Lower back injuries
According
to The Statistical Bulletin, 1999/2000 New South Wales Workers
Compensation, over 30% of all workplace injuries in 1999/2000 were
back injures. This figure has remained quite stable over the past 9
years; however the cost associated with treating back injuries has
increased by 88% in this period.
Permanent
disability cases accounted for 22.3% cases in all workplace back
injuries. Ninety six point two percent (96.2%) of permanent injury
cases involved sprains and strains. Contusions, fractures and
injuries to the nerves and spinal cords accounted for the remainder1.
Seventy
eight percent of back injuries involved temporary disabilities. The
highest number of back injuries was in the 35-39 age group,
accounting for 15% of claims.
Suggested
Guidelines for IMC’s and NTD's
Refer
for Specialist Occupational Physician assessment if any of the
following are noted:
-
The
presence of any red flag conditions
-
The
worker has had more than two weeks certified unfit for duties, or
more than one month on selected duties
-
The
worker has had more than three weeks off work, or on selected duties
and
has significant yellow flag conditions
-
Not
back at pre-injury duties within six weeks of the injury
-
There
are significant workplace conflicts, dissatisfaction, performance or
industrial issues
1
(Statistical Bulletin, 1999/2000 NSW Workers Compensation). Work
Cover Publications Sydney NSW
Suggested
Guidelines for GP’s
Re-assess
– options request information from treating GP, specialist and /or
refer for independent assessment
PROCEDURE
- LOW BACK PAIN
Stage 1 –
Triage
Stage 2 -
Assessment
-
Assurance
and explanation
-
Advice
to continue usual activities
-
Analgesics
and/or manipulation if required
-
Avoid
best rest (more than 2 days)
-
Consider
suitable alternative duties
-
Review
in 7 days if required
-
Consider
referral to health professional with expertise in lower back pain
Stage 3 –
Re-assessment
-
Full
reassessment
-
History
and examination
-
Oswesrtry
screening questionnaire
-
Screen
for red and yellow flags
-
Investigation
as appropriate
-
Consider
ongoing treatment requirements
RED
FLAG CONDITIONS
-
Features
of cauda equina syndrome (especially urinary retention, bilateral
neurological symptoms and signs, saddle anaesthesia) - this
requires very urgent referral
-
Significant
trauma
-
Weight
loss
-
History
of Cancer
-
Fever
-
Intravenous
drug use
-
Steroid
use
-
Patient
aged of 50 years
-
Severe,
unremitting night-time pain
-
Pain
that gets worse when patient is lying down
YELLOW
FLAG CONDITIONS
-
Attitudes
and beliefs about back pain
-
Emotions
-
Behaviours
-
Family
-
Compensation
issues
-
Work
-
Diagnostic
and treatment issues
-
Workplace
conflict
-
Oswestry
score more than 40 percent (at 4 weeks)
Rehabilitation
Goals
In
order of preference, you are aiming to have your ill or injured
worker return to the:
-
Pre-injury/illness
job, with the same employer
-
Modified
pre-injury/illness job, with the same employer
-
Different job, with the same
employer
-
Pre-injury/illness
job with a different employer
-
Modified
pre-injury/illness job, with a different employer
-
Different
job, with the a different employer
The
best outcomes are achieved through
-
An
early return to work
-
A work based rehabilitation system
-
Good
communication between the involved parties.
-
Medical
in confidence issues must always be considered in communication.
Possible
alternative duties
-
Maximum
lift limit (for example 5, 10 or 15 Kg, kept close to the body and
to avoid asymmetric lifting)
-
No
prolonged/ repetitive bending or stooping
-
No
bend/twist/lift combinations (asymmetric lifting)
-
Allow
freedom to sit/stand/walk as tolerated
-
No
exposure to significant whole-body vibration or impact forces
-
No
prolonged driving (at work)
-
No
prolonged or repetitive climbing
Workcover
certificate
Broader
details supplied on the Workcover Certificate ensure the patient has
been appropriately interviewed and their particular circumstances
considered. The certificate should identify the following categories.
-
Tasks
that the patient may safely carry out without exacerbating his/her
medical condition (Eg: Light duties)
-
Duties the
patient may be able to perform (Eg: Front desk duties, stock
auditing)
-
Tasks
that should be avoided (Eg: Lifting over 5 kg, bending, sitting for
prolonged periods)
-
Environments
that should be avoided (Eg: Vibration or body jolting)
When to
Refer for Specialist Opinions and Further Diagnostic Testing
In
the absence of RED flags, radiologic investigations are not normally
required in the first month after injury. A plain Xray is
inexpensive and easily obtainable, but can be difficult to interpret
as the normal (uninjured) population frequently have abnormalities on
plain Xray. An MRI is frequently the best initial investigation as
this test will give the most information about discs and nerves.
Some surgeons will request a CT Myelogram to assess a patient for
surgery. A CT scan is good for specifically investigating bone
pathology. A bone scan is a good screening test of fractures, and
can be useful at times to determine if a fracture is new or old.
Nerve Conduction Studies are sometimes useful to investigate possible
nerve root damage.
Consider
referral to a specialist if:
-
The
presence of any red flag conditions
-
The
worker has had more than two weeks certified unfit for duties, or
more than one month on selected duties
-
The
worker has had more than three weeks off work, or on selected duties
and
has significant yellow flag conditions
-
Not
back at pre-injury duties within six weeks of the injury.
Please also note that Sacroiliac Joint Dysfunction or SI Joint Dysfunction is a condition in which the joint is locked, partially dislocated or “subluxated” in a non-anatomically correct position due to hypermobility (too much movement) or hypomobility (too little movement) within the joint. Sacroiliac joint dysfunction is commonly characterized by low back and gluteal pain and may be accompanied with referred groin, hip, and sciatic leg pain (see “sciatica“).] The condition can affect one sacroiliac joint (left or right), or both joints. The degree of pain and disability due to the condition can vary widely, from an occasional discomfort that limits certain activities to severely debilitating and a constant source of pain. It is reported to affect between 15% and 38% of the general population, with women being 3 or 4 times more likely to be affected than men. In spite of these statistics, many patients with sacroiliac joint dysfunction go years without a correct diagnosis. The sacroiliac joints are often overlooked as a causative role in lower back pain.
