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Non-Physical factors as Risk to Back Injury Claim and Disability 
Panel findings and recommendations: 
 -   Social, economic, and psychological factors can significantly alter a patient's response to back symptoms and to the treatment of those symptoms.  (Strength of Evidence = B.) 
 -   In a patient with low back symptoms and no evidence of serious underlying spinal pathology, the inability to regain tolerance of required activities may indicate that unrealistic expectations or psycho-social factors need to be explored before considering referral for a more extensive evaluation or treatment program.  (Strength of Evidence = B.)  
 -   Patients with low back pain alone, who have neither suspicious findings for a significant nerve root compression nor any positive "Red Flags," do not need surgical consultation for possible herniated lumbar disc. (Strength of Evidence = D.)  
  Patients' reports of symptoms and treatment outcomes may be influenced by psychological or socioeconomic factors.  Several studies have reported a variety of such factors for patients with low back problems. These factors include work status, typical job tasks, educational level, pending litigation, worker's compensation or disability issues, failed previous treatments, substance abuse, and depression.23,38,39,41,43,50,58 
  Social, economic, and psychological factors have been reported to be more important than physical factors in affecting the symptoms, response to treatment, and long-term outcomes of patients with chronic low back problems.357 There are indications that such nonphysical factors may affect clinical outcomes for patients with low back symptoms (Attachment A5).  A heightened awareness among clinicians to the way such factors may affect a patient's response to symptoms and treatment is therefore warranted. 
See Post Procedural Care (Individual Clinician approach to Physical & Non-Physical Care after Procedures
Literature Reviewed     Evidence on Efficacy       Summary of Findings         Clinical Considerations    
Non-Physical Issues as Risk to Back Injury Claim and Disability 
Literature Reviewed_________________________________________________ 
  None of the articles screened about psycho-social factors in the assessment and treatment of low back problems were controlled trials and therefore do not meet panel review criteria for adequate evidence about efficacy.  Five articles, however, that included prospective cohort studies contained information considered useful to the panel.23, 50, 358, 359, 360 
Evidence of Efficacy____________________________________________________ 
  One large prospective study 352, 358 of asymptomatic individuals at a work-site found pre-morbid nonphysical factors (i.e., measures of low work satisfaction and distress in life) to be the best predictors of individuals reporting back problems at work.  In a second study,23 psychological variables measured early in the course of an low back episode did not predict outcome, although other nonphysical factors, such as educational level and perception of both job characteristics and "fault" concerning the back problem, were strong predictors of outcome. [More recent studies have also found pre-existing psychological distress and job dissatisfaction (Boos et al.`00, Carragee et al.`05), and  Compensation issues (Burton et al.`95) and other site(s) of chronic pain (Carragee et al.`05), to be predictors of back pain chronicity]   A population-based study359 also suggested that psycho-social issues affect how individuals with low back symptoms make decisions about working.  
Carragee et al.,`06 prospective cohort study about minor trauma found abnormal psychometric testing, smoking, and compensation issues, accurately identified 80% of serious LBP events and 93% of LBP disability events. Neither severity nor disability were predicted by structural findings or minor trauma. Subjects with advanced structural findings were not more likely to become severely symptomatic with minor trauma events than with spontaneously evolving LBP episodes. Recent studies indicate specific differences in chronically disabled patients. (See Disabling pain
  Several studies have detected a strong correlation between the outcome of lumbar spine surgery and the preoperative psychological status of the patient.50, 360  One cannot discount the association between spinal surgery with significant daily LBP suggesting that spinal surgery has failed (Spalski et al`95). Arguably, either non-physically or physically issues may trigger the disability. The conundrum as to which came first - the chicken or the egg - as resultant disability is quantifiable. Resultant loss of productivity and medical assets add up to the majority the costly back issue.  
Summary of Findings___________________________________________________ 
  The panel found evidence that psychological, social, and economic (nonphysical) factors can alter the response to symptoms and to treatment (including surgery) among patients with low back problems. While such nonphysical factors have been shown to affect outcomes, specific and effective interventions to address these factors and alter patient outcomes have yet to be defined. No studies that directly evaluated interventions aimed at psycho-social factors among patients with low back problems were found. 
  Given such limited information, the panel was unable to recommend specific assessment tools or interventions focusing on psycho-social factors potentially important for patients with low back problems. Recognizing the impact such nonphysical issues can have on outcomes, however, the panel recommended that clinicians be aware of these factors, especially in patients whose recovery of activity tolerance following an low back problem seems delayed. Further research is needed to define specific methods of detecting nonphysical factors as well as interventions that might improve outcomes for those patients slow to recover from low back problems. 
What are the strongest risk factors for disability? Since 1994 the issue of non-physical factors has been dissected further. When major trauma or serious structural disease (tumor, infection, gross instability) are excluded, Low Back Problems correlate strongly with non-physical issues (psychosocial issues, and a high co-morbidity of other chronic pain processes and mental health problems) especially those slowest to recover reasonable activity tolerance. (Bigos et al.`91, Klenerman et al.`95,  Valat et al.`97,Burton et al.`95,  Burton et al.`97, Carragee et al.`01, Linton et al.`00, Pincus et al.`02, Boersma et al.`05, Carragee et al.,`06, Brage et al.`07).  Linton's 2000 review of psychological risk factors in back and neck pain, screened 913 potentially relevant articles finding 37 studies prospective designs to ensure quality. Stress - distress, or anxiety - mood and emotions - cognitive functioning, - pain behavior were all significant risk factors while Personality factors produced mixed results and potentially abuse in related to the onset, and to acute episodes, subacute cases, and chronic pain. A Pincus et al.`02 systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain found 25 publications (18 cohorts) included psychological factors at baseline of which 6 met criteria acceptability implicated distress, depressive mood, and somatization for the transition to chronic low back pain and weak support for catastrophizing coping mechanisms.  Boersma et al.`05 found the relationship between Fear of movement and function to be moderated by stage of chronicity - not explaining pain <1 year in 48 subjects, BUT explaining pain duration of 1-3 years in 47 and >3 years in 89. A 12-year prospective cohort of 1152 Norwegians by Brage et al.`07 found Emotional Distress a predictor for low back disability but only in persons with prior low back problems.  
Also being self-employed was found protective in the 12 year Holmberg et al,`04 prospective study of Swedish farm owners or renters. Self-employed farmers with significantly more physically demanding jobs than non-farming rural cohorts had reduced back related sick leave and disability. The impact of self-employment held up even after controlling for anxiety and depression found to highly impact function in both groups. 
Clinical Considerations for Non-Physical Issues 
The work-up now verifies factor to stand in the way of improving comfortable activity tolerance through Physical Conditioning. The clinical approach must again promote activity as the key to improving comfort (conditioning) and reasonable activity tolerance (conditioning). Other than some basic elements of building endurance of the individual in general as well as, the erector spinae muscles, the clinician becomes much more entwined in the return to work activity predicament for the patient. 
No approach can afford results in all patients since non-physical factors tend to influence even reporting back problems at work more than physical factors. The clinician must realize that the non-physical pressures build in importance the longer the patient is away from normal work activity. Thus, a basic approach to the physical that is safe for the patient and an approach to exposing difficult non-physical factors and building options for the patient are of paramount importance. While this can be done very expensively, the following is a primary care clinician's opportunity to be effective as anyone in dealing with an individual's preventable morbidity, even mortality and the potential disaster for the future of a family.  Psychosocial factors and emotional distress predict low back pain outcomes better than physical exam findings, symptom severity or duration of pain (Pengel et al.`03, Fayad et al.`04, Pincus et al.`02). To date research provides no evidence on effective primary care interventions for identifying and treating such non-physical factors in patients with acute low back pain is lacking (Hay et al.`05, Jellema et al.`05). Even multidisciplinary treatment while it seems to affect the pain complaints it has little proven impact on the disability (Tvieto et al.`04). There is currently insufficient evidence to recommend optimal methods for assessing or treating psychosocial factors and emotional distress. 
Chronic treatment concerns 
Non-Physical Issues 
Individual Clinician approach to Post Procedural Physical & Non-Physical Care  
When Clinician becomes caught in the Patient Insurance Contest providing Impairment/ Disability Impressions 
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