Role of physical therapy in overcoming the barrier and
adaptive behaviour for return to work in subjects with
non-speci c chronic low back pain: A qualitative study
Waseem Mumtaz Ahamed
, Shadab Uddin*
, Fuzail Ahmad
and Kenneth Chance-Larsen
Department of Physical Therapy, Faculty of Applied Medical Sciences, Jazan University, Jazan, Kingdom of
Saudi Arabia.
Department of Physical Therapy & Health Rehabilitation, College of Applied Medical Sciences, Majmaah
University, Al Majmaah, Kingdom of Saudi Arabia.
School of Health Sciences, Associate Professor, Allied Health Program Leader, Central Queensland
University, Australia
Clinical investigation has revealed that individuals face challenges in adapting to their gruesome employee-roles after
undergoing a back intervention program. The aim of this research was to investigate the back-rehabilitated patient’s
perspectives and understandings of the dif culties faced while adapting as employees. Research aimed to extract the
patient’s perspectives and understandings of barriers, facilitators and adaptive procedures which in uenced their capa-
bility to continue their employee-roles. Qualitative investigation method was used for investigating the study topic.
Focus groups comprised of broad questions followed by probing were utilized to obtain detailed descriptions about the
client’s understandings and perspectives. Recommendations involved developing the insight of stakeholders regarding
early, valuable on-job training, initiating health-promotion by teaching in the workplace and in the society, along with
improving  exible job and health policy. Results of the investigation signify that the goal of physiotherapy and extent
of service to back injured patients needs to rebuild.
Biosci. Biotech. Res. Comm. 11(4): 619-625 (2018)
Corresponding Authors:
Received 12
Oct, 2018
Accepted after revision 23
Dec, 2018
BBRC Print ISSN: 0974-6455
Online ISSN: 2321-4007 CODEN: USA BBRCBA
Thomson Reuters ISI ESC / Clarivate Analytics USA
Mono of Clarivate Analytics and Crossref Indexed
Journal Mono of CR
NAAS Journal Score 2018: 4.31 SJIF 2017: 4.196
© A Society of Science and Nature Publication, Bhopal India
2018. All rights reserved.
Online Contents Available at:
DOI: 10.21786/bbrc/11.4/12
Waseem Mumtaz Ahamed et al.
Industrialization has resulted in increasing number of
back disabilities especially within industries which need
frequent carrying of heavy substances. Back injury is
quoted as the costliest health concerned problem within
people aged between 30-50 years and the primary reason
of disorder within population less than 45 years of age
(Jones and Kumar, 2002). Back pain which persists for
lesser than 3 months can be called ‘acute’ because a per-
son can improve without therapeutic treatment (Drezner
& Herring, 2001). The growth of a chronic condition can
be associated with fear of recurrence of injury, exces-
sively caring partners and being aware of sickness role
(Joy et al., 2000). It can hence, be debated that such sup-
porting aspects lead to an inadequate return to work rate
especially if people are being  nancially compensated
for their losses.
As per Friesen et al. (2001), employee attitudes and
motivation to participate must be acknowledged and
addressed if more injured employees are to be success-
ful within return to permanent employment. Henceforth,
theories based on the patient’s motivation were viewed
as being of value during investigating returning to work
process. Cognitive theories of motivation have been rec-
ommended as suitable constructs to understand individ-
ual dissimilarities in motivation within return to work
behaviour following work injury (Roessler, 1989). It sig-
ni es that an employee’s personal viewpoint of himself
within context of being re-injured in the work atmos-
phere plays an in uential part within returning to work
process. Research has revealed that money in form of
worker’s compensation or legal actions can also behave
as a motivator for pain behaviour, (Reneman, 2001 Can-
celliere et al., 2016 Wong et al., 2017).
It signi es that pain faced by some back injured
subjects is worthwhile within itself due to the economi-
cal rewards, empathy, notice and concern it creates in
favour of such subjects. As per Hildebrandt (1998), ef -
cacy of present intervention strategies have not been
proven considerably and it is apparent within yearly rise
of patients having Chronic Low Back Pain (CLBP). This
could be assumed that earlier back pain studies have
strong efforts on rehabilitation from a health-expert’s
viewpoint, failing to comprehensively realise the back
injured client’s perceptions or views during planning
treatment approaches, (Gatchel 2018).
Therefore this study is aimed to extract patient’s per-
spectives and understandings of barriers, facilitators and
adaptive procedures which in uenced their capability to
continue their employee-roles.
Methods: Qualitative investigation method was used
for investigating the study topic. Subjects were cho-
sen through random sampling from S.M.S (Sawai Man
Singh) Hospital, Jaipur, Rajasthan, India -Physiotherapy
Department. Focus groups comprising of broad ques-
tions followed by probing were utilized in order to obtain
detailed descriptions about the client’s understandings
and perspectives. A pilot testing group and 3 one-hour
focus groups were conducted consisting of 5 subjects
in each group on an average. Data which was produced
was qualitatively examined by manual coding system to
achieve codes, categories and themes. Aspects which were
viewed as facilitators involved enhanced communication
and precision between stakeholders, injury prevention
approaches and understanding among stakeholders which
facilitated team-work. Aspects which obstructed subjects
to resume as employees were considered to be barriers.
These involved delays and all kinds of inef cacy for
instance, inadequate management processes, bad quality
medical treatments and uncaring work atmosphere.
Study-design: As explained by Bailey (1997), a quali-
tative investigation illustrates multiple realities and
interpretations that aimed to enhance an in-depth
understanding of the perceptions and knowledge of the
participants. Because of this, a qualitative investigation
concept was selected to conduct this research. Objec-
tive of this research asked for a qualitative-methodolog-
ical-analysis to be performed because the highlight was
on illustrating the perspectives and understandings of
back-rehabilitated subjects on their return to workplace.
Focus group Interview: Focus group interview was cho-
sen for collecting data. Because of its interacting nature
they are an ideal method to explore participant’s own
meaning and to understand issues like health and illness.
This method of investigations is mainly helpful to assess
the viewpoints of those who have been inadequately
served by a traditional research Wilkinson (1998). Pilot-
focus group interviewa were conducted, to provide a
direction towards establishing a range of approaches that
were essential in order to investigate aims of the research.
When no issues were established within questions of pilot
focus group, minor modi cations were done to the ques-
tions of the focus groups which followed. Data obtained
from the pilot focus group was included in the study in
order to contribute to aim of the research.
Participants: Participants were selected from statistical
records of S.M.S Hospital-Physiotherapy Department.
Since it is the largest and only government Hospital
situated in Jaipur (capital of Rajasthan, the largest state
of India), it was ideal for selecting subjects having work-
related pain for this research. Because of the fact that a
number of subjects with different kinds of injuries are
assessed at the hospital, subjects having only back pain
Waseem Mumtaz Ahamed et al.
were selected from statistical records of the hospital.
Aim of the study was described to the participants on
telephone by contacting them at their place of work, if
employed or at their residence, if unemployed.
Sampling: Simple random sampling (Kerlinger 1986),
was utilized as a procedure in order to give every
patient on statistical records of the hospital, an equiva-
lent opportunity to be selected in the research. A table
of random digits were used to select the subjects which
was followed by giving a number to each name. A ran-
dom start-point had been selected on a random table
and  rst 24 numbers and the names that corresponded
them were selected. After that, subjects that were chosen
were invited to take part within this project.
Sample size: According to Krueger (1994), an ideal
number of participants in a focus group ought to be
between 3 and 9, therefore for this study 24 participants
(8 participants per group) were selected to be involved
within the 3 focus groups. However, only 15 participants
turned up for the interview.
Selection Criteria: The inclusion criteria for this study
were; subjects with a medically diagnosed chronic back
pain affecting their work, who had received medical and
physical therapy treatment. Subjects were not included
if they had any form of psychiatric diagnosis, or under-
gone any invasive or surgical treatment for chronic back
pain because their quality of life and psychosocial adap-
tations as employees could have provided an unhelpful
in uence on the investigation.
Study Protocol: A pilot testing group and 3 one-hour
focus groups were performed and an average of 5 partic-
ipants attended each group. It was done to serve the pur-
pose of discovering the perspectives and understandings
of a range of participants, hence to ensure dissimilarity
among the views of study participants. Broad questions
were asked which was followed by probing for eliciting
detailed and rich explanations. A kind of debrie ng was
included at the end of each session, in which subjects
were facilitated to clear their queries and express their
feelings of contributiion within a group.
Focus groups were performed within one of the con-
sulting rooms of physiotherapy department as the venue
was familiar to all the subjects. As per the convenience
of the subjects, the group session were scheduled every
afternoon between 2-3 pm, for three continuous days.
Subjects were seated around a table ensuring that there
was a proper eye contact. Name tags were given to build
a rapport between subjects. An audiotape was put at
a pre-meditated position so that all the data received
could be free from unrelated external stimuli.
Focus group questions were offered to clients both in
English and Hindi. Subjects were informed that they were
free to withdraw their consent before participating or at
any stage of discussions. Participants were introduced
to each other so that they could unwind themselves and
become familiar to each other and to the environmental
setting. Investigator set goals for discussion and guaran-
teed the clients that their feelings and views will be valued.
Questions were discussed with the tutor in advance and
changes were made accordingly. This allowed the inves-
tigator to become conscious of several group-dynamics
that could play an important part, for e.g. difference
between traditions, attitude towards life and viewpoints.
Data-analysis: Within this investigation, 4 cognitive
procedures allowed the investigator to examine the
qualitative data through comprehending, synthesizing
(de-contextualizing), theorizing and re-contextualizing
(Morse & Field, 1996).
Comprehending: Transcriptions were done directly after
interviewing, providing investigator the time to study
as well as identify the interviewed data before arrang-
ing for the next interview. After that, information was
coded through line-by-line analysis to discover essential
meanings within the transcript. Then, the investigator
became capable of identifying the experiences that are a
part of the research investigation and the patterns that
foresee possible outcomes.
De-contexualizing: This phase was achieved at the
completion of third focus group. Transcripts were evalu-
ated during analysing, where codes were built into cat-
egories through commonalities, consisting of segments
of transcripts.
Theorizing: Different descriptions were investigated
against the data until the data for the research was best
described. Questions were asked on the data for estab-
lishing links to the theory. This organized procedure
facilitated the investigator to inductively develop for-
mal themes from data. This also allowed investigator to
acknowledge the quality of data to contribute within a
particular experience or perspective.
Re-contextualizing: Comparing the similarities and dis-
similarities between the data and the published research
of other investigators played an essential role to ensure
credibility of the data. Investigator made an effort to
put the outcomes of the investigation within the context
of standard knowledge and appreciated the outcomes
which supported the literature.
The themes of the research directly associated to the
research aim and investigate the dif culties that back-
Waseem Mumtaz Ahamed et al.
Table 1. Demographic and Clinical Data of participants
Variable Category
Number of subjects in pilot
Number of subjects in focus
groups (m=men/w=women)
Men 3 7
Women 0 5
Age in years
18-40 = 2 (m)
41-65 = 1 (m)
18-40=5 (m), 41-65=2 (m), 18-40=3
(w), 41-65=2 (w)
Yes 2 8 (m), 3 (w)
No 1 2 (m), 2 (w)
Medical Intervention
Type of organizations
in which rehabilitation
was obtained
D.H = 1 (m)
B.R.F = 2 (m)
D.H=4(m), 2(w)
P.T= 1(m), 2 (w)
Data collection No. of focus groups 1 session
3 sessions (different clients in each
*Key : D.H - (Day Hospital), B.R.F - (Back Rehabilitation Facility), P.T - (Physiotherapy consultant in a home visit)
Table 2. Themes categorizing the dif culties of back-rehabilitated individuals affecting their return to work.
Themes Category Subcategory
1. Barriers (Feeling of
1. Feeling of uncertainty by
Employer building an uncaring approach and uncertainty in
the employee.
Health-service building an uncaring approach and
uncertainty in the client’s condition
2. Uncertainty in own
potentials for accomplishment
at work
Uncertainty in return to work approaches
Uncertainty in discovering a meaning within the employee-
2. Facilitators
(Approaching an idealistic
1. Informed stakeholders
Informed employers
Informed consultants
2. Work promoting approaches
Multi-trained health-experts
Pain and disorder evaluation teams
3. Adaptors
1. Managing yourself
Reorganising yourself
Building an optimistic view and accepting your clinical
2. Building competency in your
Awareness and training of the employee
Asserting yourself
rehabilitated individuals came across on their return
to work. Theme one associates with the barriers which
obstructed back injured individual’s adaptation as
employees, theme two associates with the facilitators
which supported individuals to adapt to their employee-
roles, theme three associates with the individual’s per-
ceptions and experiences of adapting to their role as
employees. Table 2 present the themes which emerged
after the data-analysis
Barriers: Fisher (1994) documented that psycho-social
maladjustment and psychological health of an injured
employee can be revealed within perspectives generated
in reaction to depressing or destructive social aspects. By
the information obtained, this was apparent that client’s
perspectives of themselves concerning their capability to
execute job-associated tasks were either pessimistic or
optimistic. Subjects frequently mentioned that unhelpful
perceptions of employers as well as society forced them
in losing self-con dence and build a feeling of uncer-
tainty within their performance capabilities.
Doleys & Gochneaur (1989) describes that not eve-
rybody who has an injury develops a chronic condi-
Waseem Mumtaz Ahamed et al.
tion. Instead, a feeling of external sense of control while
performance participation results in a sense of insuf-
ciency and it depicts itself within the employee not
being able to control the pain. By such a perception, it
could be assumed that an external feeling of control in
which client’s certainty within himself in continuing his
employee-role was affected by the perspectives of others
in the environment. Such an uncertainty affected the
person’s feelings of self-ef cacy during executing job-
associated tasks.
Bandura (1989) debated that self-ef cacy expecta-
tions powerfully in uence motivation. Few subjects in
present investigation were inadequately motivated in
returning to work after injury. Such inadequate moti-
vation can be seen as a consequence of barriers for
instance, their uncertainty in opportunities after being
injured. Subjects felt that they had not been capable
enough in performing job-tasks which they did earlier. A
sub-category ‘uncertainty in return to work approaches’
interprets their perspectives of fear in which they per-
ceived that recurring injury might cause increase in
pain and restrictions which can impact on their eco-
nomical and psycho-social conditions. Such percep-
tions caused the subjects to avoid tasks in the workplace
and lose con dence within their own potentials and
Such results correspond to those of Fritz and George
(2002) who examined fear-avoiding beliefs, and came to
a conclusion that these are signi cant variables within
foreseeing client’s achievement within treatment pro-
grams. It henceforth, signi ed that subjects who feared
re-injury may face problems to complete rehabilitation
programs and can be at risk of long-lasting work limita-
tions. Nevertheless, Forman & Murphy (1996) view the
person as an aware agent that vigorously understands
the environmental requirements and behaves accord-
ingly with these perspectives. An implication of this
would be that a person builds an internal sense of con-
trol whereby he obtains encouraging response from the
environment and builds a constructive self-perception
as well. Such a constructive self-perception re ected
within approach of the subjects during completing inter-
vention programs as well as during return to work. Sub-
jects perceived that an optimistic approach along with
internal motivation supported them to effectively com-
plete intervention programs.
Facilitators: Subjects who performed productively in the
work atmosphere repeatedly mentioned injury preven-
tion as a facilitator. Injury prevention in terms of this
research involved positive communication and con -
dence within stakeholders who were directly in touch
with the worker. The participants described that the
interpersonal-relations between the stakeholders con-
rmed that their treatment programs were frequently
supervised and hence, promoted a quicker return to
work rate.
This result is similar to a research by Friesen et al. (2001)
in which interaction, team-effort, faith and sincerity
were established to be supportive aspects during return
to work-process. Such aspects henceforth, decided suc-
cess by connecting the gaps for the patient from treat-
ment processes to participating as employees. Conven-
tional health-service has concentrated on a bio-medical
model of rehabilitation in which a person’s elements of
performances have been remediated for participating in
their work roles for instance, an employee, homemaker,
sportsperson, etc. (Smithline & Dunlop, 2001, Cancel-
liere et al., 2016). Physiotherapy consultants working
in private as well as for the government are frequently
pushed for time due to excessive patient loads that they
are bound to tackle with. It frequently leads to physi-
otherapists  nding hard to perform holistic assessment
processes like identifying the outcomes of work atmos-
phere and home atmosphere on the back injured client’s
performance. Physiotherapy consultants are in a favour-
able situation of being capable of incorporating holistic
assessment and treatment in an individual’s functioning
as an environmental frame of reference (Christiansen,
1997, Gatchel 2018).
Nonetheless, consultants who desire to practice a
career in comprehensive evaluation and intervention
of an injured worker are required to focus on particu-
lar courses on ergonomic assessment of the injured
employee’s workplace as well as develop their focus
on government laws for example, employment justice,
code of high-quality service and workplace safety. Focus
into such courses and government laws would enable
physiotherapists in empowering their back injured
patients within context of their legal rights at work-
place and would facilitate them to adapt and retain their
employee-roles. By a rise within workers taking legal
action against companies concerning workplace injuries
and unjusti ed removal, physiotherapists can be invited
in future to give specialist legal authentication on basis
of a person’s work performance.
The results signi ed that the subjects which were suc-
cessful to resume work after pain-process received a car-
ing atmosphere at home and in workplace. This meant
that barriers which impacted on the injured were mostly
environmental in nature and such barriers were viewed
as challenging when it in uenced subjects personally. A
majority of subjects within this research showed a pow-
erful internal sense of control and it was visible within
their capability to be responsible for their own treatment.
Waseem Mumtaz Ahamed et al.
Nonetheless, they had to adjust regardless of working
in an unsupportive working atmosphere. According to
their perspective, they kept trying by searching mean-
ing within the work that they were occupied with, by
precise work-placement strategies, managing injury on
their own and keeping a powerful value system which
enabled them to resume their tasks. Physiotherapists,
with their understanding about pathology and job-
placement strategies have a high in uence within the
occupational treatment  eld. This will be their duty to
facilitate an injured person in precisely identifying their
dif culties and assets with regard to their capabilities
and suitably match it to the job requirements. Subjects
in the investigation presented with restrictions concern-
ing the physical aspects of their performances such as to
bend, to carry and to climb. It forced the back injured
to observe increasing back pain. Physiotherapist will
in turn support the back injured to modify the person’s
substantial and psycho-social job surroundings. Physi-
cal adaptation was viewed as modi cation of equipment
and structural environment of the worker to equalise
their performance capabilities. Psycho-social adaptation
was viewed as informing the manager and the employee
concerning the depressing outcomes of an unhelpful
working atmosphere on the back injured person. Physi-
otherapist will henceforth, be capable of consulting with
other rehabilitation-experts as well as employers within
context of most appropriate job-placement and dealing
with approaches of back injured people.
Health-promotion was considered to be a poten-
tial structure of recommendation for building a caring
atmosphere for back injured people. Back injured client’s
workplace and home was considered to be examples of
a caring atmosphere in which preventing back disorders
and reinforcing intervention procedures can be initiated.
Back injured people have presently been on a risk for not
identifying their potentials because they do not use their
complete mental/emotional as well as physical capabil-
ity at work. Such capability in terms of this research
can henceforth, only be remediated by enhancement of a
caring society and a supportive work atmosphere.
The main aim of the research was to build a larger focus
into the issues which challenge the back injured indi-
viduals. Results of the investigation signify that the goal
of physiotherapy and extent of service to back injured
patients needs to rebuild.
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