HSEHealth & Safety

Executive

Improved early pain management for musculoskeletal disorders

Prepared by the Institute for Musculoskeletal Research and Clinical Implementation

for the Health and Safety Executive 2005

RESEARCH REPORT 399

HSEHealth & Safety

Executive

Improved early pain management for musculoskeletal disorders

Alan Breen DC PhD Jennifer Langworthy MPhil

Jeffrey Bagust PhD Institute for Musculoskeletal Research and

Clinical Implementation AECC

Bournemouth Dorset BH5 2DF

This report examines the usefulness of secondary intervention pain management techniques in helping people with musculoskeletal disorders (MSD’s) to stay at work or get back to work in the early stages of an episode. The methodology adopted was mainly that of narrative review to present the latest evidence and authoritative evidence-based guidance addressing such measures and barriers to their implementation. Care Pathways, consistent with our findings, are proposed.

The Pathways are for use in the first few weeks of an episode that threatens, or causes, work loss. They are for employees, employers and (if necessary) health professionals, where the latter can provide assessment and evidence-based intervention within one week of request. The evidence was variable in quality across the spectrum of MSDs, with upper limb disorders in need of the greatest development. As well as effective care for these disorders, we have taken into consideration their natural history and barriers to positive outcome.

This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.

HSE BOOKS

© Crown copyright 2005

First published 2005

All rights reserved. No part of this publication may bereproduced, stored in a retrieval system, or transmitted inany form or by any means (electronic, mechanical,photocopying, recording or otherwise) without the priorwritten permission of the copyright owner.

Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to hmsolicensing@cabinet-office.x.gsi.gov.uk

ii

ACKNOWLEDGEMENTS

We are grateful to the following experts who gave generously of their time to provide critical commentary on the care pathways contained in this report: Kim Burton, Nick Kendall, Bob Mootz, Margarita Nordin, Jane Reeback, Inger Scheel, Linda Stone, Gordon Waddell, and Mary Wyatt. We also wish to thank the Musculoskeletal Process of Care Collaboration: Dawn Carnes, David Evans, Nadine Foster, Suzanne Parsons, Tamar Pincus, Martin Underwood, and Steve Vogel for reviewing sections of the report and Clive Osmond for providing statistical advice. None of the above bear any responsibility for what we have written.

iii

iv

CONTENTS

ACKNOWLEDGEMENTS iii

EXECUTIVE SUMMARY vii

1. INTRODUCTION 1

2. RATIONALE FOR EARLY INTERVENTION 3

3. CULTURE AND PAIN 5 3.1 JOB CULTURE 5 3.2 ETHNICITY 5

3.3 GENDER 7

4. PAIN PHYSIOLOGY 9

5. PREDICTORS OF OUTCOME 115.1 MUSCULOSKELETAL DISORDERS GENERALLY 11 5.2 BACK PAIN 11 5.3 NECK PAIN 13

5.4 UPPER LIMB DISORDERS 14

6. SUMMARY OF CURRENT GUIDELINES, SUBSEQUENT REVIEWS 17 AND RESEARCH

6.1 GUIDELINES: MUSCULOSKELETAL DISORDERS GENERALLY 17

6.2 BACK PAIN – GUIDELINES 17 6.3 BACK PAIN - SUBSEQUENT REVIEWS AND RESEARCH 21 6.4 NECK PAIN AND UPPER LIMB DISORDERS

– GUIDELINES 22 6.5 NECK PAIN AND UPPER LIMB DISORDERS

– SUBSEQUENT REVIEWS AND RESEARCH 27 6.6. OTHER MUSCULOSKELETAL DISORDERS 31 6.7. SUMMARY OF CURRENT THINKING 31

7. PROSPECTS FOR IMPROVED CARE 33

8. CARE PATHWAYS AND CLINICAL MANAGEMENT 37 8.1. THE GENERIC CARE PATHWAY 37 8.2. THE EMPLOYER PATHWAY 38 8.3. THE EMPLOYEE PATHWAY 38 8.4. HEALTH PROFESSIONAL PATHWAY 398.5. LINKS BETWEEN THE THREE PATHWAYS 39

v

9. EARLY INTERVENTIONS BY MUSCULOSKELETAL 41 PRACTITIONERS 41 9.1. TRADITIONAL CASE MIX AND INTERVENTIONS 41 9.2. PSYCHOSOCIAL CHARACTERISTICS OF PATIENTS 41 9.3. ATTITUDES TO ANALGESIA 43 9.4. IMAGING 43 9.5. REACTIVATION 43 9.6. GUIDELINE CONSISTENT ATTITUDES GENERALLY 44 9.7. CO-MORBIDITY 44 9.8 PREVIOUS OCCUPATIONAL AND NHS USE OF

MUSCULOSKELETAL PRACTITIONERS 45 9.9. A COMMON INTERVENTION PACKAGE 46 9.10. ACUTE BACK PAIN 48 9.11. MANIPULATION, MOBILISATION AND SOFT

TISSUE TECHNIQUES 48 9.12. ADVICE AND PSYCHOSOCIAL INTERVENTIONS 49

10. SUMMARY POINTS AND GENERAL RECOMMENDATIONS 51 10.1. EMPLOYERS 51 10.2. EMPLOYEES 51 10.3. HEALTH PROFESSIONALS 51

11. REFERENCES 53

APPENDIX 1: THE CARE PATHWAYS 69 APPENDIX 2: PAIN RELIEF INFORMATION 73 APPENDIX 3: THE ATTITUDES TO BACK PAIN SCALE 75

GLOSSARY (Professional bodies and health regulators with registers ofmusculoskeletal practitioners) 77

vi

EXECUTIVE SUMMARY

Purpose of the work • The aim of this study was to establish the usefulness of early pain management

techniques in helping people, within the first 2 weeks of the onset of symptoms of an MSD, to stay at work or get back to work by: • presenting the latest evidence and authoritative evidence-based guidance

addressing these measures and barriers to their implementation • proposing care pathways that are broadly consistent with the evidence.

The role of physiology, culture and ethnicity • The main consideration in early pain management is to control pain while avoiding

withdrawal and inactivity. Job culture has more to do with this than ethnicity or gender.

• Negative neurophysiological interactions between pain and stress promote an environment that can sustain disability and absenteeism, whereas continued activity and involvement along with positive expectations oppose it.

Predictors of outcome • Social isolation, dissatisfaction in the workplace and multiple co-morbidities

(especially musculoskeletal ones) are probably the most consistent psychosocial factors associated (albeit usually only moderately) with the occurrence, duration of absence and future disability from non-specific musculoskeletal disorders. A high level of pain at the beginning of an episode is an important physical predictor. However; • Neck pain has a higher incidence and influence on work in women and in

people with previous significant injury. • Combinations of physical load factors are implicated in tenosynovitis or

peritendonitis of the wrist or forearm, but imprecise measurement of exposure makes this association undependable.

• Most of these predictors are in the low to moderate range and are not necessarily independent factors.

• Interactions with other life factors, such as social inequality, mental disorders, non-work activity and poor health may confound these associations.

Back pain – Evidence-based guidance and subsequent research • The most recent and authoritative multidisciplinary evidence-based guidelines for

acute low back pain management are from Europe and Australia. These present consistent messages that for work-related problems, early intervention should be a collaborative approach that includes the employer in:

Assessment • Diagnostic triage (Nonspecific conditions, serious pathology or root pain) • Psychosocial assessment • Reassessment

vii

Interventions for acute non-specific back pain (95% of cases) • Information, reassurance and advice to stay active • Adequate pain control • Manual therapy if not improving • Multiple interventions involving the workplace if no improvement • Temporary modified work if needed

• Recent reviews and research into early intervention for back pain emphasise the importance of worker empowerment, biopsychosocial rehabilitation and the value of combining guideline-recommended interventions.

Neck pain – Guidelines and subsequent research • There is less evidence upon which to base care decisions for neck pain than for back

pain, and much less for upper limb disorders. The most authoritative recent guidelines are from Australia, Sweden, Finland and the United States. An additional US neck pain guideline is under development

• For neck pain, current thinking, (albeit in a climate of largely inconclusive evidence) supports a very similar approach to that found in back pain guidance.

Shoulder pain – Guidelines and subsequent research • For shoulder pain, there is some support for combined interventions including

active exercises, stretching and hot and cold. There was tentative evidence for ultrasound for calcific tendonitis but not for any other shoulder disorder.

Upper limb disorders – Guidelines and subsequent research • For other upper limb disorders, current thinking focuses more on work

modifications and physical and mental reconditioning than on treatment, however, there may sometimes be value in the following treatments for resistant problems: • Rotator cuff tendonitis – subacromial steroid injection • Lateral epicondyitis – topical NSAID • Carpal tunnel syndrome – individual exercises/keyboard adaptations

Prospects for improved clinical care • NHS primary care, although at the forefront of the opportunity for early

intervention, is not generally well configured to implement the changes needed for early evidence-based intervention on biopsychosocial principles.

• Lack of awareness, inconsistent leadership, competing priorities and lack of ongoing support and commitment are common employer barriers.

• Musculoskeletal practitioners (chiropractors, osteopaths and musculoskeletal physiotherapists) are well placed for early evidence-based intervention, but their more traditional approaches may require modification.

Conclusion: Latest evidence and current thinking supports the use of biopsychosocial assessment and intervention in close proximity to work for improved early management of musculoskeletal disorders. The employer and employee have the main roles in this and musculoskeletal practitioners (chiropractors, osteopaths and musculoskeletal physiotherapists) are the most accessible qualified health professionals to support them.

viii

RECOMMENDED CARE PATHWAYS FOR EARLY MANAGEMENT OF MUSCULOSKELETAL DISORDERS

GENERIC CARE PATHWAY

Scope: Any new episode of any musculoskeletal pain that interferes with work and lasts more than a day or two if severe, or up to a week if not severe.

Note: Over-reaction to mild or resolving episodes should be avoided.

STAGE 1: Within one week from onset:

Initial discussion, assessment and planned action with employer or their services

Activity modification considered

Involvement of health professional (if concerned)

STAGE 2: Within two weeks from onset if not recovered:

Reassessment and revised action plan for recovery

Monitoring and amendment of staged recovery plan - together with employer and with particular attention to activity and function (as distinct from pain alone)- until recovery

achieved.

ix

EMPLOYER PATHWAY

Employees need to be aware of the employer’s desire to help and their policy of encouraging early discussion. The starting point for this is a key message to all employees to the effect that; “If you are having problems working because of pain in your back, neck, shoulders, arms or anywhere else, we want to help. Come in and talk to us!”

Employers also need to be aware of who is off work and why. There needs to be a ‘case manager’* at work who monitors progress, plus a standing group who address persistent reasons for absence.

STAGE 1: Within one week from onset:

Initial discussion of the problem, its nature and planning initial action with the employee (record notes for future monitoring)

Listening to the employee Employee story and concerns, nature of problem, any associated problems or

unhappiness at work, level of job demands and of personal control at work. Whether off work/having difficulty at work for non-work reasons, duration of current episode,

improving, worsening or fluctuating course, aggravating and relieving factors, other health problems, employee beliefs and expectations about work in general, about

specific work issues and recovery.

Reassurance and information Positive messages and assurance of value to organisation, commitment to overcoming the problem and why it is best to remain at work if possible. Information giving (e.g. Back Book), reasons to consult appropriate health professional (e.g. for pain control,

problem-solving, uncertainty or worry). Be willing to arrange temporary activity modification, job rotation or job sharing. Do a risk assessment and reach agreement

on a plan for recovery that includes initial work-related changes. Arrange a follow-up discussion.

STAGE 2: Within two weeks from onset if not recovered:

(Input from chiropractor, osteopath or musculoskeletal physiotherapist if needed)

Review and if necessary amend work activity modifications, again considering job rotation or job sharing.

Monitor, review and modify the plan for recovery with employee (and health professional if involved), with particular attention to activity and function, until full

recovery.

*This could be an occupational health practitioner, the personnel officer or the employer themselves, depending on the size of the organisation.

x

EMPLOYEE PATHWAY

STAGE 1: Within one week of getting the problem (it’s best to get in early!)

Most muscle and joint problems are harmless and clear up on their own (– and of course many have nothing to do with work or injury). If they need care, they respond best to a plan for recovery that is started early. In these cases, good recovery is more likely if you can control the pain, stay at work (even if you have some pain), and keep

active, perhaps with modified activities.

Tell your employer, line manager or human resources manager about the problem and discuss the effect of your activities and work.

If you are worried, consider whether you should make an appointment to see a health professional at work (if available), or a chiropractor, osteopath or musculoskeletal

physiotherapist in the community who can provide effective physical treatments, advise you on what kind of changes to make to your activities and help you to manage your

condition*. Arrange a follow-up discussion with your employer or other manager within the next week to check progress.

STAGE 2: If you have not recovered within two weeks of getting the problem:

Do not be discouraged! Make a plan to overcome the problem, using pain control and, if necessary, modified activities at work and/or other treatment. Make this together with

your employer and (if applicable) the health professional you are seeing.

Check with these people regularly that the plan is working and that your activities at work are increasing by stages. If not, reconsider your strategy together.

*You may have to pay for this.

xi

HEALTH PROFESSIONAL PATHWAY

(i.e. an occupational health practitioner at work or a chiropractor, osteopath or musculoskeletal physiotherapist at work or outside of work)

STAGE 1: First attendance with the health professional

Assessment Conduct diagnostic triage leading to a working diagnosis. Refer to secondary care if

serious pathology, systemic disorder or progressive neurological disorder is suspected. If not, decide if there is a specific diagnosis (e.g. DeQuervain’s tenosynovitis) or if the

problem is non-specific. Assess for other health problems (including other musculoskeletal disorders), psychological barriers (such as illness behaviour or low

mood) and social burdens (such as family pressures or poor housing). Become conversant with the person’s job demands, personal control at work and non-work

activities. Check that they feel supported at work and that things are going well there and at home.

Intervention Provide reassurance, information, and pain control and agree an initial re-activation

strategy with time-limited, specific activity modifications to facilitate the person’s presence at work. Seek agreement to involve (rather then simply inform) the employer

if necessary. Avoid unnecessarily attributing the problem to injury or mechanical derangement, but for conditions where there is evidence of its effectiveness, consider

using manipulative treatment to reduce pain and disability early.

Initiate Care Plan Plan for recovery, taking other health, work or social problems into consideration.

Agree staged re-activation with personalised and specific work-related activities with employee and employer. Monitor recovery, with particular attention to activity and

function. Report your findings to the patient’s general practitioner.

STAGE 2: Within four weeks from first attendance (if still not recovered):

Review Review and modify the plan for recovery of activity and function with the employer and employee. Review the role of societal factors, general health, exercise and activity in longer- term recovery and secondary prevention. If not recovering, consider initiating

an exercise program at work or other work-based intervention

xii

1. INTRODUCTION

The HSC and HSE have established a Musculoskeletal Disorders (MSD) Priority Programme as a means of contributing to a 30% reduction in days lost from workplace injuries and work-related ill-health by 2009-10. As part of the Priority Programme, a research agenda has been developed, which includes as part of its continuous improvement, the aim; ‘To understand how best to develop a culture of good practice including use of collaboration and partnership working to ensure continuous improvement in tackling MSDs.

Musculoskeletal disorders (MSDs) and stress are the most commonly reported types of work-related illness (HSE-Statistics, 2004), representing around three-quarters of cases. In 2001-2, an estimated 1,108,000 people suffered a musculoskeletal disorder that they thought was caused by or made worse by their current or past work. Although there is evidence of a decrease in the incidence of musculoskeletal disorders since 2001-2, there has been no decrease in their prevalence. The purpose of this report is twofold:

1. to present the latest evidence and authoritative evidence-based guidance addressing the usefulness of secondary intervention pain management techniques in helping people with MSDs to stay at work or get back to work, and

2. to propose Care Pathways consistent with that evidence.

The Care Pathways proposed are meant to be applicable to all employees, whether or not their organisation has occupational health support. In addition, we will present some of the contextual evidence relating to barriers to reducing current prevalence in terms of inherent environmental risks and current health care practices and provision.

The quality of evidence and subsequent authority of evidence-based guidance on early pain management for musculoskeletal disorders cannot be expected to be uniform. A small number of high-impact, non-specific conditions (notably non-specific back pain) have been studied more extensively than the many specific conditions that do not individually have as high an influence on disability and work loss. This means that they will lag behind in the amount and quality of evidence available in the literature. This report will present published authoritative guidance, even where this evidence is lacking, but more for completeness than to support recommendations for care.

1

2

2. RATIONALE FOR EARLY INTERVENTION

Why should early intervention be prioritised? Whether or not early intervention would produce better outcomes is difficult to investigate. This is partly because groups being compared may have unknown characteristics that affect outcome and partly because most musculoskeletal episodes do not last long anyway. However, from the back pain evidence that dominates the research in this area, two things are clear; first, return to work is much less likely if longer-term absence has already occurred (Clinical Standards Advisory Group [CSAG], 1994) and secondly, changes related to determinants of disability, quality of life and chronic disability can appear by 14 days after onset, supporting a policy of early assessment (Kovacs et al., 2004). Once pain has become chronic, there are neurophysiological mechanisms, notably central sensitisation (Melzack, 1999) and dorsal horn windup (Mannion and Woolft, 2000) that can perpetuate it.

Most episodes improve considerably within 1 month (Shekelle, 2003) and treatment alone does not necessarily improve outcome beyond a condition’s natural history (Indahl et al., 1995). For those who do not recover well, improvement in terms of pain, disability and return to work seem to change little after 3 months (Pengel et al., 2003) by which time fear of returning to previous activities can have increased (Grotle et al., 2004). Recovery then becomes more of a challenge. For this reason, and in the light of ongoing research into factors that may predict a poor outcome (Boersma and Linton, 2005), it seems sensible to act early and appropriately when problems are first encountered (Linton, 2000), especially with high-risk patients (Valat, 2004). However, there is a considerable body of expert opinion, with continuing support from recent research, that successful early intervention does not necessarily depend on treatment. The following are examples:

• A study by the Department of Social and Family Affairs in the Republic of Ireland (Leech, 2004) reported a 40% reduction in acute low back pain claims progressing to long duration when given early triage-type assessment and advice alone.

• A Scandinavian study of people attending chiropractors for low back pain found that they were twice as likely to be pain free by the 4th visit if their pain episode was of less than 6 months’ duration (Leboeuf-Yde et al., 2004).

• Comparing strategies in two Canadian companies, Lemstra and Olszynski (2004) found that if early intervention consisted of encouragement and reassurance at work, with modification of duties, the incidence of injury claims, duration and costs were lower than if case management passed to clinicians operating an early treatment intervention package.

• A 4.6-year follow-up survey of 300 injured workers in the US (Robinson et al., 2004) found that pain intensity, disability status and health-related quality of life did not differ significantly at follow-up between multi-disciplinary pain centre treatment and evaluation only.

• A systematic review of determinants of disability following low back injury (Crook et al., 2002) found that referral to clinics geared to occupational injuries within 30 days predicted faster return to work.

These are examples of a new approach and meaning of rehabilitation, that include psychological and social, as well as medical aspects. This involves including the use of practical considerations and personal, emotional, societal and work-related factors to promote recovery (Waddell and Burton, 2005). The scientific evidence about how best to intervene is improving slowly, and there are many gaps in our knowledge about the effectiveness of specific approaches. Current understanding of what predicts good and bad outcomes is founded on an increasing number of better quality systematic reviews and prospective cohort studies, but these do not necessarily reveal the risks in isolation. Reviews of the literature are limited by the

3

heterogeneity in interventions, patient populations, outcome measures and definition of what constitutes a given condition and exposure to a given risk. For lack of good evidence to support biomedical predictive factors, the early interventions currently recommended are more along social and occupational lines. The only exception to this is the very small proportion of sufferers with serious medical conditions.

This form of early intervention means continued activity, involvement and coping, promoted in the first instance by family, friends and employers and, only if there is concern or no improvement, by clinicians. It is focussed on reassurance and empowerment, to head off negative beliefs and behaviours, withdrawal from activity and physical deconditioning (Vlaeyen et al., 1995) (Fig 1). This combination of factors may apply when there is withdrawal from the workplace (Severeijns et al., 2005).

Figure 1 Cognitive-behavioural model of fear of movement/(re)injury Vlaeyen et al, 1995 (reproduced with kind permission of Elsevier, Netherlands)

4

3. CULTURE AND PAIN

3.1. JOB CULTURE

Industrial management styles and work practices have an influence on musculoskeletal disability. Stress at work, pieceworking and poor working conditions are also linked to absence due to these disorders. In the early management of musculoskeletal disorders, low job decision latitude and dissatisfaction are important considerations in recovery (Table 1). This suggests that innovative ways of enhancing workers’ range of opportunities to contribute, based on their individual strengths, would be a helpful cultural shift in industry (Hague et al., 2001).

3.2. ETHNICITY

In the UK, ethnic minority groups represent almost 5% of the total population (IASP, 2002; Lasch, 2002). A review of pain amongst ethnic minority groups of South Asian origin (Njobvu et al., 1999) found a higher likelihood of visiting a general practitioner than in people of British origins (although consultation rates vary considerably in different regions of the UK). However, a second review of factors associated with protracted work absence from back pain (Truchon and Fillion, 2000) did not support age, gender, ethnicity or education as predictors.

Fewer people in UK ethnic minorities are thought to present with musculoskeletal symptoms, even though conditions like low back pain seem to be more prevalent in Pakistanis living in England than in Pakistan (Njobvu et al., 1999). When Asian and African-Caribbean people do seek help from UK primary care, pain may be less focussed to specific anatomical regions of the body (Allison et al., 2002), making care sometimes more challenging.

In a subsequent qualitative study (Rogers and Allison, 2004), descriptions from a sample of South Asians in Britain suggested less demarcation between pain located in specific parts of the body and broader social and personal concerns. Help from family members was referred to more than individual strategies of managing pain. Musculoskeletal pain in ethnic minorities may also be associated with poorer housing and low income however (Njobvu et al., 1999). Given the association between musculoskeletal pain and distress (Pincus et al., 2002), newer arrivals may suffer this more than those who have had the time to become used to their new country.

5

Table 1 Summary of recent reviews and research into predictors of absence, duration of absence and future disability from musculoskeletal disorders

Occurrence of absence Duration of absence Future disability

Crook et al. (2002) older age Back pain radiating pain (review) previous episode

job problems functional disabilities

Evans, Mayer & Gatchel (2001)Back pain (cohort study)

Pincus et al. (2002) Back pain (review)

Steenstra (2004) specific LBP Back pain higher disability (review) social isolation

older age female gender social dysfunction heavier work higher compensation

van den Heuvel high disability et al. (2004) low co-worker support Back pain low job satisfaction (cohort study)

Burton et al. psychosocial distress (2005) low job satisfaction MSDs lack of social support (cohort study) attribution of problem to work

reduced control adverse organisational climate

Truchon & Fillion previous episodes (2000) low job satisfaction Back pain negative attitudes to LBP (review) radiating pain

negative coping

older age radiating pain

low job satisfaction widespread pain

previous episodes

non-work-related health conditions

higher disability greater job stability

distress depression,

low mood

high disability low co-worker support low job satisfaction

6

3.3. GENDER

Gender-related cultural issues may also contribute important pain factors. In a primary care qualitative study of women with musculoskeletal pain in Sweden (Johansson et al., 1999), bodily symptoms signalled loss of control. The explanatory models referred to physical damage and strain injuries, but were also psychological and self-blaming. The consequences of pain were described as negative consequences for the women’s everyday lives that challenged their self-perception as women. Participants' search and need for legitimization of their illness experiences, and the expectations placed on doctors as legitimizing agents were evident. Pain was expressed in terms of patients' gendered concerns and psychosocial circumstances. Gender and other physical factors can also combine. For example, female asylum seekers may suffer musculoskeletal pain related to dietary deficiency (de Torrente de la Jara et al., 2004).

One systematic review (Linton, 2000) found abuse to be a potentially significant factor in back and neck pain in women. A further study (Hamberg et al., 1999) explored experiences of abuse in a group of women suffering from long-term biomedically undefined long-term musculoskeletal pain. The women gave hints of abuse before avowing it. An understanding listener, who was expected to apprehend the hints, ask about abuse and confirm that it was valid to talk about it, was described as a precondition for disclosure. The authors concluded that it is important to explore woman abuse when investigating and treating musculoskeletal disorders, but carers must consider carefully the danger involved.

7

8

4. PAIN PHYSIOLOGY

Recent evidence supports a conceptual framework for understanding the relationship between pain and stress. This crosses a number of clinical conditions (Melzack,1999), including the group of musculoskeletal disorders considered here. Devereux et al (2004) found high job stress to be an intermediate factor and perceived life stress to be a possible independent factor in the development of musculoskeletal complaints.

The “neuromatrix theory of pain” extrapolates from the premise that pain is a multidimensional experience. The body systems involved, principally i) the sensory nervous system, ii) the cognitive and affective functions of the brain, iii) its neural modulating and inhibiting systems, and iv) endocrine and other chemical effects, as well as the individual’s genetic makeup, combine to influence recovery from painful experiences. In terms of the management of musculoskeletal disorders, the neuromatrix theory suggests that there is a synergy between musculoskeletal pain and emotional stress that can work against recovery. This supports the rationale for early reduction of anxiety and distress as an integral part of rehabilitation (Waddell and Burton, 2004). The main dimensions of the pain experience (Fig 2.) are the sensory-discriminative (S), the affective-motivational (A) and the evaluative-cognitive (E). These are influenced by somatosensory, limbic and thalamocortical components, which are accessible to external intervention (or insult).

Figure 2 The Neuromatrix Melzack, 1999 (reproduced with kind permission of Guilford Publications, New York)

For musculoskeletal disorders in the presence of stress, activity is thought to be a key element in pathophysiological progression (Melzack, 1999). Broadly, a stress response that is protracted and concurrent with musculoskeletal pain can cause sensitisation of the central nervous system (Ursin and Eriksen, 2001) and could be a catalyst not only for ongoing symptoms, but for actual muscle and bone destruction. The latter is largely related to cortisol output, which mobilises glucose for rapid energy access, plus the release of cytokines (chemical pain stimuli) from tissue

9

strain or inflammation. Activity in the form of exercise takes up the glucose, inhibits cortisol release and dilates blood vessels, reducing local cytokine concentrations and peripheral pain stimuli. By contrast, prolonged inactivity in the presence of stress raises blood pressure, narrows arteries, causes immuno-suppression, promotes tissue tenderness and sensitivity and can cause anxiety and depression. The perpetuation of stress in this way has been termed an adverse ‘neurosignature’ (Melzack, 1999), although evidence for these associations is not entirely consistent. A systematic review of studies of the relationship between recovery from physical and mental tasks and circulating levels of adrenaline and cortisol (Sluiter et al., 2000) found no conclusive evidence of such a relationship in occupational settings (unlike in sports settings). This may be because it only applies to some occupations.

Consistent with this, Harris (1999) proposed that even disorganised or inappropriate cortical representations of proprioception, signalling incongruence between motor intention and actual movement, can result in centrally-generated pain akin to that experienced in phantom limb pain. This applies to musicians, writers and keyboard operators and may be amenable to activity modification and retraining.

Depression and low mood are moderate predictors of chronicity in low back pain (Pincus et al., 2002) and a recent population-based study (Chui et al., 2005) has linked this and poor sleep to a reduced pain threshold. However, Lepine and Briley (2004) suggest that lack of clarity over the effect of depression on existing pain, and of pain on existing depression, demands that treatment of depressed people who also have pain must address the psychological, somatic and physical symptoms to be optimal. This conclusion seems to sit well with the neuromatrix theory.

The neuromatrix concept also supports a rationale for combining reactivation with reassurance in management and a possible link between severity of initial musculoskeletal pain and persistent pain later (Dworkin and Portenoy, 1996). It may also help to explain the placebo effect when expectations of positive outcome are generated. Tubach et al (2002) found that positive expectations of recovery, along with social support at work, were associated with earlier return to work and reduction in pain and functional capacity in people with acute low back pain.

Vase et al (2005) also found that repeated placebo analgesia in people with irritable bowel syndrome is associated with positive desires and expectations, but not with endogenous opioid mechanisms, tending to confirm the potential of positive emotions in suppressing pain (Rainville, 2004). The reverse effect has been observed in that the anticipation of pain evokes increased activity in the primary somatosensory cortex of the brain (Porro et al., 2002). This may partially explain the importance of pain-related fear and whether it is fear of pain or fear of activity that is paramount in the prediction of poor outcome (Vlaeyen and Linton, 2000). However, a recent study failed to find any predictive relationship between pain-related fear in the early stages of a low-back episode (<3 weeks from onset) and the persistence of pain at 3, 6 and 12 months (Sieben et al., 2005).

A recent systematic review of studies examining beliefs and expectations of people with chronic musculoskeletal pain and their primary care practitioners (Parsons et al., 2005) found evidence that a desire by patients and carers alike to avoid dissonance in the doctor-patient relationship was an important issue. This highlights the role and possible effects of this relationship on the pain experience and its outcome (Dekkers, 1998).

10

5. PREDICTORS OF OUTCOME

5.1. MUSCULOSKELETAL DISORDERS GENERALLY

Burton et al (2005) conducted a large prospective study of employees in a pharmaceutical company, measuring one psychological factor (distress) and 6 work-based psychosocial factors at baseline, and their prediction of spells and length of spells of absence attributable to musculoskeletal disorders 2 years afterwards. For all musculoskeletal disorders, higher proportions of those in manual work, and to a lesser extent older age and male gender, had previously taken such sick leave. With the exception of home-work balance, mental stress and attribution of back pain to individual factors, all psychosocial scores at baseline were modestly, but significantly higher in those who subsequently took absence. Foremost among these were job satisfaction, inevitability beliefs about low back pain, relationships at work and perceived exertion. All 6 factors investigated (psychosocial distress, job satisfaction, lack of social support, attribution of the problem to work, reduced control and adverse organisational climate) had an association with the occurrence of work absence, (with modest odds ratios between 1.6 and 2.8). The duration of subsequent absence was not convincingly predicted by the presence of psychological distress and any of the occupational psychosocial factors, with the exception of older age. However, even this could be explained by interactions with other, undisclosed factors, such as general health and previous episodes. The mean psychosocial score differences in Burton et al’s study (2005), were much fewer, and less pronounced for neck pain and upper limb disorders than for back pain, but lack of numbers taking sick time may have influenced this.

For work-related musculoskeletal disability, there is only weak evidence for which psychological factors constitute reliable predictors of poor recovery. Truchon (2001) suggests that combinations of risk factors for poor outcome could comprise the strongest indicator that recovery will be difficult. It therefore seems sensible to be aware of the range of biopsychosocial factors that predominate in the more recent reviews as well as possibly important combinations. The evidence base is not evenly developed for musculoskeletal disorders. Spinal pain research leads in the improvement of methodologies, whilst for upper limb pain syndromes case definitions are only just coming into use (Harrington et al., 1998). Thus clinicians may see the evidence as inconclusive or untested (Ferlie et al., 1999) while retaining substantial autonomy over their work practices. A safe approach to biopsychosocial assessment and management might be alertness to the presence of combinations of important factors and trying to work collaboratively with the main stakeholders in the process.

Acute episodes of musculoskeletal pain may also be recurrent ones and the recurrent nature of the complaint may have important biopsychosocial predictors. A prospective cohort study from the USA (Evans et al., 2001), comparing workers with recurrent and non-recurrent spine-related injury claims, found that the recurrent group had a greater rate of non-work-related health conditions, received higher disability payments, and had slightly greater job demands. This group also had a greater rate of pre-injury Axis I psychiatric disorders, particularly substance abuse/dependence disorders, than the NRI group. In addition, the recurrent group also had greater job stability.

5.2. BACK PAIN

The UK lifetime and one year prevalence of a disabling episode of back pain is 58.3% and 36.1% respectively (Walsh et al., 1992). However, this does not accurately reflect the severity of the episode, or its impact on work or the activities of daily living. Recent reviews of studies

11

into factors that predict new onsets or poor outcomes take either a psychological, psychosocial or a biopsychosocial approach.

A systematic review of psychological predictors of future disability in people who have back pain (Pincus et al., 2002) found these to be generally weak to moderate, with only distress, depression and low mood supported by evidence as reasonable predictors. (Four of the 18 studies reviewed were work-related.) Psychological distress has been found to have high sensitivity, but low specificity as a predictor of future functional limitations (Dionne et al., 2005). However, a list of 7 factors (expectation of return to work, severity, radiating pain, difficulty in getting comfortable, previous back surgery, self-assessed bad temper, disturbed sleep) had better results for predicting success or partial success of return to work at 2 years (Sensitivity 79.0%, Specificity 64.3%) (Dionne et al., 2005). Waxman et al (1998) found in a population study, that those consulting for back pain of more than 3 months’ duration had a greater than average depression score. One argument for early intervention is the desire to avoid the onset of depression if it is not already a factor.

Hoogendoorn et al (2000) reviewed studies of psychological and social factors associated with getting back pain. These are: low workplace support, low job satisfaction and low job decision latitude. A subsequent systematic review of inception cohort studies of workers who were on sick leave for less than 6 weeks (Steenstra et al., 2004) concluded that such factors as having a history of low back pain, degree of job satisfaction, educational level, marital status, number of dependents, smoking, working more than 8 hour shifts, type of occupation and size of company do not influence the subsequent duration of sick leave. Instead, the psychosocial factors predicting longer sick leave were: specific LBP (such as neurogenic claudication), higher disability levels, radiating pain, more social isolation, older age, female gender, heavier work and receiving higher compensation. Of these, only higher disability, social isolation and radiating pain had high effects.

This is broadly consistent with a large prospective cohort study of prognostic factors for back pain recurrence and sickness absence in a variety of worker types in the Netherlands (van den Heuvel et al., 2004). This study also found high disability, low co-worker support and low job satisfaction to be predictors of both recurrence and duration of sick leave, but none of these predictors stand out. A prospective cohort study of 189 Dutch civil servants (Verbeek and van der Beek, 1999) found that pain intensity at baseline was the best predictor of back pain at follow-up.

A Canadian review and update of occupational disability following low back injuries (Crook et al., 2002), was more or less consistent with the above, but included a number of demographic and biological factors in the list of outcomes, as follows: for work-related outcomes, having children at home, being older, having greater disability, having radiating or nerve root pain, and having pain that is worse on standing and lying merit consideration as predictors of poor outcome. Social isolation at work plus the level of disability of the episode suffered seem to be among the stronger predictors of future problems and work absence. Even so, it must be borne in mind that the risks (odds ratios) reported in these studies were not very high.

Truchon and Fillion (2000) carried out a narrative review of 18 studies of biopsychosocial determinants of prolonged work absence from low back pain and proposed that previous history of back problems, perceived inability to carry on with work and job dissatisfaction were promising indicators. Negative attitudes and beliefs about back pain in the early stages were also proposed as factors associated with prolonged absence, but not initial intensity of pain.

One small but carefully controlled inception cohort study (n=113) (Coste et al., 2004), included only subjects with acute low back pain of less than 72 hrs duration and no episodes in the

12

previous 3 months. It examined the interactions between Health-Related Quality of Life (SF­36), recovery and 11 biopsychosocial factors. Delayed recovery was associated with higher baseline disability, lower SF-36 score and temporary compensation status. In the longer term, low back pain only affected quality of life in foreign nationals, patients who already had co-morbidities, had psychiatric disorders, were unemployed or were dissatisfied with their jobs.

Low supervisor support may be a precursor to job dissatisfaction. In a cross-sectional study of young Belgian health care and distribution company workers in their first employment, Van Nieuwenhuyse et al (2004) found that first-ever occupational back pain was also associated with a combination of low psychological job demands and low supervisor support. This study also sought physical risk factors and found 1) long periods of seated work, 2) more than 12 flexion or rotation movements of the trunk per hour and 3) more than 3 years in a job involving lifting more than 25kg at least once an hour, to be weak to moderate predictors of first-ever low back pain at work.

5.3. NECK PAIN

Cote et al. (2004) conducted a large population-based prospective cohort study of the annual incidence and course of disabling neck pain. The authors found a one-year incidence of only 0.6%, of which 36.5% of episodes resolved and a further 32.7% resolved within the year. 22.8% reported a recurrent episode. The incidence of disabling neck pain was 1.67 times higher in women, in whom it was also 1.19 times more likely to persist and only 0.75 times as likely to resolve as in men. In working populations, the risk may be higher. A prospective cohort study found the 3-year incidence of neck/shoulder symptoms to be 24% and identified high job demands as a weak, but significant risk factor (RR 2.1; CI:1.2-3.6) (van den Heuvel et al., 2005).

Enthoven et al (2004) conducted a 5-year follow-up study of back and neck pain in primary care and found that half of people have some clinically important level of pain and disability at that interval, and are consuming health care for it.

A questionnaire study of 558 Austrian office and computer workers (Tilscher et al., 2005) also concluded that women experience more severe headaches, neck pain and arm pain than men, earlier in the course of work sessions and associated with fatigue. However, perceptions also appear to have some influence on the development of neck pain. A study of VDU users (Wahlstrom et al., 2003) found that those who had high job strain and perceived they had high levels of muscular tension were more likely to develop neck pain at follow up. The pattern of exacerbations and remissions of neck pain episodes seems to be similar to that of back pain (Thomas et al., 1999).

There is some evidence for a relationship between the onset of neck pain and physical risk factors such as posture and duration of sitting (Ariens et al, 2000) and psychosocial risk factors such as high job demands, low control, support and job satisfaction (Ariens et al., 2001a; Ariens et al., 2001b). These factors do not, however, predict work loss. There is also little evidence linking pushing and pulling tasks to musculoskeletal disorders other than back pain (Hoozemans et al., 1998).

A study by Hoving et al (2004) investigated perceived recovery, pain intensity and neck dysfunction in 183 general practice patients with neck pain of at least 2 weeks duration, 7 and 52 weeks later. Only older age and concurrent back pain were consistent, if moderate, predictors of these although previous trauma and previous neck pain were weak predictors. A prospective study by Croft et al (2001) found that previous significant injury was an independent and distinct risk factor for subsequent episodes.

13

The credibility of the term “whiplash injury” has been brought into serious doubt by lack of objective evidence linking structural change to the development of chronic pain (Stovner, 1996), despite reports of disc protrusions in small numbers of severe cases (Jonsson et al, 1994). This may not have as high an impact on work loss as in work-related injuries. An Australian review (Athanasou, 2005) found that return to work rates after “whiplash” and other motor vehicle accidents were considerably higher than after back injuries and other work-related accidents.

5.4. UPPER LIMB DISORDERS

The number of named conditions involved, uncertainty over the criteria for their case definitions, difficulty with quantification of exposure factors and lack of evidence for independent risk factors are reasons why sufficient prospective studies predicting outcome and treatment effects have been slow to appear. The problems of classification are formidable (Katz et al., 2000) and the view from primary care is often for simpler models more aligned to the back pain model until better prognostic information comes forward (Croft, 1999). Such is the debate even about the ergonomic work-relatedness of these disorders that the importance of exposure factors, especially relative to non-occupational causes is still in dispute (Punnett and Wegman, 2004). These authors, however, concluded that the etiologic importance of occupational ergonomic stressors for the occurrence of MSDs of the low back and upper extremities has been demonstrated.

Meaningful case definition work has now been done and has begun to be used. Harrington et al. (1998) have provided consensus-based case definitions for carpal tunnel syndrome, tenosynovitis of the wrist, De Quervrain’s syndrome, adhesive capsulitis and tendonitis of the shoulder and Helliwell et al. (2003a) have developed a classification system based on 30 variables for the same conditions, plus fibromyalgia and non-specific upper limb disorder.

An examination schedule has also been developed (Palmer et al., 2000). This tool is reported to have high inter-observer agreement - but the occurrence of such symptoms may also vary greatly according to exposure. Measurement of exposure has been found to be very imprecise (Svendsen et al., 2005), making reliable risk information difficult to obtain and perhaps accounting for the weak predictive associations of factors such as high job demands and low social support.

Viikari-Juntura (1998) summarised the epidemiologic evidence of associations between physical load and individual factors and disorders of the upper limb. Only associations with age for rotator cuff tendonitis and vibration for carpal tunnel syndrome were considered to be strongly supported by evidence. Combinations of physical work load factors have been implicated in tenosynovitis or peritendinitis of the wrist or forearm and in carpal tunnel syndrome. A large cohort study of unskilled workers doing continuous repetitive upper limb work (Bonde et al., 2005) found no association between such activities and psychological stress symptoms alone. The same research group (Bonde et al., 2003) had previously concluded that in the course of recovery from shoulder tendonitis, physical workplace exposures and perceived psychosocial job characteristics in the period preceding diagnosis seemed not to be important prognostic factors.

For lateral epicondylitis, an inception cohort study by Waugh et al. (2004) found that women and patients who report nerve symptoms are more likely to experience a poorer short-term outcome after physiotherapist management. Work-related onsets, repetitive keyboarding jobs, and cervical joint signs had a negative prognostic influence in women. A randomised trial of general practice and physiotherapy versus information giving, advice to stay active and graded, unsupervised exercise for this condition (Haahr and Andersen, 2003a) found that poor prognosis

14

at 1 yr follow-up was related to manual work and high baseline pain, whilst no relation was found between the type of medical treatment given and prognosis. This may have implications for the future management terms of a greater focus on interaction with the workplace regarding job modification to reduce physical demands during recovery. The same authors also reported on a general practice population (Haahr and Andersen, 2003b), where being a new case suffering from tennis elbow was associated with having had to adopt non-neutral postures of hands and arms, use of heavy hand held tools, and high physical strain. (The latter measured as a combination of forceful work, non-neutral posture of hands and arms, and repetition.) Tennis elbow among women was also associated with low social support at work.

The 3-year incidence of elbow/wrist/hand has been reported at 15% (van den Heuvel et al., 2005), with high job demands (RR: 1.9; CI: 1.0-3.7) and low social support of co-workers (RR: 2.2; CI: 1.0-4.9) identified as weak but significant risk factors for first onset. Both factors had interactions with stress symptoms. MacFarlane et al (2000) had previously found from a 2 year population prospective cohort study, that psychological distress, aspects of illness behaviour, and other somatic symptoms are important predictors of one-month prevalence of forearm pain in addition to work related psychosocial and mechanical factors. Future pain was associated with dissatisfaction with the support available from colleagues and supervisors and with repetitive movements of the arm or wrist. A subsequent case-control study into the prevalence of psychological factors in diffuse upper limb pain and the more focal problem of carpal tunnel syndrome (White et al., 2003) found no differences between the two conditions but this study did not include work-based factors.

Key messages:

• There are consistent and over-arching themes in the evidence about prediction of poor outcome from work-related musculoskeletal disorders, but none that are strongly associated with specific conditions. This evidence is less complete, for neck and upper limb disorders than for back pain.

• High exposure to physical stressors, high job demands, multiple co-morbidities and high psychosocial pressures, (the latter especially in relation to dissatisfaction and low social support at work,) seem to be relevant factors. However, none of these are particularly consistent across study populations.

• Improved early pain management should take account of the natural course and job-relatedness (or otherwise) of conditions. Clinicians need to be aware and responsive to psychosocial factors in their management.

15

16

6. SUMMARY OF CURRENT GUIDELINES, SUBSEQUENT REVIEWS AND RESEARCH

6.1. GUIDELINES: MUSCULOSKELETAL DISORDERS GENERALLY

An Australian government guideline group (National Health and Medical Research Council [NHMRC], 2003) developed a multidisciplinary, evidence-based national guideline that addresses acute low back pain, acute thoracic spinal pain, acute neck pain, acute shoulder pain and anterior knee pain. Its consensus panel also considered the key messages needed for the management of acute musculoskeletal pain generally. (Note: this guideline considers ‘acute’ to be the first 12 weeks of an episode.) These general messages are presented under the headings of ‘Acute Pain Management’ and ‘Effective Communication’ and are paraphrased below:

Acute Pain Management: • Develop a management plan comprising:

• Case history and physical examination (ancillary assessment only if serious condition suspected).

• Providing information, assurance and advice about resuming normal activity and other options for pain management as needed (also mentioned under ‘Non-pharmacologic interventions’).

• Reassessing the pain and revising the management plan as required. • Pharmacologic interventions if required:

• Paracetamol or other simple analgesics, administered regularly if pain mild to moderate.

• Non-steroidal anti-inflammatory medication (NSAID) if paracetamol insufficient (unless contraindicated).

• Oral opioids (regular intervals in a short course) for severe musculoskeletal pain.

• (Not recommended: anticonvulsants and antidepressants, routine use of muscle relaxants.)

Effective Communication: • Develop a management plan with the patient - avoiding jargon and alarming

labels. • Provide adequate explanation to overcome inappropriate expectations, fears or

mistaken beliefs. Printed materials may be useful. • Adapt communication to the patient’s needs and abilities and ensure

information has been understood.

These messages have considerable resonance with the other guidelines described in this report.

6.2. BACK PAIN - GUIDELINES

The most authoritative guidelines are for back pain. Collaboration between care providers, employers and social care administrators is strongly recommended in order that the care provider can propose activity modifications that will help people to recover. Incentives for the key stakeholders to engage in this kind of collaboration is encouraged by the European Acute Low Back Pain Guidelines (European Commission [EC], 2004a), but arrangements will vary depending on whether or not there is a clinical occupational health service available and whether the care provider is working in the NHS or private health sector.

17

For primary care providers, the European Commission Guidelines make 6 evidence-based recommendations about assessment and 6 about interventions for people presenting with acute back pain in the first 12 weeks of an episode (EC, 2004a).

Assessments for the diagnosis of acute non-specific low back pain

• Case history and brief examination should be carried out

• If history taking indicates serious spinal pathology or nerve root syndrome, carry out more

extensive physical examination including neurological screening when appropriate

• Undertake diagnostic triage at the first assessment as basis for management decisions

• Be aware of psychosocial factors, and review them in detail if there is no improvement

• Diagnostic imaging tests (including X-rays, CT and MRI) are not routinely indicated for

non-specific low back pain

• Reassess those patients who are not resolving within a few weeks after the first visit, or

those who are following a worsening course

Recommendations for the treatment of acute non-specific low back pain

• Give adequate information and reassure the patient

• Do not prescribe bed rest as a treatment

• Advise patients to stay active and continue normal daily activities including work if

possible

• Prescribe medication, if necessary for pain relief; preferably to be taken at regular intervals;

first choice paracetamol, second choice NSAIDs

• Consider (referral for) spinal manipulation for patients who are failing to return to normal

activities

• Multidisciplinary treatment programmes in occupational settings may be an option for

workers with sub-acute low back pain and sick leave for more than 4-8 weeks

(EC, 2004a)

The European Guidelines also remind us that the risks of individual attacks of low back pain are higher where there is:

• Heavy manual labour • Manual material handling • Awkward postures • Whole body vibration

18

They also provide key evidence based principles for back pain management in the occupational health setting. For people who are in work, these are:

• Recognising that selection at recruitment will not reduce incidence significantly. For example, there is no evidence that clinical examination or diagnostic tests such as X-rays are valid predictors of future risk. Hence they have no place in routine pre-placement screening or selection.

• Understanding that while ergonomic measures will bring some benefits there are no well-validated preventative techniques. This means that some incidents of back pain in any workforce are inevitable.

• Ensuring that the need for an active approach to case management is understood by employees and employers and planning for this in anticipation of future incidents. The educational element in this would include a shared understanding that active management reduces pain and disability and that return to work before the person is pain free will often be the best way of speeding resolution of the discomfort.

• Securing a collaborative approach to case management with primary care providers as soon as possible after an incident of back pain in order to plan an early and effective return to work, with temporary modification to tasks or working arrangements if this is likely to hasten recovery.

• Arranging access to rehabilitation for anyone who has been away from work for more than four weeks.

The implications of this for primary care providers are:

• Giving a patient entitlement to absence from work because of non-specific back pain may be essential in severe cases but should be avoided where possible as it is likely to delay rather than hasten recovery.

• Where there is occupational health provision led by a clinical health professional the provider of primary care is recommended to secure consent from the patient for an early discussion with the occupational health practitioner to agree a shared plan for case management. This should include arrangements for referral for rehabilitation if the pain persists and for prevention of return to work within four weeks.

• Where there is no clinical occupational health service, the primary care provider is recommended to review the options for collaboration on occupational aspects with the patient and liaise as appropriate to ensure that the principles outlined above are followed, if pain persists and prevents return to work.

These guidelines also provide evidence-based advice about prevention (EC, 2004b), not exclusively with a view to preventing the episodes themselves (which is impractical given the ubiquity of non-specific back pain), but the consequences of the episodes, such as disability, work loss and the development of a chronic pain state. From the standpoint of secondary prevention, therefore, its recommendations are shown below:

• Physical exercise is recommended in the prevention of low back pain, in the prevention of recurrence and for the prevention of recurrence of sick leave due to low back pain. There is insufficient evidence to recommend for or against any specific type or intensity of exercise.

• Back schools based on traditional biomedical/biomechanical information, advice and instruction are not recommended for prevention of low back pain. There is insufficient evidence to recommend for or against psychosocial information delivered at the worksite,

19

but information oriented toward promoting activity and improving coping may promote a positive shift in beliefs.

• Lumbar supports or back belts are not recommended. • Shoe inserts/orthoses are not recommended. There is insufficient evidence to recommend

for or against in-soles, soft shoes, soft flooring or antifatigue mats. • Temporary modified work and ergonomic workplace adaptors can be recommended to

facilitate earlier return to work for workers sick listed due to low back pain. • There is insufficient consistent evidence to recommend physical ergonomics interventions

alone for prevention of low back pain. There is some evidence that, to be successful, a physical ergonomics programme would need an organisational dimension and involvement of the workers. There is insufficient evidence to specify precisely the useful content of such interventions.

• There is insufficient evidence to recommend stand-alone work organisational interventions, yet such interventions could, in principle, enhance the effectiveness of physical ergonomics programmes.

• Whilst multidimensional interventions at the workplace can be recommended, it is not possible to recommend which dimensions and in what balance.

Whilst the new European Acute Back Pain and Prevention Guidelines provide us with the most recent, rigorous and widely agreed principles currently available, these are aimed at the European Economic Area generally, and offer no particular context to UK health and occupational scenarios. However, they do agree with another recently published national evidence-based guideline from Australia on all acute musculoskeletal disorders (National Health and Medical Research Council [NHMRC], 2003). This also recommends advising patients to stay active, and providing explanatory material that can empower the patient, [for example, The Back Book (Roland et al., 2002)]. Also common to both guidelines are adequate pain control that using non-invasive methods, the avoidance of imaging in the absence of clear indications of possible pathology and a care plan that is monitored and reviewed.

Prior to the European Commission Guidelines, UK Occupational Health Guidelines for the Management of Low Back Pain at Work (Waddell and Burton, 2000) had already highlighted important additional values that are commended to workers, employers and care providers in the UK. Central to these is the recommendation to advise employers that:

“High job satisfaction and good industrial relations are the most important organisational characteristics associated with low disability and sickness absence rates attributed to LBP”.

This is supported by messages contained in a four-page leaflet that urges a shared understanding between workers, employers and health professionals of the principles, reminding employers that:

• Consultation with workers/trade unions is important when developing measures to combat back pain.

• Ensure that work activities are not making unreasonable physical demands. • Explain that you want to help people recover and encourage early reporting of episodes. • Talk with people who have back pain. Discuss whether their job needs to be adapted.

Consider solutions such as rest pauses, task rotation, handling aids and extra help from colleagues.

• Make contact if people are absent and discuss solutions. • Don’t insist on freedom from pain before someone resumes normal work. • Keep a check on progress and be prepared to make further adjustments.

20

Workers are also advised that:

• Back pain is common and does not necessarily signify damage. • Inactivity can make the problem worse. • Report back pain to your employer if it is causing problems at work. • Work together to overcome the obstacles.

This approach may appear somewhat idealistic and the limitations of occupational guidelines for the management of low back pain have been noted by Staal et al (2003) in an international review. These include lack of attention to organisational barriers and cost implications and are considered further in Chapter 7. However, the main consensus points lie in the advocacy of staying at work or a phased return to it with modified duties if necessary. Reviews and research studies subsequent to these guidelines are gradually adding useful context to the recommendations.

6.3. BACK PAIN - SUBSEQUENT REVIEWS AND RESEARCH

Striking a balance between physical and psychosocial approaches to a new back pain episode can be difficult if it is uncertain which of these is contributing most to the problem. A recent epidemiologic study of nurses (Smedley et al., 2005) found a weak, but significant association between sudden onset back pain and specific patient handling tasks, whereas a gradual onset was significantly associated with psychological symptoms. However, there is little else to guide clinicians in categorising patients outside of a complete case history and assessment that includes psychological and social factors as well as physical ones.

The scientific evidence on the effectiveness of physical activity programs at worksites is still limited (Proper et al., 2002) and, judging from recent systematic reviews of the effect of ergonomic interventions on returning to work and remaining at work (Elders et al., 2000; Hoozemans et al., 1998), these may also need to go well beyond training in working methods. Success in establishing a shared plan with the patient can depend on the degree of satisfaction they feel about their treatment. A recent systematic review of 20 studies (Verbeek et al., 2004) found that being included in the decision-making, with all the interpersonal requirements that are needed for this, is a central factor.

The latest systematic review evidence of exercise therapy for non-specific low back pain (Hayden et al., 2005) did not find it to be any more effective than no treatment in the early stages, although a graded activity program subacute stage (6-12 weeks) may reduce absenteeism. Physical conditioning programs that include a cognitive-behavioural approach, plus intensive physical training (specific to the job or not) to improve aerobic capacity, muscle strength and endurance, and coordination; that are in some way work-related; and are supervised, seem to be effective in reducing the number of sick days for some workers with chronic back pain, compared to usual care. However, there is no evidence of their efficacy for acute back pain (Schonstein et al., 2002). Exercise therapy per se seems to have little or no role in early intervention strategies for back pain.

A systematic review of multidisciplinary biopsychosocial rehabilitation in the management of subacute back pain (4-12 weeks duration) (Karjalainen et al., 2001) found moderate evidence of faster return to work, reduced sick leave and reduced subjective disability compared with usual care. However, this is an expensive approach, involving combining clinical, psychological, social and/or vocational interventions. However, a workplace visit did add to the effectiveness. A recent randomised trial (Wand et al., 2004) compared patients with acute low back pain who all received early intervention in the form of assessment and advice to stay active, but were randomised to the presence or absence of biopsychosocial education, manual therapy and

21

exercise. The latter had significantly less disability at 6 week follow up although not at 6 months. This parallels another recent large trial in which patients with subacute and chronic back pain were randomised to a package of care that included clinical assessment, advice to stay active, plus manipulation and exercise by chiropractors, osteopaths and physiotherapists (UK BEAM, 2004). This was compared with “active management” advice by a GP practice team, including pain control, advice to stay active and the Back Book (Roland et al., 2002). This also showed less disability in the manual therapy group with differences still detected at one year follow-up.

6.4. NECK PAIN AND UPPER LIMB DISORDERS – GUIDELINES

Unlike for back pain, there are few national guidelines and no international consensus for neck pain or upper limb disorders. However, multidisciplinary guidelines on the evidence-based management of acute musculoskeletal pain have been developed in Australia (NHMRC, 2003) and neck pain guidelines are currently being developed by a North American Neck Pain Task Force, due to report by 2007

6.4.1. NECK PAIN

The Australian Guideline (NHMRC, 2003) gives comprehensive guidance for acute neck pain. It suggests in its evidence review that most acute neck pain is non-specific, is most commonly without known cause, and is commonly attributed to a whiplash accident. However, those who get neck pain soon after such an accident are reported to be more likely to develop chronic neck pain. Osteoarthritic change is not to be regarded as a cause or risk factor for chronicity. On the other hand, psychosocial work-related factors are weakly, but consistently associated. These conclusions are based on a relatively small number of surveys and other cohort-type studies and may be tempered by future confirmatory work.

The Australian Guideline also makes several interspersed consensus and low-level evidence-based statements about case-history taking, physical examination, ancillary investigations and appropriate terminology. These are aimed at improving diagnostic differentiation between specific and non-specific acute neck pain and therefore have direct relevance to pain management. The thinking is, if the condition is classified as non-specific, the clinician may bypass the search for a cause and turn attention directly to management and prognosis (Raspe, 2002).

These statements are:

History: • Attention should be paid to the intensity of pain because regardless of its cause, severe

pain is a prognostic risk factor for chronicity and patients with severe pain may require special or more concerted interventions. (Consensus statement)

• The hallmarks of serious causes of acute neck pain are to be found in the nature and mode of pain onset, its intensity and alerting features. (Consensus statement)

• Eliciting a history aids the identification of potentially threatening and serious causes of acute neck pain and distinguishes them from non-threatening causes. (Consensus statement)

Physical examination: • Physical examination does not provide a patho-anatomic diagnosis of acute idiopathic

or whiplash-associated neck pain as clinical tests have poor reliability and lack validity. (Evidence-based statement)

22

• Despite limitations, physical examination is an opportunity to identify features of potentially serious conditions. (Consensus statement)

• Tenderness and restricted cervical range of movement correlate well with the presence of neck pain, confirming a local cause for the pain. (Evidence statement)

Ancillary investigation: • Plain radiography is not indicated for the investigation of acute neck pain in the absence

of a history of trauma, or in the absence of clinical features of a possible serious disorder. (Evidence statement)

• In symptomatic patients with a history of trauma, radiography is indicated according to the Canadian C-Spine Rule. (Decision algorithm for using X-rays to reveal trauma) (Evidence statement)

• Computed tomography is indicated only when: plain films are positive, suspicious or inadequate; plain films are normal but neurological signs or symptoms are present; screening films suggest injury at the occiput to C2 levels; there is severe head injury; there is severe injury with signs of lower cranial nerve injury, or pain and tenderness in the sub-occipital region. (Consensus statement)

• Acute neck pain in conjunction with features alerting to the possibility of a serious underlying conditions is an indication for magnetic resonance imaging. (Consensus statement)

Terminology: • Except for serious conditions, precise identification of the cause of neck pain is

unnecessary. (Consensus statement) • Once serious causes have been recognised or excluded, terms to describe acute neck

pain can be either ‘acute idiopathic neck pain’ or ‘acute whiplash-associated neck pain’. (Consensus statement)

The Australian guideline makes only evidence-based statements (but not recommendations) about pain management approaches to acute neck pain. Four of these have evidence of benefit:

• Advice to Stay Active (Activation) – Encouraging resumption of normal activities and movement of the neck is more effective compared to a collar and rest for acute neck pain.

• Exercises – Gentle neck exercises commenced early post-injury are more effective compared to rest and analgesia or information and a collar in acute neck pain. Exercises performed at home are as effective for neck pain as tailored outpatient treatments at two months and appear to be more effective at two years after treatment.

• Multi-modal Therapy – Multi-modal (combined treatments) inclusive of cervical passive mobilisation in combination with specific exercise alone or specific exercise with other modalities are more effective for acute neck pain in the short term compared to rest, collar use and single modality approaches.

• Pulsed electromagnetic therapy (PEMT) – Pulsed electromagnetic therapy reduces pain intensity compared to placebo in the short term but is no different to placebo at 12 weeks for acute neck pain.

The Guideline lists common interventions for which there is thought so far to be insufficient evidence of effectiveness as single treatments. These are:

Acupuncture, Opioid analgesics, Simple analgesics (eg paracetamol), Cervical manipulation, Cervical passive mobilisation, Electrotherapy, Gymnastics, Microbreaks (regular breaks from computer work), Multi-disciplinary biopsychosocial rehabilitation, Muscle relaxants, Neck school, Non-steroidal anti-inflammatory drugs, Patient education, Spray and stretch therapy,

23

Traction, Transcutaneous electrical nerve stimulation. Only for soft collars was there found evidence of no benefit.

A number of Spanish neck pain guidelines were reviewed by a national group (Saturno et al., 2003) and their quality found to be low. Where such guidelines do exist, they so far address mainly physical treatments and not overall management strategies. However, there are echoes of the recommendations found in the European Guidelines for Acute Low Back Pain (EC, 2004a) in the “Whiplash Book”, for patients, (Waddell et al., 2004) in terms of the need for diagnostic triage, reassurance and the use of interventions that promote activity. Its main themes are: reassurance that serious damage is very rare, rationale and suggestions for staying active and at work, controlling pain, stress and tension, doing exercises, treatment in the form of collars, heat and cold, manipulation, and traction. The evidence review from the Quebec Task Force Guidelines for “whiplash”-associated disorders (Spitzer, 1995) underpins many of the conclusions of subsequent guidelines.

The Swedish Council on Health Technology Assessment in Health Care (SBU, 2000) reviewed the evidence on 15 common treatments for acute and chronic neck pain and concluded that it was sparse. The Australian Guidelines reflect this and many of their recommendations are consensus based and recommend advice to stay active, gentle neck exercises and ‘multi-modal’ treatment, including gentle passive mobilisation (NHMRC, 2003). The Swedish Guideline found moderate evidence against surgery for acute herniated cervical disc and limited evidence against traction and neck supports. There was also moderate evidence in favour of physical exercise and of manual therapy, when the latter was used as part of a treatment program.

The NHS support organisation, Prodigy, has also recently published guidance for the management of neck symptoms generally (Prodigy, 2004). These do address management strategies, despite the lack of evidence.

6.4.2. NECK AND SHOULDER PAIN

Guidelines on neck and shoulder pain have also been developed by the Kaiser Foundation Research Institute in the United States. These addressed a number of specific interventions, although not management strategies, for a variety of musculoskeletal disorders, including acute neck pain, calcific tendonitis of the shoulder and non-specific shoulder pain (Philadelphia-Panel, 2001; Harris and Susman, 2002).

The interventions considered for shoulder pain were:

• Ultrasound • Exercise • TENS • Massage • Thermotherapy • EMG biofeedback • Electrical stimulation • Combined rehabilitation modalities

And for neck pain additionally: • Exercise/neuromuscular re-education • Traction

The Guideline sought clinically important, as well as statistically important differences, but did not specifically address acute pain states. It found insufficient evidence to make positive

24

recommendations about any of the above interventions other than ultrasound for calcific tendonitis of the shoulder No interventions for acute neck pain were supported for lack of evidence. There was also evidence of no benefit from traction.

6.4.3. SHOULDER PAIN

For acute shoulder pain, the Australian Guideline group (NHMRC, 2003) found only low levels of evidence relating to case history taking, examination and imaging and their reliability and predictive value. However, they did report evidence of short-term benefit for corticosteroid injections, active exercises, NSAIDs, ultrasound and manual therapy when the latter is combined with stretching, hot and cold and education.

The Dutch College of General Practitioners published a mono-disciplinary consensus guideline on the management of shoulder complaints (Winters et al., 1999). This does not differentiate between acute and chronic shoulder pain, is not oriented towards occupational issues and the authors warn that its context may be specific to general practice in the Netherlands. It is aimed at improving the clinical approach in a condition, from a general practice viewpoint, where pain may be generated in other structures and pathophysiological processes. Accordingly, it gives guidance on classification, diagnostic differentiation, and performance of case history and examination, followed by management advice, paraphrased as follows:

Classification: • With or without limited passive range of motion

Diagnostic differentiation from: • Nerve root syndromes • Rheumatoid arthritis • Polymyalgia rheumatica • Systemic disorders and general illness

Case history including considerations of: • Location, restriction, neck complaints, onset, severity, sleep and function, aggravation

by movement or rest, previous episodes, treatment and its outcome Examination:

• Pain location, active and passive abduction and passive external rotation - and if these do not reproduce the pain, neck movement examination

• Imaging usually unnecessary Management:

• Information and advice (expect early recovery if of recent onset) • Simple analgesics (paracetamol, NSAID) • Corticosteroid injection if not improving within 2 weeks • Activity modification (initial protection from aggravation followed by gradual

reactivation) • Referral to physical therapy if not improving by 6 weeks

For calcific tendonitis of the shoulder, recent guidance from the National Institute for Clinical Excellence (NICE, 2003) supports the use of extracorporeal shockwave lithotripsy. However, 80% of patients experienced significant pain from the procedure.

6.4.4 UPPER LIMB DISORDERS

The South African Compensation Commissioner’s Guidelines for Health Practitioners and Employers (but not employees) to manage Work-Related Upper Limb Disorders (South African Department of Labour, 2004) suggest that employees with symptoms of short duration, but are still able to work, have the most to gain from educational interventions. Founded mainly on

25

expert opinion, these guidelines apply the European Agency for Safety and Health at Work (1999) classification of physical origins of upper limb disorders as being based in tendon, bursa, nerve, blood vessels and ‘other’; to conditions of the shoulder, elbow and upper extremity. For elbow and upper extremity disorders, their recommendations cover:

Elbow: • Cubital tunnel syndrome • Lateral humeral epicondylitis (tennis elbow) • Medial humeral epicondylitis (golfer’s elbow) • Olecranon bursitis (beat elbow)

Forearm, wrist, hand and finger: • Anterior and posterior interosseous syndrome • Carpal tunnel syndrome • De Quervrain’s tenosynovitis • Guyon (ulnar) tunnel syndrome • Intersection syndrome • Pronator teres syndrome • Radial tunnel syndrome • Tendinosis/tenosynovitis of extensor/flexor tendons • Trigger finger/thumb • White finger (Reynaud’s syndrome, vibration syndrome)

The resulting Guideline advises a diagnostic process that links the above principles to the kind of ergonomic activity involved in the worker’s job, such as consideration of the rapidity, repetitiveness, force, posture and vibration involved, and their relationship to the activity modification to be considered. The Guideline does not, however, address uncertainties in relation to agreement on criteria for case definitions, in the quantification of exposure factors or in the independence of the risk factors proposed. Nor does it consider non-work activities in the assessment. However, it does recommend the consideration of psychosocial issues, especially in the workplace and, importantly, the necessity for a care plan.

Employers are advised to: • Heed concerns of workers and supervisors • Gain better understanding of jobs and tasks • Identify existing and potential hazards • Determine underlying causes of hazards

Employers are also provided with a ‘Risk calculator’, (Kennedy, 2004) based on physical exposure factors, but this does not consider psychosocial or non-work factors that may play a role.

Health professionals are given a list of therapeutic options. However, these are mainly passive treatments most of whose efficacy has not been established by evidence. These are:

A. Employee education

B. Anti-inflammatory strategies: • Cryotherapy (ice) • Non-steroidal anti-inflammatory drugs • Electrotherapeutic modalities (physiotherapy)

26

• Infiltration with corticosteroids (dubious value)

C. Therapeutic strategies: • Initial treatment may include rest • Immobilise (splintage) – occupational therapy • Mobilise (physiotherapy) • Mobilise to appropriately strengthen muscles • Education – good work habits, pacing, joint conversation and self-management

(occupational therapy)

D. Reasonable job accommodation: • Temporary job change • Workstation redesign • Tool and equipment adaptation • Job task modifications • Retraining and reassessment • Work schedule modifications • Job enlargement • Job rotation

E. Psychological evaluation:

F. Surgery (as last resort)

An important recommendation of this Guideline is for plans of action for surveillance for WRULDs in workforces. These plans relate mainly to ergonomic assessments and prevention.

The Finnish Institute of Occupational Health (Viikari-Juntura, 1998) has recommended work modifications (that are feasible) as a front line consideration in light of evidence of associations between these and some physical load factors. This guideline also cautions against surgery for carpal tunnel syndrome where gripping is a major task, because the grip strength itself may be compromised by the surgery. Other physical treatments were found to be supported by case studies only.

A review of occupational standards and guidelines for hand-arm vibration syndrome (Pelmear and Leong, 2000) focuses on prevention based on workplace assessment, but not on early intervention or secondary prevention.

6.5. NECK PAIN AND UPPER LIMB DISORDERS – SUBSEQUENT REVIEWS AND RESEARCH

The evidence from randomised trials of interventions for neck pain and upper limb disorders lags behind back pain by some way. For example, despite the fact that some guidelines recommend manual therapy, a recent systematic review (Bronfort et al., 2004) concluded that the evidence is still inconclusive for spinal manipulation or mobilisation for acute neck pain in both the short and long terms, although Hurwitz et al (1996) had earlier interpreted the evidence to suggest that these probably provide at least some short-term benefits. It may be that manual therapy for neck pain is being too narrowly defined, or that there are important subgroups of patients who will and will not benefit from these interventions.

27

Kjellman et al (1999) also extensively reviewed the trial literature on neck pain treatments and found it unsatisfactory for drawing firm conclusions because of low methodological quality, lack of follow-up and low number of trials.

6.5.1. Upper limb disorders

In a study and review of how physiotherapists and occupational health nurses can become more effective in the treatment of people with upper limb disorders, Kupper et al (2004) found insufficient good quality research to determine what best practice should comprise. This is probably because evidence summarisation and synthesis for upper limb disorders is frustrated by lack of uniformity in defining the conditions, the outcome measures used in trials, and by the low number and quality of the trials themselves. Although greater uniformity in case definitions has become possible (Harrington et al., 1998), they do not as yet seem to have been used to support management guidelines.

Gam and Johanssen (1995) conducted a systematic review and meta-analysis of randomised trials of ultrasound therapy for a variety of musculoskeletal disorders, including: lateral epicondylitis (4 trials), bursitis of the shoulder (3 trials), scapulohumeral periarthritis (2 trials) and tendonitis of the shoulder (1 trial). This review pooled the results of a number of studies and found no advantage of ultrasound over sham ultrasound. Nevertheless, ultrasound remains a recognised treatment based on clinical experience, which undoubtedly combines it with advice about activity and work as well as other interventions.

6.5.2. Shoulder pain

A Cochrane review of common interventions for shoulder pain, which included NSAIDs, intra-articular or subacromial steroid injections, oral steroids, physiotherapy, manipulation under anaesthesia, hydrodilatation and surgery (Green et al., 2004a), found 31 trials that met its inclusion criteria. Owing to the diversity of outcome measures used and the small effect sizes in individual trials (-1.4-3.0) the review was not able to offer conclusions about the effectiveness of conservative management techniques for shoulder pain beyond the tentative one that subacromial steroid injections were more beneficial than placebo for rotator cuff tendonitis.

A previous Cochrane review of interventions commonly used by physiotherapists (Green et al., 2003) had found 21 usable trials, but did not differentiate between acute and chronic pain.. Exercise was demonstrated to be effective in terms of short term recovery in rotator cuff disease and longer term benefit with respect to function. Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone for rotator cuff disease. Laser therapy was demonstrated to be more effective than placebo for adhesive capsulitis but not for rotator cuff tendinitis. Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo in pain in calcific tendinitis. There was no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis), adhesive capsulitis or rotator cuff tendinitis. When compared to exercises, ultrasound was of no additional benefit over and above exercise alone. There was some evidence that for rotator cuff disease, corticosteroid injections are superior to ‘physiotherapy’ but no evidence that physiotherapy alone is of benefit for ‘frozen shoulder’.

A further review of common treatments for rotator cuff tears (Ejnisman et al., 2003) reported insufficient uniformity in describing the treatments to be able to draw any conclusions from the research literature.

Mitchener et al’s (2004) subsequent systematic review of the effectiveness of rehabilitation of subacromial impingement syndrome (SAIS) found that the limited evidence currently available

28

suggests that exercise and joint mobilizations are efficacious for patients with SAIS. Laser therapy appears to be of benefit when used in isolation, but not in combination with therapeutic exercise. Ultrasound is reported to be of no benefit, and acupuncture trials present equivocal evidence. These authors concluded that the evidence is insufficient to support a guideline for shoulder pain at present, but called for more and better research that could support one in the future. A further systematic review of multidisciplinary biopsychosocial intervention for neck and shoulder pain of any duration carries (Karjalainen et al., 2000) reported that compared with other rehabilitation approaches, there is little evidence as yet of any advantage.

6.5.3. Lateral elbow pain

The most recent systematic review of physical interventions for work related upper extremity disorders is by Verhagen et al (2003). Because of the wide variety of interventions used and the few studies of reasonable quality, no conclusions could be drawn about manual therapy, massage, multidisciplinary treatment, and energised splint.

A Cochrane review by Green et al (2004b) of injections and non-steroidal inflammatory drugs (NSAID), both topical and oral, for lateral elbow pain (tennis elbow) included 14 trials with some evidence of short-term effectiveness compared to placebo in all of these, but could offer little insight into their relative benefits. There was limited evidence that topical NSAIDs are more effective than placebo with respect to pain, but only in the short term. There was no evidence that oral NSAID gives lasting benefit and they had significantly more gastrointestinal effects. There was inconclusive evidence that injections may be more effective than oral NSAID in the short term.

The US Agency for Healthcare Research and Quality (AHRQ, 2002) reviewed the evidence on the diagnosis and treatment of: carpal tunnel syndrome, cubital tunnel syndrome, epicondylitis and De Quervrain’s disease.

For epicondylitis, the review found:

Diagnosis • insufficient evidence to support the use of any tests for epicondylitis • insufficient evidence to support specific indications for surgery.

Interventions for epicondylitis: Treatment (RCTs) Control Outcome

• Laser therapy vs sham laser therapy (7 RCTs) - no significant difference • Oral naproxen vs diflunisal (2 RCTs) - conflicting evidence • Ultrasound vs phonophoresis of cortisone (2RCTs) - no significant difference • Ultrasound vs sham ultrasound (3RCTs) - trend towards ultrasound • Elbow brace (2 crossover studies) - no effect • Acupuncture vs sham acupuncture (2RCTs) - +ve at 2w for pn and global • Oral NSAIDs vs steroid injection (2 RCTs) - conflicting evidence • Topical DMSO vs placebo (1 RCT) - trend to DMSO but skin irrit. • Oral diclofenac vs placebo (1RCT) - + for pain only • Topical diclofenac vs topical salicylate (1RCT) - + ve but sl occas skin irrit • Injs of glucosamines (1RCT) - +ve at 6m but site pain • Injs of Methylprednisolone vs Lidnocaine (1 RCT) - +ve for pain • Injs of Lidnocaine + triamcinolone vs lig. (1RCT) - +ve • Injs of Methylprednisolone vs hydrocortisone (1RCT) - no effect • Brace over several months vs ‘physiotherapy’ (1RCT) - +ve for control (nonsig)

29

• Brace +‘physiotherapy’ vs ‘physiotherapy’ (1RCT) - +ve • Denervation vs denervation + decompression (1RCT) - +ve • Pulsed electromagnetic field vs sham (1RCT) - no effect • Extracorporeal shock wave vs sham (1RCT) - +ve • Steroid inj vs manipulation and friction (1RCT) - +ve • Steroid inj vs brace/immobilisation (1RCT) - +ve • Acupuncture vs steroid inj (1RCT) - +ve but selection bias • TENS+phonophoresis vs ultrasound (1RCT) - no difference • Physical therapy vs ultrasound (1RCT) - no difference • Manipulation +home ex vs US+physio+ home ex(1RCT) - +ve

The review concluded, for all of the above comparisons, that there is insufficient evidence to recommend any of the above interventions that have positive trial outcomes due to trial quality or need for further replication.

6.5.4. Carpal and cubital tunnel syndromes and other upper extremity disorders

There were tentative conclusions in the Verhagen et al (2003) review in favour of individual exercises and keyboard adaptations for people with carpal tunnel syndrome, but the benefit of expensive ergonomic interventions in the workplace was not clearly demonstrated. A second Cochrane review by Verdugo et al (2004) concluded only that surgery is significantly more effective for more severe forms of carpal tunnel syndrome than is splinting.

The AHRQ (2002) reviewed 2 meta-analyses and a number of trials of physical interventions for carpal tunnel syndrome. It mainly found only trends because of small sample sizes. (Studies said to have had design difficulties have been omitted)

Interventions for carpal tunnel syndrome: Treatment Control Outcome

• Endoscopic vs open release (1 meta-analysis) - + for global improvement • No neurolysis vs neurolysis (1 meta-analysis) - +ve trend • Oral tenoxicam+trichlormethiazide vs ? (1RCT) - no effect • Carpal bone mobilisation vs ? (Unblinded RCT) - +ve trend • Physical therapy vs home exercise (1RCT) - +ve trend for return to work

For cubital tunnel syndrome, the AHRQ (2002) review found:

Interventions for carpal tunnel syndrome: Treatment Control Outcome

• Medial epicondylectomy vs anterior transposition (1RCT)- +ve for pain and global, but insufficient data to determine rates of surgical complications.

For De Quervrain’s disease, the AHRQ (2002) review found one study comparing corticosteroid plus lidnocaine injection versus immobilisation splints, but concluded that design problems prevented any conclusion.

A further randomised comparison of 268 computer operators with neck or upper limb pain to taking short breaks, adding exercises to the breaks and to controls (van den Heuvel et al., 2003) found no difference between groups in terms of sick leave or severity or frequency of the complaints, although both productivity and reported recovery were higher in the intervention groups.

30

6.5.5. Repetitive strain injury

The literature broadly acknowledges a lack of precise understanding of the term “repetitive strain injury” (Stone, 1983; Browne et al., 1984) which has been contested in current thinking (Hadler, 1999). A Cochrane review by Karjalainen et al (2000) found insufficient research to draw any conclusion about multidisciplinary biopsychosocial rehabilitation for repetitive strain injury.

6.6. OTHER MUSCULOSKELETAL DISORDERS

6.6.1. The Knee

A systematic review of conservative approaches for cruciate ligament, medial collateral ligament and meniscal injuries (Thomson et al., 2002) found a wide-ranging spread of approaches, but insufficient evidence to establish the relative effectiveness of any of them. Deep transverse friction massage is a commonly used manual therapy procedure for tendon problems, but there is little good evidence of its effectiveness. One Cochrane review (Brosseau et al., (2001) of its use in treating pain due to iliotibial band friction syndrome found only one small sample trial of low quality and could not draw any conclusions about this treatment.

6.6.2. The Ankle and Heel

Two Cochrane reviews addressed acute ankle sprains. The first (Kerkhoffs et al., 2002) reviewed the trial evidence comparing immobilisation and functional treatment and concluded tentatively that the latter is probably superior, especially in terms of time to return to work. However, van der Windt et al (2002) found unacceptably small effects of ultrasound treatment for acute ankle sprains. For plantar heel pain, although there is some limited evidence for the effectiveness of corticosteroid injections for producing temporary relief (Crawford and Thomson, 2003), there was insufficient evidence to address any other therapy.

6.7. SUMMARY OF CURRENT THINKING

6.7.1. Back PainThere is strong consensus in the latest evidence-based guidelines (EC, 2004a) that absence from work because of non-specific back pain is likely to delay, rather than hasten recovery. Many of the national guidelines for acute low back pain that were considered in developing the European ones (Koes et al., 2001) recommend a two-stage approach, which involves waiting until people were failing to recover by 4 weeks from the onset of their problem to intervene. However, failure to manage the episode optimally in its early stages by, if necessary, controlling pain, modifying activities, acting on worsening symptoms or inappropriately using bed rest, may inhibit recovery. This intervention need necessarily always involve a health professional, but should be able to bring personal, social and occupational interventions into play (Waddell and Burton, 2004).

When treatment is needed, there is also a growing level of support for multi-modal evidence-based interventions, combining the interventions recommended in current major guidelines. This implies the need to have resources to provide these efficiently and without fragmenting care across providers.

31

6.7.2. Neck pain and Upper Limb Disorders

Despite the improvement in case definitions (Harrington et al, 1998) there is a lack of internationally agreed diagnostic criteria, and of randomised controlled trials of specific interventions for specific conditions, as well as a belief that there is overlap, both in the nature and effective management of a number of these disorders (Helliwell and Taylor, 2001; Waddell and Burton, 2004). The evidence has also been thought to be insufficient to support authoritative reviews of treatments for upper limb disorders (Hoving et al., 2001).

The literature, however, also recognises a strong parallel between neck and non-specific upper limb disorders and their low back pain counterpart, especially in terms of the psychosocial predictors of outcome. Current thinking favours applying what we also know from the back pain evidence (Helliwell & Taylor, 2001; Helliwell, 2003b). It also draws a similar model to the ‘neuromatrix theory’ (Melzack, 1999) to suggest that its multifactorial nature (Helliwell, 2003b), can be made up in any combination of physical, physiological and psychological components – and can be therapeutically influenced by them. Figure 3 presents a schematic form of guidance for this, which takes these factors into account. The model presented suggests a multi-modal approach with options to overcome workplace factors with ergonomic interventions and changes in work organisation; lack of control over working practices with change in work organisation; pain with analgesia, distress with cognitive interventions and education; muscle fatigue with training and exercise, and neuroplasticity with anti-epileptic drugs. In a systematic review of return-to-work treatment programs that included all non­specific musculoskeletal disorders, Meijer et al (2005) found that all effective treatment programs consisted of such multiple components, the most prominent of which involve conditioning the sufferer in terms of their knowledge, psychological state, physical state and working conditions.

Figure 3 Possible approaches to treatment Helliwell, 1999 (reproduced with kind permission of Elsevier, Philadelphia)

Key messages:

• Multi-modal interventions, including workplace adaptations, seem to hold out the best promise for improving early pain management for musculoskeletal disorders.

• Clinical expertise, applied in collaboration with employees and employers may provide improved early care if applied along evidence-based lines.

• The evidence can be expected to become more authoritative as time passes, making radical departure from these principles inadvisable.

32

7. PROSPECTS FOR IMPROVED CARE

To what extent is it practicable to use the evidence about the early stages of musculoskeletal disorders to improve their early management? When a Clinical Standards Advisory Group report on back pain (CSAG, 1994) recommended early access to evidence-based care and a shift of resources to physical approaches in primary care, the initial response was one of poor compliance (Little et al., 1996). Soon afterwards, concise national guidelines were developed specifically for primary care and with a focus on preventing the slide into chronicity by patients with acute back pain (Waddell et al., 1999). However, despite evidence of small changes in general practitioner management, (Frankel et al., 1999), and the appearance of national referral advice for acute back pain (NICE, 2001), inappropriate referral to secondary care for musculoskeletal disorders in general seems to persist (Barnett et al., 1999; Sheehan, 2001) coupled with negative feelings toward such patients on the part of some GPs (Chaudhary et al., 2004).

Improving the management of these disorders in line with research evidence has been a slow and difficult process. Although advocated in current primary care guidelines (Waddell et al., 1999; EC, 2004b), assessment of non-medical obstacles to recovery is problematical and frustrating for health care traditionalists. For work-related musculoskeletal disorders, the British Society of Rehabilitation Medicine (BSRM, 2000) called for greater investment in Vocational Rehabilitation, including the development of a National Service Framework for services to those of working age. However, the NHS priorities reflected in the existing National Service Frameworks do not include these disorders, which are currently linked to the Long Term Conditions Framework (DH) and to the reduction of orthopaedic waiting lists. There is evidence (Maddison et al., 2004) that such a scheme can be successful for this, but do not of themselves necessarily provide early intervention before 4-6 weeks from GP referral, let alone from onset of an episode.

This puts Primary Care Trusts and general practitioners in the forefront of the public sector implementation of early intervention strategies. However, there is evidence that the implementation and quality assurance of back pain guidelines in England and Wales has so far been unsuccessful (Langworthy et al., 2005) where there has been little or no central funding for implementation. Yet a media campaign alone can alter beliefs in a positive direction that is retained years later (Buchbinder and Jolley, 2005).

Primary care low back pain research has come to refer to a ‘window of opportunity’ (Waddell et al., 2003; Waddell and Burton, 2004) in these early stages, and it is clear that for the vast majority of patients a biomedical approach is inadequate (Foster et al., 2003). However, to take advantage of this, primary care would need to be committed, co-ordinated and adequately resourced. However, consideration of the range of biopsychosocial factors involved does not fit easily into the conventional medical model of disease (Engel, 1977; Bartys et al., 2000).

There is also evidence from the back pain literature that family doctors have difficulty with such patients, who may not consult them until after private treatment has failed (Chaudhary et al., 2004). GPs’ confidence in their own abilities to assess patients and supply evidence-based care generally (Tomlin et al., 1999) and for back pain in particular is lacking and they can experience extreme difficulties (Skelton et al., 1995; Schers et al., 2000), making this an important area for improved education. However, presentations at conferences and seminars are insufficient to change general practice (Davis et al., 1995) and general practitioners may consider the implementation of evidence generally to be like fitting the square peg of research results into the round hole of patients’ lives (Freeman and Sweeney, 2001). More practice-based interventions

33

and outreach visits requiring interaction and promoting ownership (Gabbay and le May, 2004) will be needed for this. In the meantime, stress on GPs, demands on their time and the desire to avoid conflict in the doctor-patient relationship have been found to be reasons why general practitioners misuse the sickness certification system (Hussey et al., 2003).

Guidelines almost unanimously recommend that clinicians begin with diagnostic triage and a biopsychosocial assessment (Koes et al., 2001). For primary care clinicians this can present a challenge, perhaps because of the prevailing view that occupational, socioeconomic, medicolegal and psychological factors are not amenable to effective intervention by family practitioners (Valat, 2004). Unfortunately, diagnostic triage alone does little to predict either future health-related quality of life (Horng et al., 2005) or work disability (Hunt et al., 2002) leaving apparently little role for the general practitioner. A recent randomised controlled trial of a brief psychosocial intervention by Dutch general practitioners in patients with subacute low back pain (Jellema et al., 2005) found no effects of this intervention over usual care in a subgroup of patients with higher fear avoidance and catastrophising questionnaire scores. This is not surprising, since evidence that these are single strong predictors of poor outcome in the first place is lacking (Pincus et al., 2002; Sieben et al, 2005). The wider spectrum of biopsychosocial factors was not considered in the trial. This highlights the problem of unidisciplinary approaches and failure in contemporary thinking to consider multiple biopsychosocial factors.

Evidence-based early management of musculoskeletal disorders does not necessarily have a clinical component. When it does, it requires competent screening for serious disease, a functional assessment and a ready awareness of the major psychosocial factors for poor outcome. Advice about exercise, activity modification and the provision of manual therapies are generally available within a week from professionals qualified in chiropractic, osteopathy or musculoskeletal physiotherapy. These professions are publicly regulated and the first two generally work in the independent sector. Combined with the giving of accurate information and advice about pain control and continuing normal activities (Abenhaim et al., 2000), this approach has a good fit with current guidelines. However, attitudes to reactivation, collaboration with other carers and promotion of patient independence may be variable in these professionals and if they are isolated from the local health and occupational care systems this can cause fragmentation and delays if first efforts are not effective (Pincus et al., 2005a). It may also be important to determine these practitioners’ attitudes toward such factors as participants in a care pathway.

However, there is readiness to approach, report and work with employers and a balance between having all players onside and having too many limited players needs to be struck. If all players, patient, employer and health professional, are following evidence-based principles, either within or outside an occupational health facility, rapid access to these professionals could offer an improved approach for those who need clinical help.

Evidence-based guidelines are useful, but often stop short of important considerations needed for their implementation (van Tulder et al., 2004). The ones reviewed here are multidisciplinary and guidelines for individual professions are less common. Although they may be better implemented (Bekkering, 2004), there is a danger that they will digress from the evidence to suit practice conventions. It has been suggested that future mono-disciplinary guidelines should be adherent to a multidisciplinary parent to avoid this (Breen et al., 2005).

Guideline implementation has been shown to be sometimes more difficult in large organisations. The US Army Medical Department, for example, developed an implementation strategy for low back pain guidelines, broadly aligned to those discussed here (Farley et al., 2004). This involved well-resourced programs both to build ‘local ownership’ and put in place

34

the clinical and administrative systems needed to ensure staff adherence. Even this level of clinical accountability and resource did not produce the desired effect. The main barriers were inconsistent leadership due to staff rotation, lack of ongoing support and competing policies and priorities. The success that was achieved was attributed to the clarity and utility of the support materials, the technical support that backed them up and the co-ordination of information exchange.

These are familiar themes from other guideline implementation initiatives (Breen, 2003) and highlight the need to acknowledge the professional dominance model in clinical behaviour change (Ferlie et al., 1999). However, despite improved understanding of what is available to help assess guideline implementation (Pagliari and Kahan 2003), the distinction between better outcomes in terms of practitioner behaviour, patient benefits or reduced pressures on health, occupational or social support systems is blurred (Grimshaw et al., 2004). This makes generalisation about effectiveness of implementation strategies problematical.

Key messages:

• Implementation of evidence-based guidance, even if it holds out the promise of substantial improvement in care, faces formidable organisational and stakeholder barriers.

• Clarity, simplicity and improved access to early and informed decision-making involving employee, employer and (if necessary) a health professional who is committed to a collaborative approach, is necessary for improved early pain management.

35

36

8. CARE PATHWAYS AND CLINICAL MANAGEMENT

Appendix 1 contains the Care Pathways recommended. These Pathways are for employers, employees and health professionals and apply to any episode of any musculoskeletal pain that:

• interferes with work • lasts more than a day or two if severe, or • lasts up to a week if not severe

The rationale for them comes from the following conclusions drawn from the literature:

• Occasional work-related musculoskeletal discomfort can be regarded as normal, but action should be taken if it is severe, persistent or distressing.

• Rehabilitation can start as soon as a problem is identified as non-resolving. • The employer needs to know about and be supportive in the rehabilitation and secondary

prevention processes. • If initial efforts to promote recovery are not showing promise within a week, reassessment

and review should take place. • Health professionals should be able to supply expert assessment and evidence-based

interventions and work collaboratively with employers.

In compiling this report, simple, 2-stage pathways were developed and sent to 8 experts plus a research collaboration group for critical review. Based on the feedback received, they then went through 2 further refinements before being finalised.

The care pathways suggested constitute a direction to take and not a ‘quick fix’. They are also not an invitation to over-react to mild or resolving episodes. They are meant to be consistent with the Department of Work and Pensions’ Framework for Vocational Rehabilitation (VR), focussing on early intervention and the pivotal role of the employer. Because, in most cases, predictors of poor outcome are not related to any kind of serious disease process, but to psychological and social factors, these are more likely, at the outset, to be within the power of the employer and employee together to improve, without resorting to a health professional (Irving et al., 2004). The Pathways offer a rationale and method for implementing VR in light of accumulated research evidence, and expert opinion (Irving et al., 2004).

There are four Pathways; a Generic Care Pathway, which sets out the sequence common to all three stakeholders, plus individual Pathways for Employers, Employees and Health Professionals. They all operate in two stages in time, intended to resist the slide of events into chronicity or recurrent problems. For the Generic, Employer and Employee pathways, these stages are within one week from when the problem began with a follow-up within two weeks. The Health Professional Pathway’s first stage occurs at the employee’s first attendance and the second stage within four weeks thereafter.

8.1. THE GENERIC CARE PATHWAY

The process in Stage 1 depends on identifying, early, people having musculoskeletal problems that will not resolve on their own and are threatening absence from the workplace. Employers and employees can initiate together modification of at-work activities. However discussion alone may identify obvious solutions. Discussion alone can improve communication channels and lead to solutions that prevent future episodes (Linton and Bradley, 1996). Staying at work, where activities can be planned, is central to this. In terms of long-term recovery, job retention is better than going off work and then returning (DWP, 2004). The decision to involve a health

37

professional should be led by the employee and should occur if there is concern about time to recovery or the seriousness of the problem.

Stage 2 is a follow-up of Stage 1 which should happen within two weeks of the onset of the problem, if only to check that recovery has happened. If not, it is an opportunity to fine tune the initial plan, which should be thought of in terms of activity and function and not pain alone. This is a central principle. Some discomfort during recovery is normal and substantial reduction in initial pain severity (low back pain) may be necessary to produce clinically meaningful improvement in function if initial pain intensity is high (Turner et al., 2004). Some work activity, however small, generally assists recovery to take place. The Australian musculoskeletal pain guidelines (NHMRC, 2003) and the European Acute Back Pain Guidelines (EC, 2004a) both advocate reviewing and monitoring progress, which is not the same as unlimited treatment sessions, and must be distinguished from hypervigilance.

8.2. THE EMPLOYER PATHWAY

Employers need a system for the identification and monitoring of employees in difficulty. The initial discussion should be by a person for whom the employee has regard and trust. Most employers do not have occupational health resources, and line managers may be too close to the problem to help. Other options include human resources managers or the employers themselves.

Stage 1 involves listening and assimilating the employee’s problem and discovering what their proposed solution would be. This may be the cue to a prompt and collaborative solution. The main messages should be optimistic and reflect moral support, controlling pain and staying active and at work if possible. Reassurance, commitment to finding a solution and providing information (e.g. The Back Book (Roland et al., 2002) or the Neck Book (Waddell et al., 2004) are the key elements. This should be pragmatic and taken at face value. It is not the same as counselling employees about their health. A time for the second discussion should be diarised and should occur whether recovery has occurred or not. Lack of commitment on the part of either party is probably the main obstacle to the success of Stage 1 and this might be reduced by a well-circulated company policy or manifesto.

Stage 2 is a chance to discuss the prevention of a repetition of the problem, or about further measures if it is not clearing up. If necessary, a chiropractor, osteopath or musculoskeletal physiotherapist could be accessed to help. However, in many instances, just giving the employee greater control of their work situation could be an essential part of recovery. Refusing to accept the employee back at work until all symptoms have abated does not make recurrence less likely. It can prolong disability and reduce the likelihood of recovery. Where the problem does not originate in work, yet interferes with it, this also needs to be recognised.

Any health professional involved should be able to provide pain control and reactivation strategies. Prolonged passive treatment with no improvement should be avoided in favour of a multidisciplinary approach involving workplace changes. Monitoring and reassessment are important roles of the health professional.

8.3. THE EMPLOYEE PATHWAY

The aim here is early recovery. The main requirement is reassurance and open discussion with the employer. This should suggest a solution, often based on modified activities at and/or outside of work. A health professional is only needed if there is concern, or failure of early recovery. Only a tiny proportion of musculoskeletal problems underlie real threats to health. Long-term disability is more likely to result from withdrawal into inactivity, whereas recovery

38

is more likely if some activity is maintained. Therefore, some semblance of normal activity, if necessary with simple pain control measures such as over-the counter analgesics, is usually the initial consideration. People who go off work are less likely to return than those who stay and make changes (Verbeek et al., 2004).

8.3.1. Accessing musculoskeletal practitioners

Vocational Rehabilitation can be inhibited by signing off patients too readily (Irving et al., 2004), taking a ‘wait and see approach’ and the lack of NHS provision for early intervention. If a health professional outside of the employer’s occupational health provision is needed, the main practitioners who can provide early intervention are chiropractors, osteopaths and musculoskeletal physiotherapists. These professions are all regulated by statute like doctors and dentists and can be accessed in the community directly (see glossary). Most are able to see patients within one week. However, the NHS does not usually cover them (although examples of this do exist) and employees and/or employers, may have to pay.

The problem should be monitored until it is gone, but the end of the episode does not mean the end of the process. Consideration needs to be given to whether it is likely to come back and prevention. Employees should consider whether some kind of lifestyle change, for example to improve general fitness, or a change of job role is appropriate.

8.4. HEALTH PROFESSIONAL PATHWAY

The health professional consulted should have the time and competence to provide all the assessments and interventions in the pathway, including physical treatments, with knowledge of the evidence relating to them. Specific conditions (e.g. lateral epicondylitis) can be treated according to biomechanical and tissue recovery principles, plus other evidence-based interventions. All conditions should be managed under the principles of pain control and re­activation with problem-solving and staged recovery linked to everyday tasks.

If the employee is off work for more than 2 weeks, GP certification may be needed, but the Decision-maker in some DWP offices do accept certification by these musculoskeletlal practitioners. If not, a report to the GP is necessary before this point. However, findings should be reported to them at an appropriate point regardless of work absence. Monitoring of recovery by the musculoskeletal practitioner may not involve treatment, but rather modification of the patient’s own self-care, including exercise. Failure of recovery by 12 weeks from onset (CSAG, 1994; Waddell et al., 1999) should trigger a further bio-psychosocial reassessment and may lead to greater emphasis on condition management and employer involvement. Evidence of a new specific condition may require referral for investigation or for management by another health care professional.

8.5. LINKS BETWEEN THE THREE PATHWAYS

An important link between these pathways is ongoing discussion between employer and employee and the monitoring of recovery by the two parties. If a health professional is consulted, their inclusion in discussions of any work-based recovery is likely to be necessary for optimal results. The employer’s role in monitoring recovery is important. If recovery is problematical, that role increases rather than recedes.

39

40

9. EARLY INTERVENTIONS BY MUSCULOSKELETAL PRACTITIONERS

The Health Professional Pathway refers to obtaining early help from chiropractors, osteopaths and musculoskeletal physiotherapists if there is concern about disability or early recovery from a musculoskeletal disorder. Although chiropractors, and osteopaths and a minority of physiotherapists offer a full range of manual treatments, there has traditionally been confusion over terminology and what these other interventions are (Breen et al., 2000). However, there is tentative evidence from all 3 professional groups that patients who seek their help early have better outcomes than those who wait (Pringle, 1993; Leboeuf-Yde et al., 2004, Bekkering et al., 2005).

9.1. TRADITIONAL CASE MIX AND INTERVENTIONS

Surveys from the 1980s and 90s (Burton, 1981; Pedersen, 1994) found that chiropractors and osteopaths treat mainly low back pain (around 50% of their cases) and neck and arm pain (around 30% of their cases). Most patients seek their help in the first month of an episode and the vast majority can be offered an appointment within a week. Their main interventions at the first visits are ergonomic advice (62%), social/emotional counselling (28%), and manual therapies 95% (Pedersen, 1994). Physiotherapists traditionally evidence little use of manipulation, fitness programs, and multidisciplinary efforts involving behavioural aspects of treatment (Foster et al., 1999) in favour of various methods of electrotherapy. However, there is awareness among physiotherapists of the need to change (Pinnington, 2001) and this is undoubtedly now happening in those who specialise in musculoskeletal disorders.

9.2. PSYCHOSOCIAL CHARACTERISTICS OF PATIENTS

Levels of severity in secondary care rheumatology patients with back pain have been found to be higher than in those of osteopaths and chiropractors (Gillies, et al. 1993). However, little is known about the psychosocial characteristics of patients attending these practitioners. Given the possible predictors of poor outcome it would be useful to know to what extent current practice includes patients with psychosocial problems.

We are currently studying a cohort of first-time patients with a new episode of non-specific low back pain at a chiropractic clinic in the South of England. Demographic, severity and work-related data for these are shown in Table 2. The age, gender, duration of current episode in this cohort are very similar to those in a previous osteopathic cohort studied in the North of England (Burton et al., 1995). Only a small proportion were off work, but of those that were, just over half had been off for over a week.

41

Table 2 Baseline characteristics of a cohort of new back pain patients at one chiropractic clinic (n=101)

Mean age (SD) 42.9 (10.39) %

Female 55 Current episode <4w duration 57 First ever episode 24 Previous episodes but lasting<1/2 of past year 55 Employed or self-employed 86 % who generally enjoy their work 99 Currently off work due to back pain 16 % off work >1 week 63 Severity (Deyo, 1988) Back pain: mod-extreme bothersome past 1w 59 Leg pain: mod-extreme bothersome past 1w 37 Mod-extreme interference with normal work 65

Dissatisfied with current state of wellbeing 91

The baseline information gathered from these patients also included the following psychometric instruments, plus a disability scale (Deyo, 1988):

The Fear-avoidance beliefs questionnaire (Waddell et al., 1993) Catastrophising (inevitability scale of the Back Beliefs Questionnaire) (Symonds et al., 1996) Anxiety and coping scales of the Coping Strategies Questionnaire) (Rosenthiel & Keefe, 1983) Distress (General Health Questionnaire 12) (Goldberg, 1978)

Table 3 Psychometric and severity characteristics of a cohort of new back pain patients at one chiropractic clinic (n=101)

Mean Mean raw %

Scale score score Higher score denotes:

FABQ Activity (min 0 max 24) 13.4 55.8 more fear-avoidant FABQ Work (min 0 max 42) 12.8 30.5 more fear-avoidant FABQ Total (min 0 max 66) 26.2 39.7 more fear-avoidant BBQ Inevitability (min 9 max 45) 31.9 63.6 less inevitability beliefs Coping Strategies (anxiety) (min 0 max 36) 5.0 13.8 high anxiety Coping Strategies (coping) (min 0 max 36) 20.7 57.4 high coping GHQ (distress) (min 0 max 36) 12.9 35.8 high distress Disability (cut down activity past 4w) (min 0 max 28) 5.6 20.0 high disability Disability (cut down social past 4w) (min 0 max 28) 13.7 48.8 high social impairment

The results in Table 3 suggest that these patients were more fear-avoidant about activity than about work, but did not have high scores generally; that they were only moderately distressed and not very anxious, despite moderate on-average social impairment and fairly high back pain bothersomeness (see Table 2). These findings are broadly similar, where comparable, to a cohort of osteopathic patients (Burton et al., 1995).

42

9.3. ATTITUDES TO ANALGESIA

The recommendation to use analgesics at the first visit for musculoskeletal pain has traditionally been unusual for chiropractors (Pedersen, 1994), where this is reported to have been recommended in only 3% of new patients. Recent qualitative work (Grundy and Vogel, 2005) suggests that osteopaths too may have mixed feelings about ‘masking’ the pain. Furthermore, the chiropractic, osteopathic and musculoskeletal physiotherapy professions do not generally have prescribing rights, although the Health and Social Care Act (2001) holds provision for this. However, adequate pain control is seen in virtually all evidence-based guidelines as an essential option, to be used if necessary to allow reactivation in non-specific conditions and prevent a chronic pain state developing.

The European Acute Back Pain Guidelines (EC, 2004a) recommend starting with paracetamol as first line and NSAIDs as a second line and taking these at regular intervals to allow adequate buildup in the blood stream. Despite evidence for the effectiveness of muscle relaxants, (Schnitzer et al., 2004) the guidelines did not recommend them for acute back pain because of the risk of dependency after even 1 week of use. The European guidelines also recommend against using epidural steroids injections for acute low back pain.

Up to 4 grams per day of paracetamol, purchased from a pharmacy (BNF, 2004), and ibuprofen, up to 1.2 grams per day, are recommended for acute back pain by Poole Hospital Pain Clinic (Appendix 2). The importance of taking this medication at regular intervals is stressed, along with continuing the full 4 gram per day paracetamol use for at least 72 hours. It is recommended that ibuprofen, 400 mg 3 times a day after food can be added to paracetamol if pain is not coming under control.

For severe pain, the Poole Hospital Pain Clinic guidance (Appendix 2) also recommends adding 10 mg of oral morphine (Oramorph) to this medication for 2 days as a maximum. However, a prescription would be required for this and driving and the operation of machinery would not be permitted.

9.4. IMAGING

Guidelines consistently recommend against the routine use of X-rays for acute episodes of musculoskeletal pain and none of the 3 professions except UK chiropractors have traditionally used them extensively. Their use by members of the British Chiropractic Association, dropped from 71% of new and old patients in 1977 (Breen, 1977) to 22% in 2000 (Young and Breen, 2000), probably influenced by the RCGP’s Acute Back Pain Guidelines (Waddell et al., 1999).

9.5 REACTIVATION

There has also been concern about the 3 professions’ approaches to encouraging reactivation and about the number of treatment sessions they may require. A trial comparing chiropractic with hospital outpatient management for back pain (Meade et al, 1990), found that the chiropractors tended to spread the same number of sessions of over a longer period in order to monitor progress. This is consistent with current guidelines that recommend reassessment and follow-up. However, the General Chiropractic and Osteopathic Councils’ codes of practice (GCC, 2005b; GOsC, 2005) warn against promoting treatment dependence.

43

9.6. GUIDELINE CONSISTENT ATTITUDES GENERALLY

In order to establish a measure of guideline-consistent attitudes for the 3 UK professions, Pincus et al (2005b) conducted a large qualitative study to determine the principal issues for them in relation to following current guidelines. This has provided an ‘Attitudes to Back Pain Scale’ in the form of questionnaire (Pincus, 2005c) (see Appendix 3) that can be used to enquire about these. This scale determines practitioners’ attitudes to:

Personal interactions: 1. limiting the number of physical treatment sessions 2. willingness to engage psychological issues 3. interacting with other professionals in the care of the patient 4. recognising own limitations

Orientation towards treatment: 1. maintaining mobility and returning to/staying at work 2. restricting activity and vigilance over biomedical/structural systems

Use of this scale in a survey of 546 practitioners from all 3 professions (Pincus et al, 2005a), found statistically significant differences in attitudes between them. Physiotherapists were more inclined to limit treatment sessions than osteopaths, and chiropractors were the least amenable to this. This was the only large effect. The other differences were that:

• Physiotherapists and chiropractors were more inclined towards engaging psychological issues than osteopaths

• Physiotherapists perceived greater connection to the health care system than the other two.

• Osteopaths reflected greater recognition of their own limitations than physiotherapists (Comparisons with chiropractors were not significant).

• Physiotherapists were more concerned about patients returning to work and normal activities.

• Physiotherapists were less concerned about underlying structural problems and vigilance about them than the other two professions.

This is the first large-scale comparison that has been made between the 3 professions. However, it only measures attitudes and not actual behaviour and some of the differences are probably explained by the closer involvement of physiotherapists with the NHS and with being employed as opposed to self-employed.

9.7. CO-MORBIDITY

The widespread use of complementary and alternative medical (CAM) practitioners in insured schemes would be new in the UK. A recent study in the US, where this is more prevalent, (Lind et al., 2005) found that for back pain, this involved more visits but lower costs than conventional treatment. These patients also had less co-morbidity than those under conventional care.

We have to date collected 2-year follow-up data on co-morbidity in the above ongoing study of 53 new patients of working age presenting to a chiropractic clinic in the South of England. Twenty of these had other conditions (including musculoskeletal ones). Treatment sessions

44

beyond the first 6 weeks were received by 75% of these patients compared with 36% of those without co-morbidities, but these differences did not reach statistical significance.

A large UK population survey (Ong et al., 2004) found that people who had attended chiropractors and osteopaths for low back pain in the past 3 months had significant levels of disability, but more were from non-manual occupations, with better general health, than those who attended physiotherapists. It is not known whether better general health status was a result of treatment or an initial presenting feature. However, the higher likelihood of workers with non-specific low back pain and co-morbidity remaining work disabled (Nordin, 2002), may make it advisable to consider additional professional development, at least for chiropractors and osteopaths, if access to them for occupational musculoskeletal problems increases.

9.8. PREVIOUS OCCUPATIONAL AND NHS USE OF MUSCULOSKELETAL PRACTITIONERS

Green (2000) surveyed 100 UK companies and 422 employees and found considerable interest, but limited commitment to and knowledge of using osteopaths to prevent disability and work loss. This was despite considerable previous involvement with them and largely related to failure to keep accurate records of reasons for absenteeism and record previous experiences with osteopathy for future evaluation. A similar survey by Hagen (1999) found that companies, especially large ones, were interested in receiving help from chiropractors, especially in relation to reducing sickness absence, but were generally uncertain about actual effectiveness.

9.8.1. Case study 1

A pilot study (Jay et al., 1998) following 32 workers in 3 public utilities companies with back/leg or neck/arm pain over a 2-year period. Their care over this time by chiropractors was paid for by their companies. Sickness costs dropped by 30% compared to the year before the scheme and by a further 20% the following year.

9.8.2. Case study 2

Stanley et al (2001) studied the effects of providing physiotherapist-staffed back pain clinics in general practices, where patients could receive care, on average, within 4 days of referral. Among patients in work, (n=378) 53% did not take time off and of those who did, 29% went back within a week. The authors calculated that the cost of providing such a service by physiotherapists would be that of providing between 1.0 and 1.7 whole time equivalents per 100,000 head of population.

9.8.3. Case study 3

In 1995-6, the Wiltshire Health Commission mounted a pilot scheme to test the CSAG’s recommendations about the management of acute back pain (CSAG, 1994), particularly in the context of referral to chiropractors, osteopaths and musculoskeletal physiotherapists. Outcomes for 344 patients with acute back pain were compared with 194 controls, with no significant differences in age, gender, severity and previous work loss and who had been treated conventionally over the previous 4 months (Scheurmier and Breen, 1998). The results are summarised in Table 4.

45

Table 4 Outcomes in patients with acute back pain referred to chiropractors, osteopaths and musculoskeletal physiotherapists compared to controls

Outcome Study patients Control patients

Wait for consultation (mean days) 7.4 24.8 Certified days in episode (mean) 23.8 44.2 Patients certified sick (%) 52 73 Advised to pursue normal activity (%) 52 33 Prescribed medication (%) 46 59 GP consultations in episode (mean) 1.9 2.4

The examples above come from the GP fund holding era of the late 1990s, when up to 20% of chiropractors and osteopaths, and 60% of musculoskeletal physiotherapists sampled, were providing services to the NHS (Langworthy et al, 2000). Since this era has passed, such arrangements have become less common for chiropractors and osteopaths but, where available, they are more formalised. For example:

9.8.4. Case study 4

NHS funded chiropractic has been provided continuously in Wilmslow; initially through GP fundholding, but currently by the Salford Central Cheshire Primary Care Trusts (GCC, 2005).

The service has been audited and found: 90% of patients had at least 75% improvement after 4.05 visits. For every 22 patients referred, the service saves the NHS £10,000. 8 out of 10 patients waiting for orthopaedic appointments did not need them following care bythe chiropractors.

9.8.5. Case study 5

Nottingham City Primary Care Trust offers multidisciplinary service at the Waverly Health Centre (GCC, 2005). This service includes chiropractic and is available to people who live in the Hyson Green and Radford areas of Nottingham. It is called the ‘Impact’ team and receives referral from over 20 GPs and other health professionals in the area and residents can also self-refer. This service is currently undergoing evaluation, due to be completed in September 2005.

9.9. A COMMON INTERVENTION PACKAGE

A second major MRC back pain trial (UK BEAM, 2004) included osteopaths and musculoskeletal physiotherapists. In preparation for this second trial, the 3 professions collaborated to gain consensus about the treatment package for back pain that includes manipulation, irrespective of the professional group that uses it. The trial compared this with active management by a GP and with an exercise package of care. This treatment package was developed by the Trial Working Party (Harvey et al., 2003), and agreed by the professions’ main competent authorities of the time; the British Chiropractic Association, the Chartered Society of Physiotherapists and the General Council and Register of Osteopaths.

The package of care had manual (Fig 4) and non-manual elements (Fig 5) which the professions also use for neck pain and upper limb disorders. It allowed flexibility in the type of technique

46

used, the number and frequency of sessions and the inclusion of exercise and advice about how to remain active. It also included key patient advice points taken from the Royal College of General Practitioners’ guidelines for the management of acute low-back pain (Waddell et al., 1999).

Manual Elements

p

p

traction; oscillation

Soft tissue techniques: cross-fibre stretch, longitudinal stretch, direct ressure, deep friction, neural mobilisation.

Articulatory techniques (mobilisations): low- through high-amplitude assive movement of the lumbar spine and sacro-iliac joints (and

necessarily hips): flexion, extension, rotation, side-bending, manual

Thrust techniques: (‘manipulations’): high or low velocity; low amplitude; direct or leverage; directed at central lumbar, zygophphysial or sacroiliac joints; unilateral or bilateral; at one or more locations.

Figure 4 Manual elements Harvey et al., 2003

p

Non-manual Elements

Exercises: passive flexion and extension, active side bending, active trunk rotation, passive or active hip joint stretching, abdominal or lumbar strengthening and neural mobilisation.

Advice: (in line with the RCGP guidelines (Waddell et al., 1999) and the Back Book (Roland et al., 2000)

Activity: advocate continuance of leisure activities, work activities and erformance of daily tasks (do not prescribe bed rest or work absence:

analgesics are allowed by not encouraged (for purposes of the trial)

Psychosocial issues: give generally positive messages and advocate benefits of activity (with avoidance of emotive language and concepts)

Figure 5 Non-manual elements Harvey et al., 2003

47

This second trial (UK BEAM, 2004) found this package of care to be more effective and cost-effective than the two other strategies (exercise and GP care) for subacute and chronic low back pain. However, these elements are common to acute back pain also. Therefore, we can now interrogate guidelines, evidence reviews and subsequent research to assess to what extent the interventions in this package can be expected to be effective for early use in back, neck and upper limb pain. What follows assumes that a competent assessment, comprising of a case history, psychosocial assessment and a physical examination has preceded these interventions.

9.10. ACUTE BACK PAIN

Back pain can be divided into 3 distinct subgroups (CSAG, 1994): non-specific (simple) back pain (95%), nerve root compression (4%) and serious spinal pathology (1%). The most up-to-date evidence-based guideline on its management is the European Guideline for the Management of Acute Low Back Pain in Primary Care (EC, 2004a). This was the consensus of an international multidisciplinary expert panel on the recommendations of 11 evidence-based national guidelines (Koes et al., 2001) plus subsequent systematic reviews and other high-quality research. It is probably the most authoritative current guideline. Its recommendations are targeted at the 95% of cases whose back pain is non-specific.

9.11. MANIPULATION, MOBILISATION AND SOFT TISSUE TECHNIQUES

In most guidelines spinal manipulation is considered to be a therapeutic option in the first weeks of a low back pain episode (EC, 2004a). As a therapy it has been found to provide more short-term improvement in pain and functional status than no treatment or sham therapies. The European Acute Back Pain Guideline recommends: “Consider (referral for) spinal manipulation for patients who are failing to return to normal activities”. However, it is generally expected that spinal manipulation will be more effective for some patients than others. Currently we do not know which, making its use more appropriate within a package of care than as a mono-therapy. Such is the heterogeneity of techniques that it is impossible to establish which kind of manipulation is most effective for which back pain, or whether manipulation is more effective than mobilisation (articulation). There is some evidence that high-velocity thrust manipulation is more effective than other types when compared to exercise or other physical therapies (Reeve-Tucker, 2004). However, there is little evidence concerning other types of soft-tissue techniques for acute back pain except massage, which has low effects and is not recommended as a treatment (EC, 2004a).

In the UK BEAM trial (2004) high-velocity thrust manipulation to the neck was excluded because of a very small chance of serious adverse effects. The most serious of these is cerebro­basilar stroke, which comprises around 1% of all strokes and will therefore occur in around 1:100,000 adults per year (Bamford et al., 1990; Biller et al., 1999; Haldeman, et al., 1999) There are several risk factors for this kind of stroke, which can present first as a new episode of neck pain and will probably run its course regardless of whether manipulation is used or not. Practitioners who treat people with new episodes of neck pain should know these risk factors and take appropriate action if they are uncovered.

The RCGP guidelines (Waddell et al., 1999) considered that, because physical reconditioning has been shown to improve functional levels in chronic low back pain, ”referral for reactivation/rehabilitation should be considered for people who have not returned to ordinary activities and work by 6 weeks”. The subsequent European Guidelines (EC, 2004a) recommend that “…advice to stay active or to get active should be promoted, and that increase in fitness will improve general health”. The current scientific evidence does not support the use of specific strengthening or flexibility exercises as a treatment for acute non-specific low back

48

pain”. However, both guidelines seem to have considered exercise in the context of a mono-therapy.

A subsequent UK trial (Wand et al. 2004) compared patients with acute low back pain who all received early intervention by musculoskeletal physiotherapists in the form of assessment and advice to stay active, but were randomised to the presence or absence of biopsychosocial education, manual therapy and exercise. The latter had significantly less disability, better mood, better quality of life and better general health at 6 week follow up although not at 6 months. This parallels the UK BEAM trial in which patients with subacute and chronic back pain were randomised to a manipulation package of care, which included exercises, an exercise program or analgesics and advice by a GP to stay active (UK BEAM, 2004). This showed similar results, except that differences in favour of the manipulation package were still detected at one-year follow up.

Otherwise, the evidence in favour of exercise appears limited to subacute and chronic, but not acute back pain. Physical conditioning programs that include a cognitive-behavioural approach plus intensive physical training (specific to the job or not) and address aerobic capacity, muscle strength and endurance, and coordination and are in some way work-related and supervised, seem to be effective in reducing the number of sick days for some workers with chronic back pain, compared to usual care. Again, there is no evidence of their efficacy for acute back pain (Schonstein et al., 2003). An earlier systematic review of multidisciplinary biopsychosocial rehabilitation (including exercise and intervention in the workplace) in the management of subacute back pain (Karjalainen et al., 2001) found moderate evidence of faster return to work, reduced sick leave and reduced subjective disability compared with usual care. However, the scientific evidence on the effectiveness of physical activity programs at worksites is still limited (Proper et al., 2002) and, judging from recent systematic reviews of the effect of ergonomic interventions on returning to work and remaining at work, (Elders et al., 2000; Hoozemans et al., 1998), these may also need to go well beyond training in working methods and include psychosocial interventions as well (see below).

9.12. ADVICE AND PSYCHOSOCIAL INTERVENTIONS

Perhaps the strongest recommendations in evidence-based guidelines (EC, 2004a) are for acute back pain and are in terms of advice to:

• Give adequate information and reassure the patient • Do not prescribe bed rest as a treatment • Advise patients to stay active and continue normal daily activities including work if

possible

The evidence for these is consistent. They are reflected in the key advice points included in the manipulation package of care (Harvey et al., 2003) (Fig 6).

49

KeyPain Guidelines )

Give positive messages

Nerve root pain:

patient advice points for acute back pain from the RCGP Acute Back (Waddell et al., 1999

Simple backache:

There’s nothing to worry about. Backache is very common. No sign of any damage or disease. Full recovery in days or weeks – but

may vary. No permanent weakness. Recurrences possible – but does not mean harm.

Give guarded positive messages No cause for alarm Conservative treatment should suffice – but may take a month or two Full recovery expected – but recurrence possible

Possible serious spinal pathology: Avoid negative messages

Some tests are needed to make the diagnosis Often these tests are negative The specialist will advise on the beset treatment Rest or activity avoidance until appointment to see specialist

Figure 6 Key advice points for acute back pain patients Harvey et al., 2003

Success in establishing a shared plan with the patient can depend on the degree of satisfaction they feel about their treatment. A recent systematic review of 20 studies (Verbeek et al., 2004) found that being included in the decision-making, with all the interpersonal requirements that are needed for this, is a central factor. Waddell and Burton (2004) highlight the following psychosocial interventions among principal positive factors in recovery:

• reassurance • accurate information • awareness of the importance of psychosocial factors in recovery • problem-solving • a care plan (function-based and done in stages, monitored and reviewed)

These are not explicit in the above package of care agreed by the 3 professions, but may need to be if they are to meet optimal requirements for an evidence-based approach. Although they are implied in the European Acute Back Pain Guidelines (EC, 2004a) in the recommendation: “Reassess those patients who are not resolving within a few weeks after the first visit, or those who are following a worsening course…), “there are no randomised trials directly linking a (specific) intervention to psychosocial risk factors for acute low back pain.” (EC, 2004a). Therefore, this guideline does not recommend behavioural therapy for treatment of acute low back pain. However, there is a good theoretical basis for secondary prevention in teaching patients how to choose strategies centred around activity and exercise in order to cope adequately in the future (Sluijs and Knibbe, 1991). Thus it is important to note that recommendations relating to psychosocial interventions go as far as problem-solving, but do not extend to more formal behavioural therapy.

50

10. SUMMARY POINTS AND GENERAL RECOMMENDATIONS

10.1. EMPLOYERS

When considering your policy towards the early management of musculoskeletal disorders, consider: • how much occupational health support you give and whether it is adequate • the relationship between that support and the human resources and CEO • the culture in your workplace towards ‘bad’ backs, necks, arms etc: Is it healthy? • obvious psychosocial factors in your workforce: eg. life stress, burnout, single parenting

and looking after disabled dependents, alcohol, other health problems, workload, self-esteem and peer support in the workplace

• is there more than one psychosocial problem? • financial incentives to becoming disabled or incapacitated When someone reports an MSD at work, ask about: • what their explanation for the disorder is • what care, if any, is being delivered • what the person’s beliefs and expectations are about recovery and return to normal work • their personal circumstances and general health then… • Make sure they know you are concerned. • Encourage them to accept evidence-based measures aimed at recovery. • Assure them that you will welcome them to the workplace with no obligations for

performance. • Make a plan with them that includes activity modification. • Keep in touch with them.

10.2. EMPLOYEES

If you are suffering from a musculoskeletal problem that is not getting better.. • Do not worry; expect it to get better in the near future. • Discuss it with your employer and see what temporary change you can make. • Use over-the-counter medications like paracetamol to control pain if necessary. • Try to stay active and at work. • If you are still concerned, consult a chiropractor, osteopath or musculoskeletal

physiotherapist for help.

10.3. HEALTH PROFESSIONALS

• Conduct diagnostic triage from case history and examination findings. • Decide a working diagnosis and if the problem is specific or undifferentiated. • Do general health and psychosocial assessments. • Refer or treat specific conditions with manual therapies and/or other evidence-based

interventions. • Encourage normal activity and remaining at work. • Propose and monitor activity modifications. • Provide reassurance, information and pain control. • Agree on time-limited and staged reactivation within a care plan. • Note job demands and check the patient is supported at work. • Reassess and consider general fitness as a secondary prevention strategy.

51

52

11. REFERENCES

Abenhaim, L., Rossignol, M., Valat, J-P., Nordin, M., Avouac, B., Blotman, F., Charlot, J., Dreiser, R.L., Legrand, E., Rozenberg, S. and Vautravers, P. (2000) The role of activity in the therapeutic management of back pain: Report of the International Paris Task Force on Back Pain. Spine, 25(4), 1S-33S.

Agency for Healthcare Research and Quality (2002) Diagnosis and Treatment of Worker-Related Musculoskeletal Disorders of the Upper Extremity. US Department of Health and Human Services. Report/Technology Assessment No. 62.

Allison, T.R., Symmons, D.P.M., Brammah, T., Haynes, P., Rogers, A., Roxby, M. and Urwin, M. (2002) Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester. Ann Rheum Dis, 61, 151-156.

Ariens, G.A., van Mechelen, W., Bongers, P.M., Bouter, L.M. and van der Wall, G. (2000) Physical risk factors for neck pain. Scand J Work Environ Health, 26(1), 7-19.

Ariens, G.A., Bongers, P.M., Hoogendoorn, W.E., Houtman, L.D., van der Wal, G. and Mechelen, W.V. (2001a) High quantitative job demands and low co-worker support as risk factors for neck pain. Spine, 26(17), 1896-1903.

Ariens, G.A.M., van Mechelen, W., Bongers, P.M., Bouter, L.M. and van der Wall, G. (2001b) Psychosocial risk factors for neck pain: a systematic review. American Journal of Industrial Medicine, 39, 180-193.

Athanasou, J.A. (2005) Return to work following whiplash and back injury: A review and evaluation. Medico-Legal Journal, 73(1), 29-33.

Bamford, J., Sandercock, P., Dennis, M., Burn, J. and Warlow, C. (1990) A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project - 1981-86 1. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary intracerebral and subarachnoid haemorrihage. Journal of Neurology, Neurosurgery and Psychiatry, 53, 16-22.

Barnett, A.G., Underwood, M.R. and Vickers, M.R. (1999) Effect of UK national guidelines on services to treat patients with acute low back pain: follow-up questionnaire survey. BMJ, 318, 919-920.

Bartys, S., Main, C.J. and Burton, A.K. (2000) Pain management in occupational settings. In: C.J. Main and C.C. Spanswick (eds) Pain Management: an interdisciplinary approach. Edinburgh, Churchill Livingstone, p. 403-421.

Bekkering, G.E. (2004) Physiotherapy guidelines for low back pain: development, implementation and evaluation. Amsterdam, Vrije University.

Bekkering, G.E., Hendriks, H.J.M, van Tulder, M.W., Knol, D.L., Simmonds, M.J., Oostendorp, R.A.B. and Bouter, L.M. (2005) Prognostic factors for low back pain in patients referred for physiotherapy. Spine, 30(16), 1881-1886.

53

Biller, J., Garg, B.P. and Rasura, M. (1999) Epidemiology and etiology of stroke in the young: new therapeutic perspectives for prevention. In: Fisher C.F. (ed.) Prevention of Ischaemic Stroke. Martin Dunitz, Chapter 5, 79-103.

Boersma, K. and Linton, S.J. (2005) Screening to identify patients at risk: profiles of psychological risk factors for early intervention. Clin J Pain, 21(1), 38-43.

Bonde, J.P., Mikkelsen, S., Andersen, J.H., Fallentin, N., Baelum, J., Svendsen, S.W., Thomsen, J.F., Frost, P., Thomsen, G., Overgaard, E. and Kaergaard, A.; PRIM Health Study Group (2003) Prognosis of shoulder tendonitis in repetitive work: a follow up study in a cohort of Danish industrial and service workers. Occup Environ Med, 60(9),E8.

Bonde, J.P., Mikkelsen, S., Andersen, J.H., Fallentin, N., Baelum, J., Svendsen, S.W., Thomsen, J.F., Frost, P. and Kaergaard, A.; PRIM Health Study Group. (2005) Understanding work related musculoskeletal pain: does repetitive work cause stress symptoms? Occup Environ Med, 62, 41-48.

Breen, A.C. (1977) Chiropractors and the treatment of back pain. Rheumatology and Rehabilitation, 16, 46-53.

Breen, A., Carrington, M., Collier, R. and Vogel, S. (2000) Communication between general and manipulative practitioners: a survey. Complementary Therapies in Medicine, 8, 8-14.

Breen, A.C. (2003) The implementation of consensus guidelines. Rygdoktor [online]. Available from: http://www.rygdoktor.dk.

Breen, A. (2005) From Guidelines to Practice: What is the Practitioner’s Role? In: C Liebenson (ed). Rehabilitation of the Spine (2nd edition) Philadelphia: Lippincott, Williams and Wilkins, Chapter 39 (in press).

Breen, A.C., van Tulder, M.W., Koes, B.W., HJensen, I., Reardon, R. and Bronfort, G. (2005) Mono-disciplinary or multidisciplinary back pain guidelines? How can we achieve a common message in primary care? European Spine Journal [online], http://dx.doi.org/10.1007/s00586-00005-00883-00589.

British National Formulary, Joint Formulary Committee. (2005) Paracetamol and NSAID, 49. London, British Medical Association and Royal Pharmaceutical Society of Great Britain.

British Society of Rehabilitation Medicine (BSRM) (2000) Vocational rehabilitation - the way forward: report of a working party (Chair: Frank A.O.). London, British Society of Rehabilitation Medicine.

Bronfort, G., Haas, M., Evans, R.L. and Bouter, L.M. (2004) Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. The Spine Journal, 4, 335-356.

Brosseau, L., Casimiro, L.,Milner, S., Robinson, V., Shea, B., Tugwell, P. and Wells, G. (2002) Deep transverse friction massage for trating tendonitis. Cochrane Database of Systematic Reviews, Issue 1, CD003528 (ISSN 1469-493X)

Browne, C.D., Nolan, B.M. and Faithfull, D.K. (1984) Occupational repetition strain injuries; guidelines for diagnosis and management. Med J Aust, 140, 329-332.

54

Buchbinder, R. and Jolley, D. (2005) Effects of a media campaign on back beliefs is sustained 3 years after its cessation. Spine, 30(11), 1323-1330.

Burton, A.K. (1981) Back pain in osteopathic practice. Rheumatology and Rehabilitation, 20, 239-46.

Burton, A.K., Tillotson, K.M., Main, C.J. and Hollis, S. (1995) Psychosocial predictors of outcome in acute and subchronic low back trouble. Spine, 20(6), 722-8.

Burton, A.K., Bartys, S., Wright, I.A. and Main, C.J. (2005) Obstacles to recovery from musculoskeletal disorders in industry, Research Report 323. London, HSE Books. www.hse.gov.uk/research/rrhtm/

Chaudhary, N., Longworth, S. and Sell, P.J. (2004) Management of mechanical low back pain: a survey of beliefs and attitudes in GPs from Leicester and Nottingham. European Journal of General Practice, 10, 71-72.

Chiu, Y.H., Silman, A.J., Macfarlane, G.J., Ray, D., Gupta, A., Dickens, C., Morriss, R. and McBeth, J. (2005) Poor sleep and depression are independently associated with a reduced pain threshold. Results of a population based study. Pain, 115, 316-321.

Clinical Standards Advisory Group (CSAG). (1994) Back Pain. London, Department of Health.

Coste, J., Lefrancois, G., Guillemin, F., Pouchot, J. and Rheumatology, French Study Group for Quality of Life in Rheumatology. (2004) Prognosis and Quality of Life in patients with acute low back pain: insights from a comprehensive inception cohort study. Arthritis and Rheumatism, 51, 168-176.

Cote, P., Cassidy, J.D., Carroll, L.J. and Kristman, V. (2004) The annual incidence and course of neck pain in the general population: a population-based cohort study. Pain, 112, 267-273.

Crawford, F. and Thomson, C. (2003) Interventions for treating plantar heel pain. The Cochrane Database of Systematic Reviews. Issue 3, Art. No. CD000416, DOI: 10.1002/14651858.CD000416

Croft, P. (1999) Diagnosing regional pain: the view from primary care. Baillieres Best Pract Res Clin Rheumatol.13(2), 231-242.

Croft, P.R., Lewis, M., Papageorgiou, A.C., Thomas, E., Jayson, M.I.V., Macfarlane, G.J. and Silman, A.J. (2001) Risk factors for neck pain: a longitudinal study in the general population. Pain, 93, 317-325.

Crook, J., Milner, R., Schultz, I.Z. and Stringer, B. (2002) Determinants of occupational disability following a low back injury: a critical review of the literature. Journal of Occupational Rehabilitation, 12, 277-295.

Davis, D.A., Thomson, M.A., Oxman, A.D. and Haynes, R.B. (1995) Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA, 274(9), 700-705.

Dekkers, W. (1998) Hermeneutics and experiences of the body: the case of low back pain. Theoretical Medicine and Bioethics, 19, 277-293.

55

Department for Work and Pensions (DWP). (2002) Pathways to work: helping people into employment. London, Department for Work and Pensions.

Department for Work and Pensions (DWP). (2004) Building capacity for work: a UK framework for vocational rehabilitation. London, Department for Work and Pensions, Report No. ELCI 3.

de Torrente de la Jara, G., Pecoud, A. and Favrat, B. (2004) Musculoskeletal pain in female asylum seekers and hypovitaminosis D3. BMJ, 329, 156-157.

Devereux, J., Rydstedt, L., Kelly, V., Weston, P. and Buckle. P. (2004) The role of work stress and psychological factors in the development of musculoskeletal disorders: The stress and MSD study. London, HSE; Report No. 273.

Deyo, R.A. (1988) Measuring the functional status of patients with low back pain. Archives of Physical Medicine and Rehabilitation, 69, 1044-53.

Dionne, C.E., Bourbonnais, R., Fremont, P., Rossignol, M., Stock, S.R. and Larocque, I. (2005) A clinical return-to-work rule for patients with back pain. CMAJ, 172, 1559-1567.

Dworkin, R.H. and Portenoy, R.K. (1996) Pain and its persistence in herpes zoster. Pain, 67, 241-251.

Ejnisman, B., Andreoli, C.V., Soares, B.G.O., Fallopa, F., Peccin, M.S., Abdalla, R.J. and Cohen, M. (2003) Interventions for tears of the rotator cuff in adults. The Cochrane Database of Systematic Reviews, Issue 4, Art. No. CD002758.pub2, DOI:10.1002/14651858.CD002758,pub2

Elders, L.A.M., van der Beek, A.J., Burdorf, A. and Elders, L.A.M. (2000) Return to work after sickness absence due to back disorders - a systematic review on intervention strategies. Int Arch Occup Environ Health, 73, 339-348.

Engel, G.L. (1977) The need for a new medical model: a challenge for biomedicine. Science, 196, 129-136.

Enthoven, P., Skargren, E. and Oberg, B. (2004) Clinical course in patients seeking primary care for back or neck pain: a prospective 5-year follow-up of outcome and health care consumption with subgroup analysis. Spine, 29(21), 2458-2465.

European Agency for Safety and Health at Work (1999) In: P. Buckle and J. Devereux. J (eds) Work-Related Upper Limb Musculoskeletal Disorders. Luxembourg, Office for Official Publications of the European Communities.

European Commission (EC), Cost Action B13 Management Committee (2004a) European Guidelines for the management of acute nonspecific low back pain in primary care. Available from: http://www.backpaineurope.org [Accessed 14th January 2005].

European Commission (EC), Cost Action B13 Management Committee (2004b) European guidelines for prevention in low back pain. Available from: http://www.backpaineurope.org [Accessed 14th January 2005].

56

Evans, T.H., Mayer, T.G. and Gatchel, R.J. (2001) Recurrent disabling work-related spinal disorders after prior claims in a chronic low back pain population. The Spine Journal, 1(3), 183­189.

Farley, D.O., Vernez, G., Nicholas, W., Quiter, E.S., Dydek, G.J., Pieklik, S. and Cretin, S. (2004) In: Evaluation of the low back pain practice guideline implementation in the Army Medical Department. California, RAND Corporation.

Ferlie, E., Wood, M. and Fitzgerald, L. (1999) Some limits to evidence-based medicine: a case study from elective orthopaedics. Quality in Health Care, 8, 99-107.

Foster, N.E., Thompson, K.A., Baxter, G.D. and Allen, J.M. (1999) Management of nonspecific low back pain by physiotherapists in Britain and Ireland. Spine, 24(13), 1332-42.

Foster, N.E., Pincus, T., Underwood, M., Vogel, S., Breen, A. and Harding, G. (2003) Treatment and the process of care in musculoskeletal conditions: a multidisciplinary perspective and integration. Orthopedic Clinics of North America, 34(2), 239-244.

Frankel, B.S., Moffett, J.K., Keen, S. and Jackson, D. (1999) Guidelines for low back pain: changes in GP management. Fam Pract, 16, 216-222.

Freeman, A.C. and Sweeney, K. (2001) Why general practitioners do not implement evidence: qualitative study. BMJ, 323, 1-5.

Gabbay, J. and le May, A. (2004) Evidence based guidelines or collectively constructed "mindlines?": Ethnographic study of knowledge management in primary care. BMJ, 329, 1013­1017 doi:1010.1136/bmj.1329.7473.1013.

Gam, A.N. and Johannsen, F. (1995) Ultrasound therapy in musculoskeletal disorders: a meta-analysis, Pain, 63, 85-91.

General Chiropractic Council (GCC). (2005a) Musculoskeletal services framework. Doc. C-040805-11. London, General Chiropractic Council.

General Chiropractic Council (GCC). (2005b) Code of Practice and Standard of Proficiency. London, GCC. Available online at www.gcc-uk.org.

General Osteopathic Council (GOsC). (2005) Code of Practice. London, GOsC. Available online at www.osteopathy.org.uk.

Gillies, J.H., Breen, A.C., Guppy, N., Hunt, N. and Laxton, A. (1993) Disability from back pain among four groups: a working population and patients attending chiropractic, osteopathy and rheumatology clinics. European Journal of Physical Medicine & Rehabilitation, 3(2), 74-8.

Goldberg, G. (1978) The General Health Questionnaire. Windsor, Berks, NFER-Nelson Publishing Ltd.

Green, G. (2001) Osteopathy in occupational health. Occupational Health Review Issue 90, 21­25.

Green, S., Buchbinder, R. and Hetrick, S. (2003) Physiotherapy interventions for shoulder pain. Cochrane Database of Systematic Reviews, Issue 2, CD004258 (ISSN 1469-493X)

57

Green, S., Buchbinder, R., Glazier, R. and Forbes, A. (2004a) Interventions for shoulder pain (Cochrane review). In: The Cochrane Library, Issue 4. Chichester, John Wiley.

Green, S., Buchbinder, R., Barnsley, L., Hall, S., White, M., Smidt, N. and Assendelft, W. (2004b) Non-steroidal anti-inflammatory drugs (NSAIDs) for treating lateral elbow pain in adults (Cochrane review). In: The Cochrane Library, Issue 4. Chichester, John Wiley.

Grimshaw, J., Eccles, M. and Tetroe, J. (2004) Implementing clinical guidelines: current evidence and future implications. Journal of Continuing Education in the Health Professions, 24, S31-S37.

Grotle, M., Vollestad, N.K., Veierod, M.B. and Brox, J.I. (2004) Fear-avoidance beliefs and distress in relation to disability in acute and chronic low back pain. Pain, 112, 343-352.

Grundy, M. and Vogel, S. (2005) Attitudes towards prescribing rights: a qualitative focus group study with UK osteopaths. International Journal of Osteopathic Medicine, 8, 12-21.

Haahr, J.P. and Andersen, J.H. (2003a) Prognostic factors in lateral epicondylitis: a randomized trial with one-year follow-up in 266 new cases treated with minimal occupational intervention or the usual approach in general practice. Rheumatology (Oxford), 42(10), 1216-1225.

Haahr, J.P. and Andersen, J.H. (2003b) Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study. Occup Environ Med.60(5), 322-329.

Hadler, N.M. (1999) Occupational musculoskeletal disorders. Philadelphia, Lippincott Williams & Wilkins.

Hagen, K. (1999) Business managers’ attitudes towards the role of chiropractic in corporate health care. Student project. Bournemouth, UK, Anglo-European College of Chiropractic.

Hague, J., Oxborrow, L. and McAtamney, L. (2001) Musculoskeletal disorders and work organisation in the European clothing industry. Nottingham, European Trade Union Technical Bureau for Health and Safety (TUTB).

Haldeman, S., Kohlbeck, F.J. and McGregor, M. (1999) Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine, 24(8), 785-94.

Hamberg, K., Johansson, E.E. and Lindgren, G. (1999) "I was always on guard" - an exploration of woman abuse in a group of women with musculoskeletal pain. Family Practice, 16, 238-244.

Harrington, J.M., Carter, J.T., Birrell, L. and Gompertz, D. (1998) Surveillance case definitions for work related upper limb pain syndromes. Occup Environ Med, 55(4), 264-271.

Harris, A.J. (1999) Cortical origin of pathological pain. Lancet, 354, 1464-1466.

Harris, G.R. and Susman, J.L. (2002) Managing musculoskeletal complaints with rehabilitation therapy: summary of the Philadelphia Panel evidence-based clinical practice guidelines on musculoskeletal rehabilitation interventions. The Journal of Family Practice, 51(2), 1042-1046.

Harvey, E., Burton, A.K., Moffett, J.K. and Breen, A. (2003) Spinal manipulation for low-back pain: a treatment package agreed by the UK chiropractic, osteopathy and physiotherapy professional associations. Manual Therapy, 8, 46-51.

58

Hayden, J.A., van Tulder, M.W. and Tomlinson, G. (2005) Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine, 142(9), 776-785.

Health and Social Care Act (2001) Part 5, Sect 63, Wesminster, House of Commons. http://www.opsi.gov.uk/acts/acts2001/20010015.htm

Helliwell, P.S. and Taylor, W.J. (2001) Occupation and upper limb disorders. Rheumatology (Oxford), 40(6), 716-717.

Helliwell, P.S. (2003a) Psychosocial factors in diffuse upper limb disorder. J Rheum, 30(1), 7-9.

Helliwell, PS., Bennett, R.M., Littlejohn, G., Muirden, K.D. and Wigley, R.D. (2003b) Towards epidemiological criteria for soft-tissue disorders of the arm. Occup Med (London), 53(5), 313­319.

Hoogendoorn, W.E., van Poppel, M.N.M., Bongers, P.M., Koes, B.W. and Bouter, L.M. (2000) Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine, 25, 2114-2125.

Hoozemans, M.J., van der Beek, A.J., Frings-Dresen, M.H., van Dijk, F.J. and van der Woude, L.H. (1998) Pushing and pulling in relation to musculoskeletal disorders: a review of risk factors. Ergonomics, 41(6), 757-781.

Horng, Y.-S., Hwang, Y.-H., Wu, H.-C., Liang, H.-W., Jang, Y., Twu, F.-C. and Wang, J.-D. (2005) Predicting health-related quality of life in patients with low back pain. Spine, 30(5), 551­555.

Hoving, J.L., Gross, A.R., Gasner, D., Kay, T., Kennedy, C., Hondras, M.A., Haines, T. and Bouter, L.M. (2001) A critical appraisal of review articles on the effectiveness of conservative treatment for neck pain. Spine, 26(2), 196-205.

Hoving, J.L., de Vet, H.C.W., Twisk, J.W.R., Deville, L.J.M., van der Windt, D., Koes, B.W. and Bouter, L.M. (2004) Prognostic factors for neck pain in general practice. Pain, 110, 639­645.

HSE-Statistics. (2004) Musculoskeletal disorders. London, Health and Safety Executive.

Hunt, G.D., Zuberbier, O.A., Kozlowski, A.J., Berkowitz, J., Schultz, I.Z., Milner, R.A., Crook, J.M. and Turk, D.C. (2002) Are components of a comprehensive medical assessment predictive of work disability after an episode of occupational low back trouble? Spine, 27(23), 2715-2719.

Hurwitz, E.L., Aker, P.D., Adams, A.H., Meeker, W.C. and Shekelle, P.G. (1996) Manipulation and mobilisation of the cervical spine: a systematic review of the literature. Spine, 21(15), 1746­1760.

Hussey, S., Hoddinott, P., Wilson, P., Dowell, J. and Barbour, R. (2003) Sickness certification system in the United Kingdom: qualitative study of views of general practitioners in Scotland. BMJ Online First, (BMJ,doi:10.1135/bmj.37949.656389.EE)

Indahl, A., Velund, L. and Reikeraas, O. (1995) Good prognosis for low back pain when left untampered. Spine, 20, 473-477.

59

International Association for the Study of Pain (IASP). (2002) Culture and Pain. Pain: Clinical Updates, X(5), 1-8.

Irving, A., Chang, D. and Sparham, I. (2004) Developing a framework for vocational rehabilitation: qualitative research. London, Department for Work and Pensions.

Jay, T.C., Jones, S.L., Coe, N. and Breen, A.C. (1998) A chiropractic service arrangement for musculoskeletal complaints in industry: a pilot study. Occupational Medicine, 48(6), 389-95.

Jellema, P., van der Windt, D.A.W.M., van der Horst, H.E., Twisk, J.W.R., Stalman, W.A.B. and Bouter, L.M. (2005) Should treatment of (sub)acute low back pain be aimed at psychosocial prognostic factors? Cluster randomised trial in general practice. BMJ, doi:10.1136/bmj.38495.686736.EO. (20 June).

Johansson, E.E., Hamberg, K., Westman, G. and Lindgren, G. (1999) The meanings of pain: an exploration of women's description of symptoms. Soc Sci Med, 48, 1791-1802.

Jonsson, H., Cesarini, K., Sahistedt, B. and Rauschning, W. (1994) Findings and outcome in whiplash-type neck distortions. Spine, 19(24), 2733-2743.

Karjalainen, K., Malmivaara, A., van Tulder, M., Roine, R., M., J., Hurri, H. and Koes, B. (2000) Multidisciplinary biopsychosocial rehabilitation for neck and shoulder pain among working age adults (Cochrane review). In: The Cochrane Library, Issue 2, pp. 1-20. Chichester, John Wiley.

Karljalainen, K., Malmivaara, A., van Tulder, M., Raine, R., Jauhiainen, M., Hurri, H. and Koes, B. (2001) Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. In: The Cochrane Database of Systematic Reviews.

Katz, J.N., Stock, S.R., Evanoff, B.A., Rempel, D., Moore, J.S., Franzblau, A. and Gray, R.H. (2000) Classification criteria and severity assessment in work-related upper extremity disorders: Methods matter. American Journal of Industrial Medicine, 38, 369-372.

Kerkhoffs, G.M.M.J., Rowe, B.H., Assendelft, W.J.J., Kelly, K., Struijs, P.A.A. and van Dijk, C.N. (2002) Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. The Cochrane Database of Systematic Reviews, Issue 3, Art. No. CD003762, DOI: 10.1002/14651858.CD003762

Kennedy, D. (2004) WRULD’s Risk Calculator. Capetown South Africa, Ergomax (Pty) Ltd. www.ergomax.co.za.

Kjellman, G.V., Skargren, K.I. and Oberg, B.E. (1999) A critical analysis of randomised clinical trials on neck pain and treatment efficacy: a review of the literature. Scand J Rehab Med, 31, 139-152.

Koes, B.W., Van Tulder, M.W., Ostelo, R., Burton, A.K. and Waddell, G. (2001) Clinical guidelines for the management of low back pain in primary care. Spine, 26(22), 2504-2514.

Kovacs, F.M., Abraira, V., Zamora, J., Fernandez, C. and Spanish Back Pain Research Network. (2004) The transition from acute to subacute and chronic low back pain: a study based on determinants of quality of life and prediction of chronic disability. Spine (accepted for publication).

60

Kupper, A., Mackenzie, S. and Heasman, T. (2004) The challenge of managing upper limb disorders - how can health professionals become more effective? Sudbury, Suffolk, Systems Concepts for the Health and Safety Executive.

Langworthy, J., Breen, A., Vogel, S., Collier, R. and Sutherland, G. (2000) Manipulation Services for NHS Patients: Precedents and Future Models for Provision. Bournemouth, Institute for Musculoskeletal Research and Clinical Implementation.

Langworthy, J., Clow, W. and Breen, A. (2005) Low back pain: barriers to effective clinical governance. Clinical Governance: an International Journal (in press).

Lasch, K.E. (2002) Culture and Pain. Pain: Clinical Updates, X(5).

Leboeuf-Yde, C., Gronsvedt, A., Borge, J.A., Lothe, J., Magnesen, E., Nilsson, O., Rosok, G., Stig, L.-C. and Larsen, K. (2004) The Nordic back pain subpopulation program: demographic and clinical predictors for outcome in patients receiving chiropractic treatment for persistent low back pain. Journal of Manipulative and Physiological Therapeutics, 27, 493-502.

Leech, C. (2004) Renaissance Project: Preventing chronic disability from low back pain. Dublin, Department of Social and Family Affairs, Government of Ireland, pp. 1-40.

Lemstra, M. and Olszynski, W.P. (2004) The effectiveness of standard care, early intervention and occupational management in Workers' compensation claims. Spine, 29(14), 1573-1579.

Lepine, J-P. and Briley, M. (2004) The epidemiology of pain in depression. Human Psychopharmacology, 19, S3-S7.

Lind, B.K., Lafferty, W.E., Tyree, P.T., Sherman, K.J., Deyo, R.A. and Cherkin, D.C. (2005) The role of alternative medical providers for the outpatient treatment of insured patients with back pain. Spine, 30(12), 1454-1459.

Linton, S. (2000) A review of psychological risk factors in back and neck pain. Spine, 25, 1148­1156.

Linton, S.J. and Bradley, L.A. (1996) Strategies for the prevention of chronic pain. In: R.J. Gatchel and D.C. Turk (eds) Psychological approaches to pain management: a practitioner's handbook. New York, Guilford Press, p.605.

Little, P., Smith, L., Cantrell, T., Chapman, J., Langridge, J. and Pickering, R. (1996) General practitioners’ management of acute back pain: a survey of reported practice compared with clinical guidelines. BMJ, 312, 485-488.

Macfarlane, G.J., Hunt, I.M. and Silman, A.J. (2000) Role of mechanical and psychosocial factors in the onset of forearm pain: prospective population based study. BMJ, 321(7262), 676­679.

Mannion, R.J. and Woolft, C.J. (2000) Pain mechanisms and management: a central perspective. Clin J Pain, 16, S144-S156.

Meade, T.W., Dyer, S., Browne, W., Townsend, J. and Frank, A.O. (1990) Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal, 300, 1431-1437.

61

Meade, T.W., Dyer, S., Browne, W. and Frank, A.O. (1995) Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow-up. British Medical Journal, 311, 349-351.

Meijer, E.M., Sluiter, J.K. and Frings-Dresen, M.H.W. (2005) Evaluation of effective return-to-work treatment programs for sick-listed patients with non-specific musculoskeletal complaints: a systematic review. Int J Occup Med Environ Health. Springer-Verlag 10.1007/s00420-005-0622-x

Melzack, R. (1999) Pain and Stress: a new perspective. In: R.J. Gatchel and D.C. Turk (eds) Psychosocial Factors in Pain: Critical Perspectives. New York, The Guilford Press, pp. 89­106.

Michener, L.A., Walsworth, M.K. and Burnet, E.N. (2004) Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther, 17(2), 152-64

National Health and Medical Research Council (NHMRC). Australian Acute Musculoskeletal Pain Guidelines Group (2003) Evidence-based management of acute musculoskeletal pain. Brisbane, University of Queensland and the Commonwealth Department of Health and Ageing, pp. 1-246.

National Institute for Clinical Excellence (NICE). (2001) Referral advice: a guide to appropriate referral from general to specialist services. London, National Institute for Clinical Excellence.

National Institute for Clinical Excellence (2003) Extracorporeal shockwave lithotripsy for calcific tendonitis (tendinopathy) of the shoulder. Interventional Procedure Guidance 21. ISBN 1-84257-427-2. http://www.nice.org.uk/pdf/ip/IPG021guidance.pdf

Njobvu, P., Hunt, I., Pope, D. and Macfarlane, G. (1999) Pain amongst ethnic minority groups of South Asian origin in the United Kingdom: a review. Rheumatology, 38, 1184-1187.

Nordin, M. (2002) Self-care techniques for acute episodes of low back pain. Best Practice & Research Clinical Rheumatology, 16(1), 89-104.

Ong, C-K., Doll, H., Bodeker, G. and Stewart-Brown, S. (2004) Use of osteopathic or chiropractic services among people with back pain: a UK population survey. Health and Social Care in the Community, 12(3), 265-273.

Pagliari, H. and Kahan, J.P. (2003) Biomed II Concerted action on changing professional practice. A catalogue of servey items assessing attitudes towards guidelines and perceived barriers and facilitators to implementation. The CPP Perceptions Library.

Palmer, K., Walker-Bone, K., Linaker, C., Reading, I., Kellingray, S., Coggo,n D. and Cooper, C. (2000) The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb. Ann Rheum Dis, 59(1), 5-11.

Parsons, S., Breen, A., Foster, N.E., Harding, G., Pincus, T., Vogel, S. and Underwood, M.R. (2005) The influence of patients' and healthcare practitioners' beliefs and expectations about chronic musculoskeletal pain on the process of community based care: a systematic review. Soc Sci Med (submitted).

62

Pedersen, P. (1994) A survey of chiropractic practice in Europe. European Journal of Chiropractic, 42(S), 3-28.

Pelmear, P.L. and Leong, D. (2000) Review of occupational standards and guidelines for hand-arm (segmental) vibration syndrome (HAVS). Appl Occup Environ Hyg, 15, 291-302.

Pengel, L.H.M., Herbert, R.D., Maher, C.G. and Refshauge, K.M. (2003) Acute low back pain: systematic review of its prognosis. BMJ, 327, 323-325.

Philadelphia-Panel (2001) Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for neck pain. Physical Therapy, 81(10), 1701-1717.

Pincus, T., Vlaeyen, J.W.S., Kendall, N.A.S., Von Korff, M.R., Kalauokalani, D.A. and Reis, S. (2001) Cognitive-behavioural therapy and psychosocial factors in Low Back Pain: directions for the future. Spine, 27, E133-E138.

Pincus, T., Burton, K., Vogel, S. and Field, A.P. (2002) A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine, 27(5), E109-E120.

Pincus, T., Foster, N., Vogel, S., Santos, R., Underwood, M. and Breen, A. (2005a) Attitudes to back pain amongst musculoskeletal practitioners: differences between professional groups and practice settings using the ABS-mp. (submitted to Manual Therapy).

Pincus, T., Vogel, S., Breen, A., Foster, N. and Underwood, M. (2005b) Persistent back pain ­why do physical therapy practitioners continue treatment? A qualitative study of chiropractors, osteopaths and physiotherapists. European Journal of Pain (in press).

Pincus, T., Vogel, S., Santos, R., Breen, A., Foster, N. and Underwood, M. (2005c) The Attitudes to Back Pain Scale in musculoskeletal practitioners (ABS-mp); the development and testing of a new questionnaire. Clinical Journal of Pain (in press).

Pinnington, M.A. (2001) Why are we finding it so hard to change our approach to low back pain? Physiotherapy, 87(2), 58-9.

Porro, C.A., Baraldi, P., Pagnoni, G., Serafini, M., Facchin, P., Maieron, M. and Nichelli, P. (2002) Does anticipation of pain affect cortical nociceptive systems? J Neurosc, 22, 3206-3214.

Pringle, M. (1993) Change and teamwork in primary care. London, BMJ Publishing Group.

Prodigy (2004) Prodigy neck pain guidelines. London, Department of Health. http://www.prodigy.nhs.uk/guidance.asp?gt-Neck%20pain

Proper, K.I., Staal, B.J., Hildbrandt, V.H., van der Beek, A.J. and van Mechelen, W. (2002) Effectiveness of physical activity programs at worksites with respect to work-related outcomes. Scand J Work Environ Health, 28, 75-84.

Punnett, L. and Wegman, D.H.(2004) Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. J Electromyogr Kinesiol, 14(1), 13-23. (Review).

Rainville, P. (2004) Pain and emotions. In: D.D. Price and C.M. Bushell (eds) Psychological modulation of pain. Seattle, WA, IASP Press, pp. 117-142.

63

Raspe, H. (2002) How epidemiology contributes to the management of spinal disorders. Best Practice & Research in Clinical Rheumatology, 16(1), 9-21.

Reeve-Tucker, P. (2004) Is high-velocity thrust a key factor in trials of manipulation for acute low back pain? A systematic review of randomised trials. Student project. Bournemouth, UK, Anglo-European College of Chiropractic.

Robinson, J.P., Fulton-Kehoe, D., Franklin, G.M. and Rae, W. (2004) Multidisciplinary pain center outcomes in Washington State Workers' Compensation, Journal of Occupational and Environmental Medicine, 46, 473-478.

Rogers, A. and Allison, T. (2004) What if my back breaks? Making sense of musculoskeletal pain among South Asian and African-Caribbean people in the North of England. J Psychosom Res, 57, 79-87.

Roland, M., Waddell, G., Klaber Moffett, J., Burton, K. and Main, C. (2002) The Back Book: The best way to deal with back pain. London, The Stationery Office.

Rosenthiel, A.K. and Keefe, F.J. (1983) The use of coping strategies in chronic low back patients: relationship to patient characteristics and current adjustment. Pain, 17, 33-44.

Saturno, P.J., Medina, F., Valera, F., Montilla, J., Escolar, P. and Gascon, J.J. (2003) Validity and reliability of guidelines for neck pain treatment in primary health care. A nationwide empirical analysis in Spain. International Journal for Quality in Health Care, 15, 487-493.

SBU. (2000) Back Pain Neck Pain - an evidence based review. Report 145. Stockholm, SBU-Swedish Council on Technology Assessment in Health Care.

Scheurmier, N. and Breen, A.C. (1998) A pilot study of the purchase of manipulation services for acute low back pain in the United Kingdom (World Federation of Chiropractic Prize­winning paper: 3rd Prize). Journal of Manipulative and Physiological Therapeutics, 21(1), 14­18.

Schers, H., Braspenning, J., Drijver, R., Wensing, M. and Grol, R. (2000) Low back pain in general practice: reported management and reasons for not adhering to the guidelines in the Netherlands. British Journal of General Practice, 50, 640-644.

Schnitzer, T.J., Ferraro, A., Hunsche, E. and Kong, S.X. (2004) A comprehensive review of clinical trials on the efficacy and safety of drugs for the treatment of low back pain. Journal of Pain and Symptom Management, 28(1), 72-94.

Schonstein, E., Kenny, D.T., Keating, J. and Koes, B.W. (2002) Work conditioning, work hardening and functional restoration for workers with back and neck pain. The Cochrane Database of Systematic Reviews, Issue 4, Art. No. CD001822, DOI: 10.1002/14651858.CD001822

Schonstein, E., Kenny, D., Keating, J., Koes, B. and Herbert, R.D. (2003) Physical conditioning programs for workers with back and neck pain: a Cochrane systematic review. Spine, 28(19), E391-E395.

64

Severeijns, R., Vlaeyenm, J.W.S., van den Hout, M.A. and Picavet, S.J. (2005) Pain catastrophizing and consequences of musculoskeletal pain: a prospective study in the Dutch community. The Journal of Pain, 6, 125-132.

Sheehan, N.J. (2001) How effective are guidelines for the management of low back pain? Letter to the Editor. Quality in Health Care, 10, 197.

Shekelle, P. (2003) Review: Patients with acute low back pain and associated disability improve substantially within 1 month. Evidence Based Medicine for Primary Care and Internal Medicine, EBM Online, www.evidence-basedmedicine.com, 27.

Skelton, A.M., Murphy, E.A., Murphy, R.J.L. and O'Dowd, T.C. (1995) Patient education for low back pain in general practice. Patient Education and Counseling, 25, 329-334.

Sieben, J.M., Vlaeyen, W.S., Portegijs, P.J.M., Verbunt, J.A., van Riet-Rutgers, S., Kester, A.D.M., Von Korff, M., Arntz, A. and Knottnerus, J.A. (2005) A longitudinal study on the predictive validity of the fear-avoidance model in low back pain. Pain (in press).

Sluijs, E.M. and Knibbe, J.J. (1991) Patient compliance with exercise: different theoretical approaches to short-term and long-term compliance. Patient Education and Counselling, 17, 101-204.

Sluiter, J.K., Frings-Dresen, M.H., Meijman, T.F. and van der Beek, A.J. (2000) Reactivity and recovery from different types of work measured by catecholamines and cortisol: a systematic literature overview. Occup Environ Med, 57, 298-315.

Smedley, J., Inskip, H., Buckle, P., Cooper, C. and Coggon, D. (2005) Epidemiological differences between back pain of sudden and gradual onset. Journal of Rheumatology, 32, 528­532.

South African Department of Labour. (2004) Compensation Commissioner’s Guidelines for Health Practitioners and Employers to manage Work-Related Upper Limb Disorders. Circular Instruction No.180. www.labour.gov.za.

Spitzer, W.O. (1995) Scientific monograph of the Quebec Task Force on whiplash associated disorders: redefining "whiplash" and its management. Spine, 20, 85.

Staal, J.B., Hlobil, H., van Tulder, M.W., Waddell, G., Burton, A.K., Koes, B.W. and van Mechelen, W. (2003) Occupational health guidelines for the management of low back pain: an international comparison. Occup Environ Med, 60, 618-626.

Stanley, I., Miller, J., Pinnington, M.A., Rose, G. and Rose, M. (2001) Uptake of prompt access physiotherapy for new episodes of back pain presenting in primary care. Physiotherapy , 87(2), 60-7.

Steenstra, I.A., Verbeek, J.H.A.M., Heymans, M.W. and Bongers, P.M. (2004) Prognostic factors for duration of sick-leave in patients sick listed with acute low back pain: a systematic review of the literature. (submitted to Occupational and Environmental Medicine).

Stone, W.E. (1983) Repetitive strain injuries. Med J Aust, 2, 616-618.

Stovner, L.J. (1996) The nosologic status of the whiplash syndrome: a critical review based on a methodological approach. Spine, 21(23), 2735-2746.

65

Svendsen, S.W., Mathiassen, S.E. and Bonde, J.P. (2005) Task based exposure assessment in ergonomic epidemiology: a study of upper arm elevation in the jobs of machinists, car mechanics and house painters. Occup Environ Med, 62, 18-26.

Symonds, T.L., Burton, A.K., Tillotson, K.M. and Main, C.J. (1996) Do attitudes and beliefs influence work loss due to low back trouble? Occupational Medicine, 46, 25-32.

Thomas, E., Silman, A.J., Croft, P.R., Papageorgiou, A.C. and Jayson, M.I.V. (1999) Predicting who develops chronic low back pain in primary care: a prospective study. BMJ, 318, 1662­1667.

Thomson, L.C., Handoll, H.H.G., Cunningham, A. and Shaw, P.C. (2002) Physiotherapist-led programmes and interventions for rehabilitation of anterior cruciate ligament, medial collateral ligament and meniscal injuries of the knee in adults. The Cochrane Database of Systematic Reviews, Issue 1, Art. No. CD001354, DOI: 10.1002/14651858.CD001354.

Tilscher, H., Pirker-Binder, I., Kollegger, M. and Pfeiffer, F. (2005) Head, Neck, Shoulder, Arm: workplace related? An increasing problem for women (in German "Kpf-Nacken-Schulter-Arm-Beschwerden: arbeitsplatzbedingt?" Manuelle Medizin, 43, 13-18.

Tomlin, Z., Humphrey, C. and Rogers, S. (1999) General practitioners' perceptions of effective health care. BMJ, 318, 1532-1535.

Truchon, M. and Fillion, L. (2000) Biopsychosocial determinants of chronic disability and low back pain: a review. J Occup Rehabil, 10, 117-142.

Truchon, M. (2001) Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model, Disability & Rehabilitation, 23, 758-767.

Tubach, F., Leclerc. A., Landre, M.F. and Pietri-Taleb, F. (2002) Risk factors for sick leave due to low back pain: a prospective study. J Occup Environ Med, 44, 451-458.

Turner, J.A., Franklin, G., Heagerty, P.J., Wu, R., Egan, K., Fulton-Kehoe, D., Gluck, J.V. and Wickizer, T.M. (2004) The association between pain and disability. Pain, 112, 307-314.

UK BEAM Trial Team (2004) United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: effectiveness of physical treatments for back pain in primary care. BMJ, 19 November, 1-8. doi:10.1136/bmj.38282.607859.AE.

Ursin, H. and Eriksen, H.R. (2001) Sensitization, subjective health complaints and sustained arousal. Annals of the New York Academy of Sciences (Ann NY Acad Sci), 933, 119-129.

Valat, J-P. (2004) Factors involved in progression to chronicity of mechanical low back pain: Editorial. Joint Bone Spine, (in press).

Van den Heuvel, S.G., de Looze, M.P., Hildebrandt, V.H. and The, K.H. (2003) Effects of software programs stimulating regular breaks and exercises on work-related neck and upper-limb disorders. Scand J Work Environ Health, 29, 106-116.

Van den Heuvel, S.G., Ariens, G.A.M., Boshuizen, H.C., Hoogendoorn, W.E. and Bongers, P.M. (2004) Prognostic factors related to recurrent low-back pain and sickness absence. Scand J Work Environ Health, 30, 459-467.

66

Van den Heuvel, S.G., van der Beek, A.J., Blatter, B.M., Hoogendoorn, W.E. and Bongers, P.M. (2005) Psychosocial work characteristics in relation to neck and upper limb symptoms. Pain, 114, 47-53.

Van der Windt, D.A.W.M., Van der Heijden, G.J.M.G., Van den Berg, S.G.M., Ter Riet, G., De Winter, A.F. and Bouter, L.M. (2002) Ultrasound therapy for acute ankle sprains. In. Issue 1. Art. No. CD001250 The Cochrane Database of Systematic Reviews.

Van Nieuwenhuyse, A., Fatkhutdinova, L., Verbeke, G., Pirenne, D., Johannik, K., Somville, P.R., Mairiaux, P., Moens, G.F. and Masschelein, R. (2004) Risk factors for first-ever low back pain among workers in their first employment. Occupational Medicine, 54, 513-519.

Van Tulder, M.W., Tuut, M., Pennick, V., Bombardier, C. and Assendelft, W.J.J. (2004) Quality of primary care guidelines for acute low back pain. Spine, 29(17), E357-E362.

Vase, L., Robinson, M.E., Verne, G.H. and Price, D.D. (2005) Increased placebo analgesia over time in irritable bowel syndrome (IBS) patients is associated with desire and expectation but not endogenous opioid mechanisms. Pain, 115, 338-347.

Verbeek, J.H. and van der Beek, A.J. (1999) Psychosocial factors at work and back pain: a prospective study in office workers. Int J Occup Med Environ Health, 12, 29-39.

Verbeek, J., Sengers, M.-J., Riemens, L. and Haafkens, J. (2004) Patient expectations of treatment for back pain. Spine, 29(20), 2309-2318.

Verdugo, R.J., Salinas, R.S., Castillo, J. and Cea, J.G. (2004) Surgical versus non-surgical treatment for Carpal Tunnel syndrome (Cochrane review). In: The Cochrane Library, Issue 4. Chichester, John Wiley.

Verhagen, A.P., Bierma-Zeinstra, S.M.A., Feleus, A., Karelsm, C., Dahaghin, S., Burdorf, L., de Vet, H.C.W. and Koes, B.W. (2003) Ergonomic and Physiotherapeutic interventions for treating upper extremity work related disorders in adults. The Cochrane Database of Systematic Reviews, Issue 3, DOI:003410.001002/14651858.CD14003471.pub14651852.

Viikari-Juntura, E. (1998) Risk factors for upper limb disorders. Implications for prevention and treatment. Clinical Orthopaedics, 351, 39-43.

Vlaeyen, J.W.S., Kole-Snijders, A.M.J., Boeren, R.G.B. and van Eek, H. (1995) Fear of movement/(re)injury in chronic low back pain and its relation to behavioural performance. Pain, 62, 363-372.

Vlaeyen, J.W. and Linton, S.J. (2000) Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 85, 317-332.

Waddell, G., Somerville, D., Henderson, I., Newton, M. and Main, C.J. (1993) A fear avoidance beliefs questionnaire (FABQ) and the role of fear avoidance beliefs in chronic low back pain and disability. Pain, 52, 157-168.

Waddell, G., McIntosh, A., Hutchinson, A., Feder, G. and Lewis, M. (1999) Low back pain evidence review. London, Royal College of General Practitioners.

67

Waddell, G. and Burton, A.K. (2000) Occupational health guidelines for the management of low back pain at work: evidence review and recommendations. London, Faculty of Occupational Medicine.

Waddell, G., Burton, A.K. and Main, C.J. (2003) Screening to identify people at risk of long-term incapacity for work. London, Royal Society of Medicine Press Ltd.

Waddell, G. and Burton, A. (2004) Concepts of rehabilitation for the management of common health problems. London, The Stationery Office.

Waddell, G., Klaber-Moffett, J. and Burton, K. (2004) The Neck Book: The best way to deal with neck pain based on the latest research. London, The Stationery Office.

Waddell, G., Burton, K. and McClune, T. (2004) The Whiplash Book: how you can deal with a whiplash injury. London, The Stationery Office.

Wahlstrom, J., Hagberg, M., Toomingas, A. and Wigaeus Tornqvist, E. (2003) Perceived muscular tension, job strain, physical exposure, and associations with neck pain among VDU users; a prospective cohort study. Occup Environ Med, 61, 523-528.

Walsh, K., Cruddas, M. and Coggon, D. (1992) Low back pain in eight areas of Britain. Journal of Epidemiology and Community Health, 46, 227-230.

Wand, B.M., Bird, C., McAuley, J.H., Dore, C.J., MacDowell, M. and De Souza, L.H. (2004) Early intervention for the management of acute low back pain. Spine, 29(21), 2350-2356.

Waugh, E.J., Jaglal, S.B., Davis, A.M., Tomlinson, G. and Verrier, M.C. (2004) Factors associated with prognosis of lateral epicondylitis after 8 weeks of physical therapy. Arch Phys Med Rehabil, 85(2), 308-318.

Waxman, R., Tennant, A. and Helliwell, P. (1998) Community survey of factors associated with consultation for low back pain. BMJ, 317, 1564-1567.

White, P.D., Henderson, M., Pearson, R.M., Coldrick, A.R. and White, A.G. (2003) Illness behavior and psychosocial factors in diffuse upper limb pain disorder: a case-control study. J Rheum, 30, 139-145.

Winters, J.C., de Jongh, A.C., van der Windt, D.A.W.M., Jonquière, M., de Winter, A.F., van der Heijden, G.J.M.G., Sobel, J.S. and Goudswaard, A.N. (1999) Dutch College of General Practitioners (NHG) Practice Guideline 'Shoulder complaints’. Available online at http://nhg.artsennet.nl/upload/104/guidelines2/E08.htm#noot24.

Young, A. and Breen, A.C. (2000) X-ray standards audit report. Reading, British Chiropractic Association.

68

APPENDIX 1 THE CARE PATHWAYS

1. GENERIC CARE PATHWAY

Scope: Any new episode of any musculoskeletal pain that interferes with work and lasts more than a day or two if severe, or up to a week if not severe.

Note: Over-reaction to mild or resolving episodes should be avoided.

STAGE 1: Within one week from onset:

Initial discussion, assessment and planned action with employer or their services

Activity modification considered

Involvement of health professional (if concerned)

STAGE 2: Within two weeks from onset if not recovered:

Reassessment and revised action plan for recovery

Monitoring and amendment of recovery plan - together with employer and with particular attention to activity and function (as distinct from pain alone)- until recovery

achieved.

69

2. EMPLOYER PATHWAY

Employees need to be aware of the employer’s desire to help and their policy of encouraging early discussion. The starting point for this is a key message to all employees to the effect that; “If you are having problems working because of pain in your back, neck, shoulders, arms or anywhere else, we want to help. Come in and talk to us!”

Employers also need to be aware of who is off work and why. There needs to be a ‘case manager’* at work who monitors progress, plus a standing group who address persistent reasons for absence.

STAGE 1: Within one week from onset:

Initial discussion of the problem, its nature and planning initial action with the employee (record notes for future monitoring)

Listening to the employee Employee story and concerns, nature of problem, any associated problems or unhappiness at

work, level of job demands and of personal control at work. Whether off work/having difficulty at work for non-work reasons, duration of current episode, improving, worsening or fluctuating

course, aggravating and relieving factors, other health problems, employee beliefs and expectations about work in general, about specific work issues and recovery

Reassurance and information Positive messages and assurance of value to organisation, commitment to overcoming the

problem and why it is best to remain at work if possible. Information giving (e.g. Back Book), reasons to consult appropriate health professional (e.g. for pain control, problem-solving,

uncertainty or worry). Be willing to arrange temporary activity modification, job rotation or job sharing. Do a risk assessment and reach agreement on a plan for recovery that includes initial

work-related changes. Arrange a follow-up discussion.

STAGE 2: Within two weeks from onset if not recovered:

(Input from chiropractor, osteopath or musculoskeletal physiotherapist if needed)

Review and if necessary amend work activity modifications, again considering job rotation or job sharing.

Monitor, review and modify the plan for recovery with employee (and health professional if involved), with particular attention to activity and function, until full recovery.

*This could be an occupational health practitioner, the personnel officer or the employer themselves, depending on the size of the organisation.

70

3. EMPLOYEE PATHWAY

STAGE 1: Within one week of getting the problem (it’s best to get in early!)

Most muscle and joint problems are harmless and clear up on their own (– and of course many have nothing to do with work or injury). If they need care, they respond best to a plan for recovery that is started early. In these cases, good recovery is more likely if you can control the pain, stay at work (even if you have some pain), and keep

active, perhaps with modified activities.

Tell your employer, line manager or human resources manager about the problem and discuss the effect of your activities and work.

If you are worried, consider whether you should make an appointment to see a health professional at work (if available), or a chiropractor, osteopath or musculoskeletal

physiotherapist in the community who can provide effective physical treatments, advise you on what kind of changes to make to your activities and help you to manage your

condition*. Arrange a follow-up discussion with your employer or other manager within the next week to check progress.

STAGE 2: If you have not recovered within two weeks of getting the problem:

Do not be discouraged! Make a plan to overcome the problem, using pain control and, if necessary, modified activities at work and/or other treatment. Make this together with

your employer and (if applicable) the health professional you are seeing.

Check with these people regularly that the plan is working and that your activities at work are increasing by stages. If not, reconsider your strategy together.

*You may have to pay for this.

71

4. HEALTH PROFESSIONAL PATHWAY

(i.e. an occupational health practitioner at work or a chiropractor, osteopath or musculoskeletal physiotherapist at work or outside of work)

STAGE 1: First attendance with the health professional

Assessment Conduct diagnostic triage leading to a working diagnosis. Refer to secondary care if

serious pathology, systemic disorder or progressive neurological disorder is suspected. If not, decide if there is a specific diagnosis (e.g. DeQuervain’s tenosynovitis) or if the

problem is non-specific. Assess for other health problems (including other musculoskeletal disorders), psychological barriers (such as illness behaviour or low

mood) and social burdens (such as family pressures or poor housing). Become conversant with the person’s job demands, personal control at work and non-work

activities. Check that they feel supported at work and that things are going well there and at home.

Intervention Provide reassurance, information, and pain control and agree an initial re-activation

strategy with time-limited, specific activity modifications to facilitate the person’s presence at work. Seek agreement to involve (rather then simply inform) the employer

if necessary. Avoid unnecessarily attributing the problem to injury or mechanical derangement, but for conditions where there is evidence of its effectiveness, consider

using manipulative treatment to reduce pain and disability early.

Initiate Care Plan Plan for recovery, taking other health, work or social problems into consideration.

Agree staged re-activation with personalised and specific work-related activities with employee and employer. Monitor recovery, with particular attention to activity and

function. Report your findings to the patient’s general practitioner.

STAGE 2: Within four weeks from first attendance (if still not recovered):

Review Review and modify the plan for recovery of activity and function with the employer and employee. Review the role of societal factors, general health, exercise and activity in longer- term recovery and secondary prevention. If not recovering, consider initiating

an exercise program at work or other work-based intervention

72

73

74

75

76

WC1R 4ED

GLOSSARY

(Professional bodies and health regulators with registers of musculoskeletal practitioners)

The Chartered Society of Physiotherapy www.csp.org.uk Chartered Society of Physiotherapists 14 Bedford Row London WC1R 4ED

General Chiropractic Council www.gcc-uk.org General Chiropractic Council 44 Wicklow Street London WC1X 9HL

General Osteopathic Council www.osteopathy.org.uk General Osteopathic Council 176 Tower Bridge Road London SE1 3LU

77

Printed and published by the Health and Safety ExecutiveC30 1/98

Published by the Health and Safety Executive11/05

RR 399