Issue 10 May 2004
General points
- A safe and early return to work is an important part of rehabilitation and functional recovery
- Non-specific acute low back pain is one of the most common health related reasons cited for work loss, therefore it is important that treatment providers encourage and reassure patients that an early return to work is beneficial
- Often the patient can be advised to continue working. Occasionally, examination findings or history may indicate a need to temporarily or permanently modify their work
- If time off work is required treatment providers can facilitate a return to work by: developing in collaboration with the patient a plan to return to work, monitoring their progress, recommending specialist referral if necessary, and liaising with the ACC case manager and employer where appropriate
- Where a return to work is delayed the provision of indicative timeframes and information to the patient and their employer is vital to help with job retention
The Importance of Return to Work
Acute low back pain (ALBP) is one of the most common health related reasons for work loss.1 Therefore decisions about work can have a substantial impact upon the future quality of life and earning capacity. There is considerable scientific evidence and international agreement that patients with ALBP should be encouraged and supported to remain at work or return as early as possible.1-3 The patient, however, may have concerns about returning while symptomatic. It is important that treatment providers reassure patients that an early return is an important part of their rehabilitation and functional recovery and have a strategy to facilitate this process.
Clinical Care (1) - (4)
Initial and ongoing clinical review should exclude serious back injury and ‘Red’ Flags before advising a return to work. The relationship between pain, functional limitations and work demands should be assessed with intervention occurring early. Secondary prevention includes advice to eliminate obesity and smoking, increase normal physical activity and adopt sensible manual handling techniques within the ability of the individual.
Reassurance and encouragement
In most cases, the patient can be advised to continue working normally. Communication with the patient must include clear statements like ‘working heals rather than harms the back’. The patient should also be reassured that while there may be some temporary increase in pain, the physical activity is beneficial to their rehabilitation. Pain relief, using proven interventions such as regular simple analgesics and manipulation, may be important if manual labour or constrained postures are characteristics of the work.
Determining work demands
Make time, if necessary a specific appointment, to discuss work issues with the patient. Obtain an adequate description of the required work demands and the length of the work shift. ACC tools that can help assessment are available at http://www.acc.co.nz/for-providers/resources/worksheets/
Identifying barriers
Work with ACC to identify and address barriers such as difficulties travelling to/from work, job dissatisfaction and unsupportive work mates or managers. Positive, practical advice and dealing definitively with anxieties about an early return to work will promote recovery.
Return to Work Plans (3)
Occasionally, the patient’s history or examination findings may indicate the need for time off work and hence a plan to assist an early return to work. A template for devising a plan with the patient is available in the ‘Patient Guide to Acute Low Back Pain Management’ (free copies are available from Wickliffe Press by phoning 0800226440).
An individualised plan should:
- determine if alternative work duties are necessary and suggest possible alternatives
- identify barriers and address them up front
- consider if a gradual return is necessary
- advise on timelines for achievement (e.g. how long temporary changes may be required)
- monitor recovery and symptom control and modify strategies that are not working
- determine if a permanent change to work duties, different employment or re-training is required.
The Employment Maintenance Programme (EMP) and Graduated Return to Work Programme (GRTW) are two early intervention ACC vocational rehabilitation programmes designed to assist employees return to their pre-injury jobs as reasonably practicable after injury. An ACC case manager (with the general practitioner’s support) may refer eligible patients with an ACC claim accepted for cover to one of these programmes. In general, the GRTW assists those who have a medical certificate that indicates the need for a workplace assessment, and/or fitness for selected work or reduced hours. Whereas, the EMP assists those who are fit for selected work and could return to their pre-injury job on alternative duties, but the employer has indicated that no alternative duties are available. ACC engages appropriate rehabilitation and vocational practitioners to support patients through the programme until a full return to work is achieved.
Timelines (1) - (3)
Treatment providers should encourage patients to return to work as early as they feel able (with or without appropriate modifications) to avoid unnecessary and potentially harmful delays. Return to work is usually safe within days rather than weeks. Physical work requirements (especially posture, large muscular forces and spinal mobility required for bending, stooping or lifting) will affect the duration of incapacity. If the patient has not resumed normal activities at work after four weeks a formal reassessment should be conducted. If there are ongoing symptoms and incapacity four to eight weeks after onset, additional interventions or special referral may be required. Where return is delayed the provision of indicative timeframes and information to the patient and employer is vital to help job retention.
Summary
Treatment providers can support patients by providing advice, encouragement and symptom relief. Treatment providers can facilitate an early return to work by having an agreed plan with the patient, regularly reviewing their progress and recommending specialist referral if necessary. Where appropriate, liaison with the patient’s ACC case manager and employer is important for the continuation of meaningful employment.
References
- Waddel G, Burton AK. Occupational Health Guidelines for Management of low back pain at work. Occup Med. 2001;60:244-53
- Staal, JB et al Occupational health guidelines for the management of low back pain: an international comparison. Occup Environ Med 2003;60(9):618-26.
- Selander et al. Return to work following vocational rehabilitation for neck, back and shoulder problems: risk factors reviewed. Dis Rehab 2002;24(14):704-12.