Advances in Applied Sociology
2013. Vol.3, No.2, 106-113
Published Online June 2013 in SciRes (http://www.scirp.org/journal/aasoci) http://dx.doi.org/10.4236/aasoci.2013.32014
106
Return to Work and Painkiller Medication after Rehabilitation
for Subacute Back Conditions
—A 2-Year Follow-Up
Annalisa Gison*, Loredana Bruti, Valentina Dall’armi, Enzo Palma, Salvatore Giaquinto
IRCCS Rehabilitation Institute San Raffaele Pisana, Rome, Italy
Received May 1st, 2012; revised March 24th, 2013; accepted April 2nd, 2013
Copyright © 2013 Annalisa Gison et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
The study was aimed at evaluating the outcome after 2 years in a population of outpatients suffering from
Low Back Pain (LBP) who were treated with a multi-disciplinary approach. The end-points were: 1) the
rate of return to work (RTW); 2) the frequency of painkiller medication; 3) the frequency of unavoidable
surgical operation; 4) the rate of relapses. Eighty consecutive subjects (75% women) were enrolled. They
were referred by general physicians and completed the rehabilitation program at our centre. We followed
an open, prospective design. The main results were: RTW: 92.5% positive cases; 7.5% failure. Job cohort
settlement: 93.1% the same; 6.9% change. Time interval between discharge and RTW: 76.8% few days
after discharge. Painkillers: At follow-up 46 participants (57.5%) could stop the medication. Surgical op-
erations: At admission 39 participants presented with lumbar root involvement (48.7%). Only 4 of them
had a surgical intervention (10.2%). In a third of cases of the all sample relapses did not occur. In con-
clusion, a multi-disciplinary model of intervention led to a high rate of RTW, a reduction of painkiller
medication, a low rate of surgical interventions and of relapses as well. Further controlled studies are
warranted for assessing the cost/benefit ratio. The clear prevalence of LBP in women recommends meas-
ures of preventing Medicine.
Keywords: Low Back Pain; Postural Rehabilitation; Work
Introduction
Low back pain (LBP) affects approximately 80% of adults at
some time in life (Deyo, 1996) and occurs in all ages (Hart-
vigsen, 2008; Jensen, 2011). Observations indicate an annual
prevalence of symptoms in 50% of the adult working age and
15% - 20% of these are addressed in the care of the occupa-
tional physician. LBP occurs most often between 30 and 50
years of age. For people under 45 years of age, LBP is the most
common cause of disability. Pain and rigidity are the main
symptoms. These ones account for disability and lack of par-
ticipation. LBP is considered as a benign and self-limiting con-
dition. Yet, recurrence happens frequently with a small risk of
developing into a chronic condition (Croft, 1998). Long-term
sick leave is common among primary care patients with mus-
culoskeletal pain. Physical functioning and return to work
(RTW) after one year are poor (Atroshi, 2002).
Despite the post-industrial economy is less and less heavy for
the worker for increased automation of the production cycle
and medicine has developed much capacity for diagnosis and
treatment, the inability to work caused by LBP increases con-
stantly. Despite billions being spent on various diagnostic and
treatment approaches, the prevalence and disability related to
LBP has continued to increase (Deyo, 2009). LBP has an
enormous impact on individuals, families, communities, gov-
ernments and businesses throughout the world (Hoy, 2010). In
Italy where this research has been carried out 8.2% of the Ital-
ian population in 1999 suffered from LBP (ISTAT, 1999) and
13.5% reported regular use of analgesics or nonsteroidal
anti-inflammatory drugs (NSAIDs) in the two weeks preceding
the onset of LBP (Juniper, 2009). The economic burden of LBP
is of considerable relevance. In USA, the costs are estimated to
be $50 billion per year (Frymoyer, 2010). The cost of LBP in
The Netherlands in the nineties was estimated to be 1.7% of
gross national product, 93% of the cost was due to sick leave
and disability (Van Tulder, 1995). The annual direct costs of
LBP in Germany are estimated over €7000 per person. Sick
leave at work accounted for 75% of the total cost per patient for
LBP (Juniper, 2009). Neverthe- less, other authors support the
concept that treating LBP is cost- effective (Moffett, 1999).
The specific cause of LBP is unidentified in many subjects in
spite of refined diagnostic tools. An estimated 85% of subjects
have a diagnosis of unspecified LBP, which is interpreted as a
multi-factorial condition (Gore, 2011). Over 100 risk factors
have been identified (Cole, 2003). They are related to muscu-
loskeletal problems due to mechanical, inflammatory, degen-
erative, infective or neoplastic causes. Early evidence also
points to a genetic predisposition to lumbar disk disease (Paas-
silta, 2001). In recent years there has been a movement away
*Corresponding author.

A. GISON ET AL.
from the biomedical model for understanding the LBP experi-
ence toward a bio psychosocial model (Jones, 2002; Waddell,
2004). That is, LBP has increasingly been recognized as in-
volving somatic, neurophysiologic and psychological factors
that all contribute to the clinical picture clinicians encounter
(Deyo, 2009). Many environmental and personal factors influ-
ence the onset and course of low back pain. Other commonly
reported risk factors include low educational status, stress,
anxiety, depression, job dissatisfaction, low levels of social
support in the workplace and whole-body vibration (Hoy, 2010).
Although various occupational physical activities are suspected
of contributing to LBP, causal relationships have not been con-
firmed, complicating adjudication of work injuries, RTW in-
structions and preventive efforts. This may be related to insuf-
ficient or poor quality scientific literature, as well as the diffi-
culty of establishing causation of LBP. These population-level
findings do not preclude the possibility that individuals may
attribute their LBP to specific occupational physical activities
(Heneewer, 2011).
According to back school there is moderate evidence sug-
gesting that the treatment is beneficial in an occupational set-
ting, in the short and intermediate-term, compared to other
physical intervention, placebo or waiting list controls (Heymans,
2005). Exercise therapy appears to be slightly effective at de-
creasing pain and improving function. In sub-acute LBP there is
some evidence that a graded activity program improves sick
leave, though evidence for other types of exercise is unclear
(Hayden, 2005). However, there is a poor correlation between
the high number of physical interventions, which can be of
potential benefit, and the Evidence Based Medicine. First of all,
a number of articles find no evidence of their efficacy for acute
LBP (Hayden, 2005; Schonstein, 2003). Meta-analytic studies
provide a weak evidence of effectiveness. Most treatments for
chronic LBP provide poor results and the benefits can be just
transient (Cohen, 2008). In general, randomized controlled
trials (RCT) concerning RTW have failed to demonstrate sig-
nificant treatment effects for long-lasting musculoskeletal pain,
and most treatments have not been economically beneficial
(Haldorsen, 2002). Recent studies suggest that a psychosocial
intervention can lead to meaningful reductions in psychosocial
risk factors for pain and disability and may contribute to more
positive rehabilitation outcomes (Sullivan, 2010; Stapelfeldt,
2011; Middelkoop, 2011; Zampolini, 2007).
Research Ques tion and Aim
The present article summarizes the experience obtained from
a population of outpatients suffering from LBP and referred by
general physicians. A multidisciplinary intervention was ap-
plied (Giaquinto, 2010). The study was mainly aimed at evalu-
ating: 1) the rate of RTW and its interval; 2) the length of
medication usage; 3) the rate of surgical interventions on en-
trapped roots; 4) the rate of relapses.
Methods
Participants
Study design: open prospective study. The Ethical Commit-
tee approved the study. The participants gave the informed
consent. Eighty consecutive subjects suffering from subacute
LBP were enrolled after selection. Sixty participants were
women (75%). The mean age was 48 years (sd 9.1). They had
12 years of education (sd 4.1). The group included 36 white-
and 24 blue collars, 14 housewives, 4 retired and 2 unemployed
persons. Full-time job occurred in 67.2% of cases; 29.3% part
time; 3.4% timeless job. They were referred by general physi-
cians operating in the district and completed the rehabilitation
program. The inclusion spanned over 16 months. The range of
disturbance duration at program initiation was more than four
weeks but less than three months. A physician and a physio-
therapist provided detailed assessment of the participants’ his-
tory, pain, and physical check (including posture). Neuroimag-
ing at lumbar segment (either CT-scan or MRI) and EMG were
performed only in those participants complaining of irradiation
or presenting with clinical worsening.
Inclusion Criteria
Subjects suffering from subacute LBP were enrolled.
Exclusion Criteria
Cognitive and sensory impairment, lack of compliance, neu-
rological diseases, multiple myeloma or malignant tumours,
spondilytis, ankylosis, Paget disease, severe comorbilities and
malingering.
Measures
Socio-demographic data, job description, vitality indexes
(driving, sport, dance), medication usage and relapses were
recorded. The following scales were administered:
1) Mini Mental Scale for cognitive function (Folstein, 1975).
The cut-off of 24/30 was applied;
2) Cumulative Illness Rating Scale (Linn, 1975), which is an
ordinal scale, where each item can be scored from 1 = normal
to 5 = life-threatening situation. Participants scoring above 3 in
any item and those having a Comorbidity Index above 3 were
not included;
3) Oswestry Low Back Pain Disability Questionnaire (Fair-
bank, 2000). This questionnaire has been designed to give the
physical therapist information about back pain and the ability to
manage in everyday life. Index Score = Sum of all statements
selected dived by the numbers of selections with a statement
selected × 5) × 100. A recent survey recommends the scale
(Frost, 2008);
4) Trunk Control scale (0 = no control; 100 = normal) (Fran-
chignoni, 1997);
5) Motricity Index (0 = paralysis 100 = normal) (Demeu-
risse, 1980);
6) Visual-Analogue Scales was finally used to record pain
intensity (Huskisson, 1976). The scale ranges from 0 (no dis-
tress) to 10 (unbearable distress).
Information on whether patients returned to work after the
rehabilitation (RTW), LBP disability and pain intensity were
also recorded after 2 years from discharge.
Interventions
The rationale of Interventions has been already presented by
us in details (Giaquinto, 2010).
A short description is presented herewith.
The program for the present study included 3 hours of reha-
bilitative treatment three times a week, for 16 sessions. A com-
prehensive bio-psycho-social approach was followed. The pro-

A. GISON ET AL.
108
gram included:
1) Group therapy. After a warm-up a group therapy up to 8
participants performed free and progressively loaded exercises
of trunk, 1 minute each, involved both abdominal, para-verte-
bral and pelvic floor muscles under the supervision of a physic-
cal therapist. The session also included a light stretching of stiff
muscles: in other words, a biological girdle, for reducing the
pressure upon the lumbar disks. A mirror provided visual feed-
back. The intensity of the exercises was progressive over the 16
treatments with participants being invited to improve their own
performance without any competition. Short relaxation sessions
took place every 10 minutes, i.e. every block of 10 exercises.
2) Global postural retraining according to a motor control
approach was developed on the principle that participants with
LBP have a lack of control of the trunk muscles. A motor
learning approach retrained the optimal control and coordina-
tion of the spine. The intervention involved the training of pre-
activation of the deep trunk muscles, followed by more com-
plex static, dynamic, and functional tasks. Again, a tutorial
approach helped the proper contraction of superficial and deep
trunk muscles for an integrated activation. The difficulty of the
tasks was increased over time. The treatment was individually
tailored and lasted about 45 minutes.
3) Counselling and emotional support. A physician provided
participants with information on anatomy and physiology of
spine in order to improve awareness, perceived health and per-
ceived ability to perform physical tasks. A psychological ap-
proach prompted encouragement of skill acquisition, use of
pacing, setting progressive goals, confidence of progress, and
positive reinforcement of progress. The psychologist fostered
expectations, fear-avoidance, and inner locus of control. Indeed,
reassuring participants was supposed to ameliorate favourable
subjective evaluation. Participants were encouraged to exercise
at home at least once a day, to be active and to incorporate ex-
ercise into their daily activity. Leisure activities were recom-
mended. Encouraging participants to engage in problem solving
to deal with daily difficulties was supposed self-reliance.
4) Description of the workplace. In recent years there is an
increasing discussion of internal and external barriers and fa-
cilitators about RTW in patients suffering from chronic LBP as
introduced by ICF. In fact recent studies identify barriers such
as despair, lack of supervisory support in workplace system,
waiting period and long during medicalization in Healthcare
System. Always these studies identify some facilitators such as
tailored exercises and thorough protocol communication proc-
ess. A workplace visit is recommended because the treatment
effectiveness increases (Karjalainen, 2003).
When a workplace visit was difficult, information about self-
assessed work ability, and self-predicted absence status was
collected. Indeed, the information can be predictor of time until
RTW in participants with LBP certified as sick who attend a
back disorder outpatient clinic (Reiso, 2003).
After 2 years the participants were invited to a new complete
check.
Statistics
Frequencies of socio-demographic information and summary
statistics (n, mean, standard deviation (sd), minimum, 25th per-
centile, median, 75th percentile and maximum) were calculated.
Correlations were also estimated between all parameters meas-
ured on a continuous scale. The long-term effect of the reha-
bilitation on the disability and on the pain intensity was tested
by means of a linear regression, so as to estimate the impor-
tance of all covariate information (age, gender, education, type
of job, RTW) and the presence of gender-by-age and gen-
der-by-RTW interactions. All analyses were adjusted for base-
line scores. Motricity Index and Trunk Control were not in-
cluded in the model.
Results
Descriptive Statistics
The sample comprised 60 females (75%) and 20 (25%)
males, for a total of 80 participants all suffering from LBP.
Their mean age was 47.5 yr (sd 9.1, range 27 - 72). The mean
education was 11.8 yr (sd 4.1, range 3 - 26). Most patients lived
with their spouse (67.5%) and 11.2% lived alone. The majority
was married (61.2%), a good proportion were single (23.7%)
and some declared to be separated or divorced (12.5%).
Almost all participants returned to work (92.5%). The per-
centage included housewives, retired and 2 unemployed per-
sons. In these cases RTW meant housekeeping, gardening,
shopping, pet care. Job settlement was the same in 93.1%;
changed in 6.9% (formerly jobs: 1 full time warehouse-keeper,
1 part time nurse, 1 part time servant; 1 part time gym trainer
and 1 truck driver).
Four subjects scored 0 on disability at the follow-up visit and
16 scored zero on the VAS, declaring a complete lack of dis-
tress.
The mean percentage of disability was reduced by appro-
ximately 15% by the follow-up visit and an improvement was
also observed for the intensity of pain, which decreased by 3
points by the last visit. All relevant summary statistics are pro-
vided in Table 1.
Table 1.
Summary statistics for disability and pain intensity.
Minimum 25th Percentile 50th Percentile 75th Percentile Maximum
Disability 18.00 22.00 32.00 40.00 60.00
Baseline
Pain Intensity 5.00 6.00 7.00 8.00 10.00
Disability 0.00 10.00 17.00 26.00 60.00
Follow-Up Pain Intensity 0.00 1.00 4.00 6.00 10.00
Disability −32.00 −20.00 −14.00 −8.00 0.00
Difference from Baseline Pain Intensity −9.00 −5.00 −3.00 −1.00 4.00

A. GISON ET AL.
A strong positive correlation emerged between 1) the change in
pain intensity and the baseline level of disability (r = 0.30, p =
0.01), 2) the baseline pain intensity and the baseline disability
level (r = 0.61, p < 0.01). Moreover, a strong negative correla-
tion was found between 1) the change in disability and the
baseline pain intensity (r = −0.30, p = 0.01); 2) the baseline
disability and the number of years of education (r = −0.30, p =
0.01); 3) the baseline pain intensity and the number of years of
education (r = −0.23, p = 0.04); 4) the age and the number of
years of education (r = −0.39, p < 0.01). The analysis of corre-
lation output is provided in Table 2.
The fitted model (Table 3) explained 68% of the total vari-
ability in the data. Disability level significantly changed from
pre- to post-rehabilitation (time effect: p < 0.01). No other con-
sidered covariate was significantly associated to the disability
level, nor an interaction between gender and age or RTW
emerged. The p-values refer to the effect of each covariate ad-
justed for the presence of all other covariates. Statistical sig-
nificance: p < 0.05 (Table 3).
The fitted model explained 40% of the total variability in the
data (Table 4). Pain intensity changed significantly from pre- to
post-rehabilitation (time effect: p < 0.01). No other considered
covariate was significantly associated to the pain intensity, nor
an interaction between gender and age or RTW emerged. The
p-values refer to the effect of each covariate adjusted for the
presence of all other covariates. Statistical significance: p <
0.05.
Work was stopped during treatment. The mean time interval
between discharge and RTW was 6 days after discharge
(76.8%). Longer intervals occurred as 2 - 3 months (a ware-
house-keeper, a clerk); 6 months (a graphic artist); 1 year (a
truck driver).
Summing up, strong evidence was found in favour of an im-
provement of disability and pain intensity, whereas no other
main effects or interactions emerged.
Pain Killers
The most frequently used painkillers were ASA and di-
clofenac: At follow-up 46 participants (57.5%) could stop the
medication and took no painkillers at all. By contrast, 20 par-
ticipants (25%) maintained medication. Seventy percent of
them were women. However, 3 participants reported a lesser
usage than before. The free interval after discharge had a me-
dian value of 2 months (range 0 - 12). Finally, 14 participants
did not use painkillers either before the admission or after dis-
charge. The frequency of use was variable in consumers, gen-
erally every 2 weeks. Daily medication was found in 2.5% of
cases.
Surgical Operations
At admission 39 participants presented with signs of com-
pressed spinal root, that was confirmed by EMG (48.7%). Only
4 of them had a surgical intervention (10.2% of the sub-group,
5% of the total sample). A participant was operated twice. The
conservative therapy failed in one full-time school caretaker, 1
full time janitor, 1 full time clerk, 1 full time truck driver.
Relapses
Moderate relapses occurred in 53.7% (work and ADL gener-
ally continued); 12.5% very moderate; 33.7% never. The re-
lapse interval was 30.5% after 1 year; 48.1% between 2 and 8
months; 11.7% after 1 month; 5.8% after 2 - 3 weeks. Steady
pain in 3.9% of cases. When relapses occurred, the participants
used painkillers and did not return to the rehabilitation centre.
Modified Environment
No modification occurred in73.7%; of cases. Modified shoes,
bed, pillow and mattress occurred in the other cases.
Radiological E xami nations after Disch arg e
There was no examination in 68.8% of cases, 1 time in
23.7%, 2 times in 7.5%.
Sport
No sport was found in 66.2% of cases. By contrast swim-
Table 2.
Correlations between baseline disability and pain intensity, difference from baseline disability and pain intensity, age and education.
Disability Pain IntensityDisability BaselinePain Intensity Baseline Age Education
Difference from Baseline Disability 1.00
0.15 1.00
Difference from Baseline Pain Intensity0.18
−0.22 0.30 1.00
Disability Baseline 0.05 0.01
−0.30 −0.02 0.61 1.00
Pain Intensity Baseline 0.01 0.84 <0.01
0.07 0.01 0.10 −0.03 1.00
Age 0.56 0.91 0.37 0.78
0.06 −0.11 −0.30 −0.23 −0.39 1.00
Education 0.58 0.32 0.01 0.04 <0.01
Note: Bold Characters: statistical significance.

A. GISON ET AL.
Table 3.
Selected output from the linear regression analysis of the difference
from baseline disability level.
df F p
Time 1 292.51 <0.01
Gender 1 0.11 0.74
Age 1 0.14 0.71
Education 1 0.92 0.34
Job 4 1.82 0.13
RTW 1 0.00 0.95
Disability Baseline 1 3.78 0.05
Gender × Age 1 0.04 0.84
Gender × RTW 1 0.40 0.53
N 159 R^2 0.68
Variance 5.44 R^2 Adjusted 0.65
Table 4.
Selected output from the linear regression analysis of the difference
from baseline pain intensity.
df F p
Time 1 88.97 <0.01
Gender 1 1.31 0.25
Age 1 0.36 0.55
Education 1 3.94 0.05
Job 4 0.72 0.58
RTW 1 0.50 0.48
Pain Intensity Baseline 1 0.06 0.80
Gender × Age 1 1.17 0.28
Gender × RTW 1 0.41 0.52
N 160 R^2 0.40
Variance 2.02 R^2 Adjusted 0.35
ming, gym, racing, tennis; bike and motorbike were reported by
the other participants.
Driving Vehicles
The majority (83.8%) of participants drove a car or a motor-
bike. No driving occurred in 16.2%.
VAS and Oswestry Disability Rating at Follow-Up
The questionnaires at the 2-year follow-up gave the follow-
ing results:
1) RTW group: “Last week” median VAS: 3; “Now”: 3. Me-
dian Oswestry disability rating 16.
2) Failed RTW group: “Last week” median VAS: 5; “Now”:
5. Median Oswestry disability rating 36.
Discussion
The study has a cohort prospective design. The lack of a
control group places several limitations for concluding that the
multidisciplinary intervention model is cost-effective. It is eas-
ier to describe RCT than to prescribe in a rehabilitation setting.
At least in our settlement, outpatients suffering from LPB com-
municate among them and share opinions about their painful
experience. If the A treatment were more effective than the B
treatment, the patients belonging to the latter group would call
for the shift to the A group. The same may happen if we had
matched a treatment against a shorter version of itself. For ex-
ample, the psychological support was very appreciated by the
participants. Ethically, any shift to the more favourable treat-
ment can not be denied. The cross-over of participants would
clearly reduce the strength of recruitment.
Nevertheless the follow-up at 2 years of participants suffer-
ing from sub-acute and non-specific LBP provided information
of general interest. We could exploit the results of the last dec-
ade of physical therapy, being several of them obtained from
RCT studies including housewives. RTW occurred in a very
high percentage of our participants. Several factors account for
the favourable results, although the multidisciplinary design
does not allow the weight of each single intervention.
1) Early multimodal rehabilitation is important (Westman,
2006). Participants who are referred earlier have a more likely
RTW (Ehrmann-Feldman, 1996). The duration of the current
episode is also a stable predictor of prognosis in LBP (Bekker-
ing, 2005).
2) General exercise followed by Motor Therapy that was
successfully applied in controlled studies (O’Sullivan, 1997;
Macedo, 2009). It was determined for each exercise how phy-
sically active the participants were, how intense LBP was, and
was the ability of the participant to perform the exercises. Par-
ticipants were then taught the exercises and advised of the in-
tensity at which they had to exercise. Training included the
recruitment of deep muscles of the spine and reduced activity of
other muscles. The exercises aimed at improving function of
specific trunk muscles thought to control inter-segmental move-
ment of the spine.
3) Counselling. Basic knowledge of anatomy and physiology
of spine was appreciated by participants at the first phase of
counselling. We also exploited suggestions from other studies,
such as perceived ability to work again, and activity advice. A
physiatrist provided the proper advice to avoid postural errors
at work and indicated specific movements according to situa-
tions.
4) Psychological support. The fear of no-recovery should be
actively overcome (Karjalainen, 2004; Dionne, 2007). Reas-
surance, counselling are effective in many cases of acute, non-
specific LBP, which resolve in a positive way. Psycho-logical
support is an important step in our model. It reinforces the so-
called internal Locus of Control (LOC). Individuals with inter-
nal LOC expect to manage the outcome, while individuals with
external LOC expect that other, external factors affect outcome
(Selander, 2005). The expectancy might predict the future ac-
tivity. In alleviating pain, the intervention was most effective
among the participants with a high-perceived risk of failure
110

A. GISON ET AL.
(Karjalainen, 2003; Karjalainen, 2004). A meta-analysis indi-
cates that expectation is predictive of work outcome (Iles,
2008). Benefit was observed in those candidates who had high
scores on fear and low scores on function. The exposure treat-
ment is based on the pain-related fear model and as a result
improvements in function are expected to be related to changes
in fear and cognitions. Our linear Regression Analysis of the
change of Pain Intensity over time gave importance to Educa-
tion, whereas this variable was not relevant when disability was
considered. Graded exposure in vivo is a new, specific, cogni-
tive-behavioural treatment that is especially tailored to patients
with high levels of pain-related fear. Overall exposure has
moderate effects on function, fear and pain intensity and should
go in parallel with physical therapy (Linton, 2008). On this
basis we exploited the exposure and included work situations
with specific movements.
Although it is unsafe to compare data from different socio-
economical backgrounds, a survey in Norway found that about
35% of patients returned to work after 1 month, 70% had re-
turned after 3 months, and 85% had returned after 6 months.
(Hagen, 1998). Intensive reconditioning programs for LBP
participants had the following effects on RTW status after 1
year. On the basis of 109 questionnaires 57 patients (52.3%)
were working, 39 (35.8%) full time and 18 (16.5%) part time.
The remaining 52 patients were on disability leave. All partici-
pants had followed a physical reconditioning program 12
months earlier. The program included 6 h of physical and oc-
cupational therapy each day, 5 d a week for 3 weeks (Casso,
2004). Psychological support was not considered in those stud-
ies. The model that we applied prompted RTW in 92.5% of
cases at retest.
Strangely indeed, medication usage is rarely discussed in ar-
ticles on LBP, although pain-related medications are widely
prescribed (Gore, 2011). Several participants still experienced
some pain at 12 months follow-up (Bekkering, 2005). RTW
and no medication were found in another study (Iles, 2008).
During pain episodes, participants had significantly greater
disability and higher medication use (McGorry, 2000). In our
sample 66% of participants regularly used painkillers at admis-
sion. By contrast, 75% of participants had completely stopped
medication at follow-up. The medication withdrawal turns out
in both a financial saving and a removal of risk factors for gas-
tro-intestinal diseases.
Gender is an important issue in LBP. In our study women
accounted for 75% of the sample but linear regression failed to
indicate a significant relationship between outcome and gender.
In a very large sample in Norway (Hagen, 1998) the estimated
overall 1-year incidence was 2.2%. It was significantly higher
for women (2.7%) than for men (1.9%). Lifting activities in
house holding, heels and pregnancy are significant risk factors.
Indeed, an increased risk of relapse exists in case of jobs re-
quiring lifting, pulling or pushing objects >25 lbs. Prolonged
periods of standing or walking may have the same effect. Risks
are, in general, greater in women, for a first ever episode of
LBP (Heymans, 2005; Macfarlane, 1997). On the other hand,
differences of outcome after therapy still exist. A full-time be-
havioural medicine program was particularly effective in fe-
males, whereas rehabilitating men had no significant effect on
either health or costs (Jensen, 2005). In men significantly better
results for full RTW were found for light multidisciplinary
treatment compared with treatment as usual, but no differences
were found between extensive multidisciplinary treatment and
treatment as usual. No significant differences between any of
multidisciplinary treatment programs and the controls were
found for women (Skouen, 2002). Other studies found no gen-
der-dependent length of sickness leave (Indahl, 1995). In wo-
men negative predictor was also the unsatisfaction with their
physician. In men negative outcome were connected with high
pain levels, decreasing age, cigarette smoking, low self-per-
ceived health status, pain in the thoracic area and previous sur-
gical intervention on spinal roots, lack of fiscal compensation
and perception of their under-qualified or unstable job (Dionne,
2007).
One may argue that spontaneous recovery accounts for pain
relief and functional recovery. However, spontaneous recovery
generally occurs after 2 - 3 weeks after the acute onset. Another
question may arise as to whether the intervention is cost-effec-
tive. Our intervention seems to provide a positive answer, if we
calculate the saving cost in sick leave, work slowing and a sav-
ing in painkiller cost with a decrease of diseases depending on
their chronic use. The estimated cost saving of providing the
extra service of a simple back program in UK ranged between
250 pound (367 US dollars, 300 euro) and 578 pound (850 US
dollars, 694 euro) for each patient. The results indicate that the
costs of this active back program are more than reimbursed as a
consequence of earlier RTW (Wright, 2005). Although treat-
ment programs are expensive, they can reduce pension expen-
ditures, sick leave days, health care contacts, and pain (Bendix,
1996). Last but not least, we found that only 10% of those par-
ticipants suffering from root compression at admission required
surgical intervention (5% of the total sample of LBP). One of
them was operated twice, a fact indicating possible adverse
effects from surgical intervention. Thus, conservative treatment
minimizes the risk of expensive surgical procedures. The ma-
jority of our participants (over 90%) had RTW after few days
from discharge without changes in the job settlement. Possible
predictive factors from a backward selection procedure are:
self-predicted timing of RTW, pain intensity, job satisfaction,
social support, pain radiation, expectations of treatment success
of the occupational physician. Demographic, work, LBP and
psychosocial related factors improve the prediction of long-
term sick-leave. The prediction should be always careful (Hey-
mans, 2009). For a proper cost-benefit one should treat partici-
pants with musculoskeletal pain to the right level of intervene-
tion (Haldorsen, 2002). Quantitative information on the effect
of ergonomic interventions on RTW leads to conclusion that
intervention after 60 days, in the sub-acute phase of back pain,
shows the most promising results (Elders, 2000).
The factors influencing RTW are related to the individual
(such as age, education, pre-injury employment), the spine
impairment and function, the environment (culture, legislation,
services) and the workplace. Meta-analysis fail to show strong
indications of efficacy, but their conclusions can be jeopardized
by the different social milieu of Countries where observations
were done. In our opinion, the generalization of results is lim-
ited by a political and financial context. This is particularly true
for LBP. For example, even in our same Country, Italy, the
treatment varies according to geographical areas, based on the
availability of resources. Finally, we have to discuss the rela-
tively lack of weight of the Job factor in our linear regression
analysis. Class distinction between labourers and clerks is ob-
solete. Today, many labourers operate computers from a con-
sole to check the progress of industrial production. On the other
hand, store clerks are often on their feet, lifting heavy weights

A. GISON ET AL.
and moving constantly.
Conclusion
There is moderate scientific evidence in Literature showing
that multi-disciplinary rehabilitation, including a workplace
visit or more comprehensive occupational health care inter-
ventions, helps RTW with fewer sick leaves and alleviates sub-
jective disability. We have applied a multi-disciplinary model
of intervention on 80 participants and observed a high rate of
RTW, a reduction of painkiller medication, a low rate of surgi-
cal intervention and of relapses as well. Thus, our observations
indicate that surgical operation is not the first choice of inter-
vention, unless there is a severe spinal root impairment. A
lesser usage of pain-killers prevents the side effects of medica-
tion and is beneficial for health-care financial resources. A
cohort prospective design was applied. Further controlled stud-
ies are warranted for assessing the cost/benefit ratio. The clear
prevalence of LBP in women recommends measures of pre-
venting Medicine.
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