BackCare

Pain and work

2010 Author: Dr Andrew Auty

A personal account of the Department of Work and Pensions strategy on people with back pain. Dr. Andrew Auty

With apologies in advance to the DWP (Department of Work and Pensions) who have crafted their way through the back pain political quagmire with admirable tact and written genius. The following is to selectively paraphrase publications and policies produced by the DWP, but in a rather personal style, and very much more abruptly.

For decades now it has been 'obvious' that work is the main cause of back pain among the working or recently working population. The general public have accepted this view into popular culture; after all, people who frequently get back pain report that it is worse after lifting or twisting at work. Health and safety guidelines explain how work is the problem. Politicians assume it. Journalists assume it. It is therefore: a fact.  

But is it a Good Fact or a Bad Fact? Is it a Fact?

It is a Good Fact when:

• If hurt by work you will be told to go home and get medical help. 
• The cause can be identified and fixed before you get back to work.
• Work can even be designed to prevent back pain. 
• Compensation for pain and suffering and loss of earnings is there as a safety net if your employer should have done something to protect you, and didn't.

It is a Bad Fact if:

• Most back pain at work isn't actually caused by work. [but it may be more intense at work]
• Staying at or quickly returning to work is one of the best ways to accelerate recovery from back pain.
• The work can't be changed to suit you?
• Mismanagement of back pain is one of the main causes of leaving employment, permanently.

Your view of causation will be influenced by personal and national politics. As a defender of the right to normal health you will urge the avoidance of any elevated risk, as a defender of the right to work you will urge that back pain can be managed at work. Your view of causation will be influenced by the meaning you attach to it. This is a can of worms that most would choose to avoid. But we at BackCare must get involved: our mission is to help reduce the burden of back pain on individuals and in society. The DWP must get involved if avoidable unwanted worklessness is to be tackled.

So what are the DWP doing?
As is usual when opinion is hotly divided even the DWP has to start by saying,

On the one hand ...
Sometimes work does lead to back injury e.g. falling from a work platform, being struck by something heavy, slipping, overstraining while lifting a patient etc. and the 'good fact' then helps all concerned to choose appropriately. There is tissue damage, it must heal, the injury event must not be repeated, and its social and occupational effects must be put right. This must be right. HSE [now under the DWP umbrella] must help prevent it; DWP must help with any social consequences.

Scientific research shows that following a tissue damage event in the back it can take three years before the frequency of reporting back pain episodes reverts to the mean. But what is happening over those three years. Is it perhaps something about work which is reinjuring the wound? Is it hypersensitivity about unremarkable pain leading to a tendency to notice and report it? Is it that the back is more likely to be in significant pain? The management of the work and social effects of post injury pain will depend critically on which of these is correct. The pain = injury equation will obviously be foremost in everyone's mind, especially for the person with the painful spasm. The 'good fact' will drive them to follow the same path as for a high energy injury event. DWP has questioned whether this is in their best interests.

The current scientific view is that higher rates of recurrent pain reporting is usually not due to re-injury unless some new high energy event caused it, worry can play a role for some people in higher rates of reporting, but mostly, the reason is that the back is more likely to go into spasm for a while even after an injury has completely healed. Spasm hurts. It hurts as much as an injury, perhaps more, and for some people, much more. It can be triggered by anything but is known to be more likely during lifting and twisting movements. That's why so many people think normal lifting and twisting cause injury and is why so much guidance proclaims the virtues of avoiding it.

For many people the pain of spasm is overwhelming for a brief period. You can't move, even if you know that moving will help speed relief.

On the other hand ...
Once you know it is spasm and not a sign of injury, dread disease and decay would you want to be sent home until all  the pain had gone and risk starting down the road to becoming unemployed? Would you refuse to work until the work had been adjusted for you? Would you endlessly pursue your GP for a diagnosis when test after test shows there is no pathology, only spasm? Tens of thousands of people follow this path every year encouraged and assisted by the 'good fact'. Every year 100,000 people leave work permanently because of the 'good fact'. 

For many and for far too long the 'good fact' has been the only fact. There needs to be a balance and DWP has decided the balance starts now.

Some quotes from DWP publications help explain what they are doing about it.

Changing the assumptions:
The idea that people facing illness or disability should be protected from work, whatever their aspirations, is outdated and can often be detrimental to the individual - the opposite of the outcome the GP intended.

A number of initiatives are planned to help GPs work with patients, to ensure they understand the importance of work in recuperation and the negative impacts of being out of work and can support and assist people to remain in or return to work:

• to reward primary care staff who take active steps to support individuals to remain in or return to work;
• a national education programme for GPs on health and work 
• working closely with the Chartered Society of Physiotherapists to improve the work-focused messages given by their staff 
• supporting the College of Occupational Therapists, which is determined to push forward strongly in this area

In Practice
the provision of back-to-work services following self or GP referral. These have been tested by the Pathways to Work project. reviewing the format of the medical certificate (FMed 3) to make it more user-friendly and to support GPs in providing more comprehensive and robust fitness-for-work advice [a new Med 3 will be rolled out next year and will include advice on rehabilitation for the both the employee and employer to discuss]

For those on employment and support allowance, a higher rate of benefits will be paid to those who engage with return to work actions such as the condition management programme and work trials The aim is to educate, support and advise customers on how to manage their condition and to improve their functional ability using the principles of Cognitive Behavioural Therapy.

The Customer:

• understands more about his/her condition and how it can be safely managed in a work setting; 
• through exploring the health benefits of returning to work and strategies for dealing with the condition, feels more confident about seeking work and the prospect of remaining in work; and
• will recognise the early signs of a relapse or worsening of the condition and is better able to take appropriate, timely steps to seek help and/or reasonable workplace adjustments.

For those on incapacity benefit who try going to work, the system has been changed so that if they have a relapse which prevents work within two years they qualify for IB immediately and at the same rate as before the work trial.

Essentially these changes mirror the BackCare advice to avoid high energy injuries to the back, but if it happens: as soon as possible stay active, avoid actions which trigger disabling spasms, and challenge those who insist on the basis of outdated knowledge that you should stay away from work. On those occasions when the 'good fact' is actually correct the system works well but once the initial emergency has passed this fact must be balanced properly if rehabilitation is to be successful. Time will tell if the DWP approach works out. BackCare will help DWP to ensure that the balancing remains proportionate.