Introduction: Emerging Trends in Secondary Prevention of Back Pain Disability

Despite advances in workplace safety and in the assessment and treatment of occupational injuries, the prevalence of pain-related disability and the cost of compensation due to pain-related injury remain alarmingly high. Increasingly, there have been calls for the development of interventions that will minimize the probability of disability following occupational injury. Pain-related disability arising from soft tissue injuries to the back or neck have been on the rise since the 1950s. The rise in low back pain disability has been attributed to workplace, social, and psychological factors, as well as policy and administrative factors. Approximately 80% of soft tissue injuries will follow a path of uncomplicated recovery in the first 3 months after injury. A small but significant percentage of persons will remain occupationally disabled at 6 months after injury, and many of these persons will become permanently disabled. More than 80% of available health and rehabilitation resources will be consumed by the 15% of persons who remain symptomatic and occupationally disabled at 6 months after injury. A number of different secondary prevention programs have been implemented over the past decade, aimed at curbing the rate of disability subsequent to back injury. Programs have taken many forms, including advice from primary care practitioners, information pamphlets, physical therapy, aggressive multidisciplinary treatment programs, and policies restricting access to financial compensation for pain-related disability. Reviews of the outcome literature have not provided convincing evidence for the efficacy of secondary prevention programs. It has been difficult to demonstrate that secondary prevention programs impact on rehabilitation outcome beyond what would be expected from the natural course of recovery from back injury. Despite the intuitive appeal of the concept of secondary prevention, the experiences of the last decade have given rise to serious doubt that cost-effective programs can be developed to minimize the probability of prolonged pain-related disability. Is it premature to abandon the quest for cost-effective secondary prevention programs for back pain disability? This is the question that prompted the development of this Special Series. A collection of articles is presented with the aim of highlighting the challenges that have been faced in developing effective secondary prevention programs. The articles also sketch directions for innovative pathways for solving the puzzle of pain-related disability. Five papers are included in this Special Series, each describing different programs or strategies that aim to minimize the pain-disability problem subsequent to occupational injury. The articles go beyond simple description of treatment outcome to address issues related to cost-efficacy, treatment accessibility, treatment adherence, program implementation, and program sustainability. What emerges from these papers is the view that effective secondary prevention will require attention to (1) screening for risk of long-term disability, (2) timely implementation of rehabilitation interventions, (3) mechanisms for