Return to Work in Lumbar Back Pain

1. See Also
   1. Low Back Pain
   2. Start Back Screening Tool
2. Epidemiology
   1. Low Back Pain in the last 3 months is reported by 25% of working adults in U.S.
      1. Low Back Pain accounts for 1 in 20 outpatient visits
      2. However, only one third of workers with Low Back Pain seek medical attention
      3. Of those with ongoing Low Back Pain for 2 years, 70% never took medical or Sick Leave
3. Evaluation
   1. See Acute Low Back Pain
4. Risk Factors: Work-related back injury
   1. Heavy lifting (esp. >55 lb or 25 kg)
   2. Bending or twisting frequently
   3. Whole body vibration
5. Management
   1. See Low Back Pain Management
   2. Physical therapy speeds recovery
      1. Start with physical therapy 3-5 times weekly and gradually decrease frequency
      2. Initiate home therapy program at initial visit
      3. Reevaluate in clinic after 6 physical therapy visits or 2 weeks
      4. Consider multidisciplinary rehabilitation program if standard therapy fails after 4-12 weeks
         1. Team approach includes physicians, physiotherapists, and mental health counselors
         2. Back school or other work hardening programs are not recommended (low efficacy)
   3. Return to work timing
      1. Early return to work is key (despite persistent symptoms)
         1. With appropriate work restrictions, early return does not risk further injury
      2. Prolonged or recurrent work absence risks longterm Disability and joblessness
         1. Missing 4-12 weeks of work associated 40% chance of missing the next year of work
         2. Missing 2 years of work associated with high likelihood of never working again
   4. Screen and intervene with patients at high risk of chronic Low Back Pain and Disability
      1. See Start Back Screening Tool
      2. Address fear avoidance beliefs (activities that are avoided due to fear of injury)
      3. Encourage early functional return to work
      4. Provide in-depth physicial therapy
      5. Consider behavioral health follow-up (as indicated for Major Depression or Anxiety Disorder)
      6. Teach Mindfulness and stress reduction techniques
6. Instructions: Work Restrictions for light work activity
   1. Criteria that defines light work activity
      1. Primarily sitting
      2. Occasional standing and walking
      3. Lifting and carrying <20 pounds
   2. Work restrictions
      1. No lifting over 5 pounds three times per hour
      2. Change position for 5 minutes every 30 minutes
         1. Avoid prolonged sitting, standing or walking
   3. Duration of light duty restrictions
      1. Mild Low Back Pain: 0 days
      2. Severe Low Back Pain: 3 days
      3. Low Back Pain with Sciatica: 5 days
7. Instructions: Work Restrictions for medium work activity
   1. Criteria that defines moderate work activity
      1. Mix of sitting, standing and walking
      2. Occasional bending, twisting, or stooping
      3. Lifting and carrying <50 pounds
   2. Work restrictions
      1. No lifting over 5 pounds three times per hour
      2. Change position for 5 minutes every 30 minutes
         1. Avoid prolonged sitting, standing or walking
      3. Avoid bending, twisting, or stooping
   3. Duration of light duty restrictions
      1. Mild Low Back Pain: 0 weeks
      2. Severe Low Back Pain: 2-2.5 weeks
      3. Low Back Pain with Sciatica: 3 weeks
8. Instructions: Work Restrictions for heavy work activity
   1. Criteria that defines heavy work activity
      1. Primarily standinga and walking
      2. Frequent bending, twisting, or stooping
      3. Lifting and carrying as much as 100 pounds
   2. Work restrictions
      1. No lifting over 25 pounds 15 times per hour
      2. Ten minute break for every hour of standing, walking
      3. Limits on driving
         1. Light truck or car: 6 hours per day
         2. Heavy vehicle or equipment: 4 hours per day
      4. Avoid bending, twisting, or stooping
   3. Duration of light duty restrictions
      1. Mild Low Back Pain: 1-1.5 weeks
      2. Severe Low Back Pain: 4-5 weeks
      3. Low Back Pain with Sciatica: 4-5 weeks
9. Prognosis
   1. Predictors of Prolonged recovery (persistent back pain at one year)
      1. Poor pain coping skills
      2. Fear avoidance (avoiding activities due to fear that they will cause pain)
      3. Baseline functional Impairment
      4. Psychiatric illness
      5. Low general health status
   2. Additional predictors of Delayed Return to Work (or longterm Disability)
      1. Attorney involvement or active litigation
      2. Work absence beyond 30 days
      3. Workers compensation case
10. Prevention
    1. Effective Workplace Preventive Interventions
       1. Core strengthening Exercise
          1. Structured program (e.g. yoga, pilates)
          2. Unstructured program (patient performs on their own) is as effective as structured program
       2. Extension Exercises
          1. Even performing a single extension Exercise once weekly as a group at work is effective
    2. Measures that do NOT appear effective
       1. Back braces
       2. Shoe Insoles
       3. Preventive employee education
       4. Modification of ergonomic and mechanical factors at the workplace
11. References
    1. Denniston (2005) Disability Guide, Work Loss Data Inst.
    2. Becker (2019) Am Fam Physician 100(11): 697-703 [PubMed]
    3. Kinkade (2007) Am Fam Physician 75(8):1181-92 [PubMed]
    4. Nguyen (2007) Am Fam Physician 76:1497-4 [PubMed]
    5. Williams (2002) Work 19:87-93 [PubMed]