Research Updates

Expecting the worst and fearing pain are tell-tale signs of slow RTW

Julian Fernando

Identify high-risk patients to pip long term back problems at the proverbial post
Take Home Messages:

Low recovery expectations and fear avoidance beliefs are two things that should be measured early to identify those at risk of ongoing work disability.

When a person indicates a low expectation of recovery, they are likely to have identified factors which may hinder their return to work. A return to work coordinator may therefore ask specifically about these factors. This knowledge will assist in developing strategies to deal with the issues of most concern to the individual.

Fear of pain and avoidance are natural responses. However there is evidence that exaggerated levels of fear and persistence of avoidance may predict work outcomes. Assessing fear avoidance beliefs may be useful in determining work prognosis for those with back pain. Educating patients about the true relationship between pain and ongoing injury can discourage the development of long term problems.

Why the research matters:

The majority of resources devoted to low back pain are consumed by the small proportion of people who experience ongoing disability. When back pain becomes chronic and prevents a person from working, additional personal, social and economic issues come into play. It is thought that early identification of - and intervention for - those likely to experience ongoing disability may prevent chronic disability and reduce costs.

But how can we identify those at risk?

What the research involved:

Ross Iles and other researchers from the School of Physiotherapy at LaTrobe University reviewed 24 existing studies of long term back pain with the hope of identifying psychosocial predictors of failure to return to work.

Summary of research findings:

There is strong evidence that having positive expectations of recovery is predictive of good return to work outcomes. Recovery expectation is a broad concept which seems to represents how the beliefs, attitudes and experiences of the individual result in a prediction of when they will return to work.

Other studies have also shown an association between recovery expectations and positive health outcomes. One of these studies showed that rating one's chances of working in 6 months as less than 5/10 increased the chances of developing long-term disability by 30%. The authors note that identifying why the person believes their recovery may be delayed may be useful for devising interventions.

  • Fear of pain and avoidance are natural responses. However there is evidence that exaggerated levels of fear and persistence of avoidance may predict work outcomes. The authors suggest that assessing fear avoidance beliefs may be useful in determining work prognosis for those with back pain.
  • Depression has been identified as impacting the outcome of rehabilitation programs and contributing to work-related disability. However, whether depression is a cause or effect of ongoing disability is unclear.
  • Stress and anxiety, and job satisfaction were not found to be strongly related to return to work outcomes. There is insufficient evidence to specify the relationship between compensation and work outcomes.

Overall, the findings of this study suggest that recovery expectations and fear avoidance beliefs are two things that should be measured early to identify those at risk of ongoing work disability. This early assessment may allow the treating practitioner to adjust treatment if necessary or simply discuss these issues with the individual. It can also help those assisting return to work understand the issues.

The best method of measuring fear-avoidance beliefs is currently unclear. However, a commonly used instrument is the Fear-Avoidance Beliefs Questionnaire a sample of which is included below.  

The following statements are about how normal work affects or would affect your back pain: Completely disagree                  Unsure                            Completely agree
My work makes or would make my pain worse
 
1 2 3 4 5 6
I should not do my normal work with my present pain
 
1 2 3 4 5 6
I cannot do my normal work until my pain is treated
 
1 2 3 4 5 6
I do not think I will be back to my normal work within 3 months
 
1 2 3 4 5 6
I do not think I will ever be able to get back to that work
 
1 2 3 4 5 6



As with fear-avoidance beliefs, the best way of assessing work-related recovery expectation is not clear, but here are some simple questions that researchers have used; they may be useful in gauging the feelings of someone with back pain. 

  1. How certain are you that you will be working in 6 months?
  2. Do you believe work will aggravate your condition?
  3. How likely is it that you will not recover from this condition?
  4. How long do you think you will be on sick leave?

When a person indicates a low expectation of recovery, they are likely to have identified factors which may hinder their return to work. A return to work co-ordinator may therefore also ask more specifically about these factors. This knowledge will assist in developing strategies to deal with the issues of most concern to the individual.

Original research:

A systematic review of psychosocial predictors of failure to return to work in non-chronic non-specific low back pain.
Iles, R. A., Davidson, M., & Taylor, N. F. (2008).

Occupational and Environmental Medicine, 65, 507-517.

Link to PubMed abstract