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Recommendations when Normal Activity is Refused 
 
Panel findings and recommendations: 
 -   Patients with low back problems may be more comfortable if they temporarily limit or avoid specific activities known to increase mechanical stress on the spine, especially prolonged unsupported sitting, heavy lifting, and bending or twisting the back while lifting.    (Strength of Evidence = D.) 
 -   Activity recommendations for the employed patient with low back symptoms need to consider the patient's age and general health, and the physical demands of required job tasks.  (Strength of Evidence = D.)  
 
  Patients with low back problems frequently seek advice from clinicians about the physical activities they can "safely" perform. Employed patients, or their employers, also often ask health care providers to recommend work restrictions that will allow the patient to remain on the job during an episode of low back symptoms. Activity modifications are aimed at allowing the patient with a low back problem to continue sufficient physical activity to avoid debilitation (see Activity Handout). The overall goal is to aid recovery while disrupting daily activities as little as possible. CAUTION: Professionally prescriptions to Limit a patient's work activity should be approached with the same trepidation as prescribing dangerous drugs. (See Off Work Risks
 
Modification When Normal Activity is Refused 
Literature Reviewed     Evidence on Efficacy    Potential Harms and Costs      Summary of Findings    Author's Example 
 
Modification when Normal Activity is Refused 
  Literature Reviewed.  Of the articles screened dealing with work and other activity modifications for patients with low back problems, none met established panel review criteria for adequate evidence about efficacy.  However, eight articles were considered by the panel to contain useful information on these issues.221, 222, 223, 224, 225, 226, 227, 228 
 
 Evidence on Efficacy.    A number of epidemiological studies have looked at risk factors associated with developing low back problems. Although there is no clear consensus on the role of these factors, several studies have identified an increased incidence of low back problems among individuals whose work involves heavy or repetitive lifting, exposure to total body vibration (from vehicles or industrial machinery), asymmetric postures, and postures sustained for long periods of time.222, 225 (Controlled Prevention Trials since leaned away from work exposure risks.)   
 
  Other biomechanical research suggests that certain postures and activities increase the mechanical stress on the spine. 221, 223, 225  It is not clear whether these mechanical stresses are the cause of low back problems.  However, once symptoms are present, mechanical stresses correlate with worsening of symptoms.  Prolonged sitting and postures that involve bending and twisting have been shown to increase the mechanical stress on the spine according to pressure measurements in lumbar intervertebral discs.  Heavy lifting also appears to increase mechanical stress on the spine, but this stress can be reduced if the lifted object is held close to the body rather than at arm's length. 
 
  A "lifting equation" to calculate appropriate lifting limits for various tasks was part of a guideline developed in 1981 by the National Institute of Occupational Safety and Health227 and revised more recently.228 Unfortunately, the ability of the guideline to reduce the incidence of low back problems has yet to be directly validated. Other ergonomic guidelines for safe lifting have been reviewed by Dul and Hildebrandt.224 The Lifting Equations used in NIOSH Lifting Guides of 1980 & 1991 did not find the needed biological graded response for expected relationships in validation attempts by Waters et al,`99 (note in the article table that for heavy lifts the OR and both Confidence intervals are NOT greater than 1 indicating no statistical significance) and Dempsey et al.`00.  
 
 Subsequent reviews further questioned ergonomic prevention (Lahad et al.`95, Linton,`01 and Tvieto et al.`04) before a review of the literature up to late 2005 by Martimo et al.,`07 evaluated manual material handling (MMH) advice and training with or without assistive devices. They concluded these primary prevention efforst did not prevent back pain, back pain-related disability or reduce sick leave when compared to no intervention or alternative interventions. Martimo's group also reported no evidence to support MMH advice and training or MMH assistive devices for treating back pain (See Prevention Trials). Not only did primary prevention trials using Education programs teaching about proper ergonomic lifting (from Daltroy et al.'97 to Lavender et al.`07) fail but the trials using assistive devices eliminating or reducing back lifting loads (Yassi et al,'01, Smedley et al.'03, Hatvigsen et al.`05, Jensen et al.`06) failed. These trials confirmed the findings in longitudinal and prospective risk factor studies question lifting as a risk factor from the Boeing Study to Harkness '03, and Maul '03).   
 
 Potential Harms and Costs with work limitations or being off work).  The impact on the patients future comfortable activity tolerance can be negative through the debilitation of inactivity.  Other potential harms to the patient are avoidable strife at work with fellow employees and supervisors with risk of losing employment and replacement costs to employer and society. Beyond the risks of job loss and physical debilitation lurk an increase even in mortality when work is curtailed.   Ross`95 found "so heightened is the risk of death …. that being unemployed is equivalent to smoking 10 packs of cigarette/day… a higher mortality risk rate than any occupation – even the most dangerous ones" A separate report from Sweden found the risk of death before age 65 years increased 50% when retiring early for non-life threatening conditions. Gerdtham & Johannesson reported 2003 of a follow up of 30,000 Swedes (20-60 year of age) over 17 years. Early unemployment alone increases the mortality before 65 years by 50%! The 50% increased death rate was due to increase in suicides and diseases other than cancer, cardiovascular disease or motor vehicle accidents, accidents and homicides. There is no reliable studies that find avoiding work or other activity to improve health, shortening time of symptoms, reduced surgical rates or improves future back health. 
 
 Summary of Findings.  While scientific information was limited in 1994, the panel felt that activity modifications represented an important practical issue for the clinician.  Thus, the panel's recommendations were based on their interpretation of the available scientific data. Patients with low back problems were advised to try to limit temporarily any heavy lifting, prolonged sitting, and bending or twisting the back for reasons of comfort since these activities have been shown to increase mechanical stress on the spine. More resent information questions now some of these former tenets about the risk of activities like lifting that was previously based upon conventional wisdom and supported by retrospective studies. See Lifting Injury fear invalidated. 
 
  When forced to consider activity modifications for patients who work, the clinician may find it helpful to obtain from the employer a description of the physical demands of required job tasks. We once thought the nature and duration of limitations to depend on the clinical status of the patient and the physical requirements of the job. In reality limitations should be curtailed as soon as possible to avoid both unnecessary debilitation and unnecessary risks to the patient's employment, health and mortality. Activity modifications must be time-limited, clear to both patient and employer, and reviewed by the clinician on a regular basis. 
 
  Several ergonomic guidelines on lifting and materials-handling tasks are available to help the clinician provide ranges of activity alterations a work. These guidelines are based on various biomechanical assumptions and theoretical equations to build a margin of safety for individuals who have to lift at work. It should be remembered that such guidelines were developed for otherwise healthy workers and are therefore of limited use in making strict recommendations. None of these guidelines has been adequately tested to see if adherence will reduce the occurrence of low back problems. See Eliminating Lifting studies.  
 
  The panel recommends that clinicians help patients establish activity goals, in consultation with their employer when applicable. Such goals are particularly important for the small percentage of patients who are still not able to overcome activity intolerance after 1 to 2 months of symptoms. Since nonphysical factors, such as emotional distress or low work satisfaction, may also affect an individual's symptoms and response to treatment, activity goals can help keep attention focused on the expected return to full functional status and emphasize physical conditioning to improve activity tolerance. 
 
CAUTION : BE VERY CAUTIOUS ABOUT TAKING A PATIENT OFF WORK WITHOUT STRONG MEDICAL INDICATIONS OF DANGER! 
The only way a back patient can become disabled is to be taken off work. To give time off work the benefit of the doubt, consider it as a product -  medication or tampon.  Consider the plight of a company who manufactured a medication or tampon that was 95% effective and 5% ineffective with the death rate for the 5% ineffective increasing 50% before age 65 years of age! Similarly 95% of back problems recover by 3 months but the slowest 5% to recover risk a condition with a 50% increase in death before age 65 years.   What might the FDA and class action suit attorneys response be? What be the plight of the clinicians that continued to encourage the risky use of the methods after knowing the increased death risks. If you consider taking someone off work innocuous for most patients, remember for 5% the death risk before age 65 years can be increased 50%! Also where are the plethora of trials proving the effectiveness taking back patients off work in speeding recovery, avoiding debilitation, family finances, livelihoods and improving life expectancy compare to those above and many about the impact of maintaining normal activity?  
 
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