Back Injuries in the Workplace – a Rational Approach to Treatment

The ProblemThe incidence of low back and neck pain is pervasive throughout society and represents a major reason for time lost from work, costing the American economy billions of dollars per year between medical care, lost wages, and benefits. Most of these lost resources are utilized by a small minority of patients. Lost time due to occupational back injuries represents a challenge to the medical industry, and the insurance world to provide early, effective treatment. The proper approach is to provide cost effective care while improving the quality of patient care and facilitating a successful and quick return to activity by the patient.BackgroundMany patients with back problems seek early care with their primary care physician or medical generalist rather than enlisting the assistance of a spine specialist.  As a result, these patients are frequently treated symptomatically without the benefit of a defined algorithm for effective testing and treating. Studies such as MRI’s are frequently ordered when unnecessary, and patients can go weeks or months before a proper diagnosis is derived and appropriate treatment initiated.This approach is counterproductive in an industrial setting where the injured worker has a propensity for further injury and extended lost time from work, without effective care.GoalsThe goal for treatment in work related spinal injuries is to provide early intervention that identifies an accurate working diagnosis and is coupled with effective treatment modalities.  The evaluation of the patient must involve the use of established algorithms ordering tests only when necessary and avoiding wasteful testing that is not medically necessary, and does not alter the course of early treatment. Early control of pain along with effective mobilization of the patient through aggressive physical therapy provides the most effective means to quickly return patients to the work place.The ultimate goal is to return the patient to their previous level of function in society. Although it is not always possible to provide 100% resolution of the problem, it is possible to maximize one’s functional capabilities through pain control and aggressive rehabilitation. It is a well-documented fact that extended time lost from work decreases the likelihood of a successful return to the workplace.Types of Injuries and TreatmentThe overwhelming majority of injuries in the work place involve simple strains and strain type syndromes. These represent simple soft tissue related injuries that are time limited in scope and do not represent long term injuries. They are easily and effectively treated with proper early intervention. This includes interruption of the pain cycle while encouraging progressive activity levels to effectively and quickly return patients to the work place. This approach typically involves the prudent use of anti-inflammatory medication in conjunction with aggressive back reconditioning, streaming function, and strengthening.All too frequently, patients are placed on extended courses of passive modalities, which leads to extended time lost from work with further rehabilitation of the patient. Some patients develop disc related injuries, most typically a herniated disc. Most disc herniations can be treated nonoperatively and frequently improve in a period of 46 weeks. Treatment modalities again include the prudent use of medication, effective rehabilitation, and injection therapy for the control of pain. The only indication for emergent surgery involves progressive neurologic deficits.  In a select group of patients, comprehensive nonoperative treatment fails requiring surgical intervention.The advent of microsurgical procedures of the spine represents a major advance for the treatment of herniated discs. This is typically undertaken as an outpatient procedure with early mobilization of the patient, facilitating early active rehabilitation. Patients typically are successfully returned to work in a limited capacity soon after surgery with improved long term results. The combination of outpatient surgery coupled with early aggressive rehabilitation results in significant cost savings to the carrier.Failed Back SurgerySurgery should only be undertaken when there is effective correlation between a patient’s complaints, physical examination, and imaging studies. The absence of complete correlation of all factors significantly decreases the likelihood of a successful surgical outcome. Failed back surgery represents a major proportion of expense in the treatment of work related injuries.  The greatest likelihood of success is with the initial procedure. Revision spine surgery holds a more guarded prognosis and should only be undertaken by those who are highly trained in this more demanding procedure.RehabilitationEarly mobilization of the patient in conjunction with control of pain represents the cornerstone of treatment. The initial step is to obtain a pain free range of motion followed by back strengthening and reconditioning. The goal is to ultimately return the patient to prior functional levels and minimize the likelihood of recurrent injuries.ConclusionThe effective treatment of back related injuries involves the coordination of care by a spinal specialist trained in the effective diagnosis and treatment of spine related injuries. Early intervention resulting in an accurate working diagnosis, coupled with well-trained academic decision making, is the most effective way to return patients to their pre-injury level of function.Coordination of care with the case manager, clinical specialist, and employer is mandatory for a successful outcome. If things are not working within the timeframe originally projected, or there are other unresolved issues pushing end of healing out further than expected, an IME may be indicated. For more information please visit www.MedicalSystemsUSA.com

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