Health Maintenance Care in Work-Related Low Back Pain
and Its Association With Disability Recurrence
Manuel Cifuentes, MD, PhD,
Joanna Willetts, MS, and
Radoslaw Wasiak, PhD, MA, MSc
Center for Disability Research
Liberty Mutual Research Institute for Safety
University of Massachusetts Lowell
|This study is unique in that it was conducted by the Center for Disability Research at the Liberty Mutual Research Institute for Safety AND the University of Massachusetts Lowell, Hopkinton, Mass
Their objective was to compare the occurrences of repeated disability episodes between types of health care providers, who treat claimants with new episodes of work-related low back pain (LBP). They followed 894 patients over 1-year, using workers’ compensation claims data.
By controlling for demographics and severity, they determined the hazard ratio</i? (HR) for disability recurrence between 3 types of providers:
The results are quite interesting:
OBJECTIVES: To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work-related low back pain (LBP).
METHOD: A total of 894 cases followed 1 year using workers’ compensation claims data. Provider types were defined for the initial episode of disability and subsequent episode of health maintenance care.
RESULTS: Controlling for demographics and severity, the hazard ratio [HR] of disability recurrence for patients of physical therapists (HR = 2.0; 95% confidence interval [CI] = 1.0 to 3.9) or physicians (HR = 1.6; 95% CI = 0.9 to 6.2) was higher than that of chiropractor (referent, HR = 1.0), which was similar to that of the patients non-treated after return to work (HR = 1.2; 95% CI = 0.4 to 3.8).
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CONCLUSIONS: In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.
From the Full-Text Article:
Low back pain (LBP) continues to be one of the costliest work-related injuries in the United States in terms of disability and treatment costs. [1, 2] An additional, important component of the human and economic costs is the recurrence of LBP.  Recurrences of LBP are complex to study because of the difficulty in predicting recurrence and the varying definitions and measurements of recurrence. [4–9] So far, there has been little success in preventing recurrent LBP with few studies to investigate this topic. More evidence is needed to understand recurrent LBP and justify interventions to prevent recurrence.
Health maintenance care is a clinical intervention approach thought to prevent recurrent episodes of LBP. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition. Breen’s original definition of health maintenance care [10, 11] refers to “treatment after optimum recorded benefit was reached.” The definition of optimum is subject to interpretation, making it difficult to clearly distinguish curative treatment from health maintenance; it blends the public health concepts of secondary prevention (treatment and prevention of recurrences) with tertiary prevention (obtaining the best health condition while having an incurable disease).  Health maintenance care can include providing advice, information, counseling, and specific physical procedures. [10–12] Health maintenance care is predominantly and explicitly recommended by chiropractors, although some physical therapists also advocate health maintenance procedures to prevent recurrences.  Physicians do not use this terminology when assisting a patient that has reached an optimum level.
There have been few scientific studies to evaluate the effectiveness of health maintenance care. A 2008 review found only 13 eligible citations and did not arrive at any conclusion about its effectiveness, and the operational definitions of health maintenance care were vague at best.  None of these citations referred to work-related LBP.
In the occupational health field, sustained return-to-work is considered an important goal during injury recovery. Given the patient’s condition and context, going back out of work is considered an appropriate measurement of a recurrent condition because it reflects the non-sustainability of working and implies a failure of the return-to-work process. However, it is possible that different providers focus more on return to work (eg, chiropractors) than others (eg, physicians that could focus more on pain control). An association between specific type(s) of treatment or providers and significant recurrence of a condition (measured as recurrent work disability) could imply an important advancement in the treatment of work-related back injuries.
Work-related LBP is often treated by a combination of providers, including chiropractors, physical therapists, and physicians. Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP who are treated by chiropractors would have a lower risk of recurrent disability because that specific approach would be used. Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key concept to prevent recurrence. Unfortunately, there is no available data that could allow direct characterization of which procedures were specifically product of the health maintenance care approach. Therefore, the present study aims to study the association between provider type during the initial period of return to work and risk of recurrence of disability due to work-related LBP.