Multimodal treatment plans have been shown effective for low back pain (LBP), yet some patients still fail to improve. "Improvement" in this case, is often defined as returning to work. This current study attempted not to test the effectiveness of a treatment method, but to see of 143 subjects, why 17 patients failed to improve. The author hoped to assess the prognostic factors that influence a failure to return to work.
The patients were involved in a four-week treatment program that focused on restoring health and on "deconditioning" the patients of behavior influenced by fear. The fear of pain and the fear of movement have been found in other studies to significantly contribute to decreases in mobility, fitness, and strength. The patients participated in back school, stress management, and symptom and disability discussions, as well as worked on modifying harmful behaviors and emotions.
The author measured the patients' experience of pain, functional disability, psychological distress, and physical functioning. At the six-month follow-up, the author determined if they met the goal: returning to work with the same workload, with the same work demands as before undergoing the program.
There were improvements within the group. Pain intensity decreased and physical functioning increased and 120 (of 143) completely returned to work. Three variables seem to predict who would not return to work:
- Time off work.
- History of spinal surgery.
- Psychological indications of dissatisfaction and malaise.
The author notes that those who failed to return to work had lower scores on the physical measures, and higher scores on the psychological measures at pre-treatment—perhaps indicating future failure in the program.
To explain the negative influence of absence from work, the author writes, "It can be hypothesized that the longer a patient is off work, the greater the opportunity for negative experiences to reinforce the chronic sick role." Another theory mentioned is that when returning to work after a prolonged absence, patients may be treated differently by co-workers and by the employer.
"Failed back surgery" is perceived in a similar light—it seems to reinforce pain behavior, and lead to the development of chronic pain syndrome. The author also suggests that these patients become entangled in a "vicious cycle" of blaming chronic pain on the failure of physical treatment.
The dissatisfaction and malaise aspect is complex. Other research has indicated a strong correlation of this scale with low back pain. Apparently there is a certain "passivity" involved, without the patients awareness of depression or anxiety disorder. They are also characterized as having a certain "malaise" about their condition. The author writes, "Such characteristics may make them more susceptible to passivity and thus simple acceptance of their chronic disability. Less effort is invested in the improvement of their situation and thereby the risk of a poor treatment outcome is heightened."
The underlining characteristic in all three prognostic factors is a patient's feeling of disability. In the end, this study is another contribution to the body of research that stresses that a back pain patient's subjective perception of disability dictates the course of treatment and its outcome.
Vendrig A. Prognostic factors and treatment-related changes associated with return to work in the multimodal treatment of chronic back pain. Journal of Behavioral Medicine 1999;22(3):217-232.