The crystal ball: Predicting return to work following low-back pain

What factors affect how long it will take workers to return to work following an episode of acute low-back pain? A just-completed systematic review from the Institute for Work & Health points to a number of them, including workers’ recovery expectations and their interactions with health-care practitioners.

Published: January 10, 2011

It began with a question: “What influences return to work among workers in the early phase of a disability due to low-back pain?” It ended with some concrete answers, and then took one step further: a workshop to see if the answers rang true for case managers, medical examiners and clinicians.

The “it” is a systematic review led by Institute for Work & Health Associate Scientist Dr. Ivan Steenstra. Completed in September, the review updated an earlier version in 2005. The newest review identified a number of factors present at the beginning of a work absence due to low-back pain that affect the length of time before return to work (RTW).

By identifying these factors, we can potentially use them to screen those workers at high risk of long-term disability, says Steenstra. We can also try to modify those practices or factors that are shown to negatively affect return to work in order to improve outcomes.

Low-back pain is a common cause of work absence in industrialized countries. Most injured workers with it return to work following a relatively straightforward path. However, some disability episodes are long term and costly.

The research team hypothesized that certain factors present at the beginning of a sick-leave absence, for acute low-back pain, would affect the duration of the leave. The team searched the literature for studies that reported on low-back pain and sick leave that lasted more than one day but less than six weeks. In the end, the team identfied 30 relevant publications from 25 studies. 

Potentially modifiable factors

There was strong evidence showing that the following factors influence RTW among those with acute low-back pain:

  • workers’ recovery expectations;
  • interactions with health-care providers (e.g. type of provider);
  • workers’ self-reported pain and functional limitations;
  • presence of radiating pain; and
  • work-related factors, including physical demands, job satisfaction, and the offer of modified work.

Some of these factors are potentially changeable, Steenstra points out, which means RTW outcomes could be improved. He points to the first finding, about the importance of recovery expectations. Health-care providers can provide patients with positive information about prognosis in low-back pain, he says. By doing this, they can influence a patient’s recovery expectation and help the patient in his or her return to work.

Interestingly, the evidence did not point to depression as a factor affecting RTW in these cases. It appears that mental health is not a predictor of return to work until back pain becomes chronic, says Steenstra.

And age, surprisingly, was shown not to be playing a prognostic role. This seems partially caused by non-report of this factor in most studies, Steenstra says, who is dissatisfied with the way age is currently reported in RTW studies. It is taken for granted because we can’t modify age, but aging is complex. It will become increasingly important in our [aging] society.

Discrepancies with practice

Armed with these prognostic factors, the researchers decided to investigate if these factors were also understood on the front lines of helping workers with low-back pain. Earlier this year, the team conducted a workshop in Winnipeg, Manitoba, with 34 participants—clinicians, work-disability professionals and workers’ compensation case managers and medical examiners.

Participants were given cards that represented the most important prognostic factors identified in the systematic review. They were then asked to discuss the importance of each factor and determine how relevant it was to RTW, based on their own experiences. There were discrepancies between research and practice, says Steenstra.

Important according to practice Evidence from review
Psychosocial Insufficient evidence*
Fear avoidance beliefs Insufficient evidence
Work relatedness of back pain Insufficient evidence
Kinesiophobia (fear of movement/reinjury Insufficient evidence
Depression Moderate evidence for NO effect
Treatment related: content Moderate evidence
Workplace-psychosocial Moderate evidence
Claim-related factors Moderate evidence
Workplace modified duties Strong evidence
Pain Strong evidence
*Insufficient evidence: only one study available or inconsistent findings in multiple studies.

This will change how people view acute low-back pain and RTW. People working in practice have heard, over the last decade, how important psychosocial factors are, says Steenstra. Unfortunately, it is not very clear what those factors are. Through the workshops, we now know what our message for practice should look like.

The systematic review is available at: