Journal of Occupational Rehabilitation

, Volume 16, Issue 4, pp 685–695 | Cite as

Workers’ Beliefs and Expectations Affect Return to Work Over 12 Months

  • Martijn W. Heymans
  • Henrica C. W. de Vet
  • Dirk L. Knol
  • Paulien M. Bongers
  • Bart W. Koes
  • Willem van Mechelen
Original Paper


Background: Successful management of workers on sick leave due to low back pain depends on the identification by the occupational physician of modifiable prognostic factors in the early phase of sick-leave. The prognostic value of factors which influence the course of low back pain and return to work in occupational health care is unclear. Methods: Secondary data analysis in a cohort of 299 workers on sick leave between 3 and 6 weeks due to low back pain was applied. We investigated the association of a broad set of prognostic indicators related to characteristics of worker, job, low back pain and psychosocial issues on return to work lasting at least 4 weeks (lasting-RTW) and minimally 1 day of first return to work (first-RTW). Relationships were studied using Cox regression analysis and covered a follow-up period of 12 months. The explained variation of the models was also calculated. Results: The median time to return to work using lasting-RTW and first-RTW was 76 and 71 days respectively. In addition to individual analysis of potential predictive factors a backward selection procedure resulted in the following multivariable model: self-predicted timing of return to work, pain intensity, job satisfaction, social support, pain radiation, expectations of treatment succes of the occupational physician. Similar results were found for first-RTW. The explained variance of the multivariate model of lasting-RTW was 18%. Conclusions: Factors concerning the expectations and beliefs of the worker affected the RTW process. Knowledge of these factors by the occupational physician in the early phase of low back pain and sick-leave may contribute to solutions to promote return to work.


Low back pain Prognostic model Occupational health care Sick-leave Patients’ expectations 


  1. 1.
    Andersson GBJ. Epidemiological features of chronic low-back pain. Lancet 1999;354:581–85.CrossRefPubMedGoogle Scholar
  2. 2.
    Frymoyer JW. Quality: an international challenge to the diagnosis and treatment of disorders of the lumbar spine. Spine 1993;18:2147–52.CrossRefPubMedGoogle Scholar
  3. 3.
    Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain 2000; 84:95–103.CrossRefPubMedGoogle Scholar
  4. 4.
    van Tulder MW, Koes BW, Bouter LM. A cost-of-illness study of back pain in the Netherlands. Pain 1995;62:233–40.CrossRefPubMedGoogle Scholar
  5. 5.
    Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ 1998;316:1356–9.PubMedGoogle Scholar
  6. 6.
    Van Der Weide WE, Verbeek JH, Salle HJ, van Dijk FJ. Prognostic factors for chronic disability from acute low-back pain in occupational health care. Scand J Work Environ Health 1999;25:50–6.PubMedGoogle Scholar
  7. 7.
    Frank JW, Kerr MS, Brooker AS, et al. Disability resulting from occupational low back pain. Part I: What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine 1996;21:2908–17. Review.CrossRefPubMedGoogle Scholar
  8. 8.
    Crook J, Milner R, Schultz IZ, Stringer B. Determinants of occupational disability following a low back injury: a critical review of the literature. J Occup Rehabil 2002;12:277–95. Review.CrossRefPubMedGoogle Scholar
  9. 9.
    Krause N, Frank JW, Dasinger LK, Sullivan TJ, Sinclair SJ. Determinants of duration of disability and return-to-work after work-related injury and illness: challenges for future research. Am J Ind Med 2001;40:464–84. Review.CrossRefPubMedGoogle Scholar
  10. 10.
    Kendall NA Psychosocial approaches to the prevention of chronic pain: the low back paradigm. Baillieres Best Pract Res Clin Rheumatol 1999;13:545–54. Review.CrossRefPubMedGoogle Scholar
  11. 11.
    Kalauokalani D. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine 2001;26:1418–24.CrossRefPubMedGoogle Scholar
  12. 12.
    Mondloch MV, Cole DC, Frank JW. Does how you do depend on how you think you'll do? A systematic review of the evidence for a relation between patients' recovery expectations and health outcomes. CMAJ 2001;165:174–9. Review.PubMedGoogle Scholar
  13. 13.
    Hartvigsen J, Lings S, Leboeuf-Yde C, Bakketeig L. Psychosocial factors at work in relation to low back pain and consequences of low back pain; a systematic, critical review of prospective cohort studies. OEM 2004;61:e2. Review.Google Scholar
  14. 14.
    Pincus T, Vlaeyen JW, Kendall NA, et al. Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine 2002;27:E133–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Heymans MW, de Vet HCW, Bongers PM, Knol DL, Koes BW, van Mechelen W. The Effectiveness of high intensity versus low intensity back schools in an occupational setting: a pragmatic randomised controlled trial. Spine 2006;31(10):1075--82.Google Scholar
  16. 16.
    Aulman P, Bakker-Rens RM, Dielemans SF, et al. Occupational management of workers with back Pain. [In Dutch: Het handelen van de bedrijfsarts bij lage rug klachten] Eindhoven: the Netherlands: NVAB, 1999.Google Scholar
  17. 17.
    de Vet HCW, Heymans MW, Dunn KM, Pope DP, van Der Beek AJ, Macfarlane GJ, et al. Episodes of low back pain: a proposal for uniform definitions to be used in research. Spine 2002;27:2409–16.CrossRefPubMedGoogle Scholar
  18. 18.
    van Poppel MNM, de Vet HCW, Koes BW, Smid T, Bouter LM. Measuring sick-leave: a comparison of self-reported data on sick-leave and data from company records. Occup Med 2002;52:485–90.CrossRefGoogle Scholar
  19. 19.
    Vlaeyen JW, Teeken Gruben NJ, Goossens ME, Rutten van Molken MP, Pelt RA, van Eek H, et al. Cognitive-educational treatment of fibromyalgia: a randomized clinical trial. I. Clinical effects. J Rheumatol 1996;23:1237–45.PubMedGoogle Scholar
  20. 20.
    Baecke JA, Burema J, Frijters JE. A short questionnaire for the measurement of habitual physical activity in epidemiological studies. Am J Clin Nutr 1982;36:936–42.PubMedGoogle Scholar
  21. 21.
    Dolan P. Modeling valuations for EuroQol health states. Med Care 1997;35:1095–108.CrossRefPubMedGoogle Scholar
  22. 22.
    Gründemann RWM, Smulders PGW, Winter CR de. Manual questionnaire Work and Health (In Dutch: Handleiding vragenlijst Arbeid en Gezondheid). Lisse: Swets & Zeitlinger, 1993.Google Scholar
  23. 23.
    Karasek RA. Job demands, job decision lattitude, and mental strain: implications for job redesign. Administrative Sci Quarterly 1979;24:285–308.CrossRefGoogle Scholar
  24. 24.
    Hildebrandt VH, Bongers PM, van Dijk FJ, Kemper HC, Dul J. Dutch Musculoskeletal Questionnaire: description and basic qualities. Ergonomics 2001;44:1038–55.CrossRefPubMedGoogle Scholar
  25. 25.
    Gommans IHB, Koes BW, van Tulder MW. Validity and responsivity of the Dutch Roland Disability Questionnaire. [In Dutch: Validiteit en responsiviteit van de Nederlandstalige Roland Disability Questionnaire] Ned Tijdschr Fysioth 1997;107:28–33.Google Scholar
  26. 26.
    Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eek H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain 1995;62:363–72.CrossRefPubMedGoogle Scholar
  27. 27.
    Peduzzi P, Concato J, Feinstein AR, Holford TR. Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. J Clin Epidemiol 1995;48(12):1503–10.CrossRefPubMedGoogle Scholar
  28. 28.
    Kent JT, O'Quigley J. Measures of dependence for censored survival data. Biometrika 1988;75:525–34.CrossRefGoogle Scholar
  29. 29.
    Pocock SJ, Clayton TC, Altman DG. Survival plots of time-to-event outcomes in clinical trials: good practice and pitfalls. Lancet 2002;359:1686–9.CrossRefPubMedGoogle Scholar
  30. 30.
    Hoogendoorn WE, Bongers PM, de Vet HC, Ariëns GA, van Mechelen W, Bouter LM. High physical work load and low job satisfaction increase the risk of sickness absence due to low back pain: results of a prospective cohort study. Occup Environ Med 2002;59:323–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Papageorgiou AC, Croft PR, Thomas E, Silman AJ, Macfarlane GJ. Psychosocial risks for low back pain: are these related to work? Ann Rheum Dis 1998;57:500–502.PubMedCrossRefGoogle Scholar
  32. 32.
    Krause N, Ragland DR, Greiner BA, Syme SL, Fisher JM. Psychosocial job factors associated with back and neck pain in public transit operators. Scand J Work Environ Health 1997;23:179–86.PubMedGoogle Scholar
  33. 33.
    Steenstra IA, Verbeek JHAM, Heymans MW, Bongers PM. Prognostic factors for return to work in patients sick listed with acute low-back pain, a systematic review of the literature. OEM 2005;62:851–60. Review.Google Scholar
  34. 34.
    Reiso H, Nygard JF, Jorgensen GS, Holanger R, Soldal D, Bruusgaard D. Back to work: predictors of return to work among patients with back disorders certified as sick: a two-year follow-up study. Spine 2003;28:1468–73.CrossRefPubMedGoogle Scholar
  35. 35.
    Schultz IZ, Crook J, Meloche GR, Berkowitz J, Milner R, Zuberbier OA, Meloche W. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain 2004; 107:77–85.CrossRefPubMedGoogle Scholar
  36. 36.
    Turner JA, Franklin G, Turk DC. Predictors of chronic disability in injured workers: a systematic literature synthesis. Am J Ind Med 2000; 38:707–22.CrossRefPubMedGoogle Scholar
  37. 37.
    Linton SJ. A review of psychological risk factors in back and neck pain. Spine 2000;25:1148–56. Review.CrossRefPubMedGoogle Scholar
  38. 38.
    Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157–68.CrossRefPubMedGoogle Scholar
  39. 39.
    Fritz JM, George SZ. Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs. Phys Ther 2002;82:973–83.PubMedGoogle Scholar
  40. 40.
    Coste J, Delecoeuillerie G, Cohen de Lara A, Le Parc JM, Paolaggi JB. Clinical course and prognostic factors in acute low back pain: an inception cohort study in primary care practice.1994;308:577–80.Google Scholar
  41. 41.
    Nordqvist C, Holmqvist C, Alexanderson K. Views of laypersons on the role employers play in return to work when sick-listed. J Occup Rehabil 2003;13:11–20.CrossRefPubMedGoogle Scholar
  42. 42.
    Epstein RM, Alper BS, Quill TE. Communicating evidence for participatory decision making. JAMA 2004;291:2359–66. Review.CrossRefPubMedGoogle Scholar
  43. 43.
    Cole DC, Mondloch MV, Hogg-Johnson S. Early Claimant Cohort Prognostic Modelling Group. Listening to injured workers: how recovery expectations predict outcomes–a prospective study. CMAJ 2002;166:749–54.PubMedGoogle Scholar
  44. 44.
    Gross DP, Battie MC. Work-related recovery expectations and the prognosis of chronic low back pain within a workers' compensation setting. J Occup Environ Med 2005;47:428–33.CrossRefPubMedGoogle Scholar
  45. 45.
    Sandstrom J, Esbjornsson E. Return to work after rehabilitation. The significance of the patient's own prediction. Scand J Rehabil Med 1986;18:29–33.PubMedGoogle Scholar
  46. 46.
    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.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2006

Authors and Affiliations

  • Martijn W. Heymans
    • 1
    • 2
    • 3
  • Henrica C. W. de Vet
    • 3
  • Dirk L. Knol
    • 4
  • Paulien M. Bongers
    • 1
    • 2
    • 3
    • 5
  • Bart W. Koes
    • 6
  • Willem van Mechelen
    • 1
    • 2
    • 3
  1. 1.Body@Work, Research Center Physical Activity, Work and Health, TNO-VUmcAmsterdamThe Netherlands
  2. 2.Department of Public and Occupational Health, VU University Medical CenterAmsterdamThe Netherlands
  3. 3.Institute for Research in Extramural Medicine, VU University Medical CenterAmsterdamThe Netherlands
  4. 4.Department of Clinical Epidemiology and Biostatistics VU University Medical CenterAmsterdamThe Netherlands
  5. 5.Quality of LifeHoofddorpThe Netherlands
  6. 6.Department of General Practice, Erasmus Medical CenterRotterdamThe Netherlands

Personalised recommendations