A recent award-winning research paper investigates the reasons some workers become chronically disabled from back injuries whereas others do not, and looks at ways the knowledge can be used to help patients back to work. In an interview with The Ergonomics Report® in February, the principal author discusses the distinguishing features of the study, its implications and the next step for the researchers.
The International Society for the Study of the Lumbar Spine (ISSLS) named “Early Predictors of Chronic Work Disability: A Prospective, Population-Based Study of Workers With Back Injuries” the best clinical paper of 2008, a testament to its importance in the realm of workplace productivity. The paper – the product of research at the University of Washington (UW), led by Judith A. Turner, Ph.D., Professor, Psychiatry and Behavioral Sciences at UW – was published in the December issue of the journal Spine.
Explaining the reasoning behind the study, the authors note that although low back pain is the most prevalent and costly disabling work-related condition, only a small fraction of workers with acute back pain progress to chronic disability. These account for the majority of costs, they say. “The identification of early predictors … [could] lead to more effective secondary prevention efforts focused on modifiable risk factors.”
The depth and breadth of the research, as well as the clinical importance of the findings, contributed to the selection of the study for the ISSLS award. The researchers’ starting place was the Washington State Department of Labor and Industries claims database. “We identified workers based on the administrative data,” Professor Turner explained in the interview, and “attempted to contact every worker who met the study entry criteria.” This approach yielded interviews with 1,885 workers who had submitted a workers’ compensation claim for lost work time an average of three weeks after experiencing a back injury on the job. The sample was predominantly male and white non-Hispanic.
The researchers hypothesized that certain variables assessed soon after a work-related back injury would be significant predictors of chronic disability. The variables ranged through the sociodemographic and employment circumstances of the claimants, their pain and function characteristics, their clinical and health care, administrative-legal issues and health behavior and psychological domains. The researchers also hypothesized that factors from different domains would add unique information in a multivariable model predicting chronic disability.
The researchers list as statistically significant factors: the severity of the injury; the number of pain sites involved in the physical disability; a description of the job as "very hectic;" no offer of a job accommodation to enable the employee’s return to work; previous injury involving a month or more off work; and the specialty of the first health care provider for the injury. They were able to demonstrate that it is very important to assess factors in multiple domains.
Asked about characteristics of the study that set it apart from other investigations of back-injury and disability, Professor Turner pointed to the accuracy of the statistical models. “[They] showed excellent ability to predict at this very early stage who was going to be work disabled one year later.”
It is the largest prospective population-based study of risk factors for chronic work disability, as assessed very early after the work injury, she said, another factor that sets it apart.
One characteristic of the research literature is that it tends to be fragmented, she explained. “For example, one group might look at risk factors in one fairly narrow domain, such as psychosocial risk factors, and another study might look at risk factors in terms of job related issues, but few studies have tried to comprehensively look at risk factors for chronic work disability across a quite a large variety of domains.”
In the paper, the UW researchers touch on other factors that set the research apart. They note that studies of predictors of chronic back disability in workers’ compensation and other settings have yielded inconsistent findings, likely reflecting differences in samples, methods and measures.
Professor Turner places workers’ compensation agencies high on the list of potential beneficiaries from the findings of the study. At least in Washington state, where this study was performed, she explained, there’s considerable interest from the workers’ compensation agency in early intervention programs for workers who have a job injury, particularly a musculoskeletal injury like a back injury. “Workers compensation agencies would have some incentive to have patients go back to work as early as possible and not end up being chronically disabled.”
Along with patients, employers stand to benefit. “I would hope that the takeaway message for employers would be that whenever possible, offering some kind of a work accommodation would be extremely important in getting workers back to work and keeping them at work after a back injury.” There are obvious disadvantages to losing workers to disability, she noted, and one is that it costs a lot to train somebody new. “To the extent that an employer wants to retain a worker, one thing that they can do is make efforts to get the person back to work early on, with some kind of accommodation – whether that be light duty or reduced work hours, or something else, that allows them to come back.”
The challenge has always been how well you target the right program to the right workers, she said, “because it can be very expensive to have every single injured worker undergo some kind of a program early on, when the vast majority are going to be back at work and just fine within a couple of weeks. There’s interest in using the findings of the study to try to identify workers early on who could benefit from some extra help in getting back to work.“
The next step is testing the study’s findings. Professor Turner said the research team is now asking how the findings can be translated "into something that can be used practically to the benefit of workers with these [types] of injuries.”
We have been talking about trying to implement the findings – “just on a trial basis, a pilot basis – [at] a few selected clinics where a lot of patients with work injuries are seen.” The experiments would involve early screening for risk of chronic disability and an early intervention program that would involve more physician time with the patient early on. It would include education and advice about things the patient can do to remain active, “and hopefully prevent the downward spiral of persistent pain and disability.”
The early intervention could also involve better physician, patient and employer communication around how to get the worker back to their job. “If the worker is unable to return to their customary job full time, are there accommodations that the employer would be able to make to allow the person to come back? Would a physical therapy program that is targeted at increasing the patient’s ability to get back to their customary job task, would that be helpful? We have been carefully discussing an intervention along those lines, and hope to launch a little pilot project sometime this year.”
Sources: Dr. Judith A. Turner;
Article Title: Early Predictors of Chronic Work Disability: A Prospective Population-Based Study of Workers With Back Injuries
Publication: Spine, 33(25), 2809-2818, 2008
Authors: J A Turner, G Franklin, D Fulton-Kehoe, L Sheppard, B Stover, R Wu, J V Gluck, and T M Wickizer
This article originally appeared in The Ergonomics Report™ on 2009-02-18.