Low Back Pain: The Injured Worker’s Perspective  

Article 3

In clinical practice as a physical therapist, I quickly learned that there are many injuries and conditions that – following diagnosis - a patient learns about for the first time. A diagnosis of carpal tunnel syndrome, for example, requires an explanation of the relevant anatomy in the wrist and causal factors so the treatment plan and a home program can be understood. During the initial evaluation, a model of the body part or a colorful poster on the exam room wall can greatly aid this explanation.

This isn’t the case for low back injuries. If a patient hasn’t previously had a low back injury, a friend or family member has, and has passed along anecdotal accounts of the experience. Those stories, an internet search, comments from co-workers, or even comments from a healthcare provider, or a boss can shape an injured worker’s concept of low back injury and likely treatment.  

This series of articles asserts that achieving a successful outcome following low back injury depends on open dialogue and communication to surface biases, challenge assumptions, and address misconceptions or knowledge gaps. All parties involved – the injured worker, the provider(s), the payer, the employer, and potentially, the attorney - make decisions based on education and professional background, life experiences, and potentially individual bias, judgments, and assumptions. This third article in the series will explore the injured worker’s perspective.  

Age-Related Wear and Tear of the Spine 

At roughly the time of entry into the workforce as adults, the spine shows evidence of aging, a process of gradual deterioration that continues throughout life. Bone density of vertebrae in the spinal column decreases and discs between those vertebrae slowly lose water content, becoming thinner and less flexible. As the spine and core muscles age, a curved or forward-facing posture may result. These age-related spinal changes may go unnoticed for those who are active and working.  

Interpreting Imaging Results 

For those unaware of natural aging of the spine, age-related findings on an X-ray or MRI can come as a complete surprise. A friend of mine in her late forties participated in a research study as a control group member and underwent MRI imaging of her lumbar spine. She was shocked that her imaging findings included lumbar disc degeneration, as well as a mild discal bulge, even in the absence of pain or symptoms. Her first thought upon reading the results was that she had mistakenly been given someone else’s imaging report!

This sense of bewilderment may sound familiar for healthcare providers, claims adjusters, and payers in workers’ compensation familiar with low back injury. Challenging the assumption that the spine is unaffected by age-related changes is a vital component of patient education. Without this context, interpreting abnormal findings can be exceedingly difficult.  

There’s a straightforward connection between imaging results and the mechanism of injury for some body parts following a workplace injury. A carpal bone fracture reported on an x-ray seems logical after a fall onto an outstretched hand, for example. Imaging for the low back can be very different. Consider this injured worker’s interpretation of his imaging findings: 

According to my MRI, there’s tons of stuff wrong with my back. And yet you’re trying to tell me that none of it is the result of my workplace injury?! I want to see a spine surgeon. I want all this fixed!  

Incidental findings, which are unexpected abnormal findings unrelated to the reason the test was ordered, are increasingly common with the rise of advanced imaging techniques. When a workplace low back injury occurs, it can be difficult to separate degenerative spine conditions that are considered part of natural aging and not inherently compensable under workers’ compensation.

Work activities may accelerate but not cause abnormal imaging findings. Knowledge of imaging abnormalities can decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that may predispose an injured worker to chronicity.² Patient education on interpreting imaging results, in particular, incidental findings, addresses knowledge gaps and misperceptions. 

Catastrophizing Low Back Injury 

Low back injury is a condition plagued with anecdotal misinterpretations and misinformation, so it’s not surprising that an injured worker may interpret the condition as far more negative than it is. Amy Garrett, PT, DPT, a physical therapist at Nebraska Spine & Pain Center and recognized expert in workplace injuries of the spine, says many patients are concerned about further injury, including catastrophic injury such as paralysis.

Dr. Garrett has found that education and explanation of the medical facts and evidence redirect fear of the worst possible outcome. To learn more about a patient’s concerns, she’ll ask, “And you are worried what could happen if you go back to work or do some exercises?”

Dr. Garrett handles fear, anxiety, and catastrophizing by asking additional follow-up questions regarding daily activities, such as who in the household is responsible for cooking, cleaning, laundry, and grocery shopping. She will connect daily tasks such as lifting a gallon of milk to lifting 8-10 pounds, for example. She recommends taking the time to make comparisons to work tasks and break down daily tasks that may be overwhelming into smaller, manageable parts. This approach identifies strategies for solutions and creates a plan of action to allay fears and personalize a treatment plan.  

Healthcare Providers - Part of the Problem or Part of the Solution? 

It’s important that physicians, surgeons, physical therapists, and nurse case managers consider the power of their words. Dr. Garrett says patients have told her, "My doctor says I have the spine of an 80-year-old’ or ‘It’s bone on bone’ or ‘If I keep doing this job, I could end up in a wheelchair.’" Comments such as these can be unsettling since they don’t draw a connection between the patient’s symptoms and recommended treatment, for example, or identify job tasks that may be contributing to a patient’s condition.  

Emphasizing Patient Education  

Traditional medical management of low back pain has undergone a significant shift to current evidence-based guidelines. Conservative treatments such as exercise, physical therapy, and lifestyle modifications are recommended as part of early intervention with medications and more invasive procedures reserved for cases where these initial steps aren’t sufficient. Although these guidelines have been in practice for more than a decade, there’s a sizable gap between best practices and common beliefs.

Many patients expect pain medication, including opioids as first-line treatment, imaging, injections, and possibly surgery. Because of this lack of public awareness, the World Health Organization (WHO) released its first-ever guidelines on managing chronic low back pain in 2023 to reshape unhelpful beliefs. WHO Guidelines include patient education on interventions, both recommended and not recommended, and suggestions for activities to promote good physical health, such as aerobic activity, strengthening, and flexibility exercises. ¹  

Reshaping Ideas on Rest and Recovery 

Challenging the outdated belief that prolonged rest aids recovery after low back injury can be difficult. Dr. Garrett advises that providers get the patient moving again. Don’t assume they can lift or perform a particular task, though. Instead, help them gain the confidence they need to return to their life and their job.

The WHO Guidelines on low back pain state that delivery of care that is not evidence-based remains commonplace. Dr. Garrett is aware of this variation in care and the confusion it can create for injured workers. She recommends that passive modalities be avoided, especially after the first few weeks of injury.

"Get them moving.  Get them on their feet squatting, doing sit to stands and doing functional movements in a pain free range to start giving them the confidence they need to do more."

One of the most common questions injured workers ask Dr. Garrett is “How much should I push it?” Dr. Garrett finds that she delivers a lot of education regarding the spine and nerve involvement, safe limits and restrictions on "pushing into pain" with the spine versus a knee or shoulder injury, injuries where pain may be expected to re-gain range of motion of the injured body part.  

Summary  

An injured worker’s concept of low back injury can be shaped by anecdotal experiences, comments from others, and misinformation. By recognizing the influence of potential assumptions, knowledge gaps and judgments, a successful outcome can be achieved through open dialogue and communication. All stakeholders – the injured worker, the provider(s), the payer, the employer, and potentially, the attorney - can challenge assumptions, and address misconceptions or knowledge gaps. The next article in the series will explore the employer.

Watch for more on this topic!  

References 

1. World Health Organization. WHO guidelines on managing chronic low back pain. Published December 7, 2023. Accessed August 15, 2025. https://www.who.int/news/item/07-12-2023-who-releases-guidelines-on-chronic-low-back-pain 

2. Flynn TW, Smith B, Chou R. Appropriate use of diagnostic imaging in low back pain: a reminder that unnecessary imaging may do as much harm as good. J Orthop Sports Phys Ther. 2011;41(11):838-846. doi:10.2519/jospt.2011.3618 

Share This Article: