British Journal of Rheumatology
OCCUPATIONAL MEDICINE & RHEUMATIC DISEASESSERIES EDITORS: H. AVERNS and M. WEBLEY
BACK PAIN IN THE WORKPLACE
N. RATTI and K. PILLING*
Institute of Occupational Health
University of Birmingham
Rover Group Ltd
: Back pain, Workplace, Management, Occupational disease.
back pain in the workplace takes up a highpercentage of the occupational physician’s time; it iswidespread across many occupations, from heavyindustrial through to light oﬃce work.There has been much research into the ﬁeld of backpain looking at various aetiologies, the epidemiology,the eﬀects of new and existing legislation, and thesuccess of diﬀerent treatments. Despite this, if anemployee is absent from work for
6 months withback pain, there is only a 50% chance of him returningto work. This decreases to 25% if the absence is overa year . In this paper, we review current literature,attempt to clarify some grey areas, and show how anoccupational health service can tackle this signiﬁcantproblem. We also discuss the current management of low back pain as practised at the Rover Group.EPIDEMIOLOGYBack pain occurs in
80% of the population atsome stage during their working life. Of this 80%,fewer than 1% have a serious disease (primary bonecancer, paravertebral abscesses, arthritis, trauma orcauda equina lesion) and fewer than 5% have aprolapsed disc—the majority of which do not needsurgery. Most of what remains is encompassed underthe umbrella term mechanical back pain, althoughonly a proportion have a deﬁnite mechanicaldisturbance.This is not simply a new problem that has sprung outof the Western World in the last century due toincreasing industrialization. The ﬁrst recorded case of occupational back pain was a patient of Imhotep, aconstruction worker on one of the pyramids in 2780
. Back pain as a workplace injury in the UK was ﬁrstnotiﬁed in the nineteenth century and the cost sincethen has escalated. The cost of low back pain in the UKhas been estimated at £2000 million/year (1987–88) interms of lost output . In the USA, it has beenestimated that the cost in terms of medical expenses of each back care patient is $18 000 and an additional$22 000 can be added in terms of interrupted incomeand loss of related beneﬁts .Nurses appear to be the most common occupationalgroup studied epidemiologically. A French studypublished in 1994 followed up 469 nurses for a periodof 10 yr in six public sector hospitals. Usingquestionnaire analysis during that period, they foundthat 57.9% had suﬀered some back pain and 40.5%had chronic relapsing back pain. From longitudinalanalysis, the authors concluded that not only wasphysical workload a risk factor, but also other factorssuch as smoking, psychological stresses at work andeven the length of commuting . A furtherinvestigation into back injuries among nurses showeda 3.7 times greater prevalence among nursing personnelwho performed stressful patient handling taskscompared to those who did not .RISK FACTORS
Previous back injury
A study looking at possible predictors in pre-em-ployment screening showed a history of previous backinjury as the most important risk factor for futureproblems. This was supported by a recent paper whichstated that a previous history of back trouble was amuch stronger predictor of future risk of back paincompared to any anthropometric data . We believethat an applicant with a history of back pain within thelast year should be seen by an occupational physicianbefore being passed ﬁt. Heap  showed that auxiliarynurses had a higher incidence of back injury comparedto trained staﬀ, probably due to delegation of manualtasks. It is no surprise that all NHS trusts have madelifting and handling courses compulsory, and sometrusts are introducing a no-lifting policy.
related risk factors
In industry, low back pain has been the subject of many studies looking at work-related risk factors. Riskfactors looked at include the following.
. There have beencross-sectional studies looking at an associationbetween heavy physical work and radiographicallydetectable lumbar disc degeneration [8, 9]. Some of these have found an association, but other extrinsicfactors may have provided a bias in these studies.Indeed, the Clinical Standards Advisory Groupguidelines on low back pain  only recommend anX-ray if a clinical ‘red ﬂag’ is breached. These includeage at onset
55 yr, a past history of cancer,
Submitted 26 September 1996; accepted 29 September 1996.Correspondence to: K. Pilling, Rover Group Ltd, PO Box 41,Longbridge, Birmingham B31 2TB.
1997 British Society for Rheumatology260