Secondary prevention of work-related disability in nonspecific low back pain: Does problem-solving therapy help? A randomized clinical trial.

Authors: van der Klink, J. J. L., Blonk, R. W. B., & Schene, A. H.
Year Published 2003
Publication The Clinical Journal of Pain
Volume 18
Number 2
Pages 87-96
Publisher Lippincott

Indirect costs such as absenteeism and disability pensions make up about 90% of the economic burden of low back pain (LBP).Moreover, total costs of back pain are not normally distributed.A relatively small group of patients with chronic LBP, approximately 10% to 25%, is responsible for about 75% of the economic burden of LBP. The development of effective interventions to prevent chronic work disability is high priority.


This article describes a secondary preventive intervention developed against the background of a biopsychosocial model of pain. The aim of this study was to determine whether Problem-Solving Therapy (PST) had value as an adjunct to behavioral graded activity in reducing number of sick days and facilitating return to work in employees with a new episode of sick leave due to LBP.


The study setting was an unnamed rehabilitation center in the Netherlands.


Study subjects were employed patients who were recently absent due to LBP, referred to the study by general practitioners, occupational physicians, or rehabilitation physicians. Eligibility criteria for study subjects were as follows: Age between 18 and 65 years, LBP for more than 6 weeks, on sick leave with LBP but no longer than 20 weeks, and no more than 120 days of sick leave during the last year.

Data Collection

Work status information was collected one week before the intervention, a half year after the intervention, and one year after the intervention. The classification was as follows: (1) 100% return-to-work; (2) part-time return-to-work; (3) no return-to-work; (4) 100% disability pension as a result of back pain; and (5) 100% disability pension not as a result of back pain. Sick leave data were obtained from employers. Other data included demographic information, measures of pain and functional impairment, and job satisfaction. Differences in work status were assessed by means of chi-square tests regarding work status one week before the intervention, and 6 and 12 months after the intervention. Multiple linear regression analyses were conducted to test whether days of sick leave differed by treatment condition.


Two treatment conditions were compared: graded activity plus problem-solving therapy (GAPS) and graded activity plus group education (GAGE). Group education was included in both groups.


There were no significant differences between treatment conditions before treatment. Six months after the intervention, most patients (73%) had a full return-to-work in both conditions. Seven percent versus 19% of patients did not return to work at 6-month follow-up in GAPS and GAGE conditions, respectively, which was not significant. The percentage of patients with 100% return-to-work after one year is 85% versus 63% in GAPS and GAGE conditions, respectively. At one-year follow-up more patients in the GAGE condition received disability pensions, as compared with patients in the GAPS condition (23% vs. 10%, respectively).


The results show that PST had supplemental effects, which became apparent 12 months after termination of the program. The introduction of problem-solving techniques, especially in a population of employees at risk for developing chronic disability, may be a promising innovation.

Populations Male & Female
Outcomes Return to work
Research Design Randomized Controlled Trials (RCTs)
Peer Reviewed Yes