Occupational low back pain: Evaluation and management

INTRODUCTION — 

Low back pain in working individuals is a commonly encountered scenario [1]. Key responsibilities for clinicians managing occupational low back pain include performing a general and work-specific evaluation, developing evidence-based treatment recommendations to improve function and return to work, identifying psychosocial barriers to recovery when they are present, coordinating care, maintaining communication with the patient and workplace, evaluating work-relatedness, and providing education on preventing or managing recurrence or exacerbation. For some musculoskeletal disorders, the relationship of the condition to specific work activities is reasonably established [2]. However, for disorders such as low back pain, the etiology can be multifactorial and the relationship with the work environment less certain.

This topic reviews the evaluation and treatment of occupational low back pain. The general evaluation and management of acute, subacute, and chronic low back pain are presented separately (see "Evaluation of low back pain in adults" and "Treatment of acute low back pain" and "Subacute and chronic low back pain: Management" and "Subacute and chronic low back pain: Nonsurgical interventional treatment" and "Subacute and chronic low back pain: Surgical treatment"). Disability assessment and evaluation are also discussed separately. (See "Disability assessment and determination in the United States".)

EVALUATION

General assessment — The initial evaluation of patients with low back pain, whether occupational or not, is discussed in detail separately (see "Evaluation of low back pain in adults", section on 'Initial evaluation'). All patients with back pain, regardless of etiology, should have an initial evaluation that reviews these key features, which also includes an evaluation for features suggesting serious pathology or underlying systemic disease [3]. (See "Evaluation of low back pain in adults", section on 'Urgent and acute conditions'.)

Additional assessment for work-related pain — When low back pain is presumed to be work related, additional factors beyond the standard evaluation should be considered.

Determining relationship to work — For the patient who experiences acute low back pain after a specific traumatic event at work (such as a fall), the causal relationship may be evident. However, for most patients, it is less clear, and determining whether low back pain is work-related can be challenging. For example, back pain may simply reflect a common condition manifesting at work rather than one being caused, exacerbated (transient worsening of a pre-existing condition), or aggravated (permanent worsening of a pre-existing condition) by work.

Identifying low back pain as work related begins by asking patients directly about when and where the symptoms began and whether the patient believes the symptoms are work related. For patients reporting work-related low back pain, the following history should be reviewed:

●Nature of the work incident/activities, including the date, time, and specific circumstances

●Symptoms including location, nature, duration, aggravating and alleviating factors, and management to date

●Whether there has been any prior diagnostic evaluation and, if so, the results

●Past history of work-related low back pain, treatment, and duration of lost work time, as well as any residual work limitation

●Whether the patient is currently working and, if so, whether work modifications have been made

●Worker concerns regarding the ability to stay at work or return to work

●Whether a work incident report has been filed, and whether a workers' compensation claim exists and its status

●If the patient has an attorney or if there is planned or ongoing litigation

●Identification of risk factors for lost work time and low back disability (table 1)

Features that are supportive of a relationship between work and low back pain include:

●A specific work-related event or injury precipitating the onset of symptoms.

●Symptoms that are temporally related to specific work activities (in duration and/or magnitude) and that have been epidemiologically associated with back disorders. As examples, in an epidemiologic review, an association was identified between certain activities (eg, manual material handling, frequent bending and twisting, heavy physical work) and back disorders [4]. In another systematic review, however, only a moderate association was found between occupational lifting and low back pain, although lifting was not felt to be independently causative [5]. In a separate systematic review, there was no association between sitting at work and low back pain [6]. Work factors associated with lumbar radiculopathy in a systematic review included heavy, physically demanding work; bending or twisting; and combined lifting/carrying with bending or twisting. Sitting and driving at work were not observed to have an association with lumbar radiculopathy [7].

●Absence of a clear alternate nonoccupational explanation (eg, no significant pre-existing conditions, no relevant comorbidities, no nonoccupational back injuries or illnesses).

Criteria for determining work-relatedness also vary by jurisdiction, and clinicians making such determinations should be familiar with these regulatory interpretations. For example, some jurisdictions may require that work is the major contributing cause of symptoms, while others stipulate work may be any degree of a contributor or that work has exacerbated or aggravated symptoms. Clinicians should clearly document their rationale (providing "reasonable medical probability" or "more likely than not") for why they believe a patient's symptoms are or are not work related. Recommendations for data gathering and considerations involved with the determination of work-relatedness were summarized by the American College of Occupational and Environmental Medicine [8].

Health care providers may not feel comfortable with definitively determining work-relatedness, due to a lack of sufficient information regarding the work injury or events, limited familiarity with causation literature, or desire to avoid conflict with the patient. In such situations, the provider should document the patient's statements regarding symptom onset and work activities, the functional impact of the symptoms, and findings from the clinical examination without feeling compelled to opine on causation. Referral to an occupational medicine or other back pain specialist may also be appropriate. (See 'Role of the clinician' below.)

Determinations of work-relatedness can be difficult because the injury model for low back pain, which implicates a causal relationship to work activities, is complex and controversial, and multiple factors challenge this model [4,9,10]. Notably, low back pain is a common complaint, with particularly high prevalence among people in their working years [11,12]; for most workers, a specific etiology cannot be identified with certainty ("nonspecific low back pain"). The development of back pain at work may simply reflect the large percentage of waking hours spent at work. Furthermore, physical, biomechanical, and injury factors appear to have less influence in predicting outcomes in people thought to have occupational low back pain than patient expectations, psychosocial, work organizational, system, and socioeconomic factors [13].

Evaluate occupational impact — While a detailed worksite assessment is not always required, clinicians should ask about the patient's length of employment at their current job; job title; hours; duties, including physical tasks; and perceived job stress. These should include the maximal amount of weight that is lifted or carried, use of lifting devices, frequency of lifting, heights and distances that loads are carried, exposure to whole-body vibration, environmental conditions, and average daily duration for these activities [14-17].

The patient should also be asked about their beliefs and expectations regarding their treatment, recovery, and ability to work (eg, currently possible or, if not, when it might be); if symptoms limit the ability to perform regular duties; supervisor and coworker support for return to work; and if temporary modified accommodations would facilitate early return to work.

Clinicians should also review the potential options for work accommodations, consider the potential financial impact on the patient, and facilitate communication among all stakeholders in the workers' compensation system. Collaborative problem-solving including the injured worker and supervisor is often necessary to address any barriers to continued work or return to work. (See 'Return-to-work assessment' below.)

Evaluate functional abilities — The clinician should review the patient's self-assessment of functional abilities at work and at home.

The Oswestry Disability Index (ODI) is a validated, quick, and easily administered tool to quantify and monitor functional abilities such as lifting, walking, sitting, standing, social life, and traveling (figure 1) [18]. Baseline and periodic use of the ODI can be useful to observe concordance with the clinical assessment, establish a baseline level of function, determine work capabilities, and monitor recovery, including providing feedback to the patient regarding progress.

The Roland-Morris Disability Questionnaire (RMDQ) (table 2) is another example of a validated tool to assess function and can be similarly used for baseline and periodic assessment [19,20].

Clinicians treating occupational low back pain should understand the limited correlation of pain with disability [21] as well as mechanisms associated with the transition of pain to disability, including poor self-efficacy, psychologic stress, and pain-related fear [22]. Treatment plans should integrate functional outcome measurement assessments and focus on functional recovery from low back pain [23]. (See 'Counseling and education' below.)

Consider psychosocial factors — Certain psychosocial factors are associated with an increased risk for persistent back pain and an increased risk of work absence (table 1) [4,24-37] and should be specifically assessed in patients reporting work-related pain to inform prognosis. (See 'Predictors of disability' below.)

These factors include:

●General or work-related beliefs (eg, the belief that pain and activity are harmful; fear-avoidance behavior; poor expectations regarding activity and recovery, including return to work; fear of reinjury; perceived injustice)

●Work-related factors (eg, perceived work stress, poor control of one's job environment, rapid work pace, monotonous work, low job satisfaction, patient-perceived physical and psychologic demands of the job, lack of supervisor and coworker support, inability to modify work tasks)

●Other affective factors (eg, depression, anxiety, low self-efficacy, maladaptive coping [including fear avoidance and catastrophizing], somatization, substance use disorder)

Patients with a psychologic component or maladaptive coping to pain may also have associated inappropriate physical signs, also known as "Waddell's signs" (table 3). If present, these warrant a more detailed psychologic assessment to identify and address potential barriers to treatment response and return to work [38]. One study observed increased odds of somatic overreporting in chronic pain patients with two or more Waddell's signs [39], and another noted increased odds of treatment failure with interventional care, including epidural steroid, sacroiliac joint injection, or facet interventions [40]. However, these signs should not be used in isolation without considering the overall clinical evaluation, nor should the clinician conclude the presence of secondary gain or malingering based on their presence [41,42].

Multidimensional risk screening tools can help to identify patients at risk for poor outcomes and work absence or disability, though few have been specifically evaluated in work settings and studies comparing instruments are limited. Screening tools for psychosocial and return-to-work issues, as well as depression and alcohol and substance use, are discussed separately. (See 'Disability: Assessing risk' below and "Approach to the adult patient with suspected depression" and "Screening for unhealthy use of alcohol and other drugs in primary care" and "Substance use disorders: Clinical assessment".)

Disability assessment — Requests to evaluate impairment or work disability (including occupational low back pain) commonly occur within the regulatory framework of workers' compensation or other nonoccupational short- and long-term disability insurance systems. The general approach to disability assessment in the United States is discussed in detail separately. (See "Disability assessment and determination in the United States".)

Role of the clinician — In a workers' compensation work disability evaluation for back pain, the clinician needs to assess and document impairment and functional abilities. In addition, the clinician should provide an opinion as to causation; evidence-based recommendations for treatment; the potential for functional recovery and return to work, including potential job modifications; and determination of maximal medical improvement, and they should communicate the required information to all stakeholders in accordance with jurisdictional requirements. The role of the clinician in disability assessment is discussed in detail elsewhere. (See "Disability assessment and determination in the United States", section on 'Clinician role'.)

Clinicians can sometimes feel uncomfortable working with a patient seeking evaluation for a work-related condition [43-50]. Potential reasons include:

●Feeling ill-prepared because of a lack of training in occupational medicine

●Lack of confidence, clarity, or agreement about the scope of clinician responsibilities in providing information and encouraging return to work

●Knowledge gaps assessing work capacity and recovery prognosis for certain conditions

●Lack of familiarity with workers' compensation systems and treatment guidelines

●Feeling that a successful outcome may be difficult to achieve

●Concerns about patient confidentiality and disclosure of information

●Concerns about compromising the patient-clinician relationship while balancing the demands of all stakeholders

●Time constraints with a busy clinic schedule

●Inadequate financial compensation for coordination of care

Some clinicians may prefer to refer patients to occupational medicine or back pain specialists. The clinician performing the work disability assessment may sometimes feel part of an adversarial relationship between the patient, employer, and workers' compensation/disability insurer, which may undermine trust between patient and practitioner. Promoting evidence-based medical care and medically supported return to function can help maintain a focus on the best interests of the patient while balancing employer and societal considerations, even when medicolegal issues are superimposed [43,51-54]. Awareness of the elements involved in workers' compensation systems and the clinician's roles and responsibilities facilitates optimal patient outcomes, including safe return to work [55-57].

Evaluating impairment versus disability — Clinicians are occasionally asked to perform impairment evaluations. These are generally requested when the patient has experienced some loss of function and no other planned treatments are likely to result in significant functional improvement (a condition referred to as "maximal medical improvement" or "permanent and stationary").

"Impairment" (loss of use or derangement of a body structure or function) differs from "disability" (inability to engage in gainful activity due to physical or mental impairment). In the United States, individual states often specify the guidelines (table 4) that must be used to determine an impairment rating under workers' compensation [58]. Due to the lack of familiarity with these guides, clinicians may opt to defer to occupational medicine or other qualified clinicians to determine impairment ratings and assist by providing any requested medical documentation. Further discussion of impairment as it relates to disability is discussed in detail elsewhere. (See "Disability assessment and determination in the United States", section on 'Impairment'.)

Disability: Assessing risk

Predictors of disability — Predictors of work disability are similar to predictors of chronic low back pain and include [35,37,53,54,59-63]:

●Patient-related factors – Increased age, worse mental health, high perceived levels of pain and disability, somatization, low expectations for recovery and return to work, poor pain coping abilities, fear of movement or reinjury, pain and injury beliefs, prior work injury with prolonged absence, perceived injustice

●Employment-related factors – Perceived heavy physical demands, rapid work pace, perceived poor control of one's job environment, shorter job tenure, job dissatisfaction, inability to modify job tasks, absence of modified duty availability, perceived lack of supervisor or coworker support, perceived job stress, delayed injury reporting

●Treatment factors – Guideline-unsupported opioid and/or benzodiazepine prescribing, low back imaging in the absence of evidence-based indications, lumbar fusion for degenerative disease in the absence of instability or other guideline-supported indications, lack of clinician support for return to work

●Legal/system factors – Litigation related to the condition and workers' compensation policies regarding wage replacement and medical treatment

Certain psychosocial factors are associated with an increased risk for persistent back pain and delayed recovery and are more predictive than the biomechanical explanation for low back pain (table 1) [24,26-31,37,64] (see 'Consider psychosocial factors' above). As an example, in one study, functional improvement and return to work were more strongly determined by employment and psychosocial factors (job tenure, physical work demands, self-rated pain, and mood) than by history or physical examination findings [27]. In addition, other studies have found an association between coworker social support and recovery from low back pain [31], and supervisory, but not coworker, support as a factor promoting earlier return to work [30]. (See "Treatment of acute low back pain", section on 'Prognosis'.)

Screening for work disability risk — There is a lack of consensus regarding which patients may benefit from work disability risk screening, how to screen patients (eg, the specific history, examination, or screening tool to include), the optimal time to screen for risk, and how to use the results [26,34,35,65]. Despite these uncertainties, it is reasonable to screen patients who feel unable to return to regular duty during the acute phase of occupational low back pain for earlier behavioral and worksite interventions.

One option includes disability risk screening at the initial evaluation if patients are out of work or on modified duty [21,66]. Another option is to screen only those patients identified during the initial clinical evaluation with characteristics that may be associated with disability (eg, older age, high perceived levels of pain, and certain psychosocial or work organizational features) (table 1) (see 'Consider psychosocial factors' above). However, all patients who have not improved as expected despite evidence-based care within approximately four to six weeks or who have ongoing symptoms without clear medical explanation, and who have not been screened earlier, should undergo work disability risk screening and evaluation to identify barriers to recovery. An action plan should be developed for patients with increased risks identified on screening (eg, targeting specific physical, lifestyle, psychologic, or workplace or system barriers). (See 'Additional occupational interventions' below.)

There are a number of screening tools that have been developed to identify patients at risk of delayed recovery and disability, although not all have been validated for application in the occupational low back pain population. These include the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ; available in long-version 25-item and short-version 10-item formats) [67], the STarT Back tool [68], and the Back Disability Risk Questionnaire (BDRQ) [21,27], in addition to other assessments.

Clinicians should evaluate tools to assess which one would best suit their practice setting and needs.

●The 10-item ÖMPSQ (ÖMPSQ-10) is readily available and can be used for a variety of musculoskeletal conditions, including low back pain. ÖMPSQ-10 is easy to score and includes questions about pain, mood, expectations regarding pain with activity and work, as well as expectations for recovery and return to work. The ÖMPSQ-10 has been studied in primary care and in patients with acute work injury [66,69,70]. In an Australian study examining lost work time due to occupational musculoskeletal injury, a score of 48 to 50 or higher within the first 15 days was associated with an increased risk of work disability and duration of sick leave [66]. A follow-up study conducted screening within one to three weeks of injury and offered high-risk workers psychologic assessment and support, in addition to a return-to-work coordinator to help with communication among clinicians and the work supervisor as well as to work on identification of obstacles to return to work [70]. At two-year follow-up, the intervention group had significantly fewer mean lost workdays than controls (31.7 versus 66.5 days) and significantly lower total costs (AUD $16,443 versus $23,405).

●The STarT Back tool is short (nine items), easy to use, and specific for low back pain and has defined cutoff scores that can be used to stratify treatment for low- (eg, minimal intervention), medium- (eg, physical therapy), and high-risk (eg, physical therapy with a behavioral component) patients [71] (see "Subacute and chronic low back pain: Management", section on 'Risk assessment for chronic, disabling pain'). STarT Back includes questions on leg pain, mood, and expectations regarding activity with pain as well as expectations for recovery. STarT Back has not been validated in patients with occupational low back pain.

Stratified care in adults with nonoccupational low back pain is discussed in further detail separately. (See "Subacute and chronic low back pain: Management", section on 'Risk assessment for chronic, disabling pain'.)

●The BDRQ contains more work-related questions and has been validated in workers' compensation research settings; however, it is not yet available for clinical use. In a study evaluating patients with acute occupational low back pain using BDRQ, approximately 15 percent expressed multiple concerns about pain recovery, inability to return to regular work, emotional distress, and other psychosocial risks for disability [72]. A qualitative review of patient-provider conversations noted that conversations typically focused on biomedical rather than lifestyle and psychosocial issues, even with those patients with higher disability risks who may warrant a more detailed assessment of psychosocial factors.

Head-to-head comparison studies of these tools have not been performed in patients with work injuries. Comparison studies involving ÖMPSQ and STarT Back in primary care settings suggest that the tools have a moderate correlation to predicting disability and sick leave [73-75].

Completion of forms — A key step in the management of occupational low back pain is identifying what documents the clinician needs to provide to the employer and insurer and communicating this information in a timely manner. Although time-consuming, discussing the treatment and return-to-work plan and ensuring that all communications including any diagnostic testing specialists' reports are reviewed with the patient can minimize misperceptions and misunderstandings.

Specific patient status, request for treatment, or return-to-work forms are often required by workers' compensation jurisdictions, the insurer/third-party administrator, or the employer. Where jurisdictionally required, the forms can usually be downloaded from the workers' compensation commission. Using correct forms for treatment requests and return-to-work communications can avoid delays in care and improve efficiency. The return-to-work section of the forms are usually adapted from an ergonomic demands analysis, which attempts to define a job by its biomechanical components (eg, maximal weight and frequency of lifting, pushing, pulling, and carrying; duration of sitting, standing, and walking; postural issues including twisting, bending, climbing, squatting, kneeling; and other work task factors) [76].

While some of these questions may seem arbitrary, the purpose is to convey at least a general impression of the patient's abilities. Clinicians should complete information they can reasonably opine on. In most cases, clinician recommendations for return-to-work abilities can be derived using observations from the patient history of symptoms and function, validated tools like the ODI or RMDQ, examination, and a collaborative discussion with the patient. Clinicians should advise patients that there is good evidence that avoiding rest, maintaining activity, and promoting early return to function including work can improve recovery for low back pain patients [77-80]. (See "Treatment of acute low back pain", section on 'General approach to care' and "Exercise therapy for low back pain", section on 'Selected exercise modalities'.)

Since most clinicians will not perform a formal functional capacity assessment to indicate the duration of standing/sitting/bending or the amount of weight that can be carried and for how long, it is reasonable to focus on the activities that the patient needs to do as part of their job and to comment specifically on the ability to do them. As an example, if a patient works at a desk job, stating that they can sit for eight hours a day communicates that the individual is able to return to their full-time sedentary work. If a patient is required to carry 50-pound boxes, stating that they may lift up to 20 pounds conveys that the individual is not able to return to their usual job but may perform temporary alternative work. Input from a treating physical therapist can also help to address worker functional abilities. To answer questions regarding essential job functions or potential work modifications, the clinician can contact the employer to clarify the essential job functions, including physical demands, and outline modified duty options or can request an ergonomic job assessment by a qualified specialist (eg, ergonomist, physical or occupational therapist, safety professional). Nurse case managers or return-to-work coordinators from the insurer may also be available to facilitate obtaining information from the employer regarding job demands and the potential for temporary alternative work or job modifications.

Evidence-based return-to-work guidelines derived from large databases provide estimates of expected disability duration for a variety of conditions (including low back pain) and are often used by insurers when evaluating clinician return-to-work recommendations. These guideline recommendations can assist clinician decision-making and also help patients understand evidence-based observations regarding recovery and return-to-work expectations for low back disorders, including conservative care and postoperative settings.

MANAGEMENT — 

Most occupational low back pain is nonspecific or generally musculoskeletal in nature. Expected improvement in pain and function and return to work are the norm in the first four to six weeks, though low levels of pain may persist in some patients, and exacerbations are part of the natural history [81,82].

Clinicians can help improve outcomes for patients with occupational low back pain by facilitating appointments and communicating treatment requests and work status in a timely manner. Studies have observed increased odds of chronic disability in occupational low back pain claims related to delays in claim acceptance and administrative delays [83]. Increased duration of work disability from occupational low back pain has been associated with delayed injury reporting and delays in obtaining medical care [84].

The American College of Occupational and Environmental Medicine (ACOEM) has a useful stay-at-work/return-to-work position statement to help clinicians with decision-making while managing occupational low back pain [85]. Key components include guidance for clinicians in developing stay-at-work or return-to-work plans, prescribing activity, understanding the role and responsibilities of others (eg, patient, employer, insurer, attorney), respecting patient confidentiality, and managing medical information. Recommendations include using timely and evidence-based medical treatment, promptly addressing causation questions, minimizing unnecessary delays in care, providing objective and accurate medical documentation to facilitate treatment approvals and return to work, providing activity prescriptions for home and work, promoting gradual resumption of activities, identifying barriers to recovery and recommendations to overcome barriers, communicating with the patient and employer in this process, and utilizing specialists and other occupational health resources for complex cases and those with delayed recovery.

In the United States, many states and other jurisdictions have developed their own or adopted evidence-based medical treatment guidelines, including formularies, in an effort to promote reasonable and necessary treatments while reducing potentially ineffective, harmful, or costly care. There is some evidence that care consistent with high-quality, evidence-based guidelines can improve outcomes of work injuries [53,54,86-89]. The Department of Labor website has links to state workers' compensation programs where jurisdictional guidelines can be identified or referenced. Requests for treatment in these workers' compensation systems may require preauthorization with utilization review (UR) based on diagnosis, treatment request, timeline, etc. Obtaining approval for treatment is more likely when clinicians use required forms, supply medical records describing treatment rationale and concordance with any jurisdictional guideline recommendations, explain exceptional factors if treatment requests are outside of guidelines, and participate in requested peer-to-peer conversations with UR peer reviewers [54,89]. The ACOEM published guidance regarding UR in workers' compensation, addressing many of these aspects and ethical considerations [54].

General approach — The general approach to symptomatic management of occupational back pain is similar to that for nonoccupational back pain, which is discussed in detail elsewhere. (See "Treatment of acute low back pain", section on 'Initial therapy' and "Subacute and chronic low back pain: Management".)

Some recommendations in the American College of Physicians low back guideline may vary from recommendations included in occupational low back pain guidelines, however, and thus, some treatment requests may not be covered by the workers' compensation insurer.

Suggested nonpharmacologic strategies for the management of occupational back pain depend, in part, upon the nature and duration of the symptoms and functional limitations, identified psychosocial risk factors for work disability, patient goals and preferences, jurisdictional guideline recommendations and treatment timelines, and other considerations. As examples:

●Acute low back pain – Most patients with acute low back pain (less than four weeks) improve due to the benign natural history of low back pain, regardless of the recommended or chosen treatment options. Bed rest is detrimental to recovery and is not advised. We suggest that patients remain active, stay at work on medically supported modified duty, and gradually increase activities at work and at home; for patients who initially miss some time from work, early return to work is advised.

We also suggest the promotion of evidence-based care options and early referral to physical therapy for patients with occupational back pain who have significant functional limitations or high risk for chronic low back pain or work disability, including fear or concerns that activity or work will further harm their back. The management of acute low back pain is discussed in further detail separately. (See "Treatment of acute low back pain".)

●Subacute low back pain – Patients with persistent symptoms despite initial conservative care merit reassessment to identify reasons for delayed recovery, including return to work. This includes medical causes of symptoms versus nonphysical including psychosocial, workplace, or system (eg, insurance or workers' compensation system) barriers to recovery. As with patients with acute back pain, we suggest patients with subacute low back pain remain active and working in a modified duty capacity as well. Other options include graded exercise that can be combined with psychologic interventions (such as cognitive-behavioral therapy or psychologically informed physical therapy) with a work focus to address physical and behavioral barriers to recovery. For patients with continued work loss, we also suggest collaboratively (clinicians, patient, employer) exploring barriers to return to work and work accommodation to the patient's job or temporary alternative work in a different position to prevent long-term work disability. (See "Subacute and chronic low back pain: Management".)

●Chronic low back pain – For workers who are more severely limited in their function or unable to cope with their back pain, options depend on individual goals and preferences, work considerations, jurisdictional guidelines, and local availability. These may include behavioral supports, back school, functional restoration, or multidisciplinary rehabilitation. Some of these options may not be available outside of workers' compensation settings or supported by jurisdictional guidelines. (See "Subacute and chronic low back pain: Management".)

Limited role for imaging studies — Imaging is not indicated for most patients with occupational low back pain; the exception is in situations where there is a clinical suggestion of serious pathology (ie, "red flags") [90].

Among patients receiving workers' compensation for back pain, performing early imaging unsupported by clinical guidelines is associated with adverse outcomes. For example, early magnetic resonance imaging in the absence of a clinical indication is associated with increased lost work time, disability, and higher costs [91-95]. In an Australian cohort study, multiple imaging studies for occupational low back pain were associated with a longer duration of wage replacement (median 49 weeks versus 6.1 weeks with no imaging) [95]. Evidence-based recommendations for diagnostic testing in patients with occupational low back pain were published by the ACOEM [90].

Indications for imaging, including "red flag" symptoms indicating serious pathology, are discussed in detail separately. (See "Evaluation of low back pain in adults", section on 'Determining if imaging is indicated'.)

Counseling and education — Clinicians managing occupational low back pain balance patient advocacy with the promotion of functional recovery, symptom control, and effective coping. Clinicians should inquire early on about a patient's beliefs, expectations (including activity, work, recovery, and treatment), and goals and should support efforts for early, medically supported return to work, including collaborative problem-solving to overcome barriers [96-98].

Counseling and education consistent with abilities are beneficial for medical, psychologic, and socioeconomic health and well-being [99]. In addition, counseling patients with occupational low back pain may have beneficial effects on disability. As an example, in a randomized trial of 506 workers claiming disability related to low back pain, disability evaluation without counseling resulted in a greater likelihood of still being off work at one year compared with evaluation plus counseling (8.2 versus 3.6 percent; odds ratio [OR] 2.37, 95% CI 1.07-5.29) [100]. Rates of recurrent sick leave were also lower in the counseling group, but the duration of sick leave and subsequent surgery rate were similar to controls. The standard counseling advice in this study included:

●Do not let the low back pain be your guide.

●There is no sign of a serious disease other than a low back condition.

●An inflamed or cracked disc can cause reflex muscle activation, leading to stiffness and pain.

●Being too careful with activity and rest could worsen the stiffness and pain.

●Fear and pain anticipation could increase muscle activation and pain.

●Light activity can enhance the repair process.

●Fifty percent of patients resume work safely in six weeks and the majority within three months.

In addition to addressing these points, clinicians should review the natural history of recovery and return to work, the limited role of diagnostic testing, and the benefits and risks of evidence-based treatment options, taking into consideration patient goals, expectations, and preferences in an effort to build a therapeutic alliance. A number of different models of care incorporate the principle of early return to work [101,102]. One example is the SPICE model [101]:

●Simplicity – Avoid unnecessary diagnoses and medicalization of benign conditions

●Proximity – Keep the worker in close contact with the workplace

●Immediacy – Deal with work-related symptoms in a timely manner

●Centrality – All treating practitioners share a common goal and work together in close communication

●Expectancy – Setting expectations for recovery and return to work often leads to fulfillment of those expectations

A variety of interventions to educate patients with low back pain, including biomedical and biopsychosocial informational booklets, videos, and health professional discussions, have been evaluated. A systematic review concluded that education regarding the benign nature of most low back pain; the favorable prognosis of acute back pain; and recommendations to remain active, gradually resume normal activities, and promote self-care resulted in reductions in subsequent primary care visits, although the effect was small [103]. In another systematic review, intensive education (eg, a single 2.5-hour session) was more effective than no intervention in improving short- and long-term return to work for patients with subacute low back pain; however, the efficacy in chronic low back pain was unclear [104].

Activity, exercise, and physical therapy — All patients with occupational low back pain should be advised to remain active and gradually increase activities at home and work to aid recovery. (See "Treatment of acute low back pain", section on 'General approach to care'.)

In addition, for patients with fear-avoidance beliefs (eg, fear/worry that activity or work may harm their back) or other maladaptive coping behaviors, we suggest early referral to physical therapy, potentially integrating cognitive-behavioral approaches ("psychologically informed physical therapy" [105]). Similarly, patients with acute low back pain who do not progress as expected, those with recurrent low back pain, and those with more significant functional limitations are also good candidates for physical therapy. (See "Subacute and chronic low back pain: Management", section on 'Exercise therapy'.)

Key goals of physical therapy are to provide time-limited care and education to manage symptoms and improve function with an exercise program, with subsequent transition to self-care. This can often be accomplished with an initial referral for four to six physical therapy visits. Clinicians should monitor patient adherence and document response to physical therapy and exercise using symptoms (eg, pain using a visual analog scale or PEG scale [pain, enjoyment, and general activity scale for chronic pain patients]) and functional assessment tools (eg, Oswestry Disability Index (figure 1), Roland-Morris Disability Questionnaire (table 2)), focusing primarily on functional recovery. Workers' compensation treatment guidelines often include recommendations on the initial and upper limit for number of visits for different low back diagnoses. Requests for additional physical therapy visits should consider patient symptoms and functional limitations, compliance, gains with care, need for skilled physical therapy versus a home exercise program, and occupational demands.

When feasible, continuity of care with the same physical therapist should be considered. Australian analysis of occupational low back pain observed decreased duration of work loss in cases with continuity of care with one therapist [106]. Recommendations to enhance physical therapist management of patients with work-related low back pain include identifying occupational factors, including patient perceptions of physical job demands and return to work concerns, and discussing/communicating recommendations about possible job modifications [107,108]. The American Physical Therapy Association published clinical guidance to optimize work participation after injury or illness [107]. Many concepts, including timely care; therapeutic alliance; individualized care; screening for disability risks; use of valid self-reported functional inventories; communicating and coordinating with other clinicians and stakeholders; promoting modified and graded activity, including work participation; and using psychologically informed practice when indicated, are applicable to patients with occupational low back pain.

For occupational low back pain, there is some evidence that early physical therapy can improve outcomes and reduce costs, particularly for those who have disability risks such as fear-avoidance behavior [86,109,110]. The evidence evaluating exercise therapy for acute back pain in general is discussed elsewhere. (See "Treatment of acute low back pain", section on 'Exercise and physical therapy'.)

Interventional treatment — Some patients with specific clinical presentations (eg, lumbar radiculopathy) who fail initial conservative care may be candidates for invasive procedures (eg, epidural steroid injections). The ACOEM has published evidence-based recommendations for minimally invasive and invasive management, including surgical decisions in patients with occupational low back pain [111,112]. These treatments and their indications are presented in further detail separately. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)

Additional occupational interventions — Some patients with work-related low back pain experience delayed recovery and less optimal outcomes compared with patients with nonoccupational back pain. Thus, a number of occupational interventions have been evaluated to support the medical and biopsychosocial management of work-related low back pain with the intent to promote coping and recovery and facilitate early return to the workplace. Trials of workplace interventions and systematic reviews support the concept that early workplace interventions can promote earlier return to work and reduce long-term disability [113-119]. Such interventions include return-to-work barriers assessment and problem-solving, ergonomics, back school, functional restoration, and multidisciplinary rehabilitation. Evidence regarding the effectiveness of workplace interventions to reduce work loss is variable according to a Cochrane systematic review of musculoskeletal disorders, with moderate evidence of decreased time to first and lasting return to work [119].

The selection of specific interventions depends upon availability, patient goals and preferences, motivation, symptom duration, work loss, ability to modify job responsibilities, employer support for worksite interventions, applicable regulatory treatment guidelines, and insurer support and reimbursement. Quality, including outcomes and program availability, is also a major consideration.

Ergonomics — Ergonomics involves arranging the environment to fit the person [26,120]. Ergonomics may be useful in patients with subacute to chronic low back pain or multiple recurrences who are otherwise unable to return to a specific job. Successful implementation requires patient, clinician, and employer/supervisor support for exploring worksite modifications to facilitate the performance of work tasks and to overcome barriers to return to work, as well as qualified ergonomic specialists to make assessments and recommendations.

Ergonomic assessment is usually arranged through the patient's employer. Typically, an appropriately trained ergonomist, occupational health and safety professional, or physical or occupational therapist attends the job site; assesses conditions, positions, and the forces involved in the worker's tasks; and makes recommendations to optimize the interaction between worker and work environment. In office settings, for example, such recommendations may address keyboard, desk, or chair modifications, as well as lighting, ventilation, shift schedule, or other issues. Recommendations in manufacturing settings could include altering lifting characteristics or the use of lifting devices.

Evidence on the efficacy of ergonomic interventions in preventing low back pain is mixed [121-126]. One systematic review including 10 studies of varying design suggested a beneficial effect from multifactorial musculoskeletal ergonomic interventions [122]. In a subsequent trial, ergonomic interventions including workplace modifications and case management improved return-to-work rates for workers [115]. However, other studies and trials have indicated that the provision of lifting equipment and training (eg, instruction on heavy lifting techniques and material handling) are ineffective for preventing low back pain [122-125]. There is conflicting evidence regarding the effectiveness of sit-stand workstations. A systematic review of eight trials noted a lack of good-quality evidence of benefits, in part due to methodologic issues [127]. In one randomized trial of sit-stand workstations, subjects with chronic low back pain reported reduced current and worst pain compared with controls [128].

There is some support for "participatory ergonomics" to reduce disability duration. This intervention involves an ergonomist-led group, which includes the involvement of the worker, the worker's supervisor, and other stakeholders in decision-making. After observation by the ergonomist, group members rank obstacles to returning to work and find consensus regarding feasible solutions; after the interventions are applied, the outcomes are assessed. In a randomized controlled trial including 198 workers with occupational back pain causing work disability, participatory ergonomics decreased time to return to work (77 versus 104 days) [115]. In another randomized trial including 130 adults with low back pain and work disability, participatory ergonomics (integrating graded activity using a cognitive-behavioral therapy approach) resulted in a reduction of disability days compared with usual care [129]. In addition, the participatory ergonomic approach may provide psychologic as well as physical benefit to the worker [130,131].

There is no compelling evidence that lumbar supports are effective for the prevention or management of chronic low back pain [132,133]. The United States National Institute for Occupational Safety and Health (NIOSH) Back Belt Working Group does not recommend the use of back belts to prevent injuries among uninjured workers and does not consider back belts to be personal protective equipment [132]. (See "Subacute and chronic low back pain: Management", section on 'Nonpharmacologic therapies'.)

Back school — Back school programs are an option for patients with subacute to chronic low back pain who are motivated and require additional treatment (eg, after time-limited physical therapy) to improve coping and exercise participation.

Back school components vary but ideally include education and skills-based training [134]. The educational component aims to develop coping techniques through better understanding of the self-limiting nature of back pain and stress management. The skills component includes physical rehabilitation, although it may not target physical demands of specific jobs like functional restoration programs do.

The evidence supporting back schools is limited [135-141]. Although an earlier systematic review found moderate-quality evidence that back schools improve short-term recovery and return to work, they did not result in decreased pain or long-term recurrence rates [135]. Updates of that review, which focused on acute to subacute and chronic back pain separately, deemed the evidence on pain and disability outcomes to be of low quality [138,140]. Results have generally been better in trials of back schools conducted in an occupational setting and for more intensive programs based on the original Swedish back school, although the magnitude of benefits was nevertheless small. Furthermore, a separate trial of patients with subacute pain suggested the converse, that a low-intensity back school reduced work absence more than a high-intensity back school or no back school [139]. Questions regarding efficacy of back schools and lack of available quality programs are factors to consider in treatment selection. (See "Subacute and chronic low back pain: Management", section on 'Nonpharmacologic therapies'.)

Functional restoration — Functional restoration through "work conditioning" or "work hardening" programs is another option to treat motivated patients with subacute and chronic low back pain who are unable to return to their pre-injury physically demanding jobs (eg, medium demand or greater (table 5)) despite initial treatment because of mismatch between functional abilities and required job demands [142].

The goals of functional restoration are to increase physical capacity that directly supports job performance and to assess and reassure the patient of their ability to return to work safely and successfully through work conditioning or work hardening:

●Work conditioning involves single-discipline, progressively increased physical conditioning exercises targeted to the patient's work demands using simulated or actual work tests in a supervised environment to improve strength, endurance, flexibility, and cardiovascular fitness.

●Work hardening involves some interdisciplinary care including work conditioning along with psychologic support (eg, cognitive-behavioral therapy) or counseling. Periodic functional testing is performed to quantify progress towards achieving goals.

Specific program definitions, components, sequencing, intensity, and duration vary among specific programs, professional societies, accrediting entities, and various occupational treatment guidelines and should be clarified before starting. There should be a documented mismatch between physical job demands (eg, ergonomic job analysis quantifying the demands of essential job functions) and worker capabilities (determined by a physical or occupational therapist using validated test methods). Patients should not have musculoskeletal, medical, or psychologic comorbidities that preclude participation in prescribed exercise. Programs may vary from one to two hours a day (work conditioning) to half- or full-day programs and from a few days per week to daily participation, resulting in a range of 20 to 160 hours (fewer hours for work conditioning) for a full program over two to four weeks. However, there is a lack of evidence regarding optimal components, sequencing, intensity, and duration for these programs.

Participants in work-conditioning or work-hardening programs need to demonstrate compliance and functional improvement toward goals with an initial trial to support continuation beyond two weeks. In the United States, state-developed workers' compensation treatment guidelines, or other evidence-based guidelines, are used by insurers to determine inclusion criteria and certify the frequency, duration, and range of treatment.

The data on the efficacy of functional restoration programs for occupational back pain are mixed, in part because of the diversity of program interventions, but some studies demonstrate a benefit. One systematic review concluded that physical conditioning had uncertain effectiveness for reducing sick leave for patients with acute and subacute low back pain compared with usual care or exercise therapy [143]. However, another systematic review deemed functional restoration more effective than usual care or standard exercise therapy for reducing time lost from work, but only when a cognitive-behavioral component was included [144]. In a subsequent randomized trial, intensive functional restoration reduced sick leave days more than active physiotherapy among patients with chronic low back pain (mean 37.3 versus 72 days) [145]. Studies have also evaluated the effect of program type. In one randomized trial, function-centered treatment (exercises regardless of pain) improved self-efficacy, strength, and days at work more than pain-centered treatment (cease exercise if pain increased) [146]. Lower-cost, less intensive approaches (eg, 3 versus 25 hours per week; 4 versus 6 hours per week) also appear comparably effective with more aggressive interventions in motivated patients [147,148]. (See "Exercise therapy for low back pain", section on 'Selected exercise modalities'.)

Multidisciplinary (interdisciplinary) rehabilitation — Multidisciplinary or interdisciplinary rehabilitation programs involve more comprehensive multidisciplinary or interdisciplinary care than programs described above, using a biopsychosocial approach to address symptoms and physical, psychosocial, and occupational barriers to return to function. They are generally reserved for patients with chronic low back pain syndromes that limit function and work, significant psychosocial contributors to delayed recovery (eg, anxiety, depression, fear avoidance, maladaptive coping), and typically continued use of opioid analgesics without significant benefit. Multidisciplinary rehabilitation should generally only be used after less intensive physical, psychologic, pharmacologic, or interventional treatments have been unsuccessful. Patients should be motivated with no psychologic or medical comorbidities precluding participation. Programs should demonstrate or share a summary of positive outcomes.

Individual programs may vary in the degree of their focus on chronic pain (multidisciplinary pain management program) versus function (multidisciplinary functional restoration program). They also vary in their intensity (a full-time program can range up to 160 or more hours) and content, although they usually include medical (eg, pain and pharmacologic management, physical medicine and rehabilitation), physical (eg, physical or occupational therapy including graded exercise components), behavioral (eg, psychologists or counselors, individual and often group interventions), and social and work-focused vocational components. At a minimum, they combine graded exercise therapy with a cognitive-behavioral/biopsychosocial approach, which generally involves a psychologist. Periodic measurements of outcomes (eg, validated inventories tracking quantified pain, mood, coping, and function) and functional testing are performed to quantify progress toward achieving goals, including work ability. Participants need to demonstrate compliance and significant symptom and functional improvement with an initial trial to support continuation beyond two weeks. Workers' compensation treatment guidelines are used by insurers to determine inclusion criteria and certify the frequency and duration of these relatively high-cost programs.

Studies suggest positive short-term outcomes with multidisciplinary rehabilitation, but the longer-term benefit is less certain. In one systematic review, multidisciplinary rehabilitation (involving health care providers from different backgrounds and pharmacologic care or physical therapy in combination with psychosocial or occupational components) was associated with small decreases in subjective pain and disability and moderate increases in the likelihood of return to work among patients with subacute low back pain compared with usual care [149]. The review did not find evidence of better outcomes from multidisciplinary rehabilitation in contrast to a number of other treatments, but these studies had very low-quality evidence and a risk of bias [149]. Similarly, two systematic reviews on chronic low back pain found low- to moderate-quality evidence that multidisciplinary care (eg, physical, psychologic, and social/work components) reduced pain and improved function and the likelihood of return to work compared with physical treatments or usual care [150,151]. Adding a workplace intervention (eg, exercise at work, change in working conditions, vocational rehabilitation professionals) appears to improve return to work according to another systematic review [152]. In contrast, some studies of longer-term disability and clinical outcomes (eg, pain, functional status) failed to demonstrate a significant impact of multidisciplinary pain care [153,154].

Evidence regarding the optimal components, sequencing, intensity, and duration for these programs is lacking. (See "Subacute and chronic low back pain: Management", section on 'Multidisciplinary rehabilitation'.)

Limited role of surgery — Work and disability risk factors are frequently considered when surgery is contemplated for occupational low back pain. Nevertheless, the majority of patients with low back pain, occupational or otherwise, are not surgical candidates. Indications for surgical management of subacute and chronic low back pain and the evidence informing the utility (or lack thereof) of spine surgery are discussed elsewhere. (See "Subacute and chronic low back pain: Surgical treatment", section on 'Indications for spinal surgery'.)

High-quality data informing the impact of surgery for occupational back pain are limited. Several trials that failed to demonstrate the benefit of lumbar fusion versus exercise for low back pain due to degenerative disc disease excluded patients with occupational back pain [155-157]. There is a need for higher-quality studies and studies comparing pain; function; satisfaction; complications, including repeat surgery; and return to work for patients with and without work-related back pain.

However, disability factors, in particular workers' compensation involvement, have been associated with worse lumbar spine surgical outcomes in multiple studies [158-165]. In a meta-analysis of 31 studies on lumbar spine surgery outcomes including subjects with decompression alone and fusion, workers' compensation patients were more likely to fail to return to work than non-workers' compensation patients (43 versus 17 percent) and were twice as likely to have unsatisfactory outcomes [166]. In another meta-analysis of 26 studies including lumbar decompression and fusion, workers' compensation patients had worse pain, disability, satisfaction, and return to work than non-workers' compensation patients [165]. In other studies of patients with lumbar disc herniation [167,168] and cohort studies comparing outcomes of spine surgery in patients with and without workers' compensation [162-164], workers' compensation was associated with worse surgical outcomes for pain, function, and satisfaction. In one nationwide cohort study of patients receiving decompression or fusion, workers' compensation patients with anxiety and depression demonstrated even greater disparities in all outcomes, including pain, function, and return to work [162].

Lumbar fusion for occupational low back pain attributed to degenerative disease has particularly poor outcomes compared with nonoccupational low back pain [160]. As examples, in cohort studies of United States workers' compensation patients treated with lumbar fusion, there are high rates of disability at two years (64 to 74 percent) and repeat surgery (22 to 27 percent) [169-171]. Preoperative factors associated with low postoperative return to work included psychiatric history (2 percent return to work), prolonged time out of work (10.4 percent), prolonged opioid use (11.9 percent), and legal representation (20.7 percent). In addition, in a systematic review of 21 studies evaluating lumbar spinal fusion surgery, the estimated return to work was 74 percent for nonoccupational back pain patients versus 40 percent for occupational back pain [161]. Preoperative depression was also noted to be a negative factor affecting postoperative return to work [172]. An Australian cohort study observed worse rates of return to work (decompression 55.1 percent, disk replacement 40.0 percent, fusion 36.3 percent at 24 months postoperative) and higher rates of ongoing treatment for workers' compensation patients treated with fusion or disc replacement in comparison with patients with decompression alone [164].

Duration of opioid use prior to low back surgery can affect postoperative return to work. In a retrospective cohort analysis including patients with occupational low back pain who underwent lumbar discectomy, longer duration of preoperative opioid use was associated with lower return-to-work rates (0 to 14 days associated with 64.1 percent return to work; 14 to 90 days of opioids with 52.7 percent; and greater than 90 days with 36.9 percent) [173]. Psychologic illness and legal representation were also negative predictors of return to work. In addition, among this cohort, patients treated with decompression and lumbar fusion had lower rates of return to work than patients who had revision discectomy without fusion (27.0 versus 40.2 percent) [174].

Post-surgical opioid use is associated with negative outcomes. As an example, in a study of lumbar fusion surgery among patients receiving worker's compensation, 76 percent remained on opioids more than 90 days after lumbar fusion surgery; mean opioid dose increased 41 percent postoperatively, and probability of return to work decreased with increased opioid dose [170]. Another analysis of chronic opioid prescribing after lumbar fusion for degenerative disease in workers' compensation patients observed a negative impact of opioids on return to work (11 percent sustained return to work at two years for patients on chronic postoperative opioids versus 38.4 percent for patients who received temporary postoperative opioids) as well as higher medical costs and rates of psychologic diagnoses and repeat surgery (27.7 versus 11.5 percent). Preoperative factors associated with postoperative chronic opioid therapy included dose and duration of opioid prescribing, extended work loss, and clinical depression [175]. Furthermore, postoperative opioids have also been reported to be a major cause of death after lumbar fusion for work-related low back pain [176].

Considering the studies observing worse postoperative lumbar spine outcomes in workers' compensation patients, especially those treated with fusion or disc replacement, clinicians should discuss realistic surgical expectations and carefully screen patients preoperatively for psychologic comorbidities and other risk factors associated with poor postoperative outcomes. Limiting preoperative opioid prescribing (dose and duration) has the potential to improve postoperative outcomes.

Pharmacologic considerations in the occupational setting

Avoid opioid therapy — Opioids are not advised for the treatment of most occupational low back pain. When prescribed, they are reserved for patients with severe pain that is unresponsive to non-opioid therapy and who do not have major risks for opioid misuse. In general, they should not be used on a long-term basis, because of limited efficacy; side effect profile; and potential for misuse, dependence, and overdose [177-181]. (See "Treatment of acute low back pain", section on 'Limited role for opioids' and "Subacute and chronic low back pain: Management", section on 'Restricted use of opioids'.)

Many employers have drug screening requirements (eg, preplacement, postaccident, random, for safety-sensitive workers, fitness for duty). Opioid use may trigger review by a medical review officer to confirm a valid prescription and determine whether opioid use is a potential safety issue for selected jobs [182,183]. Specifically, the ACOEM recommends against acute or chronic opioid use in patients who perform safety-sensitive jobs (eg, operating motor vehicles and other modes of transportation), whose work has other injury risks (eg, work with sharps, heights), or whose work involves high levels of cognitive function and judgment [184].

In the United States, state-developed and nationally recognized, evidence-based workers' compensation medical treatment guidelines address opioid therapy for occupational low back pain. Many of these guidelines include recommendations on patient screening, criteria for initial trial and ongoing use, assessment and documentation of effectiveness, and monitoring (including state prescription drug monitoring programs and urine drug testing) and advise against exceeding a morphine equivalent dose of 50 to 90 mg daily due to the increased risk of overdose and death [180,185]. Many states have also adopted specific formulary rules for workers' compensation [186,187].

Other concerns regarding opioid therapy for occupational low back pain include lack of efficacy [181,188], longer duration of disability [189-193], and increased claim costs [191,194,195]. As examples, in one analysis, most workers treated with long-term opioid therapy for low back pain did not experience significant improvement in pain (26 percent) or function (16 percent) [188]. In another study, prescription of opioids for more than seven days and receipt of more than one opioid prescription were associated with increased work disability (seven days of opioids increased OR 2.2, >1 prescription) at one year (after adjustment for pain, function, injury severity, and other baseline variables) [189]. A systematic review of six cohort studies looked at early opioid prescribing (ie, initial 15 days) for patients with acute, work-related low back pain, finding an association between early opioid therapy, morphine equivalent amount, and longer length of disability [192]. Washington state implemented prior authorization regulations in 2013 that require documentation of significant pain and function improvement to continue opioid prescribing for injured workers beyond the acute period. The regulatory change was associated with a reduction in opioid prescribing after six weeks as well as an improvement in lost work time patterns that had risen from 1999 to 2010 [193].

Other sedating drugs are potentially hazardous — In the occupational setting, medications that alter alertness and coordination (eg, opioids, muscle relaxants, benzodiazepines, antidepressants, anticonvulsants) increase the risk of injury and may also be associated with delayed recovery and return to work. These risks may be higher upon dose initiation or adjustment and in individuals who are older, have medical conditions that affect alertness, or take other potentially sedating medications (eg, antihistamines, antidepressants, anticonvulsants) [183]. Transportation industries have regulations regarding the use of certain drug classes. Sedating medications are also contraindicated for persons who work at heights, use heavy machinery, and perform other jobs that require alertness [183].

Benzodiazepines should be avoided for work-related low back pain and other musculoskeletal injuries because of lack of efficacy, increased risk of sedation and accidents, potential dependence [196,197], sleep-disordered breathing, and increased overdose risk, especially in combination with opioids [198,199]. An analysis of various Louisiana workers' compensation lost time claims followed claims for 10 years. Early prescribing of benzodiazepines, carisoprodol, gabapentin, antidepressants, and other sedatives was significantly associated with higher claim costs [191]. Combined use of opioids and benzodiazepines to treat work-related injuries is associated with increased claim duration and cost [200], especially when benzodiazepines are combined with long-acting opioids [199] or opioids plus antidepressants [200]. Workers receiving benzodiazepines or opioids prior to their work injury were more likely to receive them after a work injury, according to a Washington State Department of Labor and Industries analysis. The prevalence of use within 90 days before work injury was 2.9 percent for benzodiazepines and 8.6 percent for opioids [201].

RETURN-TO-WORK ASSESSMENT — 

A scientific evidence review was conducted in the United Kingdom as part of their public health and welfare agenda [202]. The analysis evaluated the impact of working and work loss for working-age adults dealing with common health problems that account for the majority of sickness absences and long-term disability. The review found evidence of a strong association between worklessness and worse general and mental health, as well as higher mortality. They also found strong evidence of physical and mental health benefits of working, including benefits for most individuals with illness or injury, as long as work is safe and accommodating. Given the other socioeconomic benefits of continuing to work, clinicians managing occupational low back pain should promote and assist efforts to facilitate patients' ability to stay at work or return to work.

Evidence suggests that early (within seven days) return to work for acute, nonspecific occupational low back pain is associated with more rapid improvement of pain and function at three months postinjury [78]. The availability of modified duty, employer flexibility, and collaborative problem-solving to identify and overcome barriers to return to work can help patients manage symptoms at work and thus increase the success of return-to-work efforts. In a systematic review of the efficacy of workplace interventions in patients with musculoskeletal pain, there was strong evidence for reduced duration of time away from work and moderate evidence of reduced cost associated with the use of multidomain interventions, including domains involving health focus (eg, graded exercise, cognitive-behavioral therapy, multidisciplinary care), service coordination (eg, coordinating care and communications between health care providers and the workplace), and work modification (eg, modified duty, work accommodation) [118]. In another systematic review, similar results demonstrating the benefits of workplace interventions versus usual care on reduced duration of sick leave (first return to work and lasting return to work) for patients with musculoskeletal disorders were observed [119].

Patients with occupational low back pain who are out of work or on modified duty should be periodically assessed to determine their ability to return to work and risk factors for disability. Specific considerations to assess include:

●Do current abilities permit return to work including full or modified duty, or do functional limitations seem to preclude it?

●Could job tasks and physical demands be modified or alternate work offered to assist with return to work?

●Are there psychosocial, work organizational, medical care (eg, non-evidence-based care, care delays), or system (eg, insurance or jurisdictional) barriers to return to work?

In order to better understand barriers to return to work and potential solutions for patients who are out of work on or modified duty, clinicians should consider use of open-ended questions with the patient:

●What are your expectations and concerns about returning to work?

●What activities or job tasks will be most difficult for you?

●How helpful do you think your employer, supervisor, and coworkers will be?

●What recommendations do you have that would make it easier to return to work?

For patients who are unable to return to work, timely consultation or effective communication with the employer/supervisor, preferably with active involvement of the patient, can encourage collaborative problem-solving to identify and address barriers to return to work. Primary care providers who desire assistance in identification of return-to-work barriers and potential solutions should consider input from the employer/supervisor, patient, physical therapist, ergonomists, rehabilitation specialists, case managers or return-to-work coordinators and/or occupational medicine clinicians [85,118,203-205]. Nonmedical questions for the employer should include key physical demands of the patient's job; potential for modified duty, temporary job modification, or assistance (eg, ergonomic job evaluation); ability to alter work hours or work pace; and potential for temporary alternative work.

For patients receiving physical therapy, the therapist can have the patient perform periodic lift assessments consistent with job requirements to help quantify and document functional improvement. Physical therapists should also be encouraged to communicate information with the patient and clinicians regarding functional abilities and recommendations regarding work abilities. Information from the Oswestry or Roland-Morris disability questionnaires can also be utilized in decision-making. A more formal Functional Capacity Evaluation that involves several hours of standardized testing of performance-based measures related to physical job demands can be arranged by the insurer when fitness to work is uncertain. However, functional capacity evaluation has limitations, including the ability to assess only tolerance rather than maximal physical capacity, better correlation with short- versus long-term return to work, and inability to predict future risk [90,206].

Recommendations regarding timing and specifics of the return-to-work prescription must be tailored to each patient. The offer of modified duty can often facilitate return to work. Patients who are ready to return to work should be reassured that it is generally safe and beneficial to perform usual activities, even if some degree of pain persists or transient flare ups of pain are experienced [207,208].

Patients may have unrealistic expectations about return to work, coping issues, or fears about the seriousness of their low back pain. Work-focused cognitive-behavioral therapy should be considered in these patients [118]. Clinicians should discuss evidence regarding the benefits of return to activity and work, explore potential solutions to overcome barriers, and encourage patients to be an active participant in problem solving. Patient satisfaction may be improved if practitioners are perceived by patients to take their problem seriously, clearly explain the patient's condition, attempt to understand the patient's job, and provide practical advice to prevent re-injury [209]. There are a number of commercial online resources that use duration of disability norms and other guidelines to help establish return-to-work goals and should be shared with patients to help educate them about recovery expectations. Two of the most commonly used commercial guidelines include ODG by MCG Health [210] and ReedGroup MDGuidelines [211].

The decision to advise work restrictions is ultimately determined by an individual risk and benefit assessment based on both "scientific" (data-driven) and "intuitive" (qualitative) factors [212-214]. The adverse psychologic and physical health consequences of disablement should be weighed against the potential for further injury with unrestricted work [215].

It should be recognized, however, that an individual's function may be realistically limited by their coping abilities or tolerance of pain [212,214]. Cooperation with the treating therapist(s) to reassess and advance activities both in the rehabilitation facility and the workplace is helpful to achieve a satisfactory outcome [182,212,215].

Only a small number of studies have evaluated whether or not work restrictions are necessary or advisable in patients with low back pain, and the findings are contradictory [216-220]. Literature on the reproducibility and validity of functional capacity testing to determine work limitations is cautionary [206,221]. There are differing perspectives on the impact of work restriction for occupational low back pain. Some authorities have concerns that heavy lifting or repetitive loading can cause structural damage to the spine and further exacerbate pain [222-224], while others believe that restrictions on lifting might reinforce workers' expectations of injury and have unintended negative consequences [225].

PATIENT FOLLOW-UP — 

Patients with occupational acute low back pain should be scheduled for a timely follow-up visit to reassess symptoms, response to treatment, and work abilities. It is reasonable to provide weekly follow-up during the first month for patients who are out of work or on modified or temporary alternative work, since workers' compensation includes medical care and wage replacement. Reassessment should include discussion of:

●Current symptoms and whether they have improved, have worsened, or are unchanged using validated tools (eg, visual analog scale or PEG [pain, enjoyment, and general activity] pain scale)

●Current functional abilities and limitations and whether they have improved, have worsened, or are unchanged (eg, using the Oswestry Disability Index (figure 1), Roland-Morris Disability Questionnaire (table 2), or other validated tools; assessment of activity abilities and examination findings)

●If the patient is working: concerns, current tasks, limitations and modifications, and ability to advance work capabilities toward full duty

●If the patient is not working: concerns, activity status at home, recovery expectations, and work disability risks and perceived barriers to return to work with suggested solutions

Primary treating clinicians should inquire about other medical visits related to the patient's occupational low back pain and coordinate and communicate effectively to enhance outcomes. The workers' compensation or disability insurer may order an evaluation by other health professionals (eg, functional capacity evaluation, independent medical evaluation or second opinion, vocational rehabilitation specialist) if recovery is delayed. The evaluations could result in opinions regarding diagnosis, treatment options, functional abilities, return-to-work recommendations, maximal medical improvement, impairments, and other recommendations [226].

PROGNOSIS: LIKELIHOOD OF RETURN TO WORK — 

The majority of patients with occupational low back pain improve over time and return to work within the first four to six weeks.

In a systematic review of work absence related to low back pain, 68 percent of individuals returned to work by one month, 86 percent between one and six months, and 90.7 percent at or beyond six months [81]. However, low back pain is often recurrent, and a prospective cohort study noted that 26 percent of patients who returned to work reported reinjuring their back in the following year [227].

In addition, the longer a patient remains out of work, the smaller the probability of return [228,229]. For patients who have been out of work with low back pain for six months, the chance of ever returning to work has been estimated at 50 percent; for those out of work for at least two years, the probability of returning to work is near zero [230]. In a study based upon a review of 89,000 insurance records, 42 percent of those with back pain who remained out of work at six months had not returned to work by 12 months [231].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lower spine disorders".)

SUMMARY AND RECOMMENDATIONS

●General assessment – Patients with low back pain should receive a detailed history of the back pain, including precipitating events or activities. Physical examination should include musculoskeletal, neurologic, and psychologic evaluation and assessment of functional ability. The evaluation of low back pain is discussed in detail separately. (See "Evaluation of low back pain in adults", section on 'Initial evaluation'.)

●Additional assessment for work-related pain – When low back pain is presumed to be work related, additional factors should be considered. These include psychosocial issues (table 1), workplace factors (including specific work expectations and supervisor responsiveness), the timing of return to work, the potential for work accommodations, and the potential financial impact on the patient, among others. Collaborative problem-solving is often necessary to address any barriers to continued work or return to work. (See 'Additional assessment for work-related pain' above.)

Determining the relationship between low back pain and work can be challenging. Features that are supportive of a relationship include symptoms precipitated by a specific work-related event or injury, a temporal relationship between symptoms and specific work activities that have been epidemiologically associated with back disorders (eg, heavy physical work), and an absence of a clear alternate nonoccupational explanation. A referral to occupational medicine or other back pain specialist may be appropriate. (See 'Determining relationship to work' above.)

●Limited role for imaging – Indications for imaging are the same as with nonoccupational low back pain. In the workers' compensation population, early imaging in the absence of a clinical indication has been associated with adverse effects, including increased lost work time, disability, and higher costs. (See 'Limited role for imaging studies' above and "Evaluation of low back pain in adults", section on 'Determining if imaging is indicated'.)

●Disability assessment – The role of the clinician completing a disability assessment (eg, for workers' compensation) is to opine on causation, document findings related to the work-related condition, make treatment and return-to-work recommendations, opine on maximal medical improvement, and communicate with all stakeholders in accordance with jurisdictional regulatory requirements. Clinicians should provide information they can comment upon with reasonable medical probability. This should include a general impression of the patient's abilities, with a focus on the activities that the patient needs to do as part of their job. (See 'Disability assessment' above and "Disability assessment and determination in the United States".)

●Specific management considerations

•All patients with occupational low back pain should remain active and limit bedrest (Grade 2B). This includes staying at or returning to work whenever possible and gradually increasing activities to aid recovery. For patients with acute occupational back pain and fear-avoidance beliefs (eg, concern that activity or work will further harm their back), we suggest early referral to physical therapy (Grade 2C). We also suggest physical therapy for those with acute low back pain who do not improve as expected, those with recurrent low back pain, and those with substantial functional limitations (Grade 2B). (See 'Activity, exercise, and physical therapy' above and "Subacute and chronic low back pain: Management".)

•In the occupational setting, medications that alter alertness and coordination (eg, opioids, muscle relaxants, benzodiazepines, some antidepressants and anticonvulsants, etc) increase the risk of injury and are associated with higher claim costs, delayed recovery, and delayed return to work. (See 'Pharmacologic considerations in the occupational setting' above.)

•For patients with persistent symptoms despite exercise therapy and pharmacotherapy, we suggest a combination of behavioral support with graded exercise, referral to back school, or a functional restoration program with a cognitive-behavioral therapy component (Grade 2C). If available, functional restoration programs are most appropriate for individuals with physically demanding job requirements (medium demand or greater (table 5)). Multidisciplinary rehabilitation is individualized, intensive, and generally reserved for patients with high levels of pain, poor coping, and/or opioid use who remain work-disabled despite exhausting less intensive intervention strategies. Jurisdictional medical treatment guidelines, where established, will impact decision-making. (See 'Additional occupational interventions' above.)

•Ergonomic assessment can identify potential environmental or work modifications that can facilitate return to work. However, among potential ergonomic interventions, lumbar supports, including braces or other orthotic devices, have no established efficacy. (See 'Ergonomics' above and "Subacute and chronic low back pain: Management", section on 'Nonpharmacologic therapies'.)

●Prognosis and return to work – Most occupational low back pain resolves, with the patient returning to work within the first four to six weeks. The general approach to symptomatic management of occupational back pain is similar to that for nonoccupational back pain, which is discussed in detail separately. (See "Treatment of acute low back pain" and "Subacute and chronic low back pain: Management".)

The timing and specifics of returning to work prescription should be tailored to each patient and their work environment. Temporary reductions in the normal activities of the job (eg, reducing the number of hours spent lifting, lift frequency, or the weight of the load or distance carried) may also facilitate return to work. Patients should be reassured that pain does not need to be totally alleviated before returning to work and that early return to work consistent with abilities can improve recovery, including pain and function outcomes. Psychosocial and work organizational factors are better predictors of return to work and disability than the biomedical nature of the back pain. (See 'Return-to-work assessment' above and 'Prognosis: Likelihood of return to work' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Donald Krawciw, MD, who contributed to earlier versions of this topic review.