Back pain rehabilitation and prognosis

While back pain is unlikely to lead to permanent disability, significant pathology may affect future fitness for military service, police service and firefighting.  Lumbar disc prolapse is often cited as a significant problem, however in many cases it is asymptomatic, and in cases where discectomy is needed a full recovery is expected with a return to normal activity (Dollinger et al., 2008).  Few individuals fail to recover, and failure to recover is often linked to complex psychosocial issues.  More significant problems are associated with more complex spinal surgery, particularly decompression and fusion for conditions such as spinal stenosis, which may be complicated by disc prolapse. 

Permanent disability in individuals with chronic back pain is not therefore automatic, and many will make a good functional recovery.  Some individuals may have a psychological barrier to returning to active lifestyles and active employment, but most of these should be capable of redeployment to more predictable employment that can include significant physical work.

A number of factors affect the rate of recovery and rehabilitation besides the underlying physical cause.  Individuals intending to litigate or in the process of litigation experience a much slower recovery (Anderson, 1987).  For this reason a number of rehabilitation clinics are reluctant to take litigants because they do not respond to treatment.  Smoking is also related to a slower recovery, as are a number of other psychosocial factors.

The main factor against successful rehabilitation is the development of illness behaviour and external factors reinforcing this behaviour, where secondary gain may be a key aspect (Fordyce et al., 1973, Tollison, 1991).  The effect of a spouse can be very significant when illness behaviour is supported, and others such as workplace colleagues can also have a major impact in encouraging illness behaviour and reinforcing potential secondary gain.  Although well-meaning, this may lead to a situation where the cause of an individual's pain is the reinforcing behaviour from spouse or colleagues rather than any initial injury.

Where the individual is caught in a 'downward spiral' of inappropriate coping mechanisms and illness behaviour, it can be extremely difficult to introduce a successful rehabilitation programme without a significant change to disrupt the spiral.  One factor that may achieve this change is the clear statement that the individual is either not eligible for ill-health retirement because the condition is not permanent, or that there is insufficient evidence to support an ‘injury on duty’ award.  Great care must be taken in analyzing the history, mechanism of potential injury and evidence to support your assessment, in order to avoid further reinforcing illness behaviour.

ANDERSON, J. A. D. 1987. Back pain and occupation. In: JAYSON, M. I. V. (ed.) The lumbar spine and back pain. Edinburgh: Churchill Livingstone.

FORDYCE, W. E., FOWLER, R. S., JR., LEHMANN, J. F., DELATEUR, B. J., SAND, P. L. & TRIESCHMANN, R. B. 1973. Operant conditioning in the treatment of chronic pain. Arch Phys Med Rehabil, 54, 399-408.

TOLLISON, C. D. 1991. Psychological concepts of pain. In: MAYER, T. G., MOONEY, V. & GATCHEL, R. J. (eds.) Contemporary conservative care for painful spinal disorders. Philadelphia: Lea & Febiger.