Impact of Back Pain in the Workplace

by: Kent S. Greenawalt*

[Editor’s Note: Reprinted with permission from Journal of Compensation and Benefits© Thomson Reuters. For more information visit: https://store.legal.thomsonreuters.com/law-products/Treatises/Journal-of-Compensation-and-Benefits/p/100000474]

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The prevalence of back pain in the workplace, the associated financial burdens of this condition, and the impact on a company’s employee benefit plans are prompting human resource professionals and other decision-makers to seek greater value options for safer, more cost-effective care when they re-design their benefits packages. It becomes evident that employers will want to explore treatment options for pain relief that cost-effectively close gaps in care, enhance quality of care, and improve patient satisfaction. While many benefits packages currently include coverage for expensive, risky, and unproven results from back surgery, injections, opioids, and visits to emergency departments, benefit plan decision-makers are becoming more responsive to patient needs by incentivizing the use of noninvasive approaches to address the issues associated with low back pain. As first-line treatment, these options will reduce the utilization of expensive health services, lower treatment costs, and enhance patient safety and satisfaction with care.

INTRODUCTION

As U.S. employers face grim projections¹ that the average costs they pay for their employees’ healthcare will increase 6.5% to more than $13,800 per employee in 2023, largely due to economic inflation pressures, and more than double the 3% increase they experienced from 2021 to 2022, companies will seek greater value options under budgetary constraints. In the re-design of their benefits packages, decision-makers are likely to consider the increased prevalence, cost burdens, and workplace issues associated with back pain.

It becomes evident that employers will want to explore treatment options for pain relief that cost-effectively close gaps in care, enhance quality of care, and improve patient satisfaction. While many benefits packages currently include coverage for expensive, risky and unproven results from back surgery, injections, opioids, and visits to emergency departments, benefit plan decision-makers are becoming more responsive to patient needs by incentivizing the use of noninvasive approaches to address the issues associated with low back pain (LBP). As first-line treatment, these options will reduce the utilization of expensive health services, lower treatment costs, and enhance patient safety and satisfaction with care.

BACKGROUND

Back pain is one of the most common medical problems² in the U.S. and can range from a dull, constant ache to a sudden, sharp pain. Back problems are among patients’ most frequent complaints3 to their doctors and too often is the reason people seek medical help⁴ or miss work. Nearly 65 million Americans report a recent episode of back pain, and data from the Health Policy Institute at George Washington University shows that approximately six million adults—8% of all adults—experience persistent or chronic back pain. Adults with back pain are more likely to use healthcare services than adults without back pain, and many of the indirect costs of the condition are related to missed days of work and disability payments.

The lower back—where most back pain occurs5— includes the five vertebrae (referred to as L1-L5) in the lumbar region, which supports much of the weight of the upper body. Research suggests6 that as many as 80% of adults will experience LBP at some point in their lives, especially since back pain becomes more frequent with advancing age. According to data from the National Health Interview Survey,7 the percentage of adults aged 18 and over with back pain differs by demographic characteristics:

• The percentage of adults with back pain increased with age, from 28.4% for those aged 18–29 and 35.2% for those aged 30–44 to 44.3% for those aged 45–64 and 45.6% for those aged 65 and over.
• Women (40.6%) were more likely to experience back pain than men (37.2%).
• Estimates of back pain differed among non-Hispanic white (42.7%), non-Hispanic black (35.8%), Hispanic (31.2%), and non-Hispanic Asian (24.5%) adults.
• Notably, the percentage of adults with back pain decreased as family income increased, from 44.8% in adults with income less than 100% of the federal poverty level (FPL) to 37.6% in adults with income 200% or more of FPL.

Common causes of lower back pain include overuse injuries (from doing the same form of exercise over and over again), muscle or ligament strains or sprains, trauma (from falling down, for example), degenerative discs, spinal stenosis, osteoarthritis,⁸ and osteoporosis. Another prime culprit: sedentary behavior. A 2019 study⁹ in the journal Applied Ergonomics found an association between static sitting behavior and chronic LBP among people who worked at a call center.

Sometimes, back pain can develop slowly because of age-related degenerative changes to the spine, with clinicians and researchers describing the types of back pain in the following ways:

• Acute back pain happens suddenly and usually lasts a few days to a few weeks.
• Subacute back pain can come on suddenly or over time and lasts four to 12 weeks.
• Chronic back pain may come on quickly or slowly and lasts longer than 12 weeks.

Back Pain in the Workplace

The impact of back pain on the workplace is measurable. LBP affects men and women,¹⁰ but men are at a greater risk of work-related back pain. Back pain is considered a type of musculoskeletal disorder (MSD)¹¹ associated with high costs to employers such as absenteeism, lost productivity, and increased healthcare, disability, and workers’ compensation costs. MSD cases are more severe than the average nonfatal injury or illness.

While most back pain is not medically serious, the experience of pain can be troublesome, and back pain can lead to occupational challenges and work disruption. The prevalence¹² of both acute episodes of back pain and primary chronic back pain (greater than six months) are common among working age adults, both males and females.

Back pain is, in fact, a widespread problem among working adults, with more than one in four working adults reporting current back pain. Some 83 million days of work are lost per year¹³ due to back pain, making it a leading cause of work-loss days as well as work limitations in certain every day and work-related activities. While physical job demands account for some back pain episodes, the incidents of back pain may be both work-related and non-work related. One area that should not be overlooked is psychosocial characteristics in the workplace,14 including workload, control and support, job happiness, and job appraisal, which have been shown to predict the progression of debilitating LBP. In addition to absenteeism, back pain is a contributing factor to on-the-job productivity and work resumption.

Occupations with High Risk for Back Pain

Certain types of physical job demands increase the risk for back pain onset, but back pain can be experienced across all industries and occupations. Work-related MSDs that result in days away from work most commonly involve the back alone.¹⁵ Physical job tasks associated with back pain onset¹⁶ include awkward postures, sudden task disruptions, fatigue, heavy lifting, outdoor work, hand movements, and frequent bending and twisting. The most common causes of back pain¹⁷ at work include:

• Force: Exerting too much force on the back—such as by lifting or moving heavy objects—can cause injury.
• Repetition: Repeating certain movements, especially those that involve twisting or rotating your spine, can injure your back.
• Inactivity: An inactive job or a desk job can contribute to back pain, especially for those with poor posture or who sit all day in a chair with inadequate back support.

Jobs that require employees to apply a lot of physical effort may involve significant exposure to ergonomic risk factors and pose an increased risk of injury. For example, the degree to which employees are under biomechanical stress is usually evident in facial expressions or grimaces, as forceful exertions take more out of a person than tasks that do not require much physical effort. Whether back pain leads to disabling levels of workplace dysfunction depends on individual, system-level, and workplace characteristics, not just on pain intensity.

The following table (Figure 1) shows several of the physical work activities and workplace conditions associated with physical aspects of back pain:

Surveys of manual material handling workers¹⁸ suggest a one-year back pain prevalence of 25% for back pain lasting more than seven days, 14% for back pain requiring medical attention, and 10% for back pain requiring time away from work. After an acute episode of back pain, a majority of individuals are able to return to normal function within several weeks, but in approximately 10% of cases, acute back pain can transition to a chronic problem lasting more than six months.¹⁹ After an initial episode of back pain, recurrent episodes of back pain are common,²⁰ with recurrence estimates as high as two-thirds within 12 months of recovery.

Occupations reporting the highest rates of back pain include nursing, transportation, construction, warehousing, and landscaping. LBP is common among healthcare professionals,²¹  with the prevalence of LBP among healthcare workers being greater than those working in heavy industries. In most cases, LBP is short-lived but when it becomes chronic, it can cause significant disability, suffering, and societal costs. Costs of LBP are both from direct care and loss of productivity. Nurses,²² in particular, experience a higher rate of back injury because they spend a lot of time on their feet and sometimes act quickly to prevent weakened patients from slipping. For example, nurses often work with patients who require bed or chair transfers.

Neck and LBP are also significant health problems in sedentary office workers.²³ Persons who work remotely are at increased risk for LBP because of poor ergonomics and extended time spent sitting, according to a study²⁴ that involved 45 individuals who worked at sedentary desk jobs during COVID-19.

Moreover, it appears that the pandemic has also led to more back problems since more people are working from home. A survey of 1,000 adults across the United Kingdom²⁵ aimed to see how the COVID-19 pandemic changed daily habits and found a rising number— two-thirds (63.7%)—of Brits aged 18 to 29 experienced back pain they did not have prior to the pandemic. Thirty-two percent of respondents felt the most aches in their lower back, which is often caused by bad posture.

The remote work environment meant people did not have the proper ergonomic setup for sitting at a computer for an eight-hour workday. Despite working from the comfort of their own homes, many were not even using a chair. More than one in five young adults admit they work from bed when they are remote—the most common place to work from home. According to the survey, one in six sit on the couch and about one in 100 do their work from the floor. In fact, a lot of remote workers do not have access to a proper workspace, the findings showed.

Economic Burden of Back Pain

According to the Georgetown University Health Policy Institute, back pain is the sixth most costly condition in the U.S., with healthcare costs and indirect costs due to back pain reaching over $12 billion per year and back problems representing a patients’ most frequent complaint to doctors. Many of the indirect costs of this chronic condition are related to missed days of work and disability payments, with some 83 million days of work lost per year due to back pain. Back pain may also affect other activities, including athletic performance and exercise.

Healthcare expenditures are high for adults with back pain, and on average, almost 2.5 times those for adults without back pain—$1,440 and $589, respectively. Expenditures for services are generally higher among adults with back pain, with the exception of emergency room visits.

Annual U.S. cost for treatment and lost wages due to back pain is estimated at $253 billion, reports The Bone and Joint Initiative USA.²⁶ Over the last 20 years, several sources report that the utilization of healthcare services for chronic LBP has increased ²⁷ significantly. Recent studies²⁸ document—over approximately a decade—a 629% increase in Medicare expenditures for epidural steroid injections, a 423% increase in expenditures for opioids for back pain, a 307% increase in the number of lumbar MRIs among Medicare beneficiaries, and a 220% increase in spinal fusion surgery rates.

INVASIVE CARE IS COSTLY, RISKY

Spinal surgery is typically recommended when nonsurgical treatments have failed to relieve back pain. Based on reliable data,²⁹ the target fair price for most types of spinal surgery is $14,250, whether the individual has health insurance. The average cost for spinal decompression surgery in the United States can be as high as $23,500, and vertebral augmentation surgery can cost $23,500 to $67,900 or more. Actual prices can vary greatly depending on the specific procedure and whether the surgery is performed in the hospital or an outpatient center. Pricing pressures are one reason why individuals and payers choose to avoid surgery and seek noninvasive options.

Furthermore, failed back surgery syndrome (FBSS)³⁰ is defined by the International Association for the Study of Pain as lumbar spinal pain of unknown origin either persisting despite surgical intervention or appearing after surgical intervention for spinal pain originally in the same topographical location. The pain may originate after surgery or the surgery may exacerbate or insufficiently ameliorate existing pain. Long-term complications of the surgery, either avoidable or inevitable, may also lead to the development of FBSS in some patients. Surgery may exacerbate existing symptoms or cause new symptoms³¹ by inducing spinal stenosis, spinal instability, epidural fibrosis or disruption of adjacent discs.

Epidural steroid injections (ESIs) and lumbar nerve root block/steroid injection are commonly performed interventional treatments for spine-related pain. An epidural steroid injection will not solve the cause of the pain but can provide relief to the area while the patient engages with collaborative or alternative treatments. A lumbar epidural steroid injection (lumbar ESI) is an injection of anti-inflammatory medicine—a steroid³² or corticosteroid³³— into the epidural space around the spinal nerves in the low back with a goal to manage chronic pain³⁴ caused by irritation and inflammation of the spinal nerve roots in the low back (the lumbar region of the spine) due to certain conditions or injuries. This type of chronic pain is called lumbar radiculopathy (radicular pain), which can radiate down from the low back to the hips, legs, and/or feet.

In recent years, several systematic reviews³⁵ have disclosed controversial results regarding the efficacy of ESIs, creating a lack of consensus in the medical community. Recently, neurological complications have been reported that created a controversy with regard to neural toxicity and other adverse events and side effects of ESIs.

According to some sources, most patients seeking ESI treatment should expect to spend around $4,000 at a minimum. The sessions themselves can become more costly depending on how many injection sites are on the body. Each ESI is billed as a separate cost. The average number of sessions needed to get the full effect of the injections ranges between two and three. ESI treatment is not a cure for the pain but to lessen it and ease recovery.

According to Johns Hopkins Medicine,³⁶ there are some side effects associated with an ESI:

• “Steroid flush” or flushing of the face and chest, with warmth and an increase in temperature for several days.
• Sleeping problems.
• Anxiety.
• Menstrual changes.
• Water retention.
• In rare instances, pain that increases for several days after the procedure.
• Serious complications that are rare but can include allergic reaction, bleeding, nerve damage, infection, or paralysis.

A spinal cord stimulator³⁷ (SCS) is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain. They are mostly used after non-surgical treatment options have failed to provide sufficient relief. Stimulators require two procedures to test and implant the device: the trial and the implantation. For uninsured patients, typical out-of-pocket costs for spinal cord stimulation are $15,000 to $50,000 or more.³⁸

According to a study funded by the Washington State Department of Labor and Industries, average total medical costs of implanting a SCS system range from $19,246 to $47,190 per patient. Another study published in the Journal of Neurosurgery finds the costs per patient to be $32,882 under Medicare and $57,896 under a commercial plan (Blue Cross Blue Shield), with annual maintenance per patient of $5,071 – $21,390, depending on whether complications are present. Those figures incorporate the cost of the hospital, doctor, and equipment. Spinal cord stimulators must also be maintained.

OPIOIDS: INEFFECTIVE AND ADDICTIVE

Chronic LBP is one of the most common reasons for which patients are treated with opioids. According to the Centers for Disease Control and Prevention (CDC), opioids continue to be prescribed for LBP, despite an overall lack of evidence³⁹ to support its efficacy. In one study, opioid prescribing was common among patients with back pain, and almost 20% received long-term opioids.⁴⁰

In the U.S., 84% of individuals have healthcare coverage through federal or employer-based programs,⁴¹ which play a critical role in implementing standards to promote high-quality, evidence-based care. In the context of the opioid epidemic, large payers represent an important opportunity to encourage pharmacologic and nonpharmacologic opioid alternatives for chronic pain conditions in which the data to support the initiation of opioids as first-line treatment remain unclear. Throughout the country, opioid prescription for LBP has increased, and according to studies published by the National Institutes of Health, opioids are now the most commonly prescribed drug class,⁴² with more than half of regular opioid users reporting back pain. However, researchers report that opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care.

For chronic back pain, systematic reviews find scant evidence of efficacy. Insurance data⁴³ show that more than half of patients who continue to take opioids for at least three months are still taking them years later. Complications of opioid use include addiction and overdose-related mortality, which have risen in parallel with prescription rates. Common short-term side effects are constipation, nausea, sedation,and increased risk of falls and fractures. Longer-term side effects may include depression and sexual dysfunction.

For chronic pain, long-term opioid therapy is associated with poorer patient-reported pain, function, and quality-of-life outcomes,⁴⁴ and may be less effective among individuals with mood disorders, centralized pain syndromes, neuropathic pain, and psychiatric disorders. Studies also report that opioid therapy is also associated with numerous dose-related adverse effects,⁴⁵ such as respiratory depression and overdose, as well as dependence, tolerance, worsened pain, depression, constipation, and confusion. Approximately 20% of individuals receiving long-term opioid therapy develop an opioid use disorder.⁴⁶

In response to this national opioid crisis, the CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain⁴⁷ to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than three months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care. A note about over-the-counter pain medications to help control chronic back pain: most come with unwanted side effects and are not intended for prolonged use:

• Acetaminophen,⁴⁸ often prescribed as a first-line treatment, works by stopping the pain process but does not reduce inflammation⁴⁹ in the body. It tends to be gentler on the stomach than other medications, and while it can be helpful in relieving toothaches,⁵⁰ headaches, and pain after surgery, there is not a lot of evidence to indicate it works as well for back pain. It does carry risks: it can damage the liver⁵¹ if it is taken in high doses.
• Nonsteroidal anti-inflammatory drugs ⁵² (NSAIDs) are alternatives to acetaminophen that can be purchased without a prescription. But NSAIDs⁵³ can cause digestive problems like nausea⁵⁴ and diarrhea,⁵⁵ as well as heartburn⁵⁶ and stomach pain.⁵⁷ Rarely, they can have serious side effects like internal bleeding⁵⁸ and ulcers. They may also cause heart⁵⁹ problems and kidney⁶⁰ damage.

NONINVASIVE CARE: BETTER, SAFER, COST-EFFECTIVE OPTIONS

Given the prevalence of chronic LBP in the U.S., and with data showing that surgery and interventional⁶¹ procedures are options in only a minority of patients, it will be incumbent upon benefits professionals to identify effective, noninvasive, nonopioid alternatives for addressing chronic LBP and to include coverage for this level of care in benefits packages.

The opioid epidemic has led many respected health groups to reconsider the value of a conservative approach to LBP (the most common condition for which opioids are prescribed). Most notably, the American College of Physicians (ACP), the largest medical-specialty society in the world, updated its LBP treatment guideline in 2017 to support a conservative approach to care.

Published in the Annals of Internal Medicine and based on a review of randomized controlled trials and observational studies, the ACP guideline cites heat therapy, massage, acupuncture, and spinal manipulation as noninvasive, non-drug options for LBP treatment. Most spinal manipulations are done by doctors of chiropractic (DCs),⁶² although other licensed professionals including osteopathic physicians and physical therapists also use this technique. The ACP guideline further states that only when such treatments provide little or no relief should patients move on to medicines such as ibuprofen or muscle relaxants, which research indicates have limited pain-relief effects. According to ACP, prescription opioids should be a last resort for those suffering from LBP, as the risk of addiction, overdose, and possible death may outweigh the benefits.

Chiropractic care⁶³ includes spinal manipulation (chiropractic adjustment), exercise, advice, and self-care recommendations, helping to relieve pain and improve function in people with LBP. In one study,⁶⁴ the use of spinal manipulative therapy in the management of acute (less than or equal to weeks) LBP was associated with statistically significant benefits in both pain and function.

One of the most compelling studies to document the effectiveness of chiropractic care⁶⁵ for treating LBP was published by Harvard Medical School/JAMA Network Open. Researchers enrolled 750 active-duty military personnel who complained of back pain. Half were randomly assigned to receive usual care (including medications, self-care, and physical therapy) while the other half received usual care plus up to 12 chiropractic treatments. After six weeks of treatment, those assigned to receive chiropractic care reported less pain intensity, experienced less disability and more improvement in function, reported higher satisfaction with their treatment, and needed less pain medication

Additional documentation of chiropractic care is Duke’s Spine Health program,⁶⁶ which offers chiropractic care and other conservative treatments for back pain as part of its whole-person approach to helping people feel better faster. The Health Policy Institute at George Washington University states, “People who see chiropractors are more satisfied with their care.” They say that while people with back pain are more likely to go to a medical doctor than to a DC for relief, back pain patients who see DCs report that they are more satisfied with their care than those who see medical doctors. Patients who see DCs are more likely to say that their provider explained their treatment and provided advice on self-care.

Physical therapy (PT)⁶⁷ is also shown to have better outcomes than medical treatment or no treatment at all. Researchers cite the cost-benefits of an early treatment of acute LBP with PT with outcomes that are superior to no-treatment or medical intervention alone at one-year follow-up. A similar study found that at one-year follow-up, PT, compared with the usual primary care, is a cost-effective treatment for patients with acute and nonspecific LBP.⁶⁸

Also, it is shown that both PT and DCs⁶⁹ reduce the utilization of specific types of care (for example, diagnostic imaging procedures, magnetic resonance imaging (MRI), use of injection procedures, use of fluoroscopically-guided procedures, and prescription medication).

A new area of noninvasive care are Digital Therapeutics (DTx)⁷⁰ which are often used in combination with other current therapies, used as a sole intervention, or as an alternative to drug therapy. DTx delivers evidence-based therapeutic interventions for back pain via software, like mobile health and wellness apps, that replace or complement the existing treatment of a disease. These therapies diverge from the broader digital health market since they must be approved by regulatory bodies and display proof-of-concept.

Addressing Foot Dysfunction

In medium-and high-income countries, considerable efforts have been made to prevent the onset or exacerbation of back pain in the workplace. These efforts include reducing high physical demands and awkward postures, training workers in safer lifting and materials handling practices, and re-engineering workstations and assembly lines.

However, people do not always think to assess the foot as a contributing factor⁷¹ for back pain, although there is growing evidence among healthcare providers who treat⁷² spine problems that back pain does not operate alone. A key step in successfully addressing back pain is to evaluate and treat dysfunction of the feet which may be the root of many spine problems and associated pain. As many as 77% of people⁷³ overpronate when walking or running and just about everyone has some pronation challenge.

In short, the feet are the foundation of the body and the Kinetic Chain⁷⁴ responsible for optimal function of the knees, hips, and back. There is also an anatomy link for lower back pain. According to John Hopkins Medicine,⁷⁵ the lower back, or the five lumbar vertebrae, bear the brunt of the bending and lifting load rather than the thoracic and the cervical spine. This is where the spine connects to the pelvis, bearing the total weight of the upper body. It is a pivot point that is prone to undue stress from repetitive movement.

According to a study published in the Archives of Physical Medicine and Rehabilitation,⁷⁶ researchers demonstrated the efficacy of flexible custom orthotics with and without chiropractic treatment for LBP compared to no treatment. The randomized study concluded that among the three control groups, the groups that received flexible custom orthotics realized significantly better lower back performance in pain and motion. When chiropractic care was introduced in addition to orthotic care, there was a significant improvement gain in patient motion.

DCs increasingly recognize that the first step in treating back pain could be the use of custom flexible orthotics that are proven to work. The ideal product should address the three components of gait which divide each step into the heel strike (shock absorption), mid-stance (stabilization) and toe-off (propulsion) to manage the three arches in each foot. These three bony arches form an extremely strong, supportive planter vault⁷⁷ that distributes the weight of the entire body, keeps the body balanced, safely absorbs heel-strike shock, adapts to walking and running stresses, and propels the body forward. Over time, one or more arches can weaken due to activities of daily living or work. It is a natural process but can also be exacerbated by injuries, leg length inequality, overuse, postural instability, pregnancy, weakened ligaments and tendons, and other factors.

LOOKING AHEAD: APPROPRIATE BENEFITS PACKAGES TO SUCCESSFULLY TACKLE BACK PAIN

Compensation and benefits professionals, including Human Resource executives and other healthcare decision-makers, are discovering the importance of introducing benefits packages that include coverage for noninvasive treatment options that effectively address both the physical and psychological sides of chronic back pain. Amid new pressures to manage the escalating costs of healthcare, noninvasive care advances the goal of reducing symptoms and improving well-being. These approaches are cost-effective, yield positive outcomes, and increased patient satisfaction levels.

At the minimum, benefits packages should include appropriate coverage for:

• Incentivized Alternative Treatments: Chiropractic care, physical therapy, acupuncture, and massage can make a significant difference for chronic back pain. These professionals, who are actively participating in greater numbers in onsite or near corporate clinics, are likely to prescribe custom flexible orthotics which effectively address chronic back pain.
• Lifestyle Modification Programs: Diet, exercise, and smoking cessation programs help to minimize the impact of these activities that may accentuate pain and delay healing.
• Ergonomic Modifications: Training and education programs help to avoid and prevent back pain and injuries at work. This includes techniques for improving posture, lifting properly, modification of repetitive tasks, improving the work environment, and addressing situations that might aggravate the back.

Noninvasive care for back pain is clearly the pathway for benefits professionals to bring greater value to their employees. As first-line options that are available to the workforce and appropriately incentivized, this level of care will ensure measurable results at lower costs.

NOTES:

¹Healthcare Finance News, U.S. employer healthcare costs projected to increase 6.5% in 2023, August 22, 2022, available at https://www.healthc arefinancenews.com/news/us-employ er-healthcare-costs-projected-increas e-65-2023#:˜:text=Average%20costs%20for%20U.S.%20employers%20that%20pay%20for,budgets%20that%20employers%20experienced%20fr om%202021%20to%202022 (accessed October 14, 2022).

²National Institute of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases; Back Pain, available at https://www.niams.n ih.gov/health-topics/back-pain (accessed October 14, 2022).

³Georgetown University, Health Policy Institute, Chronic Back Pain, available at https://hpi.georgetown.ed u/backpain/ (accessed October 14, 2022).

⁴Mayo Clinic, Back Pain, available at https://www.mayoclinic.org/dis eases-conditions/back-pain/symptom s-causes/syc-20369906 (accessed October 14, 2022).

⁵National Institute of Health, National Institute of Neurological Disorders and Stroke, Low Back Bain Fact Sheet, available at https://www.ninds. nih.gov/low-back-pain-fact-sheet (accessed October 14, 2022).

⁶Fatoye, Gebrye, Odeyemi, Real-world incidence and prevalence of low back pain using routinely collected data, Rheumatology International. 2019;39(4):619–626,  doi:10.1007/s00296-019-04273-0 (accessed October 14, 2022).

⁷Lucas, Connor, and Bose, Back, Lower Limb, and Upper Limb Pain Among U.S. Adults, 2019; NCHS Data Brief No. 415, July 2021, available at https://www.cdc.gov/nchs/products/da tabriefs/db415.htm (accessed October 14, 2022).

⁸AARP, Why Your Joins Ache After 50-and What You Can Do About It, available at https://www.aarp.org/health/conditions-treatments/info-2021/joi nt-care-after-50.htm (accessed October 14, 2022).

⁹Bontrup, Taylor, Fliesser, et al., Low back pain and its relationship with sitting behaviour among sedentary office workers, Appl Ergon, 2019;81:102894,  doi:10.1016/pergo.2019.102894 (accessed October 14, 2022).

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¹²International Association for the Study of Pain, Back Pain in the Workplace, available at https://www.iasp-p ain.org/resources/fact-sheets/back-pa in-in-the-workplace/ (accessed October 14, 2022).

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¹⁵Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily, Back injuries prominent in work-related musculoskeletal disorder cases in 2016, available at https://ww w.bls.gov/opub/ted/2018/back-injurie s-prominent-in-work-related-musculos keletal-disorder-cases-in-2016.htm (accessed October 14, 2022).

¹⁶Iowa State University, Environmental Health and Safety, Risk Factors, available at https://www.ehs.iastate.edu/services/occupational/ergono mics/risk-factors (accessed October 14, 2022).

¹⁷Mayo Clinic, Back pain at work: Preventing pain and injury, June 3, 2021, available at https://www.mayocl inic.org/healthy-lifestyle/adult-health/i n-depth/back-pain/art-20044526 (accessed October 14, 2022).

¹⁸ Ferguson, Merryweather, Thiese, et al., Prevalence of low back pain, seeking medical care, and lost time due to low back pain among manual material handling workers in the United States, BMC Musculoskelet Disord, 2019 May 22;20(1):243. Doi, 10.1186/s12891-019-2594-0.

¹⁹Hayden, Dunn, van der Windt, Shaw,. What is the prognosis of back pain?, Best Pract Res Clin Rheumatol, 2010;24(2):167–179, doi:10.1016/erh.2009.12.005 (accessed October 14, 2022).

²⁰da Silva, Mills, Brown, et al., Recurrence of low back pain is common: a prospective inception cohort study, J Physiother., 2019;65(3):159–165,  doi:10.1016/j.jphys.2019.04.010 (accessed October 14, 2022).

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*KENT S. GREENAWALT is the Chairman and CEO of Foot Levelers, the world’s leading provider of custom-made orthotics. His passion for wellness, innovation, and operational excellence continue to position the company as a market leader in an increasingly competitive market driven by consumers who seek additional options for conservative care. As an innovator, philanthropist, and businessman, Mr. Greenawalt has developed and patented many healthcare products to achieve better patient outcomes and offers ongoing support to numerous colleges for healthcare research and organizations both personally and through Foot Levelers. He is a committed supporter of healthcare education and advancement, as evidenced by the numerous grants, research studies, donations, education chairs, and scholarships awarded. Serving as a board member on and advisor to numerous national and state healthcare organizations, Mr. Greenawalt continues to seek opportunities for mutually beneficial partnerships that move the needle for optimal care outcomes, resulting in advancements that elevate the patient experience.

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