Return to work and work disability in chronic pain

The workplace is the active ingredient: interventions delivered at or with the workplace speed return to work for musculoskeletal pain, and a worker's own low expectation of returning is a strong, modifiable predictor of long-term disability.

1. Workplace interventions shorten time off. A Cochrane review of 14 trials found workplace interventions improved time to first return to work versus usual care (HR 1.55, moderate quality) and reduced cumulative sickness absence (high quality) ¹.
2. The effect is clearest in musculoskeletal disorders. In that subgroup, workplace interventions shortened time to both first and lasting return to work and modestly improved pain and function ¹.
3. Expectations predict outcome. In an individual-participant meta-analysis of 2302 workers with low back pain, positive return-to-work expectations doubled the adjusted odds of returning and predicted a shorter time to return ².
4. Low expectations mark high risk. The authors conclude that workers with low expectations for return to work are at increased risk for long-term work disability, so expectations deserve direct attention ².
5. Physical conditioning helps when tied to work. For subacute back pain, intense conditioning added to usual care gave conflicting results, but programs at the workplace or including a workplace visit may have reduced sickness absence at 12 months ³.
6. Timing matters. For acute back pain, light or intense conditioning made little or no difference to sickness absence at 3–12 months compared with usual care ³.

Ask workers directly whether they expect to return: expectations stayed predictive after comprehensive adjustment for other prognostic factors, and low expectations flag the people most at risk of long-term disability ².

• Workplace interventions include adapted duties and case management involving the employer ¹.
• In musculoskeletal subgroups, the hazard ratio for lasting return to work was 1.77 (moderate quality) ¹.
• One included study found recurrences of sick leave favoured usual care, so benefits are not uniform ¹.
• Unadjusted, positive expectations nearly tripled the odds of return to work (OR 2.95) ².
• Light physical conditioning was defined as at most five sessions; intense programs exceeded five, up to full time or inpatient ³.
• Cognitive behavioural therapy was probably not superior to physical conditioning for return to work ³.
• For chronic back pain, conditioning within integrated care management may have reduced sickness absence days at 12 months (one study, low quality) ³.
• Overall, physical conditioning's effect on sick leave versus usual care or exercise therapy remains uncertain ³.

• Prescribing generic conditioning for acute back pain to speed return to work ³.
• Treating a worker's belief that they will never return as fixed rather than modifiable ².
• Assuming every workplace program reduces recurrence of sick leave ¹.