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    Dear all,


    Since I last summarised the arguments for more advanced rehabilitation systems for back injuries I have received useful comments from all over the planet (mainly from the US and New Zealand) but none from Australia. Most of them were positive but sadly a few suggested that I qualify some of the claims made for ergonomic interventions. In the interests of balance and fairness I have incorporated some of them in this revised summary. Here goes!


    The management of back injuries is complex and an improved approach to rehab for low back pain is urgently needed. Research has shown that treating doctors (especially physicians) are failing to diagnose most of the physical causes of backache (Spitzer, 1987). Medical research (by surgeons using nerve block techniques) has found that physicians are unable to detect the physical basis of about 90% of all back pain cases (Finch, 1999). Their investigations suggest that in reality only a very small percent are of "unknown etiology" (McGill, 2002).    Fortunately appropriate rehabilitation provides rapid recovery in most cases.


    Recent research suggests that a short-term intervention including bio-psychosocial education, manual therapy, activities and exercise is more effective than general advice on staying active and leads to a more rapid improvement in function, mood, quality of life and general health (Wand et al, 2004). However, if it is not provided soon enough these psychosocial benefits are not achieved. It is debatable whether the current adversarial rehab systems in Australia ever assists with the prompt provision of interventions of this type (indeed many people find that it usually makes things worse).


    By contrast some of the systems used overseas have been able to achieve impressive results. The findings of Lindström et al (1992) in Sweden suggest ideally an orthopaedic specialist should make the initial medical diagnosis. Given the current shortage of orthopaedic specialists there is a need for research into the feasibility of doing this on a large scale. His research shows that physical therapists should manage the rehab process rather than general practitioners.


    Lindstrom’s research studied the effects of a graded activity program that included measurements of functional capacity, a work-place visit and a graded exercise program (with supervised sub-maximal and gradually increasing activity) that was suited to the demands of the patient’s work. The patients in the activity group who were given physical therapy returned to work significantly earlier than did the patients in the control group. The research has high face validity because the average duration of sick leave attributable to LBP during the second follow-up year was about half that for the control group.


    More recent research in the UK based on Lindstrom’s techniques has confirmed that graded activity is particularly effective in reducing the number of days of absence from work because of low back pain (Staal et al, 2004). Research comparing the usefulness of graded activity and therapeutic exercises would be useful.


    In Canada Loisel et al (2001) did a pilot study using similar principles (Loisel et al, 1994) and subsequently promoted the "Sherbrooke Approach" using a participatory ergonomics approach i.e. one where ergonomists help the management to implement solutions that have been identified in their consultations with the workers (Loisel et al, 2001).


    It is difficult to find evidence that ergonomic programs ever prevent back pain but recent research evidence suggests that ergonomic interventions should be useful provided they reduce exposure to lifting work and back flexion wherever this is possible. A research program in the Netherlands (called "SMASH") has found a dose-response relationship between trunk flexion and sick leave due to low back pain. Sick leave due to low back pain was found to be mainly associated with work that requires lifting, flexion and rotation of the trunk and low job satisfaction (Hoogendoorn et al, 2002).


    McGill has pointed out that on the basis of the research by Loisel et al one could reasonably argue that after an initial medical check the management of back injury rehabilitation cases should be taken out of the hands of the medical profession and placed in the hands of ergonomists (McGill, 2002). Given the shortage of ergonomists this is obviously not feasible. A feasible compromise might be to allow physiotherapists with ergonomic qualifications to manage back injury rehabilitation; this would be in keeping with the advice of both Lindstrom and McGill.


    Certainly it is strong evidence for a combined rehab programs and ergonomic interventions for lower back pain. He quoted a Canadian study that tested the efficacy of different model of management of sub-acute back pain for preventing prolonged disability found that ergomomic interventions were more successful than clinical interventions (Loisel et al, 1997). It looked at how the effectiveness of the following different treatment regimes;

    • usual care
    • clinical intervention
    • ergonomic intervention, and
    • full intervention (a combination of the previous two)

    This research determined how these affected the duration of absence from regular work compared the initial functional status and pain findings with those found after a follow-up a year later. The authors concluded that close association of occupational intervention to improve ergonomic factors combined with clinical care is of primary importance in impeding progression toward chronic low back pain.

    The full intervention group returned to work 2.41 times faster than the traditional care group, and they found that most of the difference was due to the occupational (OHS) intervention. Average return-to-work times were;

    • 60 days for full intervention
    • 67 days for occupational only
    • 131 days for enhanced clinical only and
    • 120.5 days for the traditional care only.

    The workers were not assigned to a group until they had 4 weeks of absence from work. It is probable that an early intervention would have produced even better outcomes. In a follow-up study Loisel et al (2001) mention that they used a participatory ergonomics approach (i.e. one where ergonomists help the mangement to implement solutions that have been identified in their consultations with the workers).

    There has been some debate in the literature based on confusion about supposed divergences between the Swedish and Canadian approaches to rehab and in its initial stages there was also an apparent lack of confirmation for the Loisel’s "Sherbrooke approach". A review paper Karjalainen et al commended the Lindstrom approach but expressed doubts about Loisel’s strategy because of a lack of subsequent research confirming its usefulness (Karjalainen et al, 2001).


    A subsequent Cochrane Collaboration review of multidisciplinary approaches to managing sub-acute Low Back Pain Interventions published in April 2003) was based on this paper. It is on the web at;

    Soon afterwards an editorial in The Spine Journal (Gatchel and McGeary, 2002) criticised the current trend to unquestioning acceptance of “review” conclusions; after examining the review process itself Gatchel and McGeary concluded that the Cochrane review has some limitations. They pointed out that “It is a disservice to the health-care community if one reviews a series of reviews/articles that are quite heterogeneous in quality and concludes that the overall evidence for effectiveness is “inconclusive”. This is simply providing a misguided conclusion….” (p. 319).  The obvious conclusion is that we must not allow uncertainty or the lack of impeccable evidence to stifle our motivation to do further research in promising areas.


    Ironically Anema et al showed soon afterwards (2004) that it was possible replicate the success of the original Loisel approach (in Canada) in 6 other countries (Denmark, Germany, Israel, Sweden, the Netherlands and the United States). In any cases the recommendations of the two strategies are not incompatible. Lindström has since admitted that it is difficult to compare his work with the programs of Loisel and Anema because of their use of different study populations (personal communication, 2005). He also pointed out that it is not possible to compare them qualitatively because in Sweden there is no national uniformity for physical therapy regimes; there are several different treatment regimes (“There are several local or regional treatment programs and in some departments there are none”).


    McGill’s research appears to have influenced the evolution of physical therapy. In the following years therapists claimed to have had many successes with a strategy that increases the endurance of back stabilizer muscles and strongly emphasizes the correct activation of the transversus abdominis and multifidus muscles (Jemmett, 2003). This approach yields better results than those used in the past. According to Jemmett (2003) Low Back Pain (LBP) patients who have been treated with the "Australian approach" to Therapeutic Spinal Manipulation (TSM) are 12 times less likely to experience a recurrence of back pain in the year following treatment than patients who have been treated by more traditional methods. A peer-reviewed article published in Spine in 2001 (Hides, Jull and Richardson, 2001) came to similar conclusions. Jemmett’s approach to therapy for Low Back Pain (the "Australian Approach to Therapeutic Spinal Manipulation") was influenced by the research of Stuart McGill and his colleagues in Canada and the research of the Atlantic Manual Therapy Institute (AMTI) in Nova Scotia.

    More recently in the book "The Biomechanics of Back Pain" (Adams et al, 2006) Adams has recommended that (on the basis of the available evidence) the management of back pain "should be based adjust the demands of the work to match (temporarily) reduced capacity" and advised that the reduction of the physical demands of the work "can be achieved by ergonomic redesign or by reducing exposure times." They went on to say that a successful physical ergonomics programme needs an organisational dimension and the involvement of the workers (in other words a participatory ergonomics approach is needed; just as Loisel had pointed out much earlier). So it appears that many of the leading physical therapists and the medical profession are now in agreement about the best approach to the rehabilitation of back injuries.


    Thee book makes some telling criticisms on common surgical interventions for back pain. For many of the surgical procedures evidence for benefits is either doubtful or lacking. For instance, in the chapter on surgery (on page 255 in chapter 17) the authors say that "for newer treatments aimed at discogenic pain, the evidence is less clear" and "spinal fusion for discogenic pain remains controversial" (and there is actually evidence against the use one fashionable procedure for the treatment of discogenic pain known as "Intradiscal Electrothermal Therapy" (or IDET) for the majority of patients).

    Adams and co give the impression that the severe discogenic pain that afflicts the middle aged attracts far more medical attention than facet joint pain and chronic conditions. They point out that the medical evidence significance of back pain is limited as many forms of back injury (such as fibrosis of the disk) cause very little pain and in those that do (such as the prolapse of a disk) the pain is not a precise guide to the amount of injury or degeneration.


    Adams mentioned that though genetic inheritance is the main risk factor, recent pain-provocation research has shown that the value of the psychosocial approach is greatly exaggerated and the pendulum of informed opinion is swinging back to a greater focus on the usefulness of biomechanics.  When commenting on the value of "physical ergonomics" the authors say (on page 220 in chapter 14) that there is some evidence that to be successful, a physical ergonomics program would need an organizational dimension and involvement of the workers but the size of any effect may be modest. Despite this they advocate an essentially ergonomic approach to the management of back pain. In the chapter on that topic (page 234, chapter 15) they say that;

    • "The most common occupational intervention, for which there is most evidence, is to adjust the demands of the work to match (temporarily) reduced capacity."
    • "The basic idea is to reduce the physical demands of the work, which can be achieved by ergonomic redesign or by reducing exposure times."


    Hence it is advisable to redesign hazardous tasks and adjust the demands of tasks to match the capacity of the worker. In the field of ergonomics there is fairly universal agreement that the probability of Low Back Pain (LBP) is greatest when a worker lifts loads that exceed the worker’s physical capacity and that the physical capacities of workers vary greatly. Hence it is important to ensure that work that is tiring or prolonged does not exceed the worker’s "limits of strength and endurance".


    Snook has asserted that two thirds of injuries are preventable if the workers do not attempt to lift loads that they find unacceptable (Snook, 1978).  This has become known as the "maximum-acceptable-weight-of-lift" rationale (Waters et al, (1993). (See section 5.1 on p. 759 of the article on the revised NIOSH equation.) These findings show that it is important to consult workers as to whether they find loads acceptable. Hence workplace training should stress the point that workers should be instructed not to lift loads that they find unacceptable. It follows that workers should be encouraged to familiarize themselves with their strength and load capacities and they should be instructed not to handle loads that they find unacceptable.

    Clearly we need to focus most of our efforts on improved prevention strategies but as this is an imperfect world we also need to focus our attention on improved rehab strategies.


    There is anecdotal evidence that the clinical management of the rehab process by doctors often delays referrals to physiotherapists and ergonomists (if the referrals happen at all). It appears that the rehab culture in New South Wales is unduly influenced by a medical lobby that acts on behalf of general practitioners as "GPs have been happy to take money even when they often did not know what they were supposed to be doing" (Browning, 2005). This is disturbing as low back pain claims cost New South Wales about 700 million dollars a year.

    Given the evidence that (a) ergonomic interventions combined with a rehab program can halve the recovery time (according to Loisel et al, 1997) and (b) rehab program managed by physical therapists can halve the recovery time (according to Lindstrom et al, 1992) it might even be possible to combine these approaches and achieve an even faster recovery time.

    There is anecdotal evidence that the clinical management of the rehab process by doctors often delays referrals to physiotherapists and ergonomists (if the referrals happen at all). It appears that the rehab culture in New South Wales is unduly influenced by a medical lobby that acts on behalf of general practitioners as "GPs have been happy to take money even when they often did not know what they were supposed to be doing" (Browning, 2005). This is disturbing as low back pain claims cost New South Wales about 700 million dollars a year.

    On the basis of the evidence there is a need for a more advanced rehabilitation system for low back pain with the following features;

    • an initial medical diagnosis by an orthopaedic specialist
    • a rehab process managed by physical therapists with ergonomics qualifications
    • rehab programs and return-to-work programs that aim to adjust the demands of the work to match the reduced capacity of the rehabilitees by ergonomic redesign or a reduction of exposure to lifting and back flexion
    • a participatory ergonomics approach to managing workplace risks (i.e. one where ergonomists help the management to implement solutions that have been identified in their consultations with the workers).


    Has anyone any more technical comments? Has anyone any comments of creating such a system in Australia? Does anyone know if there are any plans afoot for a national system?



    David McFarlane MAppSc (Ergonomics)
    Ergonomist, WorkCover NSW



    1. Spitzer W, Leblanc F, Dupuis M, et al., (1987), “Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians. Report of the Quebec task force on spinal disorders,” Spine 12, (supplement 7): S1-S59.


    2. P. Finch, (1999), “Spinal pain – an Australian Perspective”, Proceedings of the 13th World Congress of the International Federation of Physical Medicine and Rehabilitation”, Washington, pages 243 – 246.


    3. S. McGill, (2002), "Low back disorders. Evidence-based Prevention and Rehabilitation ", (Human Kinetics, Leeds), p 5.


    4. B. Wand, C. Bird, J. McAuley, C. Doré, M. MacDowell, L. De Souza, (2004), ”Early Intervention for the Management of Acute Low Back Pain A Single-Blind Randomized Controlled Trial of Biopsychosocial Education, Manual Therapy, and Exercise”, Spine 29 (21):2350-2356. This paper can be found on the web at; http://www.medscape.com/viewarticle/492853


    5. Lindstrom I, Ohlund C, Eek C, Wallin L, Peterson LE, Fordyce WE, Nachemson AL., (1992), “The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach”, Phys Ther. 1992 Apr;72(4):279-90. The abstract is on the web at; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=1533941&query_hl=1


    6. Staal JB, Hlobil H, Twisk JW, Smid T, Koke AJ, van Mechelen W.
    ”Graded activity for low back pain in occupational health care: a randomized, controlled trial.”, Ann Intern Med. 2004 Jan 20;140(2):77-84.


    7. P. Loisel, L. Gosselin, P. Durand, J. Lemaire, Stephane Poitras and L. Abenhaim, (2001), “Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain”, Applied Ergonomics, 32, pp 53-60.


    8. Hoogendoorn W, Bongers P, de Vet H, Ariëns G, van Mechelen W, Bouter L, (2002), "High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study", Occup Environ Med, 2002 May, 59, (5), pp 323-8.


    9. S. McGill, (2002), "Low back disorders. Evidence based prevention and rehabilitation", (Human Kinetics, Leeds) pages 5 and 163.


    10. P Loisel, P Durand, L Abenhaim, L Gosselin, R Simard, J Turcotte and JM Esdaile, (1994), " Management of occupational back pain: the Sherbrooke model. Results of a pilot and feasibility study", Occupational and Environmental Medicine, Vol 51, 597-602.


    11. P. Loisel, L. Abenhaim, P. Durand, J. Esdaile, S. Suissa, L. Gosselin, R. Simard, J. Turcotte and J. Lemaire, (1997), “A population based randomized clinical trial on back pain management”, Spine. Dec 15; 22, (24), pp 2911-8. The abstract is on the web at;


    12. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B., (2001), "Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group", Spine. 2001 Feb 1;26, (3):262-9. Link;

    13. R. Gatchel and D. McGeary, (2002), "Cochrane collaboration-based reviews of health-care interventions: are they unequivocal and valid scientifically, or simply nihilistic?", The Spine Journal, 2, 315-319.


    14. Anema JR, Cuelenaere B, van der Beek AJ, Knol DL, de Vet HC, van Mechelen W., (2004), “The effectiveness of ergonomic interventions on return-to-work after low back pain; a prospective two year cohort study in six countries on low back pain patients sicklisted for 3-4 months.”, Occup Environ Med. 2004 Apr;61(4):289-94.


    15. Rick Jemmett, (2003), “Spinal Stabilization: The New Science of Back Pain”, Rev. Edition, (Novont Health Publishing, Halifax), ISBN: 0-9688715-1-8, pages 115-123.


    16. Hides J, Jull G and Richardson C., (2001), "Long-term effects of specific stabilizing exercises for first-episode low back pain." Spine. 2001 Jun 1;26 (11):E243-8. this abstract for this paper can be found on the web at; http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11389408&itool=iconabstr&query_hl=6


    17. M. Adams, N. Bogduk, K. Burton and P. Dolan, (2006), "The Biomechanics of Back Pain", second edition, (Churchill, Livingstone, Elsevier; New York), pages 2, 220, 225, 234 and 255.


    18. L Browning, (2005), “BACK PAIN. GPs take the lead”, National Safety June 2005, pages 33 to 35. (See the last paragraph on page 35.)


    19. S. Snook, (1978), "The Design of Manual Handling Tasks", Ergonomics, vol. 21, pages 963-985.


    20. 7. T. Waters, V. Putz-Anderson, A. Garg and L. Fine, (1993), "Revised NIOSH equation for the design and evaluation of manual handling tasks", Ergonomics, vol. 36, no. 7, pages 749-776.



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    Wow! Great information. Thanks.


    [private user]



    As always a professional, academic post.  I'm so glad you referenced McGill.  I have his BackCare text and have incorporated some of his exercises into my personal regieme. 


    Beverly Burke RN CMA CIE

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