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.
This study was financially supported by the Dutch Health Care Insurance Council (CVZ), grant DPZ no. 169/0.
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): 387–403PubMedCrossRefGoogle Scholar
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): 2114–25PubMedCrossRefGoogle Scholar
Lahad A, Malter AD, Berg AO, et al. The effectiveness of four interventions for the prevention of low back pain. JAMA 1994; 272 (16): 1286–91PubMedCrossRefGoogle Scholar
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): 841–7PubMedCrossRefGoogle Scholar
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): 2918–29PubMedCrossRefGoogle Scholar
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: 270–81PubMedCrossRefGoogle Scholar
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: 329–35PubMedCrossRefGoogle Scholar
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: 81–9PubMedGoogle Scholar
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: 717–25PubMedCrossRefGoogle Scholar
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: 2494–500PubMedCrossRefGoogle Scholar
Corey DT, Koepfler LE, Etlin D, et al. A limited functional restoration program injured workers: a randomized trial. J Occup Rehabil 1996; 6 (4): 239–49CrossRefGoogle Scholar
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: 1973–6PubMedCrossRefGoogle Scholar
Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered: a randomized clinical trial. Spine 1995; 20 (4): 473–7PubMedCrossRefGoogle Scholar
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: 673–8PubMedCrossRefGoogle Scholar
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): 279–93PubMedGoogle Scholar
Loisel P, Abenhaim L, Durand P, et al. A population-based, randomized clinical trial on back pain management. Spine 1997; 22 (24): 2911–8PubMedCrossRefGoogle Scholar
Rossignol M, Abenhaim L, Seguin P, et al. Coordination of primary health care for back pain: a randomized controlled trial. Spine 2000; 25 (2): 251–8PubMedCrossRefGoogle Scholar
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: 461–70PubMedCrossRefGoogle Scholar
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): 2616–24PubMedCrossRefGoogle Scholar
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: 16–25PubMedCrossRefGoogle Scholar
Fordyce WE. Behavioral methods for chronic pain and illness. St Louis (MO): CV Mosby, 1976Google Scholar
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: 597–602PubMedCrossRefGoogle Scholar
Mayer TG, Gatchel RJ. Functional restoration for spinal disorders: the sports medicine approach. Philadelphia (PA): Lea and Fabiger, 1988Google Scholar
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): 2784–96PubMedCrossRefGoogle Scholar
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): 262–9PubMedCrossRefGoogle Scholar
Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ 2001; 322 (7301): 1511–6PubMedCrossRefGoogle Scholar
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): 897–908PubMedCrossRefGoogle Scholar
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): 641–52PubMedCrossRefGoogle Scholar
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): 909–19PubMedCrossRefGoogle Scholar
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): 920–9PubMedCrossRefGoogle Scholar
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): 153–60PubMedGoogle Scholar
Waddell G. The back pain revolution. Edinburgh: Churchill Livingstone, 1998Google Scholar