Elsevier

Health Policy

Volume 121, Issue 8, August 2017, Pages 903-912
Health Policy

Review
System influences on work disability due to low back pain: An international evidence synthesis

https://doi.org/10.1016/j.healthpol.2017.05.011Get rights and content

Highlights

  • Work disability due to low back pain has a global health impact.

  • Current policy and practice does not acknowledge system influences.

  • Thus, interventions aimed at tackling work disability due to low back pain are suboptimal.

  • Unhelpful factors within relevant systems are reviewed, with recommendations for addressing them and further research.

  • Findings are relevant for international policy across industrialised nations.

Abstract

Work disability due to low back pain is a significant global health concern. Current policy and practice aimed at tackling this problem is largely informed by the biopsychosocial model. Resultant interventions have demonstrated some small-scale success, but they have not created a widespread decrease in work disability. This may be explained by the under-representation of the less measurable aspects in the biopsychosocial evidence base; namely the influence of relevant systems. Thus, a ‘best-evidence’ synthesis was conducted to collate the evidence on how compensatory (worker’s compensation and disability benefits), healthcare and family systems (spouse/partner/close others) can act as obstacles to work participation for those with low back pain. Systematic searches of several scientific and grey literature sources were conducted, resulting in 1762 records. Following a systematic exclusion process, 57 articles were selected and the evidence was assessed using a system adapted from previous large-scale policy reviews conducted in this field. Results indicated how specific features of relevant systems could act as obstacles to individual efforts/interventions aimed at tackling work disability due to LBP. These findings reinforce the need for a ‘whole-systems’ approach, with all key players onside and have implications for the revision of current biopsychosocial-informed policy and practice.

Introduction

Work disability due to low back pain (LBP) causes more global disability than any other condition [1]. In the United States (US) indirect costs of LBP are estimated to be more than US $50 billion per year, in the United Kingdom (UK) US $11 billion and in the Netherlands almost US $5 billion [2]. This burden is accounted for by approximately 10 percent of individuals with LBP, but the multi-factorial nature of work disability makes it very difficult to identify and thus prevent [3], [4], [5]. Research over the last two decades aimed at tackling this issue has shown that personal and occupational psychosocial variables play a more important role than spinal pathology or physical job demands; work disability due to LBP is now widely accepted to be a biopsychosocial phenomenon [4], [6], [7], [8], [9], [10], [11], [12].

The biopsychosocial model was developed in recognition that biological, psychological and social factors, and the interactions between them, can influence the course and outcome of any illness [13]. The approach was first introduced by Engel in 1977 [14] who stressed that the subjective experience of illness must be taken into account. The model proposes a dynamic systems approach, rather than one of linear causality or a factor-analytical approach as represented by the medical model. It also represents a shift of focus away from disease only, highlighting the importance of the illness trajectory in presenting opportunities to reduce/prevent disability. Although the International Classification of Functioning, Disability and Health (ICF) [15] acknowledges both the medical and social perspectives, it applies largely to individuals with impairments [16]. However, illness has many of the characteristics of a complex system, whereby dynamic interactions produce new properties and effects. Thus, the biopsychosocial model is particularly salient for understanding work disability due to LBP, which is now widely accepted to be the result of a trajectory of interactions between the individual and their social context [17], [18].

This understanding is reflected in the latest policy and clinical guidance for the management of LBP, which promotes early self-management and a continuation, or early resumption of, normal activities including work [19], [20]. However, the biopsychosocial evidence is dominated by research focusing on individual risk factors, despite the conception of the biopsychosocial model as a ‘whole-systems’ approach with all dimensions being equally important for work disability due to LBP [21]. Thus, resultant interventions are largely aimed at tackling unhelpful beliefs and behaviours, and whilst they have demonstrated some important successes, these are small-scale and have not created a widespread decrease in LBP disability [22]. Such individualised approaches to managing health conditions have been critiqued by not adequately taking into account the power that wider, systemic influences exert on individual will [23]. Yet research examining the non-modifiable influences operating outside an individual’s perception and control, which cannot be adequately addressed by clinical and vocational rehabilitation interventions, is under-represented in the biopsychosocial evidence base [24,25].

This issue reflects the perennial philosophical debate around the relative roles of structure and agency as they influence health [26]. The agency argument posits that health is influenced by the individual’s ability to act on decisions that arise from a unique self [27]. The structuralist view defines health as a product of context, and examines contextual factors that may impinge on individual behaviour, for example advice given by healthcare professionals [28]. To date, the biopsychosocial evidence in relation to work disability due to LBP appears to largely reflect the agency perspective, and has led to individualised interventions that are suboptimal.

In order to try and redress this imbalance in the biopsychosocial evidence base, this study provides a first attempt at collating and appraising the existing literature examining how relevant systems can act as obstacles to work participation for individuals with LBP. These systems are: compensatory (worker’s compensation and disability benefits – covering interactions with the workplace system), healthcare and family (spouse/partner/’significant others’) systems. Findings will have implications for the revision of current biopsychosocial policy and practice aimed at tackling work disability due to LBP.

Section snippets

Method

A ‘best-evidence’ synthesis was conducted. This was deemed the most appropriate method acknowledging that literature on the chosen subject is under-represented in the empirical evidence, and would be rather disparate and thus unfit for a systematic review [29]. A best-evidence synthesis gathers a range of academic (background and primary research, quantitative and qualitative) and grey literature available on the selected topic [30], [31], and draws conclusions about the balance of evidence

Results

After removing duplicates, 1762 records were retrieved. Initial title and abstract screens were conducted by one of the authors, the results of which were then discussed and agreed upon by all authors in an iterative process. Of these, further abstract/summary screenings were then undertaken by two of the authors independently, and 57 articles were finally selected for data extraction (see Fig. 1).

Information from the included articles was summarised and examined [see attached Supplementary

Discussion

For almost two decades, a ‘whole-systems’ approach to tackling work disability due to LBP has been called for [60], [82]. This was reiterated more recently by The International Labour Organization (ILO) who strongly recommended that ‘enhanced social protection’ should be a key objective in the work disability research field [95]. Despite this, evidence examining the influence of wider influences has been lacking, i.e. the ‘social’ component of the biopsychosocial evidence base. The findings of

Conclusion

The findings of this study point to specific recommendations for the revision of biopsychosocial-informed policy and practice aimed at tackling work disability due to LBP:

  • integrating compensatory and health systems to ensure individuals have access to what’s needed, when it’s needed, in a way which is personalised to their circumstances and needs;

  • embedding work as a health outcome to stimulate all healthcare professionals to implement work-focused healthcare, and to promote the need for high

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflict of interests statement

The authors declare that they do not have any competing interests.

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