Abstract
Study design: A systematic review of the literature to inform the development of occupational health guidelines for the management of low back pain at work.
Objectives: To evaluate the evidence from occupational health settings or concerning occupational outcomes.
Summary of background: Clinical guidelines for the management of low back pain (LBP) provide only limited guidance on the occupational aspects. Thus the Faculty of Occupational Medicine requested this review in order that a multi-disciplinary working group could develop the first evidence-based UK guidelines for management of LBP at work.
Methods: A systematic literature search was followed by rating of the strength of the evidence plus a narrative review, by agreement between two experienced and independently-minded reviewers. There was no attempt at blinded double review or quality scoring. The final version followed peer-review by four international experts.
Results: More than 2000 titles were considered. 34 systematic reviews, 28 narrative reviews, 52 additional scientific studies, 22 less rigorous scientific studies and 17 previous guidelines were identified and included. The evidence statements (rated for strength) were presented under headings that reflect a logical sequence of occupational health situations (Background, Pre-placement assessment, Prevention, Assessment of the worker presenting with back pain, Management principles for the worker presenting with back pain, Management of the worker having difficulty returning to normal occupational duties at 4–12 weeks). Some important areas were given additional narrative evidence-linked discussion (High risk patients/physically demanding jobs, Return to work with back pain, Rehabilitation programmes). Thirty six evidence-linked statements were developed to inform the guidelines group. The strongest evidence suggests that: generally the physical demands at work have only a modest influence on the incidence of LBP or permanent spinal damage; a history of LBP is not a reason to deny employment; preventive strategies based on the injury model do not reduce LBP or work loss; individual and work-related psychosocial factors play an important role in persisting symptoms and work loss; the management approach should be ‘active’ (including early work return); the combination of clinical, rehabilitation and organisational interventions designed to assist work return is more effective than single elements. However, further research is needed to identify the optimal roles of all stakeholders (clinicians, employers and workers) in case management.
Conclusions: This review consolidates the emerging focus on active management of LBP at work, and indicates that approaches addressing obstacles to recovery will provide greater benefits than attempts at primary prevention. The outcome of the review has resulted in what we believe are the first truly evidence-linked occupational health guidelines for back pain in the world (www.facoccmed.ac.uk).
The abstracts were prepared by Dr P Dolan. Correspondence should be addressed to him at the British Orthopaedic Association, Royal College of Surgeons, 35-43 Lincoln’s Inn Fields, London WC2A 3PN.
