Introduction

In order to discuss low back pain (LBP) in relation to work issues, it is helpful to reflect on its epidemiology, presentation and typical course in primary care and rheumatology practice. LBP is a highly common health problem (about 90% of people will experience it at least once in their adult life). At most, 20% of working-age individuals experiencing LBP seek medical help and, of those, only 20% report sickness absence and 10% file a worker’s compensation claim . Typically, medical management has little impact on the outcome of acute episodes; rapid improvement usually occurs in the short term (approximately within 1 month) for most people . In many cases, back pain amongst primary care patients runs a recurrent course characterised by variation and change, rather than an acute, self-limiting course ; however, few patients have long-term limitation in daily activities, even if some pain persists .

The small percentage who have significant pain and work disability account for most of the health-care costs and socioeconomic burden (lost productivity and prolonged work disability) of LBP. Within the 45- to 65-year-old age group, LBP is one of the most frequently reported medical reasons for work loss . According to a large cohort study of injured workers who filed workers’ compensation claims for occupational back pain in the United States, the decision to seek care and the choice of providers was associated with injury severity, occupation and employer actions . Thus, for most working patients seeking medical care, amelioration of pain is not the only outcome or treatment focus to consider. Work participation and restoring function play major roles in recovery, are beneficial to overall health and mental well-being and, are essential for the patients’ self-confidence and self-control over an important life dimension .

The International Labour Organization (2008) recently emphasised the intrinsic importance and meaning of work in the lives of people, irrespective of whether they have a medical condition or not: “work is not just an economic issue, it provides a means to prove one’s worth and ability, gain self-confidence and self-esteem, and participate in the life of the community” (International Labour Organization (ILO), 2008). Long periods out of work can cause or contribute to 2–3 times increased risk of poor general health, 2–3 times increased risk of mental health problems and even 20% excess mortality risk . Prolonged sickness absence can result in permanent disability, even without serious illness, as patients become depressed, inactive, develop catastrophic beliefs and become fixated on their disability.

First and foremost it is important to recognise that prevention of all back pain occurrence in the workplace would be optimal, but seems less feasible and less cost-effective than controlling the consequences of pain and disability . Subsequently, it is when pain first appears to lead to temporary work disability that many physicians in primary care encounter work issues in their LBP patients.

Working-age patients often consult their primary care physician when they need a sick note, or advice about how their health impacts work ability or vice versa . In many situations, patients are legally required to obtain medical certification for work disability, or clearance to return to work (RTW) . Primary care physicians thus have a secondary prevention role when making proper recommendations to patients with regard to work restrictions and participation. As first evaluators and communicators of a patient’s health and condition, they have a unique window of opportunity, early on, to prevent poor outcomes in patients at risk of experiencing prolonged pain, recurrent illness and disability .

Since attention to RTW is proven to be more important than solely focussing on treating the injury or pain, physicians need to better understand the work context in relation to the capacity and beliefs of the patient. Many do find these issues frustrating, time consuming and feel ill prepared to deal with them . However, a change in approach can improve the experience for patients, providers and employers . There is much variation across primary care practices in the specific role for dealing with work-related issues. However, current evidence leads to practical recommendations that are relevant for most providers. Many literature reviews, clinical guidelines and implementation studies are seeking to engage primary care physicians in simple but effective disability prevention practices in these encounters. For instance, clinical practice guidelines emphasise the idea of ‘do no harm’ by advising physicians not to prescribe unnecessary diagnostic tests in order to avoid catastrophic beliefs . They also suggest ways to identify risk factors for disability, suggest appropriate reassurance and encourage RTW. More recent research efforts offer new knowledge on specific work-related factors related to clinical and disability outcomes, which can be translated to clinical practice .

This article discusses these recommendations in view of improving current practices for LBP management. We review work issues in the context of managing LBP, perspectives on factors that influence work disability outcomes, guidelines and recommendations for primary care physicians as well as strategies to deal with the most common challenges.