Dear All,
 
McGill has pointed out that on the basis of the research by Loisel et al 
one could reasonably argue that after an initial medical check the 
management of back injury rehabilitation cases should be taken out of the 
hands of the medical profession and placed in the hands of ergonomists 
(McGill, 2002). Certainly it is strong evidence for a combined rehab 
programs and ergonomic interventions for lower back pain. He quoted a 
Canadian study that tested the efficacy of different model of management of 
sub-acute back pain for preventing prolonged disability found that 
ergomomic interventions were more successful than clinical interventions 
(Loisel et al, 1997).  It looked at how the effectiveness of the following 
different treatment regimes;
· usual care, 
· clinical intervention, 
· ergonomic intervention, and 
· full intervention (a combination of the previous two) 

It determined how these affected the duration of absence from regular work 
compared the initial functional status and pain findings with those found 
after a follow-up a year later. The authors concluded that close 
association of occupational intervention to improve ergonomic factors 
combined with clinical care is of primary importance in impeding 
progression toward chronic low back pain. The full intervention group 
returned to work 2.41 times faster than the traditional care group, and 
they found that most of the difference was due to the occupational (OHS) 
intervention. Average return-to-work times were;
· 60 days for full intervention, 
· 67 days for occupational only, 
· 131 days for enhanced clinical only and 
· 120.5 days for the traditional care only. 

The workers were not assigned to a group until they had 4 weeks of absence 
from work. It is probable that an early intervention would have produced 
even better outcomes. In a follow-up study Loisel et al (2001) mention that 
they used a participatory ergonomics approach (i.e. one where ergonomists 
help the management to implement solutions that have been identified in 
their consultations with the workers).
 
Anema et al have since shown (2004) that it was possible replicate the 
success of the original Loisel approach (in Canada) in 6 other countries 
(Denmark, Germany, Israel, Sweden, the Netherlands and the United States).

So far so good, but sadly one hears anecdotal evidence that the clinical 
management of the rehab process by doctors often delays referrals to 
physiotherapists and ergonomists (if the referrals happen atall). In my 
opinion the rehab culture in New South Wales appears to be unduly 
influenced by a medical lobby that acts on behalf of general practitioners; 
GPs have been happy to take money even when they often did not know what 
they were supposed to be doing (Browning, 2005). This is a worry as low 
back pain claims cost a huge amount (in New South Wales an estimated 700 
million dollars a year according to Browning) – not to mention the human 
suffering.
 
There is evidence from Sweden that suggests that (after an initial medical 
diagnosis - preferably by an orthopaedic specialist) the rehab process 
should be managed by physical therapists rather than general practitioners. 
A research project has studied the effects of a graded activity program 
that included measurements of functional capacity; a work-place visit and a 
supervised sub-maximal, gradually increased exercise program suited to the 
demands of the patient's work (Lindstrom et al, 1992). The patients in the 
activity group were given physical therapy (on average they had about 11 
appointments with a therapist). They returned to work significantly earlier 
than did the patients in the control group. The average duration of sick 
leave attributable to LBP during the second follow-up year was 12.1 weeks 
for the activity group and 19.6 weeks for a control group. QED!

Given that (a) ergonomic interventions combined with a rehab program can 
halve the recovery time (according to Loisel et al, 1997) and (b) rehab 
program managed by physical therapists can halve the recovery time 
(according to Lindstrom et al, 1992) it might be possible to combine these 
approaches and achieve an even faster recovery time!

Has anyone got any data on research on the benefits of such an approach (or 
are we all operating in first world countries where the rehabilitation 
procedures are driven by legislation and mainly benefit doctors and lawyers 
(and have their inefficiencies subsidized by insurance)? Conversely has 
anyone any data or anecdotal evidence concerning the drawbacks of existing 
rehab systems?
 
Regards,

David McFarlane 
Ergonomist, 
WorkCover Authority of New South Wales

References

1.  P Loisel, P Durand, L Abenhaim, L Gosselin, R Simard, J Turcotte 
and JM Esdaile, (1994), " Management of occupational back pain: the 
Sherbrooke model. Results of a pilot and feasibility study", Occupational 
and Environmental Medicine, Vol 51, 597-602


2. P. Loisel, L. Abenhaim, P. Durand, J. Esdaile, S. Suissa, L. Gosselin, 
R. Simard, J. Turcotte and J. Lemaire, (1997), “A population based 
randomized clinical trial on back pain management”, Spine. Dec 15; 22, 
(24), pp 2911-8. The abstract is on the web at;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9431627&itool=iconabstr&query
_hl=5

3.  S. McGill, (2002), "Low back disorders. Evidence based prevention 
and rehabilitation", (Human Kinetics, Leeds) page 163.

3. P. Loisel, L. Gosselin, P. Durand, J. Lemaire, Stephane Poitras and 
L. Abenhaim, (2001), “Implementation of a participatory ergonomics program 
in the rehabilitation of workers suffering from subacute back pain”, 
Applied Ergonomics, 32, pp 53-60.

4. Anema JR, Cuelenaere B, van der Beek AJ, Knol DL, de Vet HC, van 
Mechelen W., (2004), “The effectiveness of ergonomic interventions on 
return-to-work after low back pain; a prospective two year cohort study in 
six countries on low back pain patients sicklisted for 3-4 months.”, Occup 
Environ Med. 2004 Apr;61(4):289-94. The abstract is on the web at;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15031385&itool=iconfft&query_
hl=9

5. “BACK PAIN. GPs take the lead” (by Len Browning) National Safety June 
2005 pages 33 to 35. See the last paragraph on page 35.

6. Lindstrom I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, 
Nachemson AL., (1992), “The effect of graded activity on patients with 
subacute low back pain: a randomized prospective clinical study with an 
operant-conditioning behavioral approach”, Phys Ther. 1992 Apr;72(4):279-
90. The abstract is on the web at; 
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?
cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1533941&query_hl=1

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