Many studies have shown that the prognosis for a full return to work after time off for a broad range of back problems is poor, if the patient has not returned to work within twelve weeks of the onset of the problem. What I wish to address in this brief note are some of the possible reasons for this statistic, and make some suggestions for strategies we have found effective in the pursuit of the goal of full return to work.
Leaving aside for a moment certain aspects of the relation between injury and compensation, it should come as little surprise that return to work is less likely after a protracted period of absence: the simplest analysis suggests that the patient will have adjusted his or her lifestyle to use the time that is usually spent at work to pursue a variety of endeavours, if enough time passes. Researchers have identified a cluster of entailments that follow the identification or diagnosis of a condition by a health care professional that are called the Rumpelstiltskin effect.
The term refers to processes that occur as a result of the naming of a range of symptoms as a recognised illness or syndrome, and a number of changes in perspective immediately result: the patient is aware that the problems he or she suffer are not unique; that there may be a cure; that obligation for daily life responsibilities is lifted or reduced; that absence from work is licensed; and, in some cases, compensation or rehabilitation is available. The adoption of this cluster of effects flowing from the diagnosis has been termed the ‘sick role,’ and it is a role from which some patients never recover. As practitioners, it is our task among others to minimise the number of patients who adopt the sick role and the most effective way is to help the patient help themselves and to teach them effective ways to restore normal, or better than normal, function to the body.
Assuming the patient has a strong desire to return to full duties, let us consider some of the barriers the patient perceives are preventing that goal. In order of significance, they are pain; dysfunction; and fear of recurrence of the original injury. Further assuming that the patient is not demonstrating neurological deficits, we have found that the careful use of the Contract–Relax (C–R) approach to stretching to increase the range of movements in the affected muscles to be most effective in relieving pain (Laughlin, 1995, p. 15). The most commonly implicated muscle groups in low back pain are (in order of frequency of involvement, as found on the Overcome neck & back pain workshops, n=1,350) quadratus lumborum, erector spinae, occasionally latissimus dorsi if the pain is felt over the sacro-iliac joint, and piriformis, if hip pain or sciatica is present.
The latter muscle group can be highly significant, as cadaver studies have shown that the peroneal branch of the sciatic nerve pierces piriformis in about a fifth of the population, and simple spasm in this muscle can produce sufficient clamping force to the nerve to cause what appears to be full-blown sciatica (Travel & Simons, 1992, v. ii, p. 186 ff.). When we consider that two-thirds of the non-back-pain suffering population exhibit disc or joint pathology of sufficient severity that the identified pathology would be judged to be the cause of the pain – had they had any – one can see the necessity of ruling out piriformis syndrome (Jensen et al.). Additionally, the hip flexors need to be assessed, for approximately 30% of back and neck pain patients demonstrate tightness in this area, and this will contribute to postural dysfunction (see Laughlin, 1995).
We have found that many long-term back pain sufferers have markedly reduced flexibility in many other places in the body besides the area in which the pain is experienced. This is what is meant by dysfunction, and may not be related in any causal way to the medical problem. We have found, for example, that hip flexion and hamstring tightness is a consequence of back pain rather than a predisposing factor (in fact tight hamstrings helps flatten the lumbar curve, an exaggerated lordosis being commonly cited as a cause of low back pain). Improving range of movement at the hips (using a simple supported exercise on a chair; see exercises 1 and 2 in Overcome Neck & Back Pain) gives the patient immediate improvement in forward bending. I feel that this sort of dysfunction is nothing more than the normal protective mechanisms of the body – in this case the muscles of the trunk and of the hips tightening (the familiar ‘splinting’) to prevent further injury – but no longer serving useful purpose. We have found that this sort of dysfunction is highly correlated with the pain of the problem, and that improving the range of movement of both the affected and surrounding areas is effective.
The last point I wish to address is the patient’s fear of recurrence of the original injury. It is here that the conventional notions of rehabilitation are insufficient: returning the patient to a pre-injury state of fitness is clearly no guarantee of a further episode. Depending on the patient’s lifestyle, and upon successful completion of the basic exercises covered in chapter one of my book, the patient may proceed to the more difficult stretching exercises. Practising these movements makes the body demonstrably more supple, and the awareness of these changes is a valuable part of the progress to full return to work. We find that a month to six weeks work on the basic exercises reduces the pain experience significantly, and the majority of patients can then proceed the exercises of chapter two, Rehabilitation and prevention.
Going beyond ‘recovery’
Those patients who wish to go further are advised to consult the later chapters, which includes a range of strengthening exercises. Most people will only need the first two, which can be done at home, and which strengthen the trunk and intrinsic lumbar muscles. The more advanced stretching exercises and the basic strengthening exercises are all most people need. The practise of these movements instills confidence in the patient, and the increased awareness of placement of the body, the development of the feeling of some strength in the middle of the body, and being made aware of safe lifting techniques all contribute to the patient’s return to work.
Jensen, M. C., Brant-Zawadski, M. N., Obuchowski, N., Modic, M.T., Malkasian, D., and Ross, J. S., 1994. Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine, July 14. 331, No. 2: 69-73
Laughlin, K., 1995. Overcome Neck & Back Pain. Simon & Schuster, rewritten and revised 4th edition, 2006
Travell J. G., & Simons , D. G., 1992. Myofascial pain and dysfunction: the trigger point manual, volume 2, Williams & Wilkins, New York