Return to Work Following Low Back Pain

Tanti Ajoe Kesoema

Department of Physical Medicine and Rehabilitation, Dr. Kariadi General Hospital,

Faculty of Medicine, University of Diponegoro, Semarang, Indonesia

Tantiajoe68@gmail.com

Keywords: Return to Work, Low Back Pain, Work Hardening

Abstract: Low back pain (LBP) is a highly prevalent cause of disability and one of the most expensive health

conditions. Along with personal suffering, LBP can result in decreased productivity and absenteeism. It is

also one of the leading causes of lost work time. Rather than viewing work resumption as a discrete event,

returning to work after an episode of work disability can be viewed as process that encompasses a series of

events, transitions, and phases, and includes interactions with other individuals and the environment. The

return to work (RTW) process is conceived of as the process workers go through to reach, or attempt to

reach, their RTW goal (typically a return to their pre-disability work participation). The process is thought

of as beginning at the onset of work disability and concluding when a satisfactory long-term outcome has

been achieved. A successful RTW coordination seems more based on ergonomics job accommodation,

communication, and conflict resolution rather than on medical or purely biomechanical knowledge. It is

very substantial for Rehabilitation Medicine to pay attention to this need to achieve the goal of LBP clients

to RTW successfully.

1 INTRODUCTION

In industrialized countries, a musculoskeletal

disorder of the back or low back pain is among the

leading causes of occupational injury and disability.

Even though in most cases patients make a full

recovery from an episode of low back pain (60-70 %

recover within 6 weeks, 70-90 % within 12 weeks)

this still adds up to a large amount of lost time from

work. Besides, the recurrence rate for low back

disorders is also very high. In one year, the

recurrence rate is between 20% - 44% and over a

lifetime recurrence of up to 85% is reported. It is

important to remember that once injured, the back

becomes more susceptible and re-injury is likely to

develop if there are risk factors in the workplace that

are not corrected.

Low back disorders include spinal disc problems

such as hernias and spondylolisthesis, muscle and

soft tissue injuries. In addition to the normal

degenerative aging process, epidemiological studies

reveal that poor ergonomic factors in the workplace

contribute to low back disorders in a healthy back or

accelerate existing changes in an already damaged

back. Poor ergonomic work factors increase the load

or strain on the back. This may arise from many

situations, for example, lifting, twisting, bending,

awkward movements, stretching, and static postures.

Tasks include physical work, manual handling and

vehicle driving (where whole-body vibration is

known to be another contributing factor).

Many reviews have been published of studies

concerning the risk factors of low back disorders,

including a multitude of physical, psychosocial

and/or personal risk factors. The evidence to link

psychosocial factors with low back disorders is

growing, especially where they occur at the same

time as the physical factors. The incidence of low

back disorders has also been strongly associated

with low job content and poor work organization.

Some work factors increase the risk of low back

disorder, one stated is physical aspects of work, such

as heavy physical work, lifting and handling of loads,

awkward posture (bending, twisting, static postures)

and whole-body vibration. While the other factor is

psychosocial work-related factors that relate to low

social support and low job satisfaction. One more

factor is work organization factors which include

poor work organization and low job content.

Workers should pay attention to these risk

factors when making an assessment and selecting

prevention measures. They include the

Kesoema, T.

Return to Work Following Low Back Pain.

DOI: 10.5220/0009062700700075

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 70-75

ISBN: 978-989-758-409-1

characteristics of the load (for example: is it heavy

or difficult to hold), physical effort required (for

example: strenuous; twisting; body in an unstable

position), characteristics of the working environment

(for example: not sufficient room or other

constraints on the posture of worker such as working

height too high or low; uneven or slippery flooring),

requirements of the activity (for example: prolonged

activity or effort; insufficient rest periods; excessive

distances to move loads; imposed work rate),

individual factors (for example: clothing etc.

restricting movement; inadequate knowledge or

training.

2 DISCUSSION

2.1 The Clinical Examination Of

Workers With LBP Complaints

A primary goal of the initial evaluation is to

distinguish low back pain/strain, which is generally

self-limited and is not associated with neurological

dysfunction, from the disorders of the low back

which are associated with neurological signs and

symptoms. The interview should obtain complete

occupational and medical history. Special emphasis

should be placed on the characteristic of the pain,

previous response to treatment if any. Work

modifications also should be explored, subjects may

be asked to fill in a standardized questionnaire for

screening.

The assessment should include an investigation

of the signs and symptoms of spinal abnormalities

and movement dysfunctions, especially of the lower

back, utilizing standardized approaches and tests.

When a series of positive so-called "Waddell signs"

should prompt the examiner to investigate

psychological problems or psychosomatic disorder.

2.2 RTW Prognosis

Many studies results indicated that it is important to

recognize patients who may be at risk of long-term

disability and failure to RTW. Definitions of long-

term disability and failure to RTW are important

from this point of view. Psychological and

occupational factors have a direct impact on RTW.

Female gender, lower educational level, longer

hospitalization period, greater BMI, biological age

exceeding 40 years, employment in manual labor,

lack of encouragement by the physician to RTW,

being in pain at the time of phone interview,

negative expectations about the outcome of surgery

preoperatively, and low work satisfaction were

associated with higher frequency of delayed RTW

and failed RTW. Appropriate strategies and

teamwork involving the patient, surgeon,

rehabilitation therapist, occupational medicine

specialist, and an employer could enhance RTW.

However, further investigations are required in this

respect.

To get a more detail acknowledgment of the

work-risk factor, a scheme was developed using a

different color of flags.

Figure 1: Synthesis of red, yellow, blue and black flags for

low back pain workers.

The purely biomedical model is insufficient to

explain the complexity of persistent LBP. Thus,

some so-called ‘‘psychosocial'' factors seem to be

frequently associated with LBP progressing to

chronicity. Furthermore, individual, occupational

and organizational factors influence the risk of

progressing towards long-term incapacity and never

returning to work. It is also recommended to

evaluate prognostic factors, i.e. psychological and

behavioral factors (‘yellow flags') that could

influence the progression to chronicity as well as

socio-economic and occupational factors (‘blue' and

‘black' flags), which could impact long-term work

incapacity and delay the RTW (Fig. 1). This

assessment may require several consultations or

interviews in complex cases and must be coupled

with a thorough search for clinical symptoms of

LBP severity (‘red flags') regardless of the LBP

stage: acute, subacute or chronic.

In Netherland, a systematic review was set out to

help find pieces of information about RTW

prediction. The goal was to answer this question:

What factors affect the time until RTW among

workers who are at the beginning of sick leave

related to low-back pain? A review team included 4

researchers from the Institute for Work & Health

Return to Work Following Low Back Pain

(IWH) and a fifth from a university in The

Netherlands. The researchers involved in the recent

review looked for articles related to prognosis, back

pain and return to work in 3 databases, published up

to April 2011. The initial search yielded 4,449

research papers. In the end, 30 papers from 25

different studies were considered relevant to the

systematic review question. The quality of each of

these studies was then assessed using a rating system.

Five studies were rated as high quality, 13 as

moderate quality and seven as lower quality.

The main findings were there was strong

evidence showing that the following

factors influence RTW among those with acute low-

back pain (as the synthesis model scheme above):

 Workers' recovery expectations/beliefs (i.e.

their predictions about how likely it is they will

return to work and/or how long it will be

before they can return);



Workers’ interactions with health-care

providers (i.e. type of health-care provider seen

and nature of care received);

 Workers’ self-reported pain and functional

limitations;



Presence of radiating pain (an indication of the

severity of the injury); and

 Work-related factors, including physical

demands of the job, job satisfaction and the

offer of modified work.

The conclusions revealed workers’ recovery

expectations are the strongest predictor of return to

work, being supported by the most high-quality

studies. That is, those who expect to recover and

return to work more quickly, will do as expected.

Therefore, a simple question asking about recovery

expectations during the screening or assessment of

workers in the early stages of acute low-back pain

could help identify those at high risk of long work

absences and, in need of extra attention to help them

recover and return to work more quickly.

The next factor supported by strong evidence is

the nature of treatment care workers receive for their

acute low-back pain. In other words, the type of

health-care provider (and, thus, the type of care

provided) matters. For example, some studies show

that seeking care from a chiropractor result in a

shorter time on disability.

There is strong evidence to show workers’

reports about their pain intensity and functional

limitations are predictive of return to work: the

greater the self-reported pain and physical

limitations, the slower the return to work. Since both

can be easily measured in several ways with well-

validated questionnaires, they should be included in

assessments to determine those at high risk of long-

duration absences.

There is strong evidence to show that the

presence of radiating pain is associated with longer

periods off from work. However, radiating pain—

often used as a measure of injury severity—is

usually considered to be a "red flag" during clinical

assessments, an indication of potential neurological

problems that warrant further medical investigation.

For that reason, some people view this more as a

screening factor for more specific, less benign low-

back pain.

A few work-related factors are supported by

strong evidence as being predictive of return to

work. Physical job demands, as determined by

occupation, is one of them. That is, workers with

acute low-back pain who work in more physically

demanding jobs, such as construction or

manufacturing, are slower to return to work.

Job satisfaction is another work-related factor

shown to be predictive of RTW; the higher the

satisfaction, the more likely the return. Although job

satisfaction is probably related to any number of

factors at work, a simple question asking about job

satisfaction can be used at the very start of a work

disability process to identify those at high risk and in

need of extra attention.

The offeror availability of modified duties or

workplace accommodations is another work factor

associated with improved RTW outcomes.

Interestingly, it seems the offer of modified work,

not its actual implementation, predicts the likelihood

of a return to work.

The evidence did not point to depression as a

factor affecting RTW following acute low-back pain.

Neither did it point to pain catastrophizing. It could

be that both are not predictive of return to work until

back pain becomes chronic (long-term).

Finally, opioid use for pain management has been a

factor of great interest recently. However, it had not

yet been studied enough to show up as a predictive

factor in systematic reviews.

2.3 Functional Evaluation

Patients' perception of their incapacity is closely

related to the barriers involved in resuming activities,

especially RTW. Absence or low progression of the

patient's incapacity perception might mean that

obstacles to resuming activities and RTWdo exist

and need to be identified to be dealt with. Therefore,

it is recommended to evaluate early on and

repeatedly: pain, functional incapacity, and their

impact, as well as the main factors of work-related

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

long-term incapacity. Evaluating the functional pain

status of LBP patients enables, not only to quantify

the physical, social and occupational consequences

of LBP but also helps appreciate treatment

effectiveness. The impact of non-specific LBP can

be identified via pain self-evaluation and perceived

functional incapacity questionnaires but also using

functional capacities assessment tests (Table 1). Of

note, these parameters are related to each other in a

subtle manner and are influenced by multiple factors

and only a complete evaluation of the different pain

components can lead to a global vision of the pain

itself. Therefore, it is recommended to use the VAS

(Visual Analog Scale) (Table 1). It is also important

to periodically assess the workers' progress, give

them information back and above all support and

encourage them.

There is great variability in the objectives and

content of questionnaires evaluating the functional

impact and quality of life alterations related to LBP,

but only some are acceptable and validated: the

Roland-Morris questionnaire, the Oswestry and

Dallas questionnaires, the Quebec scale and SF-36

quality of life questionnaire (Table 1). Finally, the

evaluation of functional capacities validated by

physical tests can help write appropriate advice in

regards to the right time when patients may resume

work and/or which advice should be shared with

them. This functional capacity assessment should be

conducted each time a significant decrease in

activity or absenteeism can be suspected during the

progression of LBP. Several specific tools have been

developed but only a limited number of them have

been scientifically studied to document their

metrological properties, which vary according to

each tool (Blankenship System, ERGOS Work

Simulator, Ergo-Kit, Isernhagen Work System).

Table 1: Recommended tools for the assessment of low

back pain-related functional incapacity.

Assessed

parameters

Recommended tools

Pain

Visual Analog Scale (VAS)

Occupational

factors of

prolonged

incapacity

O¨rebro Musculoskeletal

Pain Screening Questionnaire

(O¨ MPQ)

Functional

incapacity

Roland-Morris Disability

Questionnaire and Dallas

Pain Questionnaire

Low back pain

worker’s beliefs

Work subscale of the Fear-

Avoidance Beliefs

Questionnaire

2.4 Coordination Of Intervention

Multidisciplinary Biopsychosocial Rehabilitation

(MBR) was defined as an intervention that involves

a physical component (for example an exercise

program) and at least one other element from the

biopsychosocial model, that is psychological or

social and occupational. The intervention program

had to have been delivered by clinicians from

different disciplines, which is a minimum of two

healthcare professionals from different professional

backgrounds who had to be involved in the

intervention delivery. The different components of

the intervention had to be offered as an integrated

program involving communication between the

providers responsible for the different components.

It is expected a full team which would include a

physiatrist, psychologists, physiotherapists, social

workers, occupational therapists, and orthotist.

Most recently, the interventions have focused on

the workplace environment to improve the support

of upper management and colleagues or reduce

work-related physical constraints. A successful

RTW coordination seems more based on ergonomics

job accommodation, communication, and conflict

resolution rather than on medical or purely

biomechanical knowledge. The pre-RTW

consultation(s) are precisely the right means to

promote dialogue between all actors involved and

the coordination of their actions.

2.5 Work Hardening

Work hardening is a work-oriented treatment

program that has an outcome that is measured in

terms of improvement in the client's productivity.

This is achieved through increased work tolerances,

improved work rate, mastery of pain (through the

effective use of symptom control techniques),

improved work habits, increased confidence, and

proficiency with work adaptations or assistive

devices. Work hardening involves the client in

highly structured, simulated work tasks in an

environment where expectations for basic worker

behaviors (e.g., timeliness, attendance, and dress)

are in keeping with workplace standards. The

ultimate goal of work hardening is to help the client

achieve a level of productivity that is acceptable in

the competitive labor market. This productivity

improvement is achieved at various levels through

the following techniques:

 A decrease in secondary impairment effects.

Impairment is often magnified through disuse.

Return to Work Following Low Back Pain

Work hardening improves strength, flexibility,

and endurance.



A decrease in functional limitations. The

client's style of work and the quality of his or

her work behavior often increases the

functional decrement due to the impairment.

Work hardening helps the client learn effective

adaptive behaviors.



A decrease in disability. Disability is the

impact of functional impairment on the client's

societal roles, among which work roles are

prominent. Work hardening helps the client

reestablish many of these roles. Improvement

in these other areas generalizes to work roles

and results in a concomitant decrease in work-

related disability.

 Improvement of vocational feasibility.

Feasibility, which is the client's acceptability as

an employee, is a key issue in work hardening.

Most clients with chronic industrial injuries

have not worked for several months. Thus,

work hardening identifies and remediates

potential problems with productivity, increases

safety in the workplace, and strengthens

interpersonal relations.



Improvement of employability. Employability,

which is the probability that the client will

achieve employment, is a consequence of the

levels of the client's work tolerances (e.g.,

ability to lift, carry, and stand) compared with

the tolerances of other workers in the general

labor market. Work hardening identifies and

develops these work tolerances.

 A decrease in vocational handicap. The match

between the client and job can be improved by

increasing the client's level of function and by

modifying the job's critical work demands.

The role of the rehabilitation team in the WH

program should be made in uniform treatment

planning and patient management. The rehabilitation

team (which comprises the physiatrist and therapist

involved, at a minimum) is responsible for

assessment, treatment planning – including the

global and weekly goals – and therapy. The team

approach must also guarantee the"unité de

doctrine"[uniform doctrine] regarding the method

and program structure as well as the information that

is given to the client.

2.6 Symptoms of Negotiation Training

Many clients with chronic back pain cannot

"negotiate" effectively with their symptoms or cope

with their pain. They experience their symptoms as

being more or less beyond their control. As they

cannot predict the pain behavior, they feel unable to

exert control over their pain, themselves and their

environment. This, in turn, increases the lack of self-

efficacy. Symptom negotiation training is, therefore,

an important training element for these clients in a

WH program. It is based on the following principle:

when symptoms can be predicted, they can be better

controlled. To achieve this, the therapist must create

situations in which the symptoms appear predictably

and for which prediction and control by the client

are facilitated. The most important strategies for

symptom negotiation training are:



Graded activity

This approach is based on a task presenting a

gradually increased activity level. The starting point

and the increment are set by the therapist in such a

way that a clear relationship between activity and

symptoms can easily be felt by the client. For

example, in a progressive lifting test, load, lifting

height, speed or rate can be increased. The purpose

of this exercise is not, however, to evaluate lifting

performance, but to clarify the connections between

stress level of the ask and symptoms. Some clients

have initially to learn to differentiate pain levels as

shades of grey rather than as black-or-white (i.e.,

either no pain or catastrophic pain).

 Graded exposure to eared movements

This method resembles the"graded activity", but

clients are exposed as realistically as possible to the

specific physical stress that they are afraid of: "For

example, if the patient fears the spinal compression

produced by riding a bicycle on a bumpy road, then

the graded exposure should include an activity that

mimics that specific activity, and not just a

stationary bicycle. Such an approach allows the

individual to correct inaccurate predictions about the

relationship between activities and harm".

 Pacing

Clients with painful disabilities often function

according to an"on/off" principle ("Yes, I can"or"No,

I can't"). They should experience that by adjusting

their working pace there are intermediate options:

e.g., doing things slower, making short breaks, doing

some stretching, loosening up or relaxing exercises

in between, alternating work activities, etc.

Modification of working techniques, tools or

workplace. Many clients with pain-related

disabilities have not yet learned to appreciate the

value of working smart rather than working hard.

They keep on working as uneconomically as they

did before the accident/disease or even worse. Ways

of modifying working techniques and requirements

as well as tools and workplace should be evaluated.

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

 Coping with exacerbated pain

Exacerbation of pain during rehabilitation is a

challenge for a client's self-management and should

be used for the education of proper pain behavior.

Clients should learn to avoid panic and assess the

pain situation realistically, and to avoid, for instance,

alarmed consultations at emergency wards. They

should apply the learned self-treatments for pain

relief (e.g.cool packs, relaxation technics, the

meaningful use of medicaments) and analyze the

likely causes of the acute pain attack.

It is important to give a core message to the patient,

related to their back pain, at the beginning of the

WH program:

– Chronic pain does not mean harm! It is not

dangerous to move and stress your body when you

are in pain! This is necessary to escape from the

vicious circle of avoiding physical activity, loss of

fitness and pain;

– Chronic pain usually cannot be reduced in a short

time. However, it is possible to increase

performance capacity with intensive training despite

the pain. In many cases, a reduction in pain will then

occur in the long term;

– Some pain increase usually occurs at the start of

the program as under-used muscles and joints are

now trained, and the body has to readapt to higher

activity level. This is normal!

– In this program, the primary goal is not pain

reduction but increasing your performance capacity.

This will be measured weekly as the main criterion

for program goals. An intensive training program

creates the prerequisites for a successful return to

work.

To recommend discharge of WH program with a

return to a specific job, the team has to demonstrate,

based on results of FCE (Functional Capacity

Evaluation) tests, that the worker has reached the

goals stated in the plan or a plateau in his/her

functional levels. For those clients with a specific

job to return to, the care providers must document

the worker's ability about the job requirements, and

the discharge recommendations may consist of the

following options: return to work with full duty,

modified duty, or reasonable accommodations.

3 CONCLUSION

Studies' evidence to date shows certain factors can

be used to identify workers with acute low-back pain

who are at high risk of poor outcomes. The factors

identified in this review, such as recovery

expectations, interactions with health-care providers,

self-reported pain and physical limitations, and

physical demands of the job, could be used to screen

those workers at high risk of long-term or permanent

disability.

Work hardening is a new specialty within

rehabilitation. It is addressed by several different

disciplines among which occupational therapy has

taken a leadership position. Work hardening is an

important new approach to the rehabilitation of

injured workers and others whose entry into the

workforce is under consideration.

RTW is ultimately a social phenomenon that

requires a supportive social policy that will enable

all the players to work together. Although proper

individualized RTW coordination is useful and

important, it cannot overcome policies that

marginalize workers or interfere with safe and

sustainable RTW.

Because many of the analyzed studies have some

methodical shortcomings and multidisciplinary

return-to-work programs are expensive and need to

demonstrate their cost-effectiveness also in the long

term (to demonstrate their benefit and justify

reimbursement), there is still the need for high-

quality trials in this field to address issues such as

patient selection, the optimal intensity and duration

of programs, and the most effective treatment

components.

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Return to Work Following Low Back Pain