RENAISSANCE PROJECT


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Preventing Chronic Disability from Low Back Pain

Published: September 2004

Author

Dr Clement Leech

  • Deputy Chief Medical Adviser Department of Social and Family Affairs (DSFA)
  • Fellow of the Faculty of Occupational Medicine of the Royal College of Physicians of Ireland
  • Fellow of the American Academy of Disability Evaluating Physicians
  • Chairperson of the Education Committee of the Faculty of Occupational Medicine of the Royal College of Physicians of Ireland
  • President of the Council of the European Union of Medicine in Assurance and Social Security (EUMASS)

Acknowledgments

The author wishes to thank the following:

  • Professor Gordon Waddell CBE, Professor Kim Burton and Professor Mansel Aylward CB for their pioneering work in evidence-based back pain research and disability evaluating medicine which inspired me to conceive this project.
  • The working groups responsible for Occupational Guidelines for the Management of Low Back Pain, Faculty of Occupational Medicine, Royal College of Physicians (UK) and the European Guidelines for the Management of nonspecific Low Back Pain on which the premise of this project is based.
  • The Board of the Faculty of Occupational Medicine of the Royal College of Physicians of Ireland and the Council of the European Union of Medicine in Assurance and Social Security (EUMASS) and the Health and Safety Authority who have agreed to endorse the European Guidelines.
  • Paul Morrin BA Mod. Econ., MSc for his expert statistical analysis.
  • The staff of the Department of Social and Family Affairs' Benefits Branch and Medical Review and Assessment Section for their efficiency in selecting and processing cases.
  • The Department of Social and Family Affairs' medical staff whose dedicated involvement in the project ensured the highest professional standards.
  • Minister Mary Coughlan, TD, whose personal interest in reducing chronic disability from low back pain enabled this project to be undertaken.

Minister's Foreword

Back pain is not a new phenomenon, it has been known throughout recorded history - and in recent years there has been a marked increase in chronic disability resulting from low back pain.

Despite advances in health and safety legislation, ergonomics and other areas chronic disability from lower back pain is increasing.

The Renaissance Project set out to identify whether early intervention using international evidence-based guidelines would decrease the incidence of progression to chronic disability.

The Report of the Renaissance Project demonstrates my Department's growing involvement in broadening its scope beyond the provision of income support.

The outcome of the project has shown that early intervention leads to a reduction in chronic disability resulting from lower back pain. It means a quicker return to work for those who are temporarily afflicted by lower back pain. This will be for the benefit of workers, their families who shoulder the burden of support, and employers.

There will also be benefits to society through cost savings in health care, reduced absenteeism from work and resulting decreased production and reduced numbers going on to long-term illness benefit schemes.

Implementing this report will require a multi-faceted response, and I look forward to working with the required coalition of professionals in a wide range of representative bodies to spread the message that early intervention works in dealing with lower back pain.

Finally, I would like to place on the record my gratitude to all those who participated in the project.

Mary Coughlan, TD

Minister for Social and Family Affairs


CONTENTS

  1. Introduction
  2. Definitions
  3. Background
  4. Aim of Project
  5. Method
  6. Processing the Targeted Claims
  7. Medical Assessments
  8. Results
  9. Promoting the Renaissance Project
  10. Conclusions
  11. Recommendations
  12. Extending the Practice of Early Intervention

For APPENDICES see full report in PDF.

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1 Introduction

Back pain is not a new phenomenon. Man has suffered from back pain throughout recorded history. There is no evidence that back pain has increased in incidence or severity throughout the ages. Despite this, however, in Western society, particularly in the past two decades, there has been a marked increase in chronic disability resulting from low back pain. In the hope of arresting, and perhaps, reversing this trend the Renaissance Project was conceived. The conduct, conclusions and recommendations of the project are outlined below.

2 Definitions

Pain The International Association for the Study of Pain defined pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".

Low Back Pain (LBP) is pain in the lumbo-sacral region, buttocks and thighs.

Disability The World Health Organisation (WHO) defined disability as "any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being".

Chronic Disability is disability lasting continuously for a period of 3 months or more.

Diagnostic Triage diagnostic tool for the differential diagnosis of LBP. See Appendix A for further details.

3 Background

3.1 Problem Identified

Chronic disability, arising from LBP, is increasing. This trend is common to most industrialised countries and worryingly continues in spite of Health and Safety legislation, improved ergonomic practice, automation and advances in technology and medical science.

In addition to the human suffering involved there are substantial financial implications involving healthcare cost, absenteeism, loss of production, insurance and sickness benefit costs. See Appendix B for increase in numbers and expenditure in social welfare illness-related schemes in Ireland. A proportion of this increase (approximately 27%) is due to musculo-skeletal problems, the majority of which is due to LBP.

This is not solely a medical problem, there are many players involved who need courageously, objectively and critically to reassess their particular roles in the management of low back pain. This presents a challenge to all of the players involved, the main players being:

  • General Public, its Attitudes and Beliefs
  • Person with LBP
  • Medical Profession
  • Legal Profession
  • Employers
  • Unions
  • The Health and Safety Authority
  • Insurance Industry
  • Social Welfare Illness-Related Schemes
3.2 Re-Assessment of Role of Social Welfare Illness-Related Schemes

In facing its challenge the Department of Social and Family Affairs (DSFA) decided to re-assess its particular role in the management of LBP.

In appreciation of the facts that:

  1. while necessary to the maintenance of the integrity of society - by providing income support for those who cannot work - illness benefit schemes can, by their nature, facilitate, reinforce and perpetuate disability,
  2. the longer a person is off work with LBP, the lower their chances of ever returning to work, and
  3. most people with simple LBP are able to return to work despite persistent symptoms, have a better outcome and less chance of re-injury than those who rest and avoid work,

the DSFA decided to address the problem in the acute, sub-acute and chronic stages by implementing the Renaissance Project, so called, so as to rekindle the Hippocratic Principle 'first, do no harm'.

The acute stage was considered to be from 0 to 6 weeks, the sub-acute from 6 weeks to 3 months and the chronic for durations in excess of 3 months.

Priority was afforded to the acute stage in the first instance. We would attempt to 'turn off the tap' as it were, rather than 'continuously mop up the floor'.

The sub-acute and chronic stages are to be addressed with job retention, rehabilitation and work re-integration schemes.

4 Aim of Project

The aim of the project was to determine if early intervention, using international evidence-based guidelines in the assessment of claimants with LBP, would decrease the incidence of progression to chronic disability. Statements from international guidelines are given in Appendix C.

5 Method

In the period January to June 2003 new Disability Benefit (DB) and Injury Benefit (IB) claimants, aged 20 to 50 years in Dublin and Cork who were certified by their General Practitioners to be suffering from LBP, were targeted for early intervention. Approximately 3,300 new claims were involved. The claims covered in the project areas account for approximately 34% of all new LBP claims for persons aged 20-50 nationwide in 2003.

A control group of cases, similar to those targeted in the project, for the period January to June 2002 was used to make some comparisons with the results of the project.

6 Processing the Targeted Claims

In processing the 3,300 claims in the project the following outcomes occurred:

  • As expected, 1,700 claimants (51.5%) returned to work within 4 weeks of their own volition.
  • Approximately 1,600 claimants were selected for early referral and invited to attend for medical assessment at 4 to 6 weeks from date of claim. (Hitherto, referral would have taken a considerably longer period and the problem would have gone beyond the acute stage).
  • Interestingly, on receipt of invitation to attend for assessment, a significant proportion of the 1,600 claimants - 1,000 (62.5%) - came off benefit and returned to work.
  • The remaining 600 (approximately) were assessed using the 'Diagnostic Triage' system of assessment.

7 Medical Assessments

As part of the project it was necessary to train medical assessors in the use of the Diagnostic Triage which categorises LBP into 3 main groups, to determine management.

The 3 groups are:

  1. Simple Back Pain - majority of cases (approximately 95%), prognosis is excellent, with recovery expected in days to weeks.
  2. Nerve Root Pain - 3-5% of cases, prognosis is moderate, with recovery expected in weeks to months, only a minority requiring surgery
  3. Potential Serious Spinal Pathology - 1-2% of cases, which includes fractures, infections, inflammatory conditions and tumours. Prognosis depends on the diagnosis.

Cases in the Simple Back Pain category were considered for work capacity.

Fitness for work was determined not solely through categorisation as Simple LBP. Medical assessors also took into consideration other relevant factors such as the severity of the symptoms, type of work involved and potential for work restriction or accommodation in the workplace.

Cases in the other categories Nerve Root Pain and Potential Serious Spinal Pathology were considered to be unfit for work for varying periods, depending on the diagnosis.

Detailed records of medical assessments were held for analysis which included a breakdown by gender, work type and age group. See Appendix D.

8 Results

The incidence of progression from the acute Simple LBP to chronic disability employing the method described above was reduced significantly; 64 per cent of the LBP cases assessed under the project were declared capable of work, compared to circa 20 per cent of all claimants with a variety of illnesses, including LBP, who were assessed under the DB/IB schemes in 2002. See Appendix E.

Under the DB/IB schemes where a person is found capable of work s/he can appeal against this finding. When this occurs the person undergoes a second assessment by a different assessor who can find the person capable or incapable of work. Under the project fewer people appealed against the capable decision than for all DB/IB claims in 2002 (44% versus 61%). Following the second assessment the percentage of people found incapable was 17% under the project. For all DB/IB claims in 2002 the percentage found incapable at the second assessment was 49%. See Appendix F.

In comparisons with a similar group over a similar period in the previous year (the control group) there was a circa 40% reduction in claims progressing to long duration. See Appendices G and H.

A secondary benefit of the project is that the reduction in duration resulted in a reduction in expenditure on the DB/IB schemes. If the patterns in expenditure in the project were retrospectively applied to expenditure in 2002 the estimated savings that would have occurred in DB/IB expenditure on LBP claims in 2002 are shown in Appendix I.

9 Promoting the Renaissance Project

To assist in the dissemination of the guidelines on which the project is based and to encourage their implementation in other areas the author has:

  • made the 'Back Book', published by TSO (the UK Stationery Office), available, free of charge, to DSFA customers and relevant organisations
  • obtained commitments from
  1. the Board of the Faculty of Occupational Medicine of the Royal College of Physicians of Ireland
  2. the Health and Safety Authority
  3. the Council of the European Union of Medicine in Assurance and Social Security (EUMASS)

to endorse the European Guidelines on Best Management of Acute Low Back Pain, to assist in their dissemination and to encourage their implementation

  • made several presentations at conferences nationally and internationally to medical and relevant non-medical audiences
  • contributed to the media dissemination of the guidelines.

10 Conclusions

The Renaissance Project employing early intervention by the DSFA has resulted in a significant reduction in the progression to chronic disability from simple LBP. The impact of this early intervention in the acute stage should result not only in the improved health of LBP suffers in the long term but also in decreased health care costs, reduced absenteeism, increased production and significant savings in long-term illness benefit schemes.

11 Recommendations

Whereas, unilateral intervention by the DSFA has proved to be effective in reducing chronic disability from LBP, it is only part of a solution to a multi-faceted problem.

Ideally, to sustain and improve the effectiveness of early intervention a coalition of disability managers, mainly representing those players listed in 3.1 above, needs to be formed. This coalition should implement a universally agreed, evidence-based protocol for best management of LBP.

In this regard some initial progress has been made. The Health and Safety Authority, in association with the DSFA, is to launch a poster campaign to effect a change in the attitudes and beliefs of the general public regarding LBP. This initiative has been endorsed by the majority of the role players.

12 Extending the Practice of Early Intervention

As a consequence of the results being achieved in the project it was decided to extend beyond June 2003 the processing of LBP cases in the manner described above This involved the targeting of a further 8,400 cases in Dublin, Cork and Galway in the period July 2003 to June 2004. Approximately 3,700 of these cases have been referred for assessment and the findings to date have remained consistent with those in the project. (See Appendix J).

Last modified:07/11/2013
 

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