Workers' Compensation: A Risk Factor After Back Surgery?
The question of whether or not patients on Workers' Compensation have different results after treatment for back pain has challenged the health care profession for years now. And this study is no different. Here, the researchers compare Workers' Compensation to non-Workers' Compensation patients with back pain. Both groups were divided further by type of treatment: conservative (nonoperative) care or surgery. The results of treatment were compared at regular intervals from six weeks to two years.
The goal of a study like this is to see what effect Workers' Compensation status has on patient outcomes. Is one treatment better than another? Do Workers' Compensation patients have equal results to non-Workers' Comp patients when the same treatment is applied? Patients with a lumbar disc herniation treated at 13 U.S. Spine Centers were included in the study. This study was part of a larger on-going research project called Spine Patient Outcomes Research Trial or SPORT.
Low back pain and sciatica (leg pain) were the main symptoms interfering with work and daily life for the nearly 1,000 people in this study. The symptoms persisted for more than six weeks. Most (811) were not on Workers' Compensation. The minority (113) were Workers' Compensation patients. Only adults who were not already considered disabled and could return to work (including unemployed patients but not retired folks, homemakers, or students) were included in the study. Conservative or usual care consisted of active physical therapy along with a home exercise program, education and counseling, and medication (anti-inflammatories). Surgery was an open incision discectomy (disc removal).
Everyone was tested before treatment to form a baseline (starting point) of data. They filled out forms that gave a self-report of pain, function, and perceived disability. The same tests were repeated at each follow-up visit with an additional tool to measure satisfaction with treatment. For those familiar with the various questionnaires used to assess patients with back pain, the tools used included: Short Form-36, Oswestry Disability Index (ODI), and the Sciatica bothersome index. One other marker used to measure results included work status such as return to work (yes or no), usual work hours (fewer than before the injury?), loss of pay, and legal status.
Clinical findings such as any neurologic signs (change in sensation, change in reflexes, muscle weakness) and patient characteristics (smoker, other health problems, education level, income, age, sex, racial/ethnic background) were also recorded and analyzed. One final piece of information the researchers used to compare results equally from group to group and treatment to treatment was the duration of symptoms before treatment was started. Some people had suffered with painful symptoms much longer than others before treatment was begun.
By factoring all these variables into the statistical analysis, they could tell which ones were directly linked with results -- in other words, which patient factors affected the final outcome. That way if something was a more important factor than Workers' Compensation status, it would show up. As it turned out, everyone in the study got better with treatment -- that was true for both groups and both types of treatment.
A closer look at all the data also revealed that Workers' Comp patients who had surgery didn't have as good of results as nonWorkers' Comp patients who had surgery. And over time, the benefit the Workers' Comp patients showed early on deteriorated. And at the end of two years' time, surgery really didn't improve work or disability status compared with usual (conservative) care. This finding was true for both groups of patients (with and without Workers' Comp).
It's not entirely clear why Workers' Comp patients had worse outcomes after surgery. Despite analysis of the other factors, nothing stood out as a significant factor except Workers' Comp status -- and that was true for patients at all 13 treatment centers. It's possible that the Workers' Comp patients go into treatment with different expectations, ideas, and perceptions than nonWorkers' Comp patients. Some Workers' Comp patients may feel pushed to have surgery rather than wait for natural healing to occur in order to get back to work sooner. More study will be needed to investigate some of these ideas.
For now, we know that low back pain is a common problem interfering with working status in many adults across the United States. Previous studies have shown differences based on Workers' Compensation status. This study added data to support those findings. SPORT researchers will continue to look for the underlying reasons why this is so. The authors concluded that their results suggest a more complex relationship between work, Workers' Compensation, and treatment outcomes -- whether that treatment is usual care or surgical intervention. They hope to help patients, physicians, and employers find the best way to get these workers back on the job in the shortest time with the least invasive treatment.
Steven J. Atlas, MD, MPH, et al. The Impact of Workers' Compensation on Outcomes of Surgical and Nonoperative Therapy for Patients with a Lumbar Disc Herniation. In Spine. January 2010. Vol. 35. No. 1. Pp. 89-97.