From the Guidelines
Patients with subjective pain but no objective evidence of pathology can generally return to work with appropriate accommodations and support, as this approach is associated with improvement in health-related quality of life, reduction in work disability, and return to work 1. The decision should be based on a comprehensive assessment of the patient's functional capacity rather than solely on pain reports. Start with a gradual return-to-work plan, beginning with modified duties or reduced hours before progressing to full duties. Pain management during this transition may include non-pharmacological approaches such as exercise, multidisciplinary rehabilitation, acupuncture, or mindfulness-based stress reduction, as recommended for patients with chronic low back pain 1. Some key points to consider when returning a patient to work include:
- Gradual return to work to avoid exacerbating the condition
- Modified duties or reduced hours to ease the transition
- Regular follow-up appointments to monitor progress and adjust the plan as needed
- Encouragement of non-pharmacological approaches for pain management
- Workplace ergonomic assessments to reduce the risk of further injury This approach recognizes that pain without objective findings is still legitimate and that work participation often improves recovery outcomes through maintaining physical activity, social connections, and purpose, which can actually reduce pain perception and prevent disability through deconditioning. Key benefits of returning to work include:
- Improvement in back-specific and overall function
- Reduction in work disability and return to work
- Global improvement
- Patient satisfaction
- Adverse effects reduction As stated in the guideline, clinicians and patients should select nonpharmacologic treatment with superficial heat, massage, acupuncture, or spinal manipulation for acute or subacute low back pain, and exercise, multidisciplinary rehabilitation, acupuncture, or mindfulness-based stress reduction for chronic low back pain 1.
From the Research
Returning to Work with Subjective Pain and No Objective Evidence of Pathology
- There is limited direct evidence to support returning a patient to work with subjective pain and no objective evidence of pathology 2, 3.
- However, studies suggest that cognitive behavioral therapy (CBT) and other psychologically based interventions can be effective in managing chronic pain and improving functioning, even in the absence of objective evidence of pathology 4, 5, 6.
- These interventions aim to target pain-related fears, cognitions, and behaviors, and can be delivered in primary care settings or by physical therapists 4, 5.
- Mediation and moderation analyses have identified specific treatment targets, such as pain-related fear, catastrophizing, and self-efficacy, that can mediate the effects of CBT on disability and pain intensity 6.
- While the evidence is not directly applicable to returning to work, it suggests that addressing psychological and behavioral factors can be an important component of managing chronic pain and improving functioning, even in the absence of objective evidence of pathology 4, 5, 6.
Considerations for Returning to Work
- The decision to return to work should be based on a comprehensive assessment of the individual's functional abilities and limitations, as well as their psychological and social factors 2, 3.
- A multidisciplinary approach, involving healthcare providers, physical therapists, and other stakeholders, may be necessary to develop a plan for returning to work that takes into account the individual's unique needs and circumstances 4, 5.
- Further research is needed to develop evidence-based guidelines for returning to work with subjective pain and no objective evidence of pathology 2, 3.