Getting back to work – how physical conditioning exercises can help

Low back pain is a major problem throughout the world; it is common, and often recurrent. A recent systematic review of 165 studies on the epidemiology of back pain estimated that 23.2% (±2.9%) of people in the world suffer back pain each month. (Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64:2028.)

Whilst there are many studies looking at the prevalence of back pain in terms of the effect of the condition on individuals, there has been less information about the burden of back pain from an occupational perspective. Estimates of the percentage of sickness absence due to back pain each year range from 9% of the working population of New Zealand (Widanarko B, Less S, Stevenson M, et al. Prevalence of work-related risk factors for reduced activities and absenteeism due to low back symptoms. Appl Ergon 2012;43:72737) to 32% of hospital employees in Ireland. (Cunningham CG, Flynn T, Blake C. Low back pain and occupation among Irish health service workers. Occup Med-C 2006;56:44754.) 

 In the UK it is estimated that 12.5% of all work absence is attributable to back pain. (Bevan S, Quadrello T, McGee R, et al. Fit for work? Musculoskeletal disorders in the European workforce (2012). The Work Foundation Report.)

Lower back injuries result in approximately 149 million lost work days per year in America. The annual productivity losses resulting from lost work days are estimated to be $28 billion. (Maetzel A, Li L. The economic burden of low back pain: a review of studies published between 1996 and 2001. Best Pract Res Clin Rheumatol. 2002;16:2330). Additionally, it is estimated that back pain costs US insurance companies $20 billion to $50 billion each year. (Pai S, Sundaram LJ. Low back pain: an economic assessment in the United States. Orthop Clin North Am. 2004;35:15.)

If people are absent from work due to back pain, early return to work is important not only for economic reasons but also social and health reasons. With the increase in length of work absence and disability, comes a lower probability of returning to work. Return to work rates in those who have short-term absence due to an episode of back pain range between 80% and 90%. (Bevan S, Quadrello T, McGee R, et al. Fit for work? Musculoskeletal disorders in the European workforce (2012). The Work Foundation Report.)

 In those with chronic occupational back pain, sustainable return to work rates are reported to be between 22% and 62% after 2 years. (Anem JR, Schellart AJM, Cassidy JD, et al. Can cross country differences in return to work after chronic occupational back pain be explained? an exploratory analysis on disability policies in a six country cohort study. J Occup Rehabil 2009;19:41926.)

 Personal expectations, i.e. what the individual with back pain believes about their prognosis, also play a significant role in how quickly people with back pain return to work. A 2012 study by Hallegraeff et al (Expectations about recovery from acute non-specific low back pain predict absence from usual work due to chronic low back pain: a systematic review), concluded that the odds that adults with acute or subacute non-specific low back pain and negative recovery expectations will remain absent from work due to progression to chronic low back pain are two times greater than for those with more positive expectations.

This phenomenon is exacerbated by the old adage "use it or lose it!". Long periods of inactivity, particularly where individuals are not performing their usual daily life activities, increases the likelihood of people becoming physically deconditioned (Polatin and Mayer, 1998. Functional restoration and other rehabilitation approaches to chronic musculoske- letal pain disability syndromes. Critical Reviews in Physical and Rehabilitation Medicine 1998;10(3):209 221). Being deconditioned presents itself as reduced muscle bulk, stiff joints, and pain on movement. Moreover, workers who have not returned to work (or their normal work duties) after 3-6 months are at risk of permanent disability (Waddell and Burton, 1999. Evidence Review for Faculty of Occupational Medicine, London.) or other ill health effects of a sedentary lifestyle.

A sedentary lifestyle is defined as a type of lifestyle where an individual does not receive regular amounts of physical activity. Endurance capacity quickly reduces when activity levels are reduced through either bed rest or cessation of training. (MacDougall JD, Elder GC, Sale DG, et al. Effects of strength training and immobilization on human muscle fibres. Eur J Appl Physiol Occup Physiol 1980; 43: 2534.)

 n 2005, James A. Levine, an obesity specialist at Mayo Clinic, highlighted the negative effects of a sedentary lifestyle in an article in Science Magazine: “Any extended sitting – such as behind a desk at work or behind a wheel – can be harmful”.

According to the World Health Organisation (WHO), 60 to 85% of the population worldwide does not engage in enough activity. Making physical inactivity the fourth leading risk factor for global mortality. There is general consensus amongst health professionals that taking 10,000 steps a day (the equivalent of walking approximately 5 miles) is the ideal goal to set for improving health and reducing the health risks caused by inactivity.

The Technogym app, for example, is design to motivate individuals to move more and become healthier. Users can use it to track their activity, set goals to motivate them to move more and access their wellness data anywhere. For workers whose jobs consist of long periods of sitting, the Technogym Wellness Ball uses active sitting technology that helps strengthen muscles, increase balance and improve flexibility, coordination and posture.

If people with back pain are encouraged to resume normal activities as soon as they are considered medically stable, even if they are still experiencing persistent pain, they are more likely to avoid the effects of physical deconditioning or a sedentary lifestyle.

Specialised exercise programs focussed on functional activities and return to work outcomes are advocated for workers with back pain. These programs are referred to as either physical conditioning, work-conditioning, work-hardening or functional restoration, and are work relevant, intensive, goal oriented programs designed to restore work performance.

Developed in America in the mid-1980s by the rehabilitation services industry, physical conditioning programs were initially widely promoted as part of a return to work strategy to reduce sickness absence for workers with back pain. Physical conditioning differs from usual exercise programs in that their objective is to prepare the injured worker for a return to work, job search or job retraining. This is achieved by providing an intensive, active, rehabilitation program that addresses the worker’s physical needs.

Whilst the literature describing these programs, indicates a great deal of variability in outcomes, between programs and between countries (Teasell and Harth, 1996), a recent review of 25 studies by the Cochrane Collaboration (2013 - Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain) found that "for workers with chronic back pain, there is moderate quality evidence that intense physical conditioning probably reduces sickness absence duration slightly compared to care as usual."

The Cochrane Collaboration paper recommends that more research is undertaken to provide a more definitive answer. However in the absence of this, physical conditioning still offers the general benefits for overall wellness associated with increased activity and exercise. Namely:

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