CHRONIC BACK PAIN AND WORK DISABILITY - VOCATIONAL OUTCOMES FOLLOWINGMULTIDISCIPLINARY REHABILITATION

Studies indicate that work disabled chronic back pain patients out of work for longer than three months have a reduced probability of return ing to work. The escalating personal and economic costs (indemnity and health care) associated with such long term disability have facilitat ed efforts at multiple levels to prevent and more effectively manage w ork disability. Multidisciplinary rehabilitation (MDR) targeted at ret urn to work represents one such approach. The approach is based upon a multidimensional conceptualization of work disability and integrates medical, physical, psychological, educational and vocational intervent ions to increase physical function, reduce pain, increase stress copin g skills and facilitate return to work. Seven outpatient multidiscipli nary rehabilitation outcome studies for chronic back pain were identif ied that met the following selection criteria: 1) diagnosis of back pa in, low back pain, spinal disorder (specific and nonspecific diagnosis ), 2) chronic back pain of either longer than three months since injur y or longer than three months absence from work, 3) use of an outpatie nt multidisciplinary rehabilitation approach that included some combin ation of medical management, physical conditioning, pain and stress ma nagement vocational counseling/placement and education regarding back safety and health, and 4) work reentry was the primary focus of outcom e. These were reviewed to determine the effectiveness of MDR in terms of return to work outcome. Analyses revealed that an average of 71 per cent of work disabled chronic back pain patients who completed a multi disciplinary rehabilitation program were working or involved in vocati onal rehabilitation efforts at 12 month follow-up in contrast to an av erage of 44 percent in corresponding comparison groups. While these st udies suggest the clinical utility of a multidisciplinary approach as compared to usual care in facilitating return to work for chronic back pain patients, the literature was characterized by several methodolog ical limitations including the absence of randomization in the majorit y of studies, use of insurance company denials as control groups, hete rogenous samples in terms of duration of work disability job availabil ity at discharge, extent of impairment and disability, age and duratio n of pain disorder, lack of specification as to exact treatment delive red in the control or usual care groups and varying definitions of ret urn to work outcome Research on predictors of return to work outcome f ollowing MDR were identified and included variables in five categories : demographics, medical history, physical findings, pain and psycholog ical characteristics. The literature provides support for the use of i ntegrated approaches that target the medical, physical, ergonomic and psychosocial factors that can exacerbate and/or maintain work disabili ty. Future research should address current methodological limitations in the literature and focus on: 1) identifying critical treatment comp onents of such approaches, 2) developing innovative screening methods to identify high risk cases to facilitate earlier more targeted effort s to assist such individuals, and 3) consider variations in the stagin g of various combinations of interventions in an effort to develop mor e cost-effective variations in the multidisciplinary approach.