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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
History and examination
Perform diagnostic triage
Assess for red flags
Assess for yellow flags
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.