The otherwise-excellent articles on neck1 and low-back pain2 may have misled physicians about how best to prevent chronic pain disability. For example, Ian Tsang encourages physicians to “identify the pathology early so that these patients can be managed properly” but warns that “in most cases of neck pain, no clear-cut underlying definable pathology can be identified.”1 Advising physicians to first establish a specific diagnosis leads them to perform repeated investigations and seek multiple consultations with specialists. I have repeatedly seen this strategy produce iatrogenic outcomes such as false-positive diagnoses, unnecessary treatments and fear and distress in the patient. Physicians consequently become barriers to more timely interventions.
Work-related musculoskeletal disorders often have multifactorial causes.3 It is primarily the family physician's responsibility, not a specialist's, to rule out serious organic disease by means of a simple history and examination. Then, without delay, the family physician should clearly communicate to the patient a confident, optimistic diagnosis and a treatment plan that encourages “the maintenance of an active life including work activity.”2
What is insufficiently appreciated is that a patient with a work-related musculoskeletal disorder who has been off work for 4 weeks is at high risk for long-term disability.4 High levels of pain and the presence of Waddell's nonorganic signs should alert the physician that a patient is in distress and in imminent danger of becoming a “claimant,” with all the suffering and insecurity that this label may entail. The best evidence suggests that it is urgent at the subacute stage (4–12 weeks postinjury) to refer these high-risk patients to a multidisciplinary cognitive–behavioural rehabilitation program.5 These programs focus on ergonomic and psychosocial workplace issues and teach patients strategies to manage pain and increase function. Physicians should work with employers and insurers to make such programs more widely available for their patients.
Signature
David Etlin
Medical Director Functional Restoration Program Toronto Western Hospital Toronto, Ont.
References
- 1.Tsang I. Rheumatology: 12. Pain in the neck. CMAJ 2001;164(8):1182-7. [PMC free article] [PubMed]
- 2.Wing P. Rheumatology: 13. Minimizing disability in patients with low-back pain. CMAJ 2001; 164 (10):1459-68. [PMC free article] [PubMed]
- 3.Sullivan T, editor. Injury and the new world of work. Vancouver: UBC Press; 2000.
- 4.Frank J, Sinclair S, Hogg-Johnson S, Shannon H, Bombardier C, Beaton D, et al. Preventing disability from work-related low-back pain: new evidence gives new hope — if we can just get all the players onside. CMAJ 1998;158(12):1625-31. [PMC free article] [PubMed]
- 5.Chronic pain initiative: report of the Chair of the Chronic Pain Panels. Toronto: Ontario Workplace Safety and Insurance Board; 2000. Available: www.wsib.on.ca./wsib/wsibsite.nsf/public/chronicpainreport (accessed 2001 June 27).