Abstract
Many factors have been linked to return to work after a back pain episode, but our understanding of this phenomenon is limited and cross-sectional dichotomous indices of return to work are not valid measures of this construct. To describe the course of “return to work in good health” (RWGH—a composite index of back pain outcome) among workers who consulted in primary care settings for back pain and identify its determinants, a 2-year prospective study was conducted. Subjects (n = 1,007, 68.4%) were workers who consulted in primary care settings of the Quebec City area for a nonspecific back pain. They completed five telephone interviews over 2 years (follow-up = 86%). Analyses linking baseline variables with 2-year outcome were conducted with polytomous logistic regression. The proportion of “success” in RWGH increased from 18% at 6 weeks to 57% at 2 years. In women, persistent pain, pain radiating to extremities, increasing job seniority, not having a unionized job, feeling that the physician did listen carefully and increasing fear-avoidance beliefs towards work and activity were determinants of “failure” in RWGH. In men, decreasing age, cigarette smoking, poor self-reported health status, pain in the thoracic area, previous back surgeries, a non-compensated injury, high pain levels, belief that job is below qualifications, likelihood of losing job, job status, satisfaction with health services and fear-avoidance beliefs towards work were all significant. RWGH among workers with back pain receives multiple influences, especially among men. In both genders, however, fear-avoidance beliefs about work are associated with failure and high self-efficacy is associated with success.
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Notes
“To stop working is to become poor” (man, horticulturalist). “You are forced to work to respect some economical standards” (man, horticulturalist). “You can’t stay at home. I have to take care of my family. Working is more rewarding than staying at home, even if you are sick” (man, worker in a paper mill). “Supervisors piss you off, it frustrates me; colleagues piss you off, make your life a living hell. When I retire in 2–3 years, I will still work, but in a much better environment” (man, wrapping clerk). “For me, my absence from work not only meant a loss of earnings, but also more debts and becoming poorer” (summary of 3–4 persons).
“Physicians don’t take us seriously. When they do, they can’t help us” (summary of 3–4 persons). “Nobody will do it for you” (summary of 3–4 persons).
(Centre Hospitalier Universitaire de Québec—CHUQ, Centre Hospitalier Affilié Universitaire de Québec—CHAUQ, CLSC Haute-Ville-des-Rivières, and Centre Hospitalier Affilié Universitaire Hôtel-Dieu de Lévis).
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Acknowledgments
The authors thank all the study participants, the staff of the Population Health Research Unit, and all the research assistants who worked on this study. Thanks also to the following physicians for their help with the recruitment of subjects: Dr. Stéphane Bergeron, Dr. Alexandra Dansereau, Dr. Georges Dufresne, Dr. Louis Larue, Dr. Natalie Le Sage, Dr. Jean Maziade, and Dr. Jean Ouellet. Special thanks to Julie Soucy, PhD, for her participation to the coordination of the study. This study was supported by a grant (#97-061) from the Quebec Institute for Occupational Safety and Health (Institut de recherche Robert-Sauvé en santé et en sécurité du travail du Québec—IRSST). CE Dionne and R Bourbonnais are Quebec Health Research Fund Scholars. This study was approved annually by the Ethics Committees of all the hospitals involved in the recruitment of participants. Footnote 3 It complies with current Canadian laws.
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Appendix
Appendix
List of constructs measured
Sociodemographic factors |
Age |
Current financial problems because of back pain |
Education |
Ethnic origin |
Gender |
Gross annual family income |
Living with spouse |
Maternal language |
Number of household members |
Number of children under 5 years |
Anthropometric factors |
Body mass index (kg/m2) |
Hand dominance |
Height |
Weight |
Health behavior factors |
Alcoholism |
Cigarette smoking |
Coffee/tea consumption |
Physical activity/sports when no pain |
Regular meditation or relaxation |
Sleep during past 2 weeks |
Usual sleep |
Clinical factors/back pain history |
Age at menopause |
Average pain, past 6 months |
Current functional limitations |
Current pain level |
Diagnostic category |
Duration of current episode at time of consultation |
Duration of pain, past 6 months |
Number of previous surgeries for back pain |
Number of days with pain since index consultation |
Number of times gave birth |
Pain radiating to upper or lower limb |
Previous back pain episode affecting work capacity—when? |
Reduction of daily life activities because of back pain, past 6 months |
Reduction of work capacity because of back pain, past 6 months |
Self-reported health status |
Self-reported type of back pain |
Site of pain |
Worst pain, past 6 months |
Years since onset of back pain |
Health services utilization |
Duration of index-consultation |
Number of visits to the same clinic during the past 12 months |
Number of hospitalizations for back pain during the past 12 months |
Perception that the doctor’s diagnosis of back problem is correct |
Satisfaction with health services since index consultation |
“The doctor asked you to undress for the physical examination of your back” |
“The doctor, physical therapist, or another health professional helped you learn exercises for your back to help in your recovery” |
“The doctor showed interest in you as a person” |
“The doctor asked about your lifestyle and stress that may affect your back pain” |
“The doctor discussed options with you, asked your opinion, and offered choices about the care of your back pain” |
“The doctor relieved any concern about the cause of your back pain” |
“Your visit to the doctor helped you feel that you could control your back pain” |
“You were treated like your back pain was an important problem, and not “all in your head” |
“The doctor listened carefully while you described your back problem” |
“The doctor took time to answer all your questions about your back pain” |
“The doctor asked you about your occupation and took time to give you advices” |
“Your doctor, physical therapist or another professional showed you how to work to protect your back from injury” |
Weight of the medical file |
Dramatization of diagnosis |
“The doctor asked you to get an X-Ray, CT-Scan, myelography, magnetic resonance imaging, or other radiological examination” |
“The doctor told you to stay in bed” – number of days recommended |
“The doctor asked you to schedule a check back visit” |
“The doctor mentioned that you might need surgery for your back problem” |
Occupational factors |
Adaptation of work environment is possible |
Change of job or employer in the past 12 months |
Company size |
Current financial compensation for back pain |
Days of sick-leave permitted without medical certificate |
Declared professional lesion |
Effort–reward imbalance (Siegrist’s model) |
Exposure to cold at work |
Job decision latitude (Karasek’s model) |
Job satisfaction |
Job seniority |
Job status at time of consultation (permanent/occasional or seasonal/self-employed/other) |
Likelihood of losing job during the next 2 years |
Number of days off-work or with modified duties or schedule, past 12 months |
Number of jobs |
Number of previous sick-leave (or modified duties or schedule) for back pain in the last 10 years |
Pace of work |
Physical demands of the job (sitting and standing, forward and lateral trunk flexion, rotation of the trunk, manipulation of charges, efforts made with tools, lifting or transportation of persons, whole body vibrations, physical strength) |
Previous financial compensation for back pain |
Psychological demands of work (Karasek’s model) |
Responsibility of household chores |
Satisfaction concerning possibilities of work adaptation |
Social support at work |
“Supervisor takes back pain seriously” |
Time to commute to work |
Unionized job |
“When did you modify work or stop working for the current episode” |
Work schedule (Full time/Part time) |
Work shift (Day/Evening/Night/Variable) |
Work status at time of consultation (At regular job/Completely off-work/Modified duties/Modified schedule/Job assignment) |
Psychological factors |
Aggressiveness |
Exposure to stressful events during the past 12 months (changed job for worse, divorced or separated, financial problems, got gravely sick, significant other got gravely sick, death of spouse, death of other significant other) |
Fear-avoidance beliefs-activity |
Fear-avoidance beliefs-work |
Health Locus of Control (internal, external, chance) |
Pain control strategies |
Psychological trauma before age 18 |
Self-efficacy with regards to work capacity |
Symptoms of depression |
Symptoms of somatization |
Social support outside work |
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Dionne, C.E., Bourbonnais, R., Frémont, P. et al. Determinants of “return to work in good health” among workers with back pain who consult in primary care settings: a 2-year prospective study. Eur Spine J 16, 641–655 (2007). https://doi.org/10.1007/s00586-006-0180-2
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DOI: https://doi.org/10.1007/s00586-006-0180-2