed by the professions’
main competent authorities of the time; the British Chiropractic Association, the Chartered
Society of Physiotherapists and the General Council and Register of Osteopaths.
The package of care had manual (Fig 4) and non-manual elements (Fig 5) which the professions
also use for neck pain and upper limb disorders. It allowed flexibility in the type of technique
46
used, the number and frequency of sessions and the inclusion of exercise and advice about how
to remain active. It also included key patient advice points taken from the Royal College of
General Practitioners’ guidelines for the management of acute low-back pain (Waddell et al.,
1999).
Manual Elements
Soft tissue techniques: cross-fibre stretch, longitudinal stretch, direct
pressure, deep friction, neural mobilisation.
Articulatory techniques (mobilisations): low- through high-amplitude
passive movement of the lumbar spine and sacro-iliac joints (and
necessarily hips): flexion, extension, rotation, side-bending, manual
traction; oscillation
Thrust techniques: (‘manipulations’): high or low velocity; low
amplitude; direct or leverage; directed at central lumbar,
zygophphysial or sacroiliac joints; unilateral or bilateral; at one or
more locations.
Figure 4 Manual elements
Harvey et al., 2003
Non-manual Elements
Exercises: passive flexion and extension, active side bending, active trunk
rotation, passive or active hip joint stretching, abdominal or lumbar
strengthening and neural mobilisation.
Advice: (in line with the RCGP guidelines (Waddell et al., 1999) and the Back
Book (Roland et al., 2000)
Activity: advocate continuance of leisure activities, work activities and
performance of daily tasks (do not prescribe bed rest or work absence:
analgesics are allowed by not encouraged (for purposes of the trial)
Psychosocial issues: give generally positive messages and advocate benefits of
activity (with avoidance of emotive language and concepts)
Figure 5 Non-manual elements
Harvey et al., 2003
47
This second trial (UK BEAM, 2004) found this package of care to be more effective and costeffective than the two other strategies (exercise and GP care) for subacute and chronic low back
pain. However, these elements are common to acute back pain also. Therefore, we can now
interrogate guidelines, evidence reviews and subsequent research to assess to what extent the
interventions in this package can be expected to be effective for early use in back, neck and
upper limb pain. What follows assumes that a competent assessment, comprising of a case
history, psychosocial assessment and a physical examination has preceded these interventions.
9.10. ACUTE BACK PAIN
Back pain can be divided into 3 distinct subgroups (CSAG, 1994): non-specific (simple) back
pain (95%), nerve root compression (4%) and serious spinal pathology (1%). The most up-todate evidence-based guideline on its management is the European Guideline for the
Management of Acute Low Back Pain in Primary Care (EC, 2004a). This was the consensus of
an international multidisciplinary expert panel on the recommendations of 11 evidence-based
national guidelines (Koes et al., 2001) plus subsequent systematic reviews and other highquality research. It is probably the most authoritative current guideline. Its recommendations
are targeted at the 95% of cases whose back pain is non-specific.
9.11. MANIPULATION, MOBILISATION AND SOFT TISSUE TECHNIQUES
In most guidelines spinal manipulation is considered to be a therapeutic option in the first weeks
of a low back pain episode (EC, 2004a). As a therapy it has been found to provide more shortterm improvement in pain and functional status than no treatment or sham therapies. The
European Acute Back Pain Guideline recommends: “Consider (referral for) spinal manipulation
for patients who are failing to return to normal activities”. However, it is generally expected
that spinal manipulation will be more effective for some patients than others. Currently we do
not know which, making its use more appropriate within a package of care than as a monotherapy. Such is the heterogeneity of techniques that it is impossible to establish which kind of
manipulation is most effective for which back pain, or whether manipulation is more effective
than mobilisation (articulation). There is some evidence that high-velocity thrust manipulation
is more effective than other types when compared to exercise or other physical therapies
(Reeve-Tucker, 2004). However, there is little evidence concerning other types of soft-tissue
techniques for acute back pain except massage, which has low effects and is not recommended
as a treatment (EC, 2004a).
In the UK BEAM trial (2004) high-velocity thrust manipulation to the neck was excluded
because of a very small chance of serious adverse effects. The most serious of these is cerebro­
basilar stroke, which comprises around 1% of all strokes and will therefore occur in around
1:100,000 adults per year (Bamford et al., 1990; Biller et al., 1999; Haldeman, et al., 1999)
There are several risk factors for this kind of stroke, which can present first as a new episode of
neck pain and will probably run its course regardless of whether manipulation is used or not.
Practitioners who treat people with new episodes of neck pain should know these risk factors
and take appropriate action if they are uncovered.
The RCGP guidelines (Waddell et al., 1999) considered that, because physical reconditioning
has been shown to improve functional levels in chronic low back pain, ”referral for
reactivation/rehabilitation should be considered for people who have not returned to ordinary
activities and work by 6 weeks”. The subsequent European Guidelines (EC, 2004a) recommend
that “…advice to stay active or to get active should be promoted, and that increase in fitness
will improve general health”. The current scientific evidence does not support the use of
specific strengthening or flexibility exercises as a treatment for acute non-specific low back
48
pain”. However, both guidelines seem to have considered exercise in the context of a monotherapy.
A subsequent UK trial (Wand et al. 2004) compared patients with acute low back pain who all
received early intervention by musculoskeletal physiotherapists in the form of assessment and
advice to stay active, but were randomised to the presence or absence of biopsychosocial
education, manual therapy and exercise. The latter had significantly less disability, better mood,
better quality of life and better general health at 6 week follow up although not at 6 months.
This parallels the UK BEAM trial in which patients with subacute and chronic back pain were
randomised to a manipulation package of care, which included exercises, an exercise program
or analgesics and advice by a GP to stay active (UK BEAM, 2004). This showed similar
results, except that differences in favour of the manipulation package were still detected at oneyear follow up.
Otherwise, the evidence in favour of exercise appears limited to subacute and chronic, but not
acute back pain. Physical conditioning programs that include a cognitive-behavioural approach
plus intensive physical training (specific to the job or not) and address aerobic capacity, muscle
strength and endurance, and coordination and are in some way work-related and supervised,
seem to be effective in reducing the number of sick days for some workers with chronic back
pain, compared to usual care. Again, there is no evidence of their efficacy for acute back pain
(Schonstein et al., 2003). An earlier systematic review of multidisciplinary biopsychosocial
rehabilitation (including exercise and intervention in the workplace) in the management of
subacute back pain (Karjalainen et al., 2001) found moderate evidence of faster return to work,
reduced sick leave and reduced subjective disability compared with usual care. However, the
scientific evidence on the effectiveness of physical activity programs at worksites is still limited
(Proper et al., 2002) and, judging from recent systematic reviews of the effect of ergonomic
interventions on returning to work and remaining at work, (Elders et al., 2000; Hoozemans et
al., 1998), these may also need to go well beyond training in working methods and include
psychosocial interventions as well (see below).
9.12. ADVICE AND PSYCHOSOCIAL INTERVENTIONS
Perhaps the strongest recommendations in evidence-based guidelines (EC, 2004a) are for acute
back pain and are in terms of advice to:
• Give adequate information and reassure the patient
• Do not prescribe bed rest as a treatment
• Advise patients to stay active and continue normal daily activities including work if
possible
The evidence for these is consistent. They are reflected in the key advice points included in the
manipulation package of care (Harvey et al., 2003) (Fig 6).
49
Key patient advice points for acute back pain from the RCGP Acute Back
Pain Guidelines (Waddell et al., 1999)
Simple backache:
Give positive messages
There’s nothing to worry about. Backache is very common.
No sign of any damage or disease. Full recovery in days or weeks – but
may vary.
No permanent weakness. Recurrences possible – but does not mean harm.
Nerve root pain:
Give guarded positive messages
No cause for alarm
Conservative treatment should suffice – but may take a month or two
Full recovery expected – but recurrence possible
Possible serious spinal pathology:
Avoid negative messages
Some tests are needed to make the diagnosis
Often these tests are negative
The specialist will advise on the beset treatment
Rest or activity avoidance until appointment to see specialist
Figure 6 Key advice points for acute back pain patients
Harvey et al., 2003
Success in establishing a shared plan with the patient can depend on the degree of satisfaction
they feel about their treatment. A recent systematic review of 20 studies (Verbeek et al., 2004)
found that being included in the decision-making, with all the interpersonal requirements that
are needed for this, is a central factor. Waddell and Burton (2004) highlight the following
psychosocial interventions among principal positive factors in recovery:
•
•
•
•
•
reassurance
accurate information
awareness of the importance of psychosocial factors in recovery
problem-solving
a care plan (function-based and done in stages, monitored and reviewed)
These are not explicit in the above package of care agreed by the 3 professions, but may need to
be if they are to meet optimal requirements for an evidence-based approach. Although they are
implied in the European Acute Back Pain Guidelines (EC, 2004a) in the recommendation:
“Reassess those patients who are not resolving within a few weeks after the first visit, or those
who are following a worsening course…), “there are no randomised trials directly linking a
(specific) intervention to psychosocial risk factors for acute low back pain.” (EC, 2004a).
Therefore, this guideline does not recommend behavioural therapy for treatment of acute low
back pain. However, there is a good theoretical basis for secondary prevention in teaching
patients how to choose strategies centred around activity and exercise in order to cope
adequately in the future (Sluijs and Knibbe, 1991). Thus it is important to note that
recommendations relating to psychosocial interventions go as far as problem-solving, but do not
extend to more formal behavioural therapy.
50
10. SUMMARY POINTS AND GENERAL RECOMMENDATIONS
10.1. EMPLOYERS
When considering your policy towards the early management of musculoskeletal disorders,
consider:
• how much occupational health support you give and whether it is adequate
• the relationship between that support and the human resources and CEO
• the culture in your workplace towards ‘bad’ backs, necks, arms etc: Is it healthy?
• obvious psychosocial factors in your workforce: eg. life stress, burnout, single parenting
and looking after disabled dependents, alcohol, other health problems, workload, selfesteem and peer support in the workplace
• is there more than one psychosocial problem?
• financial incentives to becoming disabled or incapacitated
When someone reports an MSD at work, ask about:
• what their explanation for the disorder is
• what care, if any, is being delivered
• what the person’s beliefs and expectations are about recovery and return to normal work
• their personal circumstances and general health
then…
• Make sure they know you are concerned.
• Encourage them to accept evidence-based measures aimed at recovery.
• Assure them that you will welcome them to the workplace with no obligations for
performance.
• Make a plan with them that includes activity modification.
• Keep in touch with them.
10.2. EMPLOYEES
If you are suffering from a musculoskeletal problem that is not getting better..
Do not worry; expect it to get better in the near future.
Discuss it with your employer and see what temporary change you can make.
Use over-the-counter medications like paracetamol to control pain if necessary.
Try to stay active and at work.
If you are still concerned, consult a chiropractor, osteopath or musculoskeletal
physiotherapist for help.
•
•
•
•
•
10.3. HEALTH PROFESSIONALS
•
•
•
•
•
•
•
•
•
•
Conduct diagnostic triage from case history and examination findings.
Decide a working diagnosis and if the problem is specific or undifferentiated.
Do general health and psychosocial assessments.
Refer or treat specific conditions with manual therapies and/or other evidence-based
interventions.
Encourage normal activity and remaining at work.
Propose and monitor activity modifications.
Provide reassurance, information and pain control.
Agree on time-limited and staged reactivation within a care plan.
Note job demands and check the patient is supported at work.
Reassess and consider general fitness as a secondary prevention strategy.
51
52
11. REFERENCES
Abenhaim, L., Rossignol, M., Valat, J-P., Nordin, M., Avouac, B., Blotman, F., Charlot, J.,
Dreiser, R.L., Legrand, E., Rozenberg, S. and Vautravers, P. (2000) The role of activity in the
therapeutic management of back pain: Report of the International Paris Task Force on Back
Pain. Spine, 25(4), 1S-33S.
Agency for Healthcare Research and Quality (2002) Diagnosis and Treatment of WorkerRelated Musculoskeletal Disorders of the Upper Extremity. US Department of Health and
Human Services. Report/Technology Assessment No. 62.
Allison, T.R., Symmons, D.P.M., Brammah, T., Haynes, P., Rogers, A., Roxby, M. and Urwin,
M. (2002) Musculoskeletal pain is more generalised among people from ethnic minorities than
among white people in Greater Manchester. Ann Rheum Dis, 61, 151-156.
Ariens, G.A., van Mechelen, W., Bongers, P.M., Bouter, L.M. and van der Wall, G. (2000)
Physical risk factors for neck pain. Scand J Work Environ Health, 26(1), 7-19.
Ariens, G.A., Bongers, P.M., Hoogendoorn, W.E., Houtman, L.D., van der Wal, G. and
Mechelen, W.V. (2001a) High quantitative job demands and low co-worker support as risk
factors for neck pain. Spine, 26(17), 1896-1903.
Ariens, G.A.M., van Mechelen, W., Bongers, P.M., Bouter, L.M. and van der Wall, G. (2001b)
Psychosocial risk factors for neck pain: a systematic review. American Journal of Industrial
Medicine, 39, 180-193.
Athanasou, J.A. (2005) Return to work following whiplash and back injury: A review and
evaluation. Medico-Legal Journal, 73(1), 29-33.
Bamford, J., Sandercock, P., Dennis, M., Burn, J. and Warlow, C. (1990) A prospective study of
acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86 1. Incidence, case fatality rates and overall outcome at one year of cerebral infarction,
primary intracerebral and subarachnoid haemorrihage. Journal of Neurology, Neurosurgery and
Psychiatry, 53, 16-22.
Barnett, A.G., Underwood, M.R. and Vickers, M.R. (1999) Effect of UK national guidelines on
services to treat patients with acute low back pain: follow-up questionnaire survey. BMJ, 318,
919-920.
Bartys, S., Main, C.J. and Burton, A.K. (2000) Pain management in occupational settings. In:
C.J. Main and C.C. Spanswick (eds) Pain Management: an interdisciplinary approach.
Edinburgh, Churchill Livingstone, p. 403-421.
Bekkering, G.E. (2004) Physiotherapy guidelines for low back pain: development,
implementation and evaluation. Amsterdam, Vrije University.
Bekkering, G.E., Hendriks, H.J.M, van Tulder, M.W., Knol, D.L., Simmonds, M.J.,
Oostendorp, R.A.B. and Bouter, L.M. (2005) Prognostic factors for low back pain in patients
referred for physiotherapy. Spine, 30(16), 1881-1886.
53
Biller, J., Garg, B.P. and Rasura, M. (1999) Epidemiology and etiology of stroke in the young:
new therapeutic perspectives for prevention. In: Fisher C.F. (ed.) Prevention of Ischaemic
Stroke. Martin Dunitz, Chapter 5, 79-103.
Boersma, K. and Linton, S.J. (2005) Screening to identify patients at risk: profiles of
psychological risk factors for early intervention. Clin J Pain, 21(1), 38-43.
Bonde, J.P., Mikkelsen, S., Andersen, J.H., Fallentin, N., Baelum, J., Svendsen, S.W., Thomsen,
J.F., Frost, P., Thomsen, G., Overgaard, E. and Kaergaard, A.; PRIM Health Study Group
(2003) Prognosis of shoulder tendonitis in repetitive work: a follow up study in a cohort of
Danish industrial and service workers. Occup Environ Med, 60(9),E8.
Bonde, J.P., Mikkelsen, S., Andersen, J.H., Fallentin, N., Baelum, J., Svendsen, S.W., Thomsen,
J.F., Frost, P. and Kaergaard, A.; PRIM Health Study Group. (2005) Understanding work
related musculoskeletal pain: does repetitive work cause stress symptoms? Occup Environ Med,
62, 41-48.
Breen, A.C. (1977) Chiropractors and the treatment of back pain. Rheumatology and
Rehabilitation, 16, 46-53.
Breen, A., Carrington, M., Collier, R. and Vogel, S. (2000) Communication between general
and manipulative practitioners: a survey. Complementary Therapies in Medicine, 8, 8-14.
Breen, A.C. (2003) The implementation of consensus guidelines. Rygdoktor [online]. Available
from: http://www.rygdoktor.dk.
Breen, A. (2005) From Guidelines to Practice: What is the Practitioner’s Role? In: C Liebenson
(ed). Rehabilitation of the Spine (2nd edition) Philadelphia: Lippincott, Williams and Wilkins,
Chapter 39 (in press).
Breen, A.C., van Tulder, M.W., Koes, B.W., HJensen, I., Reardon, R. and Bronfort, G. (2005)
Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common
message in primary care? European Spine Journal [online], http://dx.doi.org/10.1007/s0058600005-00883-00589.
British National Formulary, Joint Formulary Committee. (2005) Paracetamol and NSAID, 49.
London, British Medical Association and Royal Pharmaceutical Society of Great Britain.
British Society of Rehabilitation Medicine (BSRM) (2000) Vocational rehabilitation - the way
forward: report of a working party (Chair: Frank A.O.). London, British Society of
Rehabilitation Medicine.
Bronfort, G., Haas, M., Evans, R.L. and Bouter, L.M. (2004) Efficacy of spinal manipulation
and mobilization for low back pain and neck pain: a systematic review and best evidence
synthesis. The Spine Journal, 4, 335-356.
Brosseau, L., Casimiro, L.,Milner, S., Robinson, V., Shea, B., Tugwell, P. and Wells, G. (2002)
Deep transverse friction massage for trating tendonitis. Cochrane Database of Systematic
Reviews, Issue 1, CD003528 (ISSN 1469-493X)
Browne, C.D., Nolan, B.M. and Faithfull, D.K. (1984) Occupational repetition strain injuries;
guidelines for diagnosis and management. Med J Aust, 140, 329-332.
54
Buchbinder, R. and Jolley, D. (2005) Effects of a media campaign on back beliefs is sustained 3
years after its cessation. Spine, 30(11), 1323-1330.
Burton, A.K. (1981) Back pain in osteopathic practice. Rheumatology and Rehabilitation, 20,
239-46.
Burton, A.K., Tillotson, K.M., Main, C.J. and Hollis, S. (1995) Psychosocial predictors of
outcome in acute and subchronic low back trouble. Spine, 20(6), 722-8.
Burton, A.K., Bartys, S., Wright, I.A. and Main, C.J. (2005) Obstacles to recovery from
musculoskeletal disorders in industry, Research Report 323. London, HSE Books.
www.hse.gov.uk/research/rrhtm/
Chaudhary, N., Longworth, S. and Sell, P.J. (2004) Management of mechanical low back pain:
a survey of beliefs and attitudes in GPs from Leicester and Nottingham. European Journal of
General Practice, 10, 71-72.
Chiu, Y.H., Silman, A.J., Macfarlane, G.J., Ray, D., Gupta, A., Dickens, C., Morriss, R. and
McBeth, J. (2005) Poor sleep and depression are independently associated with a reduced pain
threshold. Results of a population based study. Pain, 115, 316-321.
Clinical Standards Advisory Group (CSAG). (1994) Back Pain. London, Department of Health.
Coste, J., Lefrancois, G., Guillemin, F., Pouchot, J. and Rheumatology, French Study Group for
Quality of Life in Rheumatology. (2004) Prognosis and Quality of Life in patients with acute
low back pain: insights from a comprehensive inception cohort study. Arthritis and
Rheumatism, 51, 168-176.
Cote, P., Cassidy, J.D., Carroll, L.J. and Kristman, V. (2004) The annual incidence and course
of neck pain in the general population: a population-based cohort study. Pain, 112, 267-273.
Crawford, F. and Thomson, C. (2003) Interventions for treating plantar heel pain. The Cochrane
Database of Systematic Reviews. Issue 3, Art. No. CD000416, DOI:
10.1002/14651858.CD000416
Croft, P. (1999) Diagnosing regional pain: the view from primary care. Baillieres Best Pract
Res Clin Rheumatol.13(2), 231-242.
Croft, P.R., Lewis, M., Papageorgiou, A.C., Thomas, E., Jayson, M.I.V., Macfarlane, G.J. and
Silman, A.J. (2001) Risk factors for neck pain: a longitudinal study in the general population.
Pain, 93, 317-325.
Crook, J., Milner, R., Schultz, I.Z. and Stringer, B. (2002) Determinants of occupational
disability following a low back injury: a critical review of the literature. Journal of
Occupational Rehabilitation, 12, 277-295.
Davis, D.A., Thomson, M.A., Oxman, A.D. and Haynes, R.B. (1995) Changing physician
performance: a systematic review of the effect of continuing medical education strategies.
JAMA, 274(9), 700-705.
Dekkers, W. (1998) Hermeneutics and experiences of the body: the case of low back pain.
Theoretical Medicine and Bioethics, 19, 277-293.
55
Department for Work and Pensions (DWP). (2002) Pathways to work: helping people into
employment. London, Department for Work and Pensions.
Department for Work and Pensions (DWP). (2004) Building capacity for work: a UK
framework for vocational rehabilitation. London, Department for Work and Pensions, Report
No. ELCI 3.
de Torrente de la Jara, G., Pecoud, A. and Favrat, B. (2004) Musculoskeletal pain in female
asylum seekers and hypovitaminosis D3. BMJ, 329, 156-157.
Devereux, J., Rydstedt, L., Kelly, V., Weston, P. and Buckle. P. (2004) The role of work stress
and psychological factors in the development of musculoskeletal disorders: The stress and MSD
study. London, HSE; Report No. 273.
Deyo, R.A. (1988) Measuring the functional status of patients with low back pain. Archives of
Physical Medicine and Rehabilitation, 69, 1044-53.
Dionne, C.E., Bourbonnais, R., Fremont, P., Rossignol, M., Stock, S.R. and Larocque, I. (2005)
A clinical return-to-work rule for patients with back pain. CMAJ, 172, 1559-1567.
Dworkin, R.H. and Portenoy, R.K. (1996) Pain and its persistence in herpes zoster. Pain, 67,
241-251.
Ejnisman, B., Andreoli, C.V., Soares, B.G.O., Fallopa, F., Peccin, M.S., Abdalla, R.J. and
Cohen, M. (2003) Interventions for tears of the rotator cuff in adults. The Cochrane Database of
Systematic Reviews, Issue 4, Art. No. CD002758.pub2,
DOI:10.1002/14651858.CD002758,pub2
Elders, L.A.M., van der Beek, A.J., Burdorf, A. and Elders, L.A.M. (2000) Return to work after
sickness absence due to back disorders - a systematic review on intervention strategies. Int Arch
Occup Environ Health, 73, 339-348.
Engel, G.L. (1977) The need for a new medical model: a challenge for biomedicine. Science,
196, 129-136.
Enthoven, P., Skargren, E. and Oberg, B. (2004) Clinical course in patients seeking primary
care for back or neck pain: a prospective 5-year follow-up of outcome and health care
consumption with subgroup analysis. Spine, 29(21), 2458-2465.
European Agency for Safety and Health at Work (1999) In: P. Buckle and J. Devereux. J (eds)
Work-Related Upper Limb Musculoskeletal Disorders. Luxembourg, Office for Official
Publications of the European Communities.
European Commission (EC), Cost Action B13 Management Committee (2004a) European
Guidelines for the management of acute nonspecific low back pain in primary care. Available
from: http://www.backpaineurope.org [Accessed 14th January 2005].
European Commission (EC), Cost Action B13 Management Committee (2004b) European
guidelines for prevention in low back pain. Available from: http://www.backpaineurope.org
[Accessed 14th January 2005].
56
Evans, T.H., Mayer, T.G. and Gatchel, R.J. (2001) Recurrent disabling work-related spinal
disorders after prior claims in a chronic low back pain population. The Spine Journal, 1(3), 183­
189.
Farley, D.O., Vernez, G., Nicholas, W., Quiter, E.S., Dydek, G.J., Pieklik, S. and Cretin, S.
(2004) In: Evaluation of the low back pain practice guideline implementation in the Army
Medical Department. California, RAND Corporation.
Ferlie, E., Wood, M. and Fitzgerald, L. (1999) Some limits to evidence-based medicine: a case
study from elective orthopaedics. Quality in Health Care, 8, 99-107.
Foster, N.E., Thompson, K.A., Baxter, G.D. and Allen, J.M. (1999) Management of nonspecific
low back pain by physiotherapists in Britain and Ireland. Spine, 24(13), 1332-42.
Foster, N.E., Pincus, T., Underwood, M., Vogel, S., Breen, A. and Harding, G. (2003)
Treatment and the process of care in musculoskeletal conditions: a multidisciplinary perspective
and integration. Orthopedic Clinics of North America, 34(2), 239-244.
Frankel, B.S., Moffett, J.K., Keen, S. and Jackson, D. (1999) Guidelines for low back pain:
changes in GP management. Fam Pract, 16, 216-222.
Freeman, A.C. and Sweeney, K. (2001) Why general practitioners do not implement evidence:
qualitative study. BMJ, 323, 1-5.
Gabbay, J. and le May, A. (2004) Evidence based guidelines or collectively constructed
"mindlines?": Ethnographic study of knowledge management in primary care. BMJ, 329, 1013­
1017 doi:1010.1136/bmj.1329.7473.1013.
Gam, A.N. and Johannsen, F. (1995) Ultrasound therapy in musculoskeletal disorders: a metaanalysis, Pain, 63, 85-91.
General Chiropractic Council (GCC). (2005a) Musculoskeletal services framework. Doc. C040805-11. London, General Chiropractic Council.
General Chiropractic Council (GCC). (2005b) Code of Practice and Standard of Proficiency.
London, GCC. Available online at www.gcc-uk.org.
General Osteopathic Council (GOsC). (2005) Code of Practice. London, GOsC. Available
online at www.osteopathy.org.uk.
Gillies, J.H., Breen, A.C., Guppy, N., Hunt, N. and Laxton, A. (1993) Disability from back pain
among four groups: a working population and patients attending chiropractic, osteopathy and
rheumatology clinics. European Journal of Physical Medicine & Rehabilitation, 3(2), 74-8.
Goldberg, G. (1978) The General Health Questionnaire. Windsor, Berks, NFER-Nelson
Publishing Ltd.
Green, G. (2001) Osteopathy in occupational health. Occupational Health Review Issue 90, 21­
25.
Green, S., Buchbinder, R. and Hetrick, S. (2003) Physiotherapy interventions for shoulder pain.
Cochrane Database of Systematic Reviews, Issue 2, CD004258 (ISSN 1469-493X)
57
Green, S., Buchbinder, R., Glazier, R. and Forbes, A. (2004a) Interventions for shoulder pain
(Cochrane review). In: The Cochrane Library, Issue 4. Chichester, John Wiley.
Green, S., Buchbinder, R., Barnsley, L., Hall, S., White, M., Smidt, N. and Assendelft, W.
(2004b) Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in
adults (Cochrane review). In: The Cochrane Library, Issue 4. Chichester, John Wiley.
Grimshaw, J., Eccles, M. and Tetroe, J. (2004) Implementing clinical guidelines: current
evidence and future implications. Journal of Continuing Education in the Health Professions,
24, S31-S37.
Grotle, M., Vollestad, N.K., Veierod, M.B. and Brox, J.I. (2004) Fear-avoidance beliefs and
distress in relation to disability in acute and chronic low back pain. Pain, 112, 343-352.
Grundy, M. and Vogel, S. (2005) Attitudes towards prescribing rights: a qualitative focus group
study with UK osteopaths. International Journal of Osteopathic Medicine, 8, 12-21.
Haahr, J.P. and Andersen, J.H. (2003a) Prognostic factors in lateral epicondylitis: a randomized
trial with one-year follow-up in 266 new cases treated with minimal occupational intervention
or the usual approach in general practice. Rheumatology (Oxford), 42(10), 1216-1225.
Haahr, J.P. and Andersen, J.H. (2003b) Physical and psychosocial risk factors for lateral
epicondylitis: a population based case-referent study. Occup Environ Med.60(5), 322-329.
Hadler, N.M. (1999) Occupational musculoskeletal disorders. Philadelphia, Lippincott
Williams & Wilkins.
Hagen, K. (1999) Business managers’ attitudes towards the role of chiropractic in corporate
health care. Student project. Bournemouth, UK, Anglo-European College of Chiropractic.
Hague, J., Oxborrow, L. and McAtamney, L. (2001) Musculoskeletal disorders and work
organisation in the European clothing industry. Nottingham, European Trade Union Technical
Bureau for Health and Safety (TUTB).
Haldeman, S., Kohlbeck, F.J. and McGregor, M. (1999) Risk factors and precipitating neck
movements causing vertebrobasilar artery dissection after cervical trauma and spinal
manipulation. Spine, 24(8), 785-94.
Hamberg, K., Johansson, E.E. and Lindgren, G. (1999) "I was always on guard" - an exploration
of woman abuse in a group of women with musculoskeletal pain. Family Practice, 16, 238-244.
Harrington, J.M., Carter, J.T., Birrell, L. and Gompertz, D. (1998) Surveillance case definitions
for work related upper limb pain syndromes. Occup Environ Med, 55(4), 264-271.
Harris, A.J. (1999) Cortical origin of pathological pain. Lancet, 354, 1464-1466.
Harris, G.R. and Susman, J.L. (2002) Managing musculoskeletal complaints with rehabilitation
therapy: summary of the Philadelphia Panel evidence-based clinical practice guidelines on
musculoskeletal rehabilitation interventions. The Journal of Family Practice, 51(2), 1042-1046.
Harvey, E., Burton, A.K., Moffett, J.K. and Breen, A. (2003) Spinal manipulation for low-back
pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy
professional associations. Manual Therapy, 8, 46-51.
58
Hayden, J.A., van Tulder, M.W. and Tomlinson, G. (2005) Systematic review: strategies for
using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal
Medicine, 142(9), 776-785.
Health and Social Care Act (2001) Part 5, Sect 63, Wesminster, House of Commons.
http://www.opsi.gov.uk/acts/acts2001/20010015.htm
Helliwell, P.S. and Taylor, W.J. (2001) Occupation and upper limb disorders. Rheumatology
(Oxford), 40(6), 716-717.
Helliwell, P.S. (2003a) Psychosocial factors in diffuse upper limb disorder. J Rheum, 30(1), 7-9.
Helliwell, PS., Bennett, R.M., Littlejohn, G., Muirden, K.D. and Wigley, R.D. (2003b) Towards
epidemiological criteria for soft-tissue disorders of the arm. Occup Med (London), 53(5), 313­
319.
Hoogendoorn, W.E., van Poppel, M.N.M., Bongers, P.M., Koes, B.W. and Bouter, L.M. (2000)
Systematic review of psychosocial factors at work and private life as risk factors for back pain.
Spine, 25, 2114-2125.
Hoozemans, M.J., van der Beek, A.J., Frings-Dresen, M.H., van Dijk, F.J. and van der Woude,
L.H. (1998) Pushing and pulling in relation to musculoskeletal disorders: a review of risk
factors. Ergonomics, 41(6), 757-781.
Horng, Y.-S., Hwang, Y.-H., Wu, H.-C., Liang, H.-W., Jang, Y., Twu, F.-C. and Wang, J.-D.
(2005) Predicting health-related quality of life in patients with low back pain. Spine, 30(5), 551­
555.
Hoving, J.L., Gross, A.R., Gasner, D., Kay, T., Kennedy, C., Hondras, M.A., Haines, T. and
Bouter, L.M. (2001) A critical appraisal of review articles on the effectiveness of conservative
treatment for neck pain. Spine, 26(2), 196-205.
Hoving, J.L., de Vet, H.C.W., Twisk, J.W.R., Deville, L.J.M., van der Windt, D., Koes, B.W.
and Bouter, L.M. (2004) Prognostic factors for neck pain in general practice. Pain, 110, 639­
645.
HSE-Statistics. (2004) Musculoskeletal disorders. London, Health and Safety Executive.
Hunt, G.D., Zuberbier, O.A., Kozlowski, A.J., Berkowitz, J., Schultz, I.Z., Milner, R.A., Crook,
J.M. and Turk, D.C. (2002) Are components of a comprehensive medical assessment predictive
of work disability after an episode of occupational low back trouble? Spine, 27(23), 2715-2719.
Hurwitz, E.L., Aker, P.D., Adams, A.H., Meeker, W.C. and Shekelle, P.G. (1996) Manipulation
and mobilisation of the cervical spine: a systematic review of the literature. Spine, 21(15), 1746­
1760.
Hussey, S., Hoddinott, P., Wilson, P., Dowell, J. and Barbour, R. (2003) Sickness certification
system in the United Kingdom: qualitative study of views of general practitioners in Scotland.
BMJ Online First, (BMJ,doi:10.1135/bmj.37949.656389.EE)
Indahl, A., Velund, L. and Reikeraas, O. (1995) Good prognosis for low back pain when left
untampered. Spine, 20, 473-477.
59
International Association for the Study of Pain (IASP). (2002) Culture and Pain. Pain: Clinical
Updates, X(5), 1-8.
Irving, A., Chang, D. and Sparham, I. (2004) Developing a framework for vocational
rehabilitation: qualitative research. London, Department for Work and Pensions.
Jay, T.C., Jones, S.L., Coe, N. and Breen, A.C. (1998) A chiropractic service arrangement for
musculoskeletal complaints in industry: a pilot study. Occupational Medicine, 48(6), 389-95.
Jellema, P., van der Windt, D.A.W.M., van der Horst, H.E., Twisk, J.W.R., Stalman, W.A.B.
and Bouter, L.M. (2005) Should treatment of (sub)acute low back pain be aimed at psychosocial
prognostic factors? Cluster randomised trial in general practice. BMJ,
doi:10.1136/bmj.38495.686736.EO. (20 June).
Johansson, E.E., Hamberg, K., Westman, G. and Lindgren, G. (1999) The meanings of pain: an
exploration of women's description of symptoms. Soc Sci Med, 48, 1791-1802.
Jonsson, H., Cesarini, K., Sahistedt, B. and Rauschning, W. (1994) Findings and outcome in
whiplash-type neck distortions. Spine, 19(24), 2733-2743.
Karjalainen, K., Malmivaara, A., van Tulder, M., Roine, R., M., J., Hurri, H. and Koes, B.
(2000) Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among
working age adults (Cochrane review). In: The Cochrane Library, Issue 2, pp. 1-20. Chichester,
John Wiley.
Karljalainen, K., Malmivaara, A., van Tulder, M., Raine, R., Jauhiainen, M., Hurri, H. and
Koes, B. (2001) Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain
among working age adults. In: The Cochrane Database of Systematic Reviews.
Katz, J.N., Stock, S.R., Evanoff, B.A., Rempel, D., Moore, J.S., Franzblau, A. and Gray, R.H.
(2000) Classification criteria and severity assessment in work-related upper extremity disorders:
Methods matter. American Journal of Industrial Medicine, 38, 369-372.
Kerkhoffs, G.M.M.J., Rowe, B.H., Assendelft, W.J.J., Kelly, K., Struijs, P.A.A. and van Dijk,
C.N. (2002) Immobilisation and functional treatment for acute lateral ankle ligament injuries in
adults. The Cochrane Database of Systematic Reviews, Issue 3, Art. No. CD003762, DOI:
10.1002/14651858.CD003762
Kennedy, D. (2004) WRULD’s Risk Calculator. Capetown South Africa, Ergomax (Pty) Ltd.
www.ergomax.co.za.
Kjellman, G.V., Skargren, K.I. and Oberg, B.E. (1999) A critical analysis of randomised clinical
trials on neck pain and treatment efficacy: a review of the literature. Scand J Rehab Med, 31,
139-152.
Koes, B.W., Van Tulder, M.W., Ostelo, R., Burton, A.K. and Waddell, G. (2001) Clinical
guidelines for the management of low back pain in primary care. Spine, 26(22), 2504-2514.
Kovacs, F.M., Abraira, V., Zamora, J., Fernandez, C. and Spanish Back Pain Research
Network. (2004) The transition from acute to subacute and chronic low back pain: a study based
on determinants of quality of life and prediction of chronic disability. Spine (accepted for
publication).
60
Kupper, A., Mackenzie, S. and Heasman, T. (2004) The challenge of managing upper limb
disorders - how can health professionals become more effective? Sudbury, Suffolk, Systems
Concepts for the Health and Safety Executive.
Langworthy, J., Breen, A., Vogel, S., Collier, R. and Sutherland, G. (2000) Manipulation
Services for NHS Patients: Precedents and Future Models for Provision. Bournemouth,
Institute for Musculoskeletal Research and Clinical Implementation.
Langworthy, J., Clow, W. and Breen, A. (2005) Low back pain: barriers to effective clinical
governance. Clinical Governance: an International Journal (in press).
Lasch, K.E. (2002) Culture and Pain. Pain: Clinical Updates, X(5).
Leboeuf-Yde, C., Gronsvedt, A., Borge, J.A., Lothe, J., Magnesen, E., Nilsson, O., Rosok, G.,
Stig, L.-C. and Larsen, K. (2004) The Nordic back pain subpopulation program: demographic
and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low
back pain. Journal of Manipulative and Physiological Therapeutics, 27, 493-502.
Leech, C. (2004) Renaissance Project: Preventing chronic disability from low back pain.
Dublin, Department of Social and Family Affairs, Government of Ireland, pp. 1-40.
Lemstra, M. and Olszynski, W.P. (2004) The effectiveness of standard care, early intervention
and occupational management in Workers' compensation claims. Spine, 29(14), 1573-1579.
Lepine, J-P. and Briley, M. (2004) The epidemiology of pain in depression. Human
Psychopharmacology, 19, S3-S7.
Lind, B.K., Lafferty, W.E., Tyree, P.T., Sherman, K.J., Deyo, R.A. and Cherkin, D.C. (2005)
The role of alternative medical providers for the outpatient treatment of insured patients with
back pain. Spine, 30(12), 1454-1459.
Linton, S. (2000) A review of psychological risk factors in back and neck pain. Spine, 25, 1148­
1156.
Linton, S.J. and Bradley, L.A. (1996) Strategies for the prevention of chronic pain. In: R.J.
Gatchel and D.C. Turk (eds) Psychological approaches to pain management: a practitioner's
handbook. New York, Guilford Press, p.605.
Little, P., Smith, L., Cantrell, T., Chapman, J., Langridge, J. and Pickering, R. (1996) General
practitioners’ management of acute back pain: a survey of reported practice compared with
clinical guidelines. BMJ, 312, 485-488.
Macfarlane, G.J., Hunt, I.M. and Silman, A.J. (2000) Role of mechanical and psychosocial
factors in the onset of forearm pain: prospective population based study. BMJ, 321(7262), 676­
679.
Mannion, R.J. and Woolft, C.J. (2000) Pain mechanisms and management: a central
perspective. Clin J Pain, 16, S144-S156.
Meade, T.W., Dyer, S., Browne, W., Townsend, J. and Frank, A.O. (1990) Low back pain of
mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment.
British Medical Journal, 300, 1431-1437.
61
Meade, T.W., Dyer, S., Browne, W. and Frank, A.O. (1995) Randomised comparison of
chiropractic and hospital outpatient management for low back pain: results from extended
follow-up. British Medical Journal, 311, 349-351.
Meijer, E.M., Sluiter, J.K. and Frings-Dresen, M.H.W. (2005) Evaluation of effective return-towork treatment programs for sick-listed patients with non-specific musculoskeletal complaints:
a systematic review. Int J Occup Med Environ Health. Springer-Verlag 10.1007/s00420-0050622-x
Melzack, R. (1999) Pain and Stress: a new perspective. In: R.J. Gatchel and D.C. Turk (eds)
Psychosocial Factors in Pain: Critical Perspectives. New York, The Guilford Press, pp. 89­
106.
Michener, L.A., Walsworth, M.K. and Burnet, E.N. (2004) Effectiveness of rehabilitation for
patients with subacromial impingement syndrome: a systematic review. J Hand Ther, 17(2),
152-64
National Health and Medical Research Council (NHMRC). Australian Acute Musculoskeletal
Pain Guidelines Group (2003) Evidence-based management of acute musculoskeletal pain.
Brisbane, University of Queensland and the Commonwealth Department of Health and Ageing,
pp. 1-246.
National Institute for Clinical Excellence (NICE). (2001) Referral advice: a guide to
appropriate referral from general to specialist services. London, National Institute for Clinical
Excellence.
National Institute for Clinical Excellence (2003) Extracorporeal shockwave lithotripsy for
calcific tendonitis (tendinopathy) of the shoulder. Interventional Procedure Guidance 21. ISBN
1-84257-427-2. http://www.nice.org.uk/pdf/ip/IPG021guidance.pdf
Njobvu, P., Hunt, I., Pope, D. and Macfarlane, G. (1999) Pain amongst ethnic minority groups
of South Asian origin in the United Kingdom: a review. Rheumatology, 38, 1184-1187.
Nordin, M. (2002) Self-care techniques for acute episodes of low back pain. Best Practice &
Research Clinical Rheumatology, 16(1), 89-104.
Ong, C-K., Doll, H., Bodeker, G. and Stewart-Brown, S. (2004) Use of osteopathic or
chiropractic services among people with back pain: a UK population survey. Health and Social
Care in the Community, 12(3), 265-273.
Pagliari, H. and Kahan, J.P. (2003) Biomed II Concerted action on changing professional
practice. A catalogue of servey items assessing attitudes towards guidelines and perceived
barriers and facilitators to implementation. The CPP Perceptions Library.
Palmer, K., Walker-Bone, K., Linaker, C., Reading, I., Kellingray, S., Coggo,n D. and Cooper,
C. (2000) The Southampton examination schedule for the diagnosis of musculoskeletal
disorders of the upper limb. Ann Rheum Dis, 59(1), 5-11.
Parsons, S., Breen, A., Foster, N.E., Harding, G., Pincus, T., Vogel, S. and Underwood, M.R.
(2005) The influence of patients' and healthcare practitioners' beliefs and expectations about
chronic musculoskeletal pain on the process of community based care: a systematic review. Soc
Sci Med (submitted).
62
Pedersen, P. (1994) A survey of chiropractic practice in Europe. European Journal of
Chiropractic, 42(S), 3-28.
Pelmear, P.L. and Leong, D. (2000) Review of occupational standards and guidelines for handarm (segmental) vibration syndrome (HAVS). Appl Occup Environ Hyg, 15, 291-302.
Pengel, L.H.M., Herbert, R.D., Maher, C.G. and Refshauge, K.M. (2003) Acute low back pain:
systematic review of its prognosis. BMJ, 327, 323-325.
Philadelphia-Panel (2001) Philadelphia Panel evidence-based clinical practice guidelines on
selected rehabilitation interventions for neck pain. Physical Therapy, 81(10), 1701-1717.
Pincus, T., Vlaeyen, J.W.S., Kendall, N.A.S., Von Korff, M.R., Kalauokalani, D.A. and Reis, S.
(2001) Cognitive-behavioural therapy and psychosocial factors in Low Back Pain: directions for
the future. Spine, 27, E133-E138.
Pincus, T., Burton, K., Vogel, S. and Field, A.P. (2002) A systematic review of psychological
factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine,
27(5), E109-E120.
Pincus, T., Foster, N., Vogel, S., Santos, R., Underwood, M. and Breen, A. (2005a) Attitudes to
back pain amongst musculoskeletal practitioners: differences between professional groups and
practice settings using the ABS-mp. (submitted to Manual Therapy).
Pincus, T., Vogel, S., Breen, A., Foster, N. and Underwood, M. (2005b) Persistent back pain ­
why do physical therapy practitioners continue treatment? A qualitative study of chiropractors,
osteopaths and physiotherapists. European Journal of Pain (in press).
Pincus, T., Vogel, S., Santos, R., Breen, A., Foster, N. and Underwood, M. (2005c) The
Attitudes to Back Pain Scale in musculoskeletal practitioners (ABS-mp); the development and
testing of a new questionnaire. Clinical Journal of Pain (in press).
Pinnington, M.A. (2001) Why are we finding it so hard to change our approach to low back
pain? Physiotherapy, 87(2), 58-9.
Porro, C.A., Baraldi, P., Pagnoni, G., Serafini, M., Facchin, P., Maieron, M. and Nichelli, P.
(2002) Does anticipation of pain affect cortical nociceptive systems? J Neurosc, 22, 3206-3214.
Pringle, M. (1993) Change and teamwork in primary care. London, BMJ Publishing Group.
Prodigy (2004) Prodigy neck pain guidelines. London, Department of Health.
http://www.prodigy.nhs.uk/guidance.asp?gt-Neck%20pain
Proper, K.I., Staal, B.J., Hildbrandt, V.H., van der Beek, A.J. and van Mechelen, W. (2002)
Effectiveness of physical activity programs at worksites with respect to work-related outcomes.
Scand J Work Environ Health, 28, 75-84.
Punnett, L. and Wegman, D.H.(2004) Work-related musculoskeletal disorders: the
epidemiologic evidence and the debate. J Electromyogr Kinesiol, 14(1), 13-23. (Review).
Rainville, P. (2004) Pain and emotions. In: D.D. Price and C.M. Bushell (eds) Psychological
modulation of pain. Seattle, WA, IASP Press, pp. 117-142.
63
Raspe, H. (2002) How epidemiology contributes to the management of spinal disorders. Best
Practice & Research in Clinical Rheumatology, 16(1), 9-21.
Reeve-Tucker, P. (2004) Is high-velocity thrust a key factor in trials of manipulation for acute
low back pain? A systematic review of randomised trials. Student project. Bournemouth, UK,
Anglo-European College of Chiropractic.
Robinson, J.P., Fulton-Kehoe, D., Franklin, G.M. and Rae, W. (2004) Multidisciplinary pain
center outcomes in Washington State Workers' Compensation, Journal of Occupational and
Environmental Medicine, 46, 473-478.
Rogers, A. and Allison, T. (2004) What if my back breaks? Making sense of musculoskeletal
pain among South Asian and African-Caribbean people in the North of England. J Psychosom
Res, 57, 79-87.
Roland, M., Waddell, G., Klaber Moffett, J., Burton, K. and Main, C. (2002) The Back Book:
The best way to deal with back pain. London, The Stationery Office.
Rosenthiel, A.K. and Keefe, F.J. (1983) The use of coping strategies in chronic low back
patients: relationship to patient characteristics and current adjustment. Pain, 17, 33-44.
Saturno, P.J., Medina, F., Valera, F., Montilla, J., Escolar, P. and Gascon, J.J. (2003) Validity
and reliability of guidelines for neck pain treatment in primary health care. A nationwide
empirical analysis in Spain. International Journal for Quality in Health Care, 15, 487-493.
SBU. (2000) Back Pain Neck Pain - an evidence based review. Report 145. Stockholm, SBUSwedish Council on Technology Assessment in Health Care.
Scheurmier, N. and Breen, A.C. (1998) A pilot study of the purchase of manipulation services
for acute low back pain in the United Kingdom (World Federation of Chiropractic Prize­
winning paper: 3rd Prize). Journal of Manipulative and Physiological Therapeutics, 21(1), 14­
18.
Schers, H., Braspenning, J., Drijver, R., Wensing, M. and Grol, R. (2000) Low back pain in
general practice: reported management and reasons for not adhering to the guidelines in the
Netherlands. British Journal of General Practice, 50, 640-644.
Schnitzer, T.J., Ferraro, A., Hunsche, E. and Kong, S.X. (2004) A comprehensive review of
clinical trials on the efficacy and safety of drugs for the treatment of low back pain. Journal of
Pain and Symptom Management, 28(1), 72-94.
Schonstein, E., Kenny, D.T., Keating, J. and Koes, B.W. (2002) Work conditioning, work
hardening and functional restoration for workers with back and neck pain. The Cochrane
Database of Systematic Reviews, Issue 4, Art. No. CD001822, DOI:
10.1002/14651858.CD001822
Schonstein, E., Kenny, D., Keating, J., Koes, B. and Herbert, R.D. (2003) Physical conditioning
programs for workers with back and neck pain: a Cochrane systematic review. Spine, 28(19),
E391-E395.
64
Severeijns, R., Vlaeyenm, J.W.S., van den Hout, M.A. and Picavet, S.J. (2005) Pain
catastrophizing and consequences of musculoskeletal pain: a prospective study in the Dutch
community. The Journal of Pain, 6, 125-132.
Sheehan, N.J. (2001) How effective are guidelines for the management of low back pain? Letter
to the Editor. Quality in Health Care, 10, 197.
Shekelle, P. (2003) Review: Patients with acute low back pain and associated disability improve
substantially within 1 month. Evidence Based Medicine for Primary Care and Internal
Medicine, EBM Online, www.evidence-basedmedicine.com, 27.
Skelton, A.M., Murphy, E.A., Murphy, R.J.L. and O'Dowd, T.C. (1995) Patient education for
low back pain in general practice. Patient Education and Counseling, 25, 329-334.
Sieben, J.M., Vlaeyen, W.S., Portegijs, P.J.M., Verbunt, J.A., van Riet-Rutgers, S., Kester,
A.D.M., Von Korff, M., Arntz, A. and Knottnerus, J.A. (2005) A longitudinal study on the
predictive validity of the fear-avoidance model in low back pain. Pain (in press).
Sluijs, E.M. and Knibbe, J.J. (1991) Patient compliance with exercise: different theoretical
approaches to short-term and long-term compliance. Patient Education and Counselling, 17,
101-204.
Sluiter, J.K., Frings-Dresen, M.H., Meijman, T.F. and van der Beek, A.J. (2000) Reactivity and
recovery from different types of work measured by catecholamines and cortisol: a systematic
literature overview. Occup Environ Med, 57, 298-315.
Smedley, J., Inskip, H., Buckle, P., Cooper, C. and Coggon, D. (2005) Epidemiological
differences between back pain of sudden and gradual onset. Journal of Rheumatology, 32, 528­
532.
South African Department of Labour. (2004) Compensation Commissioner’s Guidelines for
Health Practitioners and Employers to manage Work-Related Upper Limb Disorders. Circular
Instruction No.180. www.labour.gov.za.
Spitzer, W.O. (1995) Scientific monograph of the Quebec Task Force on whiplash associated
disorders: redefining "whiplash" and its management. Spine, 20, 85.
Staal, J.B., Hlobil, H., van Tulder, M.W., Waddell, G., Burton, A.K., Koes, B.W. and van
Mechelen, W. (2003) Occupational health guidelines for the management of low back pain: an
international comparison. Occup Environ Med, 60, 618-626.
Stanley, I., Miller, J., Pinnington, M.A., Rose, G. and Rose, M. (2001) Uptake of prompt access
physiotherapy for new episodes of back pain presenting in primary care. Physiotherapy , 87(2),
60-7.
Steenstra, I.A., Verbeek, J.H.A.M., Heymans, M.W. and Bongers, P.M. (2004) Prognostic
factors for duration of sick-leave in patients sick listed with acute low back pain: a systematic
review of the literature. (submitted to Occupational and Environmental Medicine).
Stone, W.E. (1983) Repetitive strain injuries. Med J Aust, 2, 616-618.
Stovner, L.J. (1996) The nosologic status of the whiplash syndrome: a critical review based on a
methodological approach. Spine, 21(23), 2735-2746.
65
Svendsen, S.W., Mathiassen, S.E. and Bonde, J.P. (2005) Task based exposure assessment in
ergonomic epidemiology: a study of upper arm elevation in the jobs of machinists, car
mechanics and house painters. Occup Environ Med, 62, 18-26.
Symonds, T.L., Burton, A.K., Tillotson, K.M. and Main, C.J. (1996) Do attitudes and beliefs
influence work loss due to low back trouble? Occupational Medicine, 46, 25-32.
Thomas, E., Silman, A.J., Croft, P.R., Papageorgiou, A.C. and Jayson, M.I.V. (1999) Predicting
who develops chronic low back pain in primary care: a prospective study. BMJ, 318, 1662­
1667.
Thomson, L.C., Handoll, H.H.G., Cunningham, A. and Shaw, P.C. (2002) Physiotherapist-led
programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral
ligament and meniscal injuries of the knee in adults. The Cochrane Database of Systematic
Reviews, Issue 1, Art. No. CD001354, DOI: 10.1002/14651858.CD001354.
Tilscher, H., Pirker-Binder, I., Kollegger, M. and Pfeiffer, F. (2005) Head, Neck, Shoulder,
Arm: workplace related? An increasing problem for women (in German "Kpf-Nacken-SchulterArm-Beschwerden: arbeitsplatzbedingt?" Manuelle Medizin, 43, 13-18.
Tomlin, Z., Humphrey, C. and Rogers, S. (1999) General practitioners' perceptions of effective
health care. BMJ, 318, 1532-1535.
Truchon, M. and Fillion, L. (2000) Biopsychosocial determinants of chronic disability and low
back pain: a review. J Occup Rehabil, 10, 117-142.
Truchon, M. (2001) Determinants of chronic disability related to low back pain: Towards an
integrative biopsychosocial model, Disability & Rehabilitation, 23, 758-767.
Tubach, F., Leclerc. A., Landre, M.F. and Pietri-Taleb, F. (2002) Risk factors for sick leave due
to low back pain: a prospective study. J Occup Environ Med, 44, 451-458.
Turner, J.A., Franklin, G., Heagerty, P.J., Wu, R., Egan, K., Fulton-Kehoe, D., Gluck, J.V. and
Wickizer, T.M. (2004) The association between pain and disability. Pain, 112, 307-314.
UK BEAM Trial Team (2004) United Kingdom back pain exercise and manipulation (UK
BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care.
BMJ, 19 November, 1-8. doi:10.1136/bmj.38282.607859.AE.
Ursin, H. and Eriksen, H.R. (2001) Sensitization, subjective health complaints and sustained
arousal. Annals of the New York Academy of Sciences (Ann NY Acad Sci), 933, 119-129.
Valat, J-P. (2004) Factors involved in progression to chronicity of mechanical low back pain:
Editorial. Joint Bone Spine, (in press).
Van den Heuvel, S.G., de Looze, M.P., Hildebrandt, V.H. and The, K.H. (2003) Effects of
software programs stimulating regular breaks and exercises on work-related neck and upperlimb disorders. Scand J Work Environ Health, 29, 106-116.
Van den Heuvel, S.G., Ariens, G.A.M., Boshuizen, H.C., Hoogendoorn, W.E. and Bongers,
P.M. (2004) Prognostic factors related to recurrent low-back pain and sickness absence. Scand J
Work Environ Health, 30, 459-467.
66
Van den Heuvel, S.G., van der Beek, A.J., Blatter, B.M., Hoogendoorn, W.E. and Bongers,
P.M. (2005) Psychosocial work characteristics in relation to neck and upper limb symptoms.
Pain, 114, 47-53.
Van der Windt, D.A.W.M., Van der Heijden, G.J.M.G., Van den Berg, S.G.M., Ter Riet, G., De
Winter, A.F. and Bouter, L.M. (2002) Ultrasound therapy for acute ankle sprains. In. Issue 1.
Art. No. CD001250 The Cochrane Database of Systematic Reviews.
Van Nieuwenhuyse, A., Fatkhutdinova, L., Verbeke, G., Pirenne, D., Johannik, K., Somville,
P.R., Mairiaux, P., Moens, G.F. and Masschelein, R. (2004) Risk factors for first-ever low back
pain among workers in their first employment. Occupational Medicine, 54, 513-519.
Van Tulder, M.W., Tuut, M., Pennick, V., Bombardier, C. and Assendelft, W.J.J. (2004)
Quality of primary care guidelines for acute low back pain. Spine, 29(17), E357-E362.
Vase, L., Robinson, M.E., Verne, G.H. and Price, D.D. (2005) Increased placebo analgesia over
time in irritable bowel syndrome (IBS) patients is associated with desire and expectation but not
endogenous opioid mechanisms. Pain, 115, 338-347.
Verbeek, J.H. and van der Beek, A.J. (1999) Psychosocial factors at work and back pain: a
prospective study in office workers. Int J Occup Med Environ Health, 12, 29-39.
Verbeek, J., Sengers, M.-J., Riemens, L. and Haafkens, J. (2004) Patient expectations of
treatment for back pain. Spine, 29(20), 2309-2318.
Verdugo, R.J., Salinas, R.S., Castillo, J. and Cea, J.G. (2004) Surgical versus non-surgical
treatment for Carpal Tunnel syndrome (Cochrane review). In: The Cochrane Library, Issue 4.
Chichester, John Wiley.
Verhagen, A.P., Bierma-Zeinstra, S.M.A., Feleus, A., Karelsm, C., Dahaghin, S., Burdorf, L.,
de Vet, H.C.W. and Koes, B.W. (2003) Ergonomic and Physiotherapeutic interventions for
treating upper extremity work related disorders in adults. The Cochrane Database of Systematic
Reviews, Issue 3, DOI:003410.001002/14651858.CD14003471.pub14651852.
Viikari-Juntura, E. (1998) Risk factors for upper limb disorders. Implications for prevention and
treatment. Clinical Orthopaedics, 351, 39-43.
Vlaeyen, J.W.S., Kole-Snijders, A.M.J., Boeren, R.G.B. and van Eek, H. (1995) Fear of
movement/(re)injury in chronic low back pain and its relation to behavioural performance. Pain,
62, 363-372.
Vlaeyen, J.W. and Linton, S.J. (2000) Fear-avoidance and its consequences in chronic
musculoskeletal pain: a state of the art. Pain, 85, 317-332.
Waddell, G., Somerville, D., Henderson, I., Newton, M. and Main, C.J. (1993) A fear avoidance
beliefs questionnaire (FABQ) and the role of fear avoidance beliefs in chronic low back pain
and disability. Pain, 52, 157-168.
Waddell, G., McIntosh, A., Hutchinson, A., Feder, G. and Lewis, M. (1999) Low back pain
evidence review. London, Royal College of General Practitioners.
67
Waddell, G. and Burton, A.K. (2000) Occupational health guidelines for the management of
low back pain at work: evidence review and recommendations. London, Faculty of
Occupational Medicine.
Waddell, G., Burton, A.K. and Main, C.J. (2003) Screening to identify people at risk of longterm incapacity for work. London, Royal Society of Medicine Press Ltd.
Waddell, G. and Burton, A. (2004) Concepts of rehabilitation for the management of common
health problems. London, The Stationery Office.
Waddell, G., Klaber-Moffett, J. and Burton, K. (2004) The Neck Book: The best way to deal
with neck pain based on the latest research. London, The Stationery Office.
Waddell, G., Burton, K. and McClune, T. (2004) The Whiplash Book: how you can deal with a
whiplash injury. London, The Stationery Office.
Wahlstrom, J., Hagberg, M., Toomingas, A. and Wigaeus Tornqvist, E. (2003) Perceived
muscular tension, job strain, physical exposure, and associations with neck pain among VDU
users; a prospective cohort study. Occup Environ Med, 61, 523-528.
Walsh, K., Cruddas, M. and Coggon, D. (1992) Low back pain in eight areas of Britain. Journal
of Epidemiology and Community Health, 46, 227-230.
Wand, B.M., Bird, C., McAuley, J.H., Dore, C.J., MacDowell, M. and De Souza, L.H. (2004)
Early intervention for the management of acute low back pain. Spine, 29(21), 2350-2356.
Waugh, E.J., Jaglal, S.B., Davis, A.M., Tomlinson, G. and Verrier, M.C. (2004) Factors
associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy. Arch Phys
Med Rehabil, 85(2), 308-318.
Waxman, R., Tennant, A. and Helliwell, P. (1998) Community survey of factors associated with
consultation for low back pain. BMJ, 317, 1564-1567.
White, P.D., Henderson, M., Pearson, R.M., Coldrick, A.R. and White, A.G. (2003) Illness
behavior and psychosocial factors in diffuse upper limb pain disorder: a case-control study. J
Rheum, 30, 139-145.
Winters, J.C., de Jongh, A.C., van der Windt, D.A.W.M., Jonquière, M., de Winter, A.F., van
der Heijden, G.J.M.G., Sobel, J.S. and Goudswaard, A.N. (1999) Dutch College of General
Practitioners (NHG) Practice Guideline 'Shoulder complaints’. Available online at
http://nhg.artsennet.nl/upload/104/guidelines2/E08.htm#noot24.
Young, A. and Breen, A.C. (2000) X-ray standards audit report. Reading, British Chiropractic
Association.
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APPENDIX 1 THE CARE PATHWAYS
1. GENERIC CARE PATHWAY
Scope: Any new episode of any musculoskeletal pain that interferes with work and
lasts more than a day or two if severe, or up to a week if not severe.
Note: Over-reaction to mild or resolving episodes should be avoided.
STAGE 1: Within one week from onset:
Initial discussion, assessment and planned action with employer or their services
Activity modification considered
Involvement of health professional (if concerned)
STAGE 2: Within two weeks from onset
if not recovered:
Reassessment and revised action plan for recovery
Monitoring and amendment of recovery plan - together with employer and with
particular attention to activity and function (as distinct from pain alone)- until recovery
achieved.
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2. EMPLOYER PATHWAY
Employees need to be aware of the employer’s desire to help and their policy of encouraging
early discussion. The starting point for this is a key message to all employees to the effect that;
“If you are having problems working because of pain in your back, neck, shoulders, arms or
anywhere else, we want to help. Come in and talk to us!”
Employers also need to be aware of who is off work and why. There needs to be a ‘case
manager’* at work who monitors progress, plus a standing group who address persistent reasons
for absence.
STAGE 1: Within one week from onset:
Initial discussion of the problem, its nature and planning initial action with the employee
(record notes for future monitoring)
Listening to the employee
Employee story and concerns, nature of problem, any associated problems or unhappiness at
work, level of job demands and of personal control at work. Whether off work/having difficulty
at work for non-work reasons, duration of current episode, improving, worsening or fluctuating
course, aggravating and relieving factors, other health problems, employee beliefs and
expectations about work in general, about specific work issues and recovery
Reassurance and information
Positive messages and assurance of value to organisation, commitment to overcoming the
problem and why it is best to remain at work if possible. Information giving (e.g. Back Book),
reasons to consult appropriate health professional (e.g. for pain control, problem-solving,
uncertainty or worry). Be willing to arrange temporary activity modification, job rotation or job
sharing. Do a risk assessment and reach agreement on a plan for recovery that includes initial
work-related changes. Arrange a follow-up discussion.
STAGE 2: Within two weeks from onset if not recovered:
(Input from chiropractor, osteopath
or musculoskeletal physiotherapist if needed)
Review and if necessary amend work activity
modifications, again considering
job rotation or job sharing.
Monitor, review and modify the plan for recovery with employee (and health professional if
involved), with particular attention to activity and function, until full recovery.
*This could be an occupational health practitioner, the personnel officer or the employer themselves, depending on
the size of the organisation.
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3. EMPLOYEE PATHWAY
STAGE 1: Within one week of getting the problem (it’s best to get in early!)
Most muscle and joint problems are harmless and clear up on their own (– and of
course many have nothing to do with work or injury). If they need care, they respond
best to a plan for recovery that is started early. In these cases, good recovery is more
likely if you can control the pain, stay at work (even if you have some pain), and keep
active, perhaps with modified activities.
Tell your employer, line manager or human resources manager about the problem and
discuss the effect of your activities and work.
If you are worried, consider whether you should make an appointment to see a health
professional at work (if available), or a chiropractor, osteopath or musculoskeletal
physiotherapist in the community who can provide effective physical treatments, advise
you on what kind of changes to make to your activities and help you to manage your
condition*. Arrange a follow-up discussion with your employer or other manager
within the next week to check progress.
STAGE 2: If you have not recovered within two weeks of getting the problem:
Do not be discouraged! Make a plan to overcome the problem, using pain control and, if
necessary, modified activities at work and/or other treatment. Make this together with
your employer and (if applicable) the health professional you are seeing.
Check with these people regularly that the plan is working and that your activities at
work are increasing by stages. If not, reconsider your strategy together.
*You may have to pay for this.
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4. HEALTH PROFESSIONAL PATHWAY
(i.e. an occupational health practitioner at work or a chiropractor, osteopath or
musculoskeletal physiotherapist at work or outside of work)
STAGE 1: First attendance with the health professional
Assessment
Conduct diagnostic triage leading to a working diagnosis. Refer to secondary care if
serious pathology, systemic disorder or progressive neurological disorder is suspected.
If not, decide if there is a specific diagnosis (e.g. DeQuervain’s tenosynovitis) or if the
problem is non-specific. Assess for other health problems (including other
musculoskeletal disorders), psychological barriers (such as illness behaviour or low
mood) and social burdens (such as family pressures or poor housing). Become
conversant with the person’s job demands, personal control at work and non-work
activities. Check that they feel supported at work and that things are going well there
and at home.
Intervention
Provide reassurance, information, and pain control and agree an initial re-activation
strategy with time-limited, specific activity modifications to facilitate the person’s
presence at work. Seek agreement to involve (rather then simply inform) the employer
if necessary. Avoid unnecessarily attributing the problem to injury or mechanical
derangement, but for conditions where there is evidence of its effectiveness, consider
using manipulative treatment to reduce pain and disability early.
Initiate Care Plan
Plan for recovery, taking other health, work or social problems into consideration.
Agree staged re-activation with personalised and specific work-related activities with
employee and employer. Monitor recovery, with particular attention to activity and
function. Report your findings to the patient’s general practitioner.
STAGE 2: Within four weeks from first attendance (if still not recovered):
Review
Review and modify the plan for recovery of activity and function with the employer and
employee. Review the role of societal factors, general health, exercise and activity in
longer- term recovery and secondary prevention. If not recovering, consider initiating
an exercise program at work or other work-based intervention
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74
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GLOSSARY
(Professional bodies and health regulators with registers of musculoskeletal
practitioners)
The Chartered Society of Physiotherapy
Chartered Society of Physiotherapists
14 Bedford Row
London
WC1R 4ED WC1R 4ED
www.csp.org.uk
General Chiropractic Council
General Chiropractic Council
44 Wicklow Street
London
WC1X 9HL
www.gcc-uk.org
General Osteopathic Council
General Osteopathic Council
176 Tower Bridge Road
London
SE1 3LU
www.osteopathy.org.uk
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Published by the Health and Safety Executive
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