Male gender and initial job demand predicts successful re-integration and return to work: results from 20-years of experience with a multidisciplinary programme for rehabilitation of chronic low back pain

Abstract

Introduction: Low back pain (LBP) is highly disabling with significant healthcare burden worldwide. Rehabilitation and reintegration of this group of patients back to the working population, is paramount to alleviating medical and social costs. Since 1996, we have adopted a 14-week intensive multidisciplinary programme targeting patients with chronic LBP, providing functional rehabilitation aiming at re-integration back to the society. This study aims to review its outcomes, as well as to identify factors predicting successful return to work. Methods: This was an analysis of a prospectively collected cohort of chronic LBP patients consecutively enrolled into the programme. Rigorous pre-admission assessment was performed to identify patients with functional deficits while excluding patients with surgically treatable diseases or psychological disorders. These patients all failed to return to work previously despite a prolonged period of conservative treatment. Assessments were performed at baseline, 8-weeks and 14-weeks. Sitting, standing and walking tolerance, and straight leg raise test were studied. Pain was assessed by Visual Analogue Scale (VAS) and functional assessment was performed by Oswestry Disability Index (ODI), Acceptance of Illness Scale (AIS), Bradburn Affect Balance Scale (BABS) and Spinal Function Sort Score (SFSS). Final capacity for returning to work was defined by matched achieved work strength level with the job demand. Wilcoxon signed-rank test and paired t-tests were performed to determine differences in parameters before and after the programme. Spearman’s correlation analysis and chi-square test of independence were used to delineate any significant associations between different factors and the ability to return to work. Based on these tests, a multivariate logistic regression model was generated to ascertain the effect of factors on predicting ability to return to work. Results: 191 patients (26.2% female) with mean age 40.2 years were recruited. Up to 89.0% of patients had an injury on duty. There was significant improvement in ODI (46.9 to 43.9, p<0.05), SFSS (98.3 to 108.1, p<0.05), sitting (50.3 to 60.7, p<0.001), standing (40.2 to 46.6, p<0.001) and walking tolerance (50.7 to 59.1, p<0.001), and straight leg raising test (Right: 73.3 to 77.1, p<0.01; Left: 74.3 to 76.7, p<0.001). Psychological parameters also improved (AIS: 21.4 to 22.6, p<0.05; BABS: 0 to 4.3, p<0.001). However, their mood deteriorated (BDI: 17 to 19.5, p<0.05). After the programme, 41.9% of patients met their work demand. Our model showed that male patients were 5.9 times (p=0.17) more likely to meet work demand level as is initial job demand (p=0.002). Factors including change in sitting tolerance, VAS under exertion, mood, general psychological wellbeing and injury on duty status did not affect the ability to return to work. Discussion: This programme is effective in improving outcomes of patients with chronic LBP. There was significant improvement in physical tolerance of daily activities despite persistent negative cognitions and low mood. However, they were more accepting towards chronic LBP, and enjoyed better general wellbeing. Male patients with higher job demand were more likely to return to their work. From our data, we have constructed a viable tool to determine patients most suitable for this intensive rehabilitation programme.