Study Design. An intervention study by the medical advisers of a social security sickness fund on a mandatorily insured patient population after open discectomy for herniated lumbar intervertebral disc. The medical advisers were randomized into two groups: a control group (n = 30) and an intervention group (n = 30).
Objectives. To compare a rehabilitation-oriented approach in insurance medicine focused primarily on early mobilization and early resumption of professional activities with the usual claim-based practice.
Summary of Background Data. This study included 710 patients, with a mean age of 39.2 years, who underwent surgery for herniated lumbar disc.
Methods. Medical advisers in the rehabilitation-oriented group examined the patients monthly, starting at 6 weeks after the surgical intervention. They used a newly developed protocol to motivate the patients and treating physicians toward social and professional reintegration.
Results. At 52 weeks, 10.1% of the patients guided by medical advisers from the rehabilitation-oriented group had not resumed work in contrast to 18.1% of the patients in the control group. It was statistically proven that this effect also holds during the follow-up period.
Conclusions. A rehabilitation-oriented approach by the medical advisers of social security can increase the probability of a return to work for patients after lumbar disc herniation surgery. [Key words: intervention, lumbar disc herniation, outcomes, rehabilitation, return to work, surgery]
There is a persistent controversy about the duration and necessity for postoperation restriction of activities after a lumbar discectomy for herniated intervertebral disc. 3 Although many back researchers over the years have offered postoperation rehabilitation recommendations and prescribed physical fitness programs, there still are persistent fears of causing reinjury, reherniation, or instability. 12,13
According to Keel, 11 increasing physical inactivity and persistent disability and prolonged absence from work are biopsychosocial factors that may lead to the development of chronic low back pain. Additionally, from a controlled trial in 1993, it is concluded that a rehabilitation program of intensive exercises not limited by the occurrence of back pain appears to increase patient behavioral support, resulting in work capacity improvements. 14 Both the therapist and the patient are better served by following the adage don't let the pain be your guide. 12
In Belgium, patients reportedly return to work an average of 12 to 16 weeks after surgery for lumbar disc herniation. However, there are studies that lend credence to the value of an earlier stimulation for return to work and performance of normal activities after a limited discectomy. Carragee et al 3 followed a cohort of 50 consecutive patients for 2 to 7 years and urged them to return to full activities as soon as possible. The mean time from surgery to return to work was 1.7 weeks. At follow-up assessment, it was found that no patient had changed employment because of back or leg pain.
The sooner the recommendation is made to return to work and perform normal activities, the more likely the patient is to comply. According to Andersson et al, 1 patients with ongoing disabling back conditions have a low priority for return to work. The probability of return to work decreases as time off work increases. Each return-to-work recommendation should be based on a comparison of objective patient measurements and anticipated job demands. 7 This is not always the case, and patients completing a back rehabilitation program often are advised to return either to full duty or to modified employment without objective medical justification for the distinction.
Moreover, the return-to-work decision frequently is based solely on the patient's report of pain. Hall et al 7 reported that physical activity in the presence of pain can lead to physiologic improvement and is beneficial to overall function, and that physical activity can become an integral part of the treatment process when integrated into the process of back rehabilitation. They found no conclusive evidence that an early return to work causes harm to the back. Fordyce et al 6 concluded that the clinician who relies on patient definitions of pain or illness is in peril of promoting chronicity. Lack of focus on a return to work acknowledges the patient's view of himself as incapable. 4
According to Battié, an adequate explanation of the problem, a sense of the prognosis, a recommendation for controlling symptoms, and activity guidelines are the keystones for a successful rehabilitation. 2 Moreover, general guidelines as opposed to statements that patients can work or cannot work give patients a clearer idea of activities to avoid or to engage in with caution. Such guidelines also give the employer an opportunity to accommodate an employee's restrictions. 2 It is the current authors' opinion that, in practice, these rehabilitation measures are not met, and that frequently medical conclusions from physicians involved in insurance medicine are purely claim-related. In addition, many return-to-work restrictions are not based on clinical findings, but reflect the therapist's fear that an unrestricted return to work will result in further physical harm. 7 This is especially true in Belgium, where 20% of individuals did not resume work activities after surgery for a disc herniation of the lumbar spine. 5
In Belgium, the medical advisers of sickness funds have an important role legally in the assessment of working capacity and medical rehabilitation measures for employees whose fitness for work is jeopardized or diminished for health reasons. The measures are laid down in the sickness and invalidity legislation. They are in accordance with the principle of preventing long-term disability. It is apparent from the authors' experience that these measures are not adapted consistently in medical practice. Most of the medical advisers are focusing purely on evaluation of corporal damage, leaving little or no time for rehabilitation efforts. In many other countries, the evaluation of work capacity is done by social security doctors with a comparable task.
The objective of the current study was to test whether an intervention program by the social security medical adviser, which is focused on early mobilization and early resumption of professional activities, could improve the return-to-work rates after disc herniation surgery as observed in an individual follow-up of 1 year. Success was defined as return to work.