Epidemiological Analysis of the Relationship Between Lower Back Pain Incidence and Implementation of Occupational Preventative Measures

Roughly 60 to 80% of individuals in the United States population have experienced lower back pain at some point in their life [1]. Lower back pain (LBP) is generally defined as pain, muscle tension, or stiffness localised below the costal margin and above the inferior gluteal folds. The most debilitating consequences of general lower back pain include inflammatory discomfort and functional disability. Approximately one-third of American workers are at an increased risk for  developing back disorders as a product of their jobs [3]. This results in  time taken off work, causing the annual direct cost of LBP in the United States to approach more than 25 billion US dollars. Similarly, indirect costs vary widely to a total of 100 billion US dollars per year [1]. There are well‐established clinical guidelines for the management of low back pain, but these provide limited guidance regarding  occupational aspects. Occupational LBP is a multifactorial condition that requires the understanding of common causative physical and psychosocial risk factors and their associated treatment measures in order to fully address the condition at every level-preventive, secondary occurrence, chronicity and disability.

The United States Department of Labor reported LBP  to be the leading event or exposure to pain for those working as nursing aides, orderlies, attendants, laborers and freight, janitors, cleaners, and most of all, truck drivers. LBP in these specific careers account for  44.9% to 59.2% of total injuries of all musculoskeletal disorders [2].  According to Chou et al., approximately 2% of the U.S. workforce compensated for back injuries each year, resulting in tremendous indirect costs related to time lost from work [3]. Risk factors for lower back pain may include heavy physical work, heavy or frequent lifting, combined postures with rotation and flexion, pushing and pulling, and exposure to whole body vibration, such as motor vehicle driving [3].  Occupational related LBP characteristics also include factors such as age, gender, and duration of service with an individual’s employer. Moreover, there is growing evidence linking psychosocial risk factors to occupational back pain, particularly monotonous work, perceived high workload, pressure of time, lack of decision-making authority, and job dissatisfaction [4].

The causes of occupational back pain are multifactorial and must be investigated during clinical assessment. This multifactorial nature of LBP is seen in the influence of prolonged sitting on incidence of LBP; sitting alone is not associated with the risk of developing LBP. However, when the co-exposure factors of WBV and awkward postures were added to the analysis, the risk of LBP increased fourfold [9]. This failure to undertake a comprehensive diagnostic approach when evaluating patients with occupationally induced LBP can lead to mismanagement and further chronicity, when the proper causes and hazards are not identified. It is known that any structure that involves the spine is a potential source of back pain. Consequently, it is considered to be a symptom of a wide range of possible injuries, with a wide range of causative diagnoses [1]. 

Primary prevention before any incidence of back pain in the workplace is usually the most common strategy utilized by employers to prevent LBP in employees. Many cases of LBP could be prevented by incorporating changes in the workplace that focus on reducing the incidence of new episodes of occupational back pain. For instance, pre-placement assessments that evaluate individual health, fitness, and strength can help identify employees  who may be at a higher risk for LBP in a certain occupational position, given that these factors can affect the ability of workers to safely perform manual tasks.. With this information in mind, it aims to place workers with the highest risk of LBP in the jobs that impose the least physical demands. This works as a preventative measure for individuals with a proclivity for a musculoskeletal disorder [8]. Moreover, an increased resistance to back pain can be fostered by teaching workers about causes, risk factors, management, and prevention. This is significant for manual labor intensive work, where the teaching of “proper” lifting techniques to material handlers has been proven to be effective in reducing occupational back pain [5]. For instance, mechanical hoists are used in hospitals to reduce the load of patient lifting for nurses. Among health care personnel, nurses have the highest rate of back pain, with an annual prevalence of 40-50% and a lifetime prevalence of 35-80%. The benefit of assistive patient handling equipment is characterized by the simultaneous reduction of the risk of musculoskeletal injury to the nursing staff and improvement in the quality of care for patient populations. Ergonomics involves the use of mechanical devices (e.g., walking belt and mechanical hoist) to aid in patient lifting and transferring tasks. Guldmann Inc. has devised ceiling lift systems and slings during the past 20 years. They have successfully completed thousands of installations worldwide, covering a wide range of challenging conditions and complex environments. [10].

Secondary prevention aims to reduce the impact of a disease or injury that has already occurred. This is done by detecting and treating disease or injury as soon as possible to halt or slow its progress, encouraging personal strategies to prevent reinjury or recurrence, and implementing programs to return people to their original health and function to prevent long-term problems.For individuals with a recurrence of symptoms, there is considerable promise for minimization of pain and disability in symptomatic patients through secondary prevention. The majority of patients (80%) in the acute phase (symptoms of back pain lasting only  3–4 weeks) will have good prognosis even with minimal investigation and treatment. During this phase, secondary prevention in the workplace emphasizes the discouragement of bed rest and an advocacy for remaining active among LBP sufferers. In the chronic cases, physiotherapy and an investigation of the psychosocial risks are more applicable  [6]. These secondary measures aim to reduce sick leave in order to make it possible for the individual to return to work earlier; this ensures a cost-effective mechanism for employers to encourage early return; this financial feasibility encourages employers to promote these practices to prevent LBP and LBP reoccurrence. 

Tertiary prevention includes the practices used in occupational settings to reduce disability. Prompt return to work has a clear impact in reducing disability [7]. However, this requires flexible modified work for the employee with back pain, which can be difficult for smaller companies. We must also acknowledge the limits and legitimate contributions of rehabilitation programs in the management of chronic back pain. It is important to consider that this level of prevention is difficult to achieve unless the patient is motivated to enroll in a rehabilitation program, and the psychosocial factors of occupational back pain are dealt with in a multidisciplinary manner [6].

Occupational back pain is a condition commonly encountered in outpatient clinics and it is very costly for the healthcare system and industry. It can easily be prevented, and physicians can play a major role in this regard to stop it from becoming chronic and disabling. Physicians must standardize their clinical approach to the patient with occupational back pain by encouraging employers to implement clinical guidelines for this condition in the workplace. This requires the interaction of employers in industry and physicians in order to best devise preventative and rehabilitative practices while remaining cost-effective and financially feasible.

References:

1. Al-Otaibi S. T. (2015). Prevention of occupational Back Pain. Journal of family & community medicine, 22(2), 73–77. https://doi.org/10.4103/2230-8229.155370
2. Bureau of Labor Statistics. Nonfatal occupational injuries and illnesses requiring days away from work. United States: Department of Labor, 2009.
3. Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK. 2007. “Clinical Efficacy Assessment Subcommittee of the American College of Physicians; American College of Physicians; American Pain Society Low Back Pain Guidelines Panel.” The American College of Physicians and the American Pain Society. Ann Intern Med.. https://doi.org/10.7326/0003-4819-147-7-200710020-00006
4. Michael K. Nicholas, Steven J. Linton, Paul J. Watson, Chris J. Main, the “Decade of the Flags” Working Group, Early Identification and Management of Psychological Risk Factors (“Yellow Flags”) in Patients With Low Back Pain: A Reappraisal, Physical Therapy, Volume 91, Issue 5, 1 May 2011, Pages 737–753, https://doi.org/10.2522/ptj.20100224
5. Martimo, K. P., Verbeek, J., Karppinen, J., Furlan, A. D., Takala, E. P., Kuijer, P. P., Jauhiainen, M., & Viikari-Juntura, E. (2008). Effect of training and lifting equipment for preventing back pain in lifting and handling: systematic review. BMJ (Clinical research ed.), 336(7641), 429–431. https://doi.org/10.1136/bmj.39463.418380.BE
6. Hayden, J. A., van Tulder, M. W., Malmivaara, A. V., & Koes, B. W. (2005). Meta-analysis: exercise therapy for nonspecific low back pain. Annals of internal medicine, 142(9), 765–775. https://doi.org/10.7326/0003-4819-142-9-200505030-00013
7. U.S. Preventive Services Task Force. Primary care interventions to prevent low back pain in adults: Recommendation statement. Am Fam Physician. 2005;71:2337–8. https://pubmed.ncbi.nlm.nih.gov/15999872/
8. Waters, T. R., Lu, M. L., Piacitelli, L. A., Werren, D., & Deddens, J. A. (2011). Efficacy of the revised NIOSH lifting equation to predict risk of low back pain due to manual lifting: expanded cross-sectional analysis. Journal of occupational and environmental medicine, 53(9), 1061–1067. https://doi.org/10.1097/JOM.0b013e31822cfe5e
9. Lis, A. M., Black, K. M., Korn, H., & Nordin, M. (2007). Association between sitting and occupational LBP. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society, 16(2). https://doi.org/10.1007/s00586-006-0143-7
10. Edlich, R. F., Winters, K. L., Hudson, M. A., Britt, L. D., & Long, W. B. (2004). Prevention of disabling back injuries in nurses by the use of mechanical patient lift systems. Journal of long-term effects of medical implants, 14(6), 521–533. https://doi.org/10.1615/jlongtermeffmedimplants.v14.i6.70