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"Spinal disorders vary in their clinical presentation, and it is well-established that physical examination findings and imaging studies do not correlate well with function," says Dr. Marjorie Eskay-Auerbach.

The Arizona-based specialist in spine, orthopedic surgery, and legal medicine has just completed a chapter for a revised return-to-work publication from the American Medical Association. In her chapter on low back pain, Eskay-Auerbach explains that physicians are often relying on what their patients say rather than on proven science.

The workers' comp system typically supports physicians' orders to restrict a patient's activities -- even if it is inappropriate. The workers' comp system, she says, needs to change.

"The treating physician still has the most sway," she says. "Administrative law judges make decisions but are loathe to say a person doesn't need restrictions."

The evidence. Physician-imposed restrictions are historically based on a perceived risk of reinjury. But it is important to distinguish between reinjury and the presence of recurrent symptoms.

Eskay-Auerbach says medical professionals often impose restrictions based on the patient's reported tolerance to carry out certain activities. In the return-to-work realm, tolerance is the ability to endure physical symptoms while undertaking work activities the individual is able to perform.

"The current literature demonstrates no evidence that restrictions determined in this manner reduce the incidence of reinjury," she says.

As an example, Eskay-Auerbach offers the case of symptomatic lumbar disk herniation. When treated surgically, restrictions are often recommended in an effort to mitigate the risk of recurrent disk herniation.

"However, this presumes that specific activities can be implicated as causing lumbar disk herniations," Eskay-Auerbach says. "Recent studies have shown that in many cases, outside of the work setting, patients are unable to identify a specific initiating event."

These patients generally are restricted from lifting more than a specific weight based on the assumption that lifting activities cause lumbar disk herniations and avoiding lifting can limit the incidence of recurrence. It's an assumption that ignores the evidence.

"The incidence of recurrent disk herniations is reported between 5 percent and 12 percent without reference to a specific incident as the cause," she says. "Other recent studies have demonstrated that return to work occurred earlier in the absence of post-operative restrictions after limited discectomy [the surgical removal of herniated disk material that presses on a nerve root or the spinal cord] for treatment of a lumbar disk herniation. Most patients with a diagnosis of lumbar disk herniation should eventually return to their original form of work."

Despite the lack of evidence suggesting lifting leads to lumbar disk herniations, many patients believe there is a link, which affects their understanding of risk of reinjury and hinders their return to usual activities. Eskay-Auerbach says physicians need to understand the science and take the lead in helping their patients recover.

Causes of low back pain. The scientific literature does not conclusively point to work activities as a major cause of low back pain, Eskay-Auerbach asserts. In fact, she says it's quite the opposite.

"Nonspecific low back pain or lumbar sprain/strain is a frequent complaint, often attributed to a particular activity," she says. "Most often, the underlying pathology is not known."

Jobs requiring heavy material handling, postural loading, and vehicular vibration have been implicated as accelerating degenerative changes in the spine. This, according to the evidence, is erroneous.

"Disk degeneration and low back pain are not synonymous, and the relationship between the two is not well-defined as of yet," she says.

Eskay-Auerbach points to several recent studies that examined the causes of low back pain, saying there is no evidence of a clear causal relationship between occupational bending or twisting and low back pain.

Recurrent low back pain is common. But rather than work activities, Eskay-Auerbach says the independent factors that are predictors include poor physical health, high stress, and frequent job changes.

"Most patients with low back pain are physically capable of activity but intolerant of the associated pain and therefore choose to avoid those activities. However, tolerance appears to have a psychosocial factor, identified in many studies," she says. "Most importantly, tolerance is not a basis for physician-imposed work restrictions or work limitations since tolerance issues are a patient choice."

Read more at the WorkersComp Forum homepage.

November 21, 2011

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