Occupational Health Advice

A View of pain from a group of Consultant Occupational Physicians at Medigold

1) What is pain?

Often the cause of pain is obvious, a broken leg or a bruise, but there are times when the source of the pain is unseen, for example a slipped disc.  Occasionally it is very difficult to find the exact cause for a person’s pain.

Health professionals use different terms for different types of pain:

• Short-term pain is called acute pain, for example a soft tissue injury or sprained ankle.
• Long-term pain is called persistent or chronic pain.
• Pain that comes and goes is called recurrent or intermittent pain.

Many acute pains are like an alarm telling us that something is wrong.  Most minor ones are easy to treat; others may be a sign of something more serious.  For example, the pain of a broken leg will make us rest the leg until it heals and here the pain is helping.

Persistent pain, or chronic pain, often serves no useful purpose and the message from the warning system linked to long-term conditions like arthritis or back pain are not needed – just annoying and distressing.  Over time, it may affect what we can do, our ability to work and/or our sleep patterns.  It can have strong negative effects on our family and friends too.

Chronic pain represents a complex and varied condition associated with a multitude of potential underlying causes. 

The modern management of back pain highlights the importance of the biopsychosocial model.

In the past, medical and other training focused largely on the biological (the structure of the body and its systems and their abnormality) aspects of diseases and conditions, including pain.  However, over the years there has been increasing understanding of the close and complex interrelationship of this and with the psychological processes going on in the individual and that individual’s interaction with their social environment.  All three areas are of considerable importance in the overall experience of pain.

Occupational medicine is the medical speciality dealing with the interaction of health and wellbeing in the working environment.  Our aim is for healthy working lives through:

• Maximising people’s opportunities to benefit from healthy and rewarding work whilst not putting themselves or others at unreasonable risk.
• Elimination of preventable injury or illness caused or aggravated by work.

How can Occupational Health help?

Working in our Organisation we are fortunate in having a full hour to undertake an assessment and often find that this is the first time that the individual has had sufficient time to discuss the impact that the chronic pain is having on them.

Communicating with the individual’s consent, we can facilitate and signpost further support, for example:

• Physiotherapy.
• Pain Clinic referrals.
• Functional rehabilitation referrals.
• The input of a Clinical Psychologist with the aim of helping the patient to cope and return to normal activities.
• Educating the employer about the impact of the condition on the individual and facilitating further support, for example:
 Through Access to Work.
 Engaging the support of the Disability Advisory Service, where available.
 Suggesting and recommending adjustments to be considered in the workplace, allowing an individual to return to work at an early stage, or to cope better at work.

Clearly each individual has different requirements and will benefit from different levels of support and this will be assessed in detail at the clinical assessment.

Some examples of adjustments that may be suggested would include:

• Undertaking a Workplace Assessment and the provision of suitable ergonomic adjustments.  This may be as simple as providing a suitably designed ergonomic chair.
• Restrictions may be required with regard to manual handling activities, such as lifting and carrying.
• A phased return to work, by working at reduced hours or with some restrictions in manual handling, over a limited period, may facilitate an early return to work.

Access to Work can provide practical support, including financial support to provide for example:

• Adaptations to the equipment used.
• Special equipment.
• Fares to work, if an individual cannot use public transport.
• A Support Worker or Job Coach to help an individual in the workplace.
• A support service and disability awareness training for colleagues.

An Occupational Health Clinician will also be able to give an opinion as to whether the condition would be covered by any disability discrimination provisions under the Equality Act 2010 and advise both employee and employer about suitable adjustments to be considered, although ultimately this would be a legal rather than a medical decision.

We are acutely aware that good work is very important to the wellbeing of most individuals and with our expert guidance, most individuals we see with chronic pain can return to work and indeed benefit from doing so.

2) A major example of the type of difficult pain related conditions which we see:

Back Pain

Occupational aspects of back pain

Lower back pain is a major cause of discomfort and absence from work. When pain causes problems with work; employers and employees want to know what to do.
This brief guide tells you what you can do and who can help you. It gives some important new facts about the treatment of back pain, based on the latest scientific and medical information.
More detailed guidance is available for GPs and occupational health advisers helping them to give you the best possible advice.

The Reality

Each year:

• 50 million working days are lost.
• It costs about £5 billion (or £200 for every employee) in sickness absence costs. Source: Clinical Standards Advisory Group
• Back pain is very common; according to a survey published in 2000 almost half the adult population of the UK (49%) report low back pain lasting for at least 24 hours at some time in the year.
• It is estimated that four out of every five adults (80%) will experience back pain at some stage in their life.
• Although in most cases back pain is nothing serious and disappears spontaneously, the sheer number of people affected makes it a very costly condition imposing a considerable burden on the individual and society.
• Simple measures can be taken to reduce the chances of developing back pain and thereby reducing the impact of existing back pain.
Not all back pain is caused by work - but factors at work which may trigger it, or make it worse, are some of the easiest to tackle effectively. Employers also have a legal responsibility to prevent harm from work.
For people with back pain inactivity and bed rest increase the chance of disability - an active approach to treatment and return to work brings benefits to everyone.

The number of people with back pain increases with advancing age, starting in school children and peaking in adults of 35 to 55 years of age. Back pain is just as common in adolescents as in adults.

CAUSES OF BACK PAIN

• In most cases it is very difficult to identify a single cause for back pain. In about 85% of back pain sufferers no clear pathology can be identified.
• The following factors could contribute to back pain:
Having had back pain in the past, smoking and obesity.
Physical factors such as heavy physical work, frequent bending, twisting, lifting, pulling and pushing, repetitive work, static postures and vibrations.
Psychosocial factors such as stress, anxiety, depression, job satisfaction, mental stress.

RECOVERY FROM BACK PAIN

• Back pain is, in most cases, a self-limiting condition and 90% of people with acute back pain will recover within 6 weeks.
• Up to 7% of people with acute back pain will develop chronic back pain. These chronic patients have considerable discomfort and account for approximately 80% of the social and health care costs.

THE COSTS OF BACK PAIN

• The National Health Service spends more than £1 billion per year on back pain related costs, this includes:
£512 million on hospital costs for back pain patients.
£141 million on GP consultations for back pain.
£150.6 million on physiotherapy treatments for back pain.
• In the private healthcare sector £565 million is spent on back pain every year.
• This brings the healthcare costs for back pain to a total of £1.6 billion per year.
• In addition there are other (indirect) costs. The Health and Safety Executive estimates that musculoskeletal disorders, which include back pain cost UK employers between £590 million and £624 million per year. 
• The total cost of back pain corresponds to between 1% and 2% of gross national product (GDP).
Other European countries report similar high costs; back pain related costs in The Netherlands in 1991 were more than 4 billion euro. For Sweden in 1995 these were more than 2 billion euro. 

THE IMPACT OF BACK PAIN ON THE INDIVIDUAL

• Back pain, in particular persistent back pain (i.e. <3 months), can have a significant impact on people’s lives. It frequently reduces their quality of life and adversely affects their family and social relationships.
 
THE IMPACT OF BACK PAIN ON WORK AND SICK LEAVE

• Nearly 5 million working days were lost as a result of back pain in 2003-04. This means that on any one day 1% of the working population are on sickness leave due to a back problem.
• Back pain is the number 2 reason for long term sickness in much of the UK. In manual labour jobs, back pain is the number one reason.

THE TREATMENT OF BACK PAIN

• Nearly 40% of back pain sufferers consulted a GP for help; 10% visited a practitioner of complementary medicine (osteopaths, chiropractors and acupuncturists).
• When experiencing back pain it is very important to stay active. Bed rest will only make the pain worse.
• Physical exercise can be a very effective method to reduce the pain and discomfort that long-term pain sufferers experience.

Employers - What can you do?

At the Workplace

• Consultation is important. Involve employees / trade unions when you develop measures to combat back pain:

This joint approach has proved effective in reducing the impact of back pain at work.
Together with your staff / trade unions, review the need for any workplace back care or occupational health advice. An OH adviser can help you to improve all aspects of back pain management and put you in touch with the rest of the health care system.

• Ensure that work activities are comfortable and not making unreasonable physical demands:

The Manual Handling Regulations (1992) and the Display Screen Equipment Regulations (1992) and associated guidance explain how to do this, as well as defining your legal duties.
Discuss pace, load and rotation of work with experienced workers / trade union safety representatives and with occupational health or back care advisers.

• Research shows that some widely used approaches do not work:

There are no valid methods of pre-placement screening which detect those at risk.
A history of back pain should not generally be a reason for refusing employment.
Lumbar supports (back belts) do not protect against back pain.

• Explain that you want to help people recover. Encourage early reporting of back pain if it is causing problems at work:

Set up a system which deals promptly with reports of back pain.
Review these reports to see if your prevention measures can be improved.
If anyone reporting back pain is seeing their GP, either write a note or suggest that they tell the GP that you are ready to support treatment aimed at a rapid return to full activities. This will usually be based on the Royal College of General Practitioners guidelines.

• Talk with people who have back pain.

Discuss whether their job needs to be adapted to help them return quickly to full activities. Consider solutions such as rest pauses, task rotation, handling aids and extra help from colleagues.
Make sure the work can be done safely.
Give help with particular tasks if the job cannot be changed.
Don't insist on freedom from pain before someone resumes normal work - it may delay recovery.
Keep a cheek on progress and be prepared to make further adjustments.

Someone is absent

• Make contact as soon as possible and keep in touch with them until return. Tell them you are ready to help if necessary.
• Arrange a meeting to discuss how their job could be adapted temporarily to help them return to full activities. Stress that you want to help recovery. Keep in mind that inactivity and bed rest can lead to the development of disability.
• Ask if you can have consent to contact their GP to discuss how you might help with plans for return to work.

Absence of more than 4 weeks

• The emphasis should change to an active programme of rehabilitation.

If you have access to an occupational health adviser ask them to sort out arrangements.
The longer the time off work the greater the chance of damage to long term quality of life. The chance of ever returning to work also reduces (50% of people return at six months, and only 5% after one year).
The effectiveness of rehabilitation reduces rapidly the longer it is delayed.

Employees - Do you have back pain?

• Back pain is common: it often settles down quickly and usually doesn't mean your back is damaged.
• In many cases taking time off work won't help. In fact, inactivity can make the problem worse.
• If back pain is causing you problems at work report this to your employer. Work together on possible ways to deal with it:
• see if your normal work can be done in a better way e.g. by better handling methods, and use of mechanical aids.
• until you can resume with normal work, is there anything else you can do which is easier for your back?
• if you have access to an occupational health or back care adviser at work they can give you advice based on carefully researched guidelines. If not and your pain is recurring and causing problems see your General Practitioner who also has research based guidelines.
• If you have to be off work don't stop using your back, and don't stay in bed, unless your doctor tells you to. Inactivity or bed rest can make your back worse.
• The Back Book (published by The Stationery Office) has helpful advice on back pain. Your GP or employer may be able to give you a copy, or you can order it from a book shop.

© Medigold Health Consultancy Ltd 2014

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