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Is there a basis for weight lifting limits after lumbar disc surgery and in the workplace?24 May at 17:43 from atlas
26 October 2017
All spinal surgeons are desirous of giving advice to both their patients as treating surgeon and to Insurers as an IME , in respect of the most appropriate post-lumbar discectomy advice to minimise recurrent herniation, progressive degeneration, adjacent level degeneration and spondylolisthesis.The important issue is to try to minimise,or eliminate the risk of recurrence which is important to the patient, the employer/insurer and the surgeon,with the most accurate advice possible. The surgeon is cognisant that advising 'no lift over 15 kg', may result in loss of employment,or employability for his ,or her patient. The employer may have no suitable role ,or be unable to continue pre-operative employment as the perceived risk based on this advice to be unmanageable.To complicate matters the surgeon does not want to expose his postoperative patient to unacceptable, or negligent advice.
The exact incidence of recurrent lumbar herniations is unknown in the absence of routine scheduled MRIs or such prospective studies to date.Recurrences are identified in most series of cases representing and coming to re-operation.Recurrent lumbar herniations occur in 5 to 11% of series.(Postacchini).Mattman 1971 %..Schramm 1978 %.Naylor 1974 %.
There remains a general continuing trend for patients, employers and insurers to enquire of 'the safe lifting capacity ' and this is accompanied by a weight in kilograms.State and Federal legislation has moved away from the ' lifting weight' paradigm as the main index of RTW to be assessed.This is because weight alone is inaccurate in predicting risk-so there are no longer 'safe weight lifting limits'.
In the post-operative situation, as in the unoperated on cohort this is now recognised as an inaccurate index translating to risk. There are many factors other than weight being lifted that may , or may not affect the spine, both operated and unoperated.Indeed, State and Federal legislation no longer refers to a 'safe-lifting weight'.As spinal surgeons we recognise that lifting 20 kg can be affected by many factors: age of patient, sex, height, distance from body, height, length of upper and lower limbs, size of load, grip factors, level of floor surface,lifting technique ,posture, frequency, duration of lift, need for twisting and side bending etc.Signing of on a 7.5 kg lift may actually be a hazardous lift when all factors are considered.
I will discuss the literature and texts on post lumbar disc surgery lifting advice, the history and recent loss of significance of NIOSH limits, current State and Federal safe-work considerations (which no longer refer to weight in Australia) and how to handle the need to advise.
SURVEY OF POST-LUMBAR SPINE SURGERY WEIGHT RELATED ADVICE / GUIDELINES / STUDIES.
(1).Carragee EJ, Han MY ,Jang B et al.Activity restrictions after posterior lumbar discectomy:a prospective study of 152 cases with no post-operative restrictions.Spine.1999;24:2346-51.
A prospective study of 152 patients was performed. Freed of healthcare professionals' imposed post-operative restrictions.patients returned to work more rapidly and in apparent safety.
(2). Magnusson ML,Pope MH, Wilder DG et al.Is there a rational basis for post-surgical lifting restrictions? Currrent understanding.Eur Spine J 1999;8:170-7.
The authors found 'no rational basis for lifting restrictions after lumbar spine surgery.'
(3). Text: Rehabilitation of the Spine: A Practitioner's Manual: Craig Liebenson.
a)The authors referred to Watkins ..no lift > coffee cup 2 weeks and no lift > 20 kg to 6 weeks.
b)They referred to Carragee noting no post-operative restrictions resulted in early RTW with no increased complications. Mean time from surgery to RTW 1.7 weeks and 25% RTW following day.
c) Cochrane: There is no evidence that patients need to have their activities restricted after first lumbar microdiscectomy surgery.
(4).Text:The Lumbar Spine: Harry N. Herkowitz.
a).Carragee EJ et al.The fear of recurrence, rein jury and instability results in several post-operative protocols to restrict activity post-opertaively that may not be necessary.
b).Magnusson ML et al.'no rational basis for lifting restrictions after lumbar spine surgery'.
c).Ostelo RWG et al. (see below). 'Intensive exercise programs at 4 - 6 weeks were more effective in improving functional status and faster return to work than mild exercise programs'.
(5),Ostelo RWG, de Vet HCW, Waddell G. Rehabilitation after lumbar disc surgery ( Cochrane Review). Issue 2.2002.
'Intensive exercise programs at 4 - 6 weeks were more effective in improving functional status and faster return to work than mild exercise programs'.
(6).Text : Lumbar Disc Herniation: Franco Postacchini: 1999: Springer-Verlag.
There are no definite time limits as to when to resume work after surgery for lumbar disc herniation.Numerous factors may influence postoperative sick-leave, besides the patient's ability to work.
a)Patients who do a sedentary job can generally return to work 3 to 6 weeks after surgery.Those who return earlier should work part-time in the first few weeks. prolonged sitting may cause back pain, in this event the patient should frequently get up and move around or do some exercises.On the other hand , patients whose jobs require prolonged standing should have the possibility of sitting frequently for a few minutes.
b). Patients who do moderately heavy work ( frequent lifting or carrying objects weighing 15 kg and / or occasional lifting of no more than 25 kg at a time) should not resume work before 6 to 8 weeks after the operation. During the first month, they should carry out a semi-sedentary job or at least not lift objects weighing more than 10-15 kg, driving a heavy vehicle is comparable to moderately heavy work ; during the first month back at work, patients should not drive more than 4 to 6 hours a day. If the hours driven are consecutive , the patient should get out of the vehicle and have a brief stroll or do some exercises.
c). Those who do heavy or extremely heavy work ( frequent lifting or carrying of objects sighing 25 kgs or more and / or occasional lifting of 50 kg or more at a time) should not return to work before 3 months after the operation ..and..also do a lighter work for a few weeks before returning to their usual activity.
d) Patients who do moderately heavy or heavy/extremely heavy work should attend a low back school and continue to regularly perform the exercises taught for at least 3 to 6 months after returning to work.
( Profs Franco Postacchini and Stefano Gumina refer to Wiesel SW, Feffer HL , Borentstein DG et al .Industrial Low Back pain: a comprehensive approach.2nd Edition.1989.in respect of the advices regarding moderate, heavy and extremely heavy lifting workers above on page 471 and 472).
e).Patients with persistent lumboradicular pain 1 to 3 months after the operation or low back pain of greater severity than normal, return to work should be delayed. It has been shown that return to work before 3 months in the presence of persistent lumboradicular symptoms, negatively affects the long-term results of surgery. In this respect however, many factors, such as the patient;s will to return to work and the cause of the persistent lumboradicular symptoms, may play a relevant role. Sick-leave of more than 4 months is generally unjustified in the absence of clear evidence of a pathologic condition responsible for an abnormal postoperative course and, thus, for persistent symptomatology (Page 472-3).
(7).Royal National Orthopaedic Hospital:NHS Trust: Reviewed 2014.
Restrictions after spine surgery: designed to allow the disc to heal...balanced against evidence supporting a return to early function and activity which reduces the risk of a poor outcome...an appropriate return to work should be planned for about 4 weeks and it should be phased/part time..if the job involves heavy manual work the aim would be to return by 3 months with a planned phased return if appropriate....avoid heavy lifting (> 10 kg) until 12 weeks post-operation or until the surgeon advises...
(8).Mater Private Hospital, Brisbane: Spinal Care following surgery.
(http://brochures.mater.org.au/Home/Brochures/Mater-Private-Hospital-Brisbane/Spinal-care-following-surgery.).(Last reviewed 29 May 2014).
You should not be lifting anything heavier than a couple of kilograms for the first four weeks or heavier than 10 kilograms for the first 3 months following surgery.At 12 weeks you can perform these tasks, including light resistive work. However, heavy lifting ( more than 20 kg for men and more than 10 kg for women) and any repetitive lifting(more than 10 kg for men and more than 5 kilograms for women) should be permanently avoided to reduce the risk of damage to the discs above and below the surgery site.These approximate limits will be dependent on your sage and physical capacity.
WEIGHT IS NO LONGER ASSESSED AS 'SAFE' OR 'HAZARDOUS' IN AUSTRALIAN & STATE LEGISLATION.
1.National Code of Practice for Manual Handling (NOHSC:200591990)).
Purpose is to provide practical advice in meeting the requirements of the National Standard for manual Handling for the identification.assessment and control of risks arising from manual handling activity in workplaces.
An employer shall take all workable steps to make sure:(a)..the plant,equipment...safe and without risk to health and safety when handled,(b) that the work practices carried out in the workplace involving manual handling are designed to be as far as workable, safe and without risk to health and safety, and (c) the working environment is designed..as far as workable, consistent with safe manual handling practices.
2.19.Weight is not used to prescribe absolute limits. However, particular attention should be given to Sections 4.21-4.26 and 5.19 - 5.43 ..which provide a general guide to weights which it is recommended that adults and juniors should not handle unaided.
4.21 The weight of any load which is manually handled shall be considered in relation to other key risk factors including, and in particular:(a)frequency and duration,(b)position of load relative to the body,(c)distance moved,(d) characteristics of the load.
4.23 For lifting,in seated work it is advisable not to lift loads in excess of 4.5 kg.(b) some evidence shows that the risk of back injury increases from 16 kg up to 55 kg..(c)more care is required for weights above 16 kg and up to 55 kg.,(d)generally no person should be required to lift,lower or carry loads above 55 kg, unless mechanical assistance or team lifting arrangements are provided to lower the risk of injury.
5.19 Modify object..lighter, smaller containers,less bulky,edges less sharp etc
5.20 Modify Workplace Layout etc to 5.26.
2. NIOSH and difficulties focussing on one 'critical' parameter (weight) in a complex situation.
NIOSH (National Institute for Occupational Safety)(Waters,Putz-Anderson,Garg and Fine,1993)used physical parameters to determine recommended Weight Limit(RWL) and the Lifting Index(LI).The form of the Asymmetry Multiplier was found to be in error as it was non-linear.ElfeituriFE et Taboun SM Int Jnl Occ Safety and Ergonomics(JOSE)2002,Vol 8,No.2, 243-258)demonstrated the limitations of the original and revised NIOSH lifting equation, particularly in assessing realistic industrial jobs.
3. Workplace Health and Safety Queensland(Safety Link)-Manual Tasks-2000)
Weight limit cannot be set because of the many factors other than weight involved.factors: weight, distance from centre of gravity,effect of posture, distance load has to be lifted,twisting, frequency,duration of lift,load placement clearance, load shape and composition,off-centre loads, grippability of load,workplace conditions, the weather,the individual's physical capacity, etc.
Employers MUST design work processes and equipment to eliminate or minimise risk, train workers,provide mechanical handling aids, modify the handling task,improve storage of loads, change location of loads, avoid double handling, use team handling, train and supervise workers...WEIGHT LIMITS CANNOT BE SET BECAUSE OF THE MANY FACTORS OTHER THAN WEIGHT INVOLVED...THE LEVEL OF LOADING ON THE WORKER'S SPINE IS THE VITAL FACTOR, BUT IT IS DIFFICULT TO MEASURE.
4. Victorian OHS Legislation.
There is not a mandated actual maximum weight an employee can manually lift...Victorian OHS legislation refers to HAZARDOUS MANUAL HANDLING, stating that employers need to identify tasks that involve hazardous manual handling and take actions to eliminate or reduce the risk identified.
SUMMARY : (1)There has been a shift away from emphasising weight of lift as the most significant, and guiding factor in assessing manual handling, including lifting injury workplace risk. The complexities and unworkability of NIOSH as a tool were impractical and further practical experience indicated that weight was ONLY one factor and it was not safe, or possible to determine safety , or hazard from weight alone. A particular weight can be both 'safe' and 'dangerous' in varying circumstances and different workers, conditions etc. Assessment of manual handling risk or hazard is the current standard -it is no longer numerical i.e a WEIGHT determined from the NIOSH calculator or medical texts and definitions of heavy , extremely heavy etc.
(2). After spinal surgery ensuring a safe return to the workplace is important for the patient, the employer, the insurer and the surgeon. There is no accepted 'best practice' uniform consensus opinion on whether there is a need for restrictions , and what they are and for how long they shield apply after lumbar spine discectomy surgery.Most spinal surgeons agree on a gradual or staged RTW if work is non-sedentary with manual handling and safe -lifting programs for workers performing more physically demanding work.Every patient and workplace is different and there does not appear to be a standard code of post-lumbar discectomy RTW guidelines.
(3). Regardless of the skill of the surgeon,technique utilised, post-operation actions (including manual handling delayed re-intiduction, back care programs, assessment of manual handling hazard risks/ modification / elimination), avoidance of smoking and obesity, warm ups pre-work ...there will always be a defined lumbar disc recurrent prolapse rate (5-11%)...this is a FACT.Degeneration ,age and loading due to the bipedal nature of humans cannot be eliminated. When a spinal surgeon baulks at advising , and tacitly or directly 'approving' a certain 'safe' weight lifting limit in kgs or 'capacity' to lift a certain weight in kgs after surgery-please refer to the complexities herein..or read NIOSH !
Patients and IMEs are advised to follow the advice of their treating medical practitioner / indemnity insurer at all times.The opinions stated herein are those of the author.
Dr Michael Coroneos is a senior Brisbane neurosurgeon with six surgical Fellowships and was honoured to be elevated to Master CIME status by the American Board of Independent Medical Examiners (by 3 examinations and training 2012 to 2017) in May 2017.
Qualifications and Memberships : MCIME FRACS FACS(USA) FRCS(Glasg) FRCS(IRE) FRCS(ENG) FRCS(EDIN)SN MB BS(1st Cl Honours, 1980, UQ) MNSA MNSQ MAPS MASE
Senior Clinical RACS OSCE Examiner/ Mortality Assessor RACS (QASM)/ Honorary Clinical Adjunct Assistant Professor and Examiner / Senior Neurosurgeon/ Master CIME/ Member RACS Academy Surgical Educators.