Abstract
Low back pain is a major medical and social problem associated with disability, work absenteeism and high costs. Given the impact of the problem, there is a need for effective treatment interventions in occupational healthcare that aim at the prevention of chronic disability and the realisation of return to work. These so-called return-to-work (RTW)interventions are becoming increasingly popular. As well as questions concerning the effectiveness of RTW interventions, there are also important questions on the actual content and underlying concepts of these multifactorial intervention strategies.
The purpose of this review is to examine the literature on the content and underlying concepts of RTW interventions for low back pain. Asystematic literature search identified 14 randomised controlled trials (RCTs) evaluating the effects of 19 RTW interventions. The content and concepts of these RTW interventions are described, compared and discussed in this review. Further, the contents of the RTW interventions are classified by the use of predefined components (physical exercises, education, behavioural treatments and ergonomic measures).
The identified RTW interventions varied with respect to the disciplines involved, the target population and the number and duration of sessions. The classification showed that physical exercises were a component of most of the selected interventions, followed by education, behavioural treatments and ergonomic measures. The most prevalent combination of components was the combination of physical exercises, behavioural treatment and education. However, the types of physical exercises, behavioural treatment and education varied widely among the RTW interventions.
The described concepts for the physical exercises were an increase of muscle strength, coordination, range of motion of the spine and cardiovascular fitness, and a decrease of muscle tension. Education as a part of RTW interventions is believed to increase the understanding of patients regarding their disorder and treatment. Behavioural treatments were mainly based on the gate control theory of pain (psychophysiological processes are involved in pain perception) and/or the operant conditioning hypothesis (pain behaviour is determined by its consequences). No concepts were described for ergonomic measures.
Finally, the plausibility of the described concepts is discussed. Future RCTs on this topic should evaluate the underlying concepts of the RTW intervention in addition to its effectiveness.
Similar content being viewed by others
References
Waddell G. A new clinical model for the treatment of low back pain. Spine 1987; 12: 632–44
Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in general practice: a prospective study. BMJ 1998; 316 (7141): 1356–9
Anderson GBJ. The epidemiology of spinal disorders. In: Frymoyer JW, editor. The adult spine: principles and practice. New York (NY): Raven Press Ltd., 1991: 107–46
Frymoyer JW. Quality: an international challenge to the diagnosis and treatment of disorders of the lumbar spine. Spine 1993; 18: 2147–52
Van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of back pain in the Netherlands. Pain 1995; 62: 233–40
Deyo RA, Phillips WR. Low back pain: a primary care challenge. Spine 1996; 21: 2826–32
Hoogendoorn WE, van Poppel MN, Bongers PM, et al. Physical load during work and leisure time as risk factors for back pain. Scand J Work Environ Health 1999; 25 (5): 387–403
Hoogendoorn WE, van Poppel MN, Bongers PM, et al. Systematic review of psychosocial factors at work and private life as risk factors for back pain. Spine 2000; 25 (16): 2114–25
Lahad A, Malter AD, Berg AO, et al. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994; 272 (16): 1286–91
van Poppel MN, Koes BW, Smid T, et al. A systematic review of controlled clinical trials on the prevention of back pain in industry. Occup Environ Med 1997; 54 (12): 841–7
Frank JW, Brooker AS, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: what do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 1996; 21 (24): 2918–29
van Tulder MW, Ostelo R, Vlaeyen JWS, et al. Behavioral treatment for chronic low back pain: a systematic review within the framework of the Cochrane Back Review Group. Spine 2001; 26: 270–81
The discipline of ergonomics. International Ergonomics Association [online]. Available from URL: http://www.iea.cc/ergonomics [Accessed 2002 Jan 11]
Altmaier EM, Lehmann TR, Russell DW, et al. The effectiveness of psychological interventions for the rehabilitation of low back pain: a randomized controlled trial evaluation. Pain 1992; 49: 329–35
Bendix AF, Bendix T, Lund C, et al. Comparison of three intensive programs for chronic low back pain patients: a prospective, randomized, observer-blinded study with one-year follow-up. Scand J Rehabil Med 1997; 29: 81–9
Bendix AF, Bendix T, Labriola M, et al. Functional restoration for chronic lowback pain: two-year follow-up of two randomized clinical trials. Spine 1998; 23: 717–25
Bendix T, Bendix AF, Labriola M, et al. Functional restoration versus outpatient physical training in chronic low back pain: a randomized comparative study. Spine 2000; 25: 2494–500
Corey DT, Koepfler LE, Etlin D, et al. A limited functional restoration program injured workers: a randomized trial. J Occup Rehabil 1996; 6 (4): 239–49
Hagen EM, Eriksen HR, Ursin H. Does early intervention with a light mobilization program reduce long-term sick leave for low back pain? Spine 2000; 25: 1973–6
Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomized clinical trial. Spine 1995; 20 (4): 473–7
Leclaire R, Esdaile JM, Suissa S, et al. Back school in a first episode of compensated acute low back pain: a clinical trial to assess efficacy and prevent relapse. Arch Phys Med Rehabil 1996; 77: 673–8
Lindström I, Öhlund C, Eek C, et al. The effect of graded activity on patients with subacute low back pain: a randomized prospective clinical study with an operant-conditioning behavioral approach. Phys Ther 1992; 72 (4): 279–93
Loisel P, Abenhaim L, Durand P, et al. A population-based, randomized clinical trial on back pain management. Spine 1997; 22 (24): 2911–8
Rossignol M, Abenhaim L, Seguin P, et al. Coordination of primary health care for back pain: a randomized controlled trial. Spine 2000; 25 (2): 251–8
Seferlis T, Nemeth G, Carlsson AM, et al. Conservative treatment in patients sick-listed for acute low-back pain: a prospective randomized study with 12 months’ follow-up. Eur Spine J 1998; 7: 461–70
Torstensen TA, Ljunggren AE, Meen HD, et al. Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain: a pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up. Spine 1998; 23 (23): 2616–24
Haldorsen EMH, Kronholm K, Skouen JS, et al. Multimodal cognitive behavioral treatment of patients sick listed for musculoskeletal pain. A randomized controlled study. Scand J Rheumatol 1998; 27: 16–25
Fordyce WE. Behavioral methods for chronic pain and illness. St Louis (MO): CV Mosby, 1976
Loisel P, Durand P, Abenhaim L, et al. Management of occupational back pain: the Sherbrooke model. Results of a pilot and feasibility study. Occup Environ Med 1994; 51: 597–602
Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965; 150 (699): 971–9
Turner JA, Chapman CR. Psychological interventions for chronic pain: a critical review. I: relaxation training and biofeedback. Pain 1982; 56: 1–21
Turner JA, Chapman CR. Psychological interventions for chronic pain: a critical review. II: operant conditioning, hypnosis, and cognitive-behavioral therapy. Pain 1982; 56: 261–6
Linton SJ. Behavioral remediation of chronic pain: a status report. Pain 1986; 24: 125–41
Mayer TG, Gatchel RJ. Functional restoration for spinal disorders: the sports medicine approach. Philadelphia (PA): Lea and Fabiger, 1988
van Tulder M, Malmivaara A, Esmail R, et al. Exercise therapy for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000; 25 (21): 2784–96
Karjalainen K, Malmivaara A, van Tulder M, et al. Multidisciplinary biopsychosocial rehabilitation for subacute low back pain in working-age adults: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2001; 26 (3): 262–9
Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001; 322 (7301): 1511–6
Mannion AF, Taimela S, Muntener M, et al. Active therapy for chronic low back pain. Part 1: effects on back muscle activation, fatigability, and strength. Spine 2001; 26 (8): 897–908
Lindström I, Ohlund C, Eek C, et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain: a randomized prospective clinical study with a behavioral therapy approach. Spine 1992; 17 (6): 641–52
Käser L, Mannion AF, Rhyner A, et al. Active therapy for chronic low back pain. Part 2: effects on paraspinal muscle cross-sectional area, fiber type size, and distribution. Spine 2001; 26 (8): 909–19
Mannion AF, Junge A, Taimela S, et al. Active therapy for chronic low back pain. Part 3: factors influencing self-rated disability and its change following therapy. Spine 2001; 26 (8): 920–9
Lindstrom I, Ohlund C, Nachemson A. Physical performance, pain, pain behavior and subjective disability in patients with subacute low back pain. Scand J Rehabil Med 1995; 27 (3): 153–60
Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone, 1998
Acknowledgements
This study was financially supported by the Dutch Health Care Insurance Council (CVZ), grant DPZ no. 169/0.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Bart Staal, J., Hlobil, H., van Tulder, M.W. et al. Return-to-Work Interventions for Low Back Pain. Sports Med 32, 251–267 (2002). https://doi.org/10.2165/00007256-200232040-00004
Published:
Issue Date:
DOI: https://doi.org/10.2165/00007256-200232040-00004