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

ABSTRACT

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.

KEY WORDS: BACK INJURED PERSON, BACK REHABILITATION, BARRIERS, FACILITATORS AND ADAPTIVE PROCEDURES

619

Medical

Communication

Biosci. Biotech. Res. Comm. 11(4): 619-625 (2018)

ARTICLE INFORMATION:

Corresponding Authors: ssabauddin@jazanu.edu.sa

drshadabuddins@gmail.com

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

Online Contents Available at:

http//www.bbrc.in/

DOI: 10.21786/bbrc/11.4/12

Waseem Mumtaz Ahamed et al.

620 ROLE OF PHYSICAL THERAPY IN OVERCOMING THE BARRIER AND ADAPTIVE BEHAVIOUR BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

INTRODUCTION

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.

DATA COLLECTING PROCEDURE

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.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS ROLE OF PHYSICAL THERAPY IN OVERCOMING THE BARRIER AND ADAPTIVE BEHAVIOUR 621

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.

RESULTS

THEMES

The themes of the research directly associated to the

research aim and investigate the dif culties that back-

Waseem Mumtaz Ahamed et al.

622 ROLE OF PHYSICAL THERAPY IN OVERCOMING THE BARRIER AND ADAPTIVE BEHAVIOUR BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Table 1. Demographic and Clinical Data of participants

Variable Category

Number of subjects in pilot

group(m=men/w=women)

Number of subjects in focus

groups (m=men/w=women)

Gender

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)

Employed

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)

B.R.F=2(m),1(w)

P.T= 1(m), 2 (w)

Data collection No. of focus groups 1 session

3 sessions (different clients in each

group)

*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

Uncertainty)

1. Feeling of uncertainty by

stakeholders

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-

role

2. Facilitators

(Approaching an idealistic

rehabilitation-program)

1. Informed stakeholders

Informed employers

Informed consultants

2. Work promoting approaches

Multi-trained health-experts

Pain and disorder evaluation teams

3. Adaptors

(Self-Responsible)

1. Managing yourself

Reorganising yourself

Building an optimistic view and accepting your clinical

condition

2. Building competency in your

employee-role

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.

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS ROLE OF PHYSICAL THERAPY IN OVERCOMING THE BARRIER AND ADAPTIVE BEHAVIOUR 623

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

capabilities.

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.

DISCUSSION

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.

624 ROLE OF PHYSICAL THERAPY IN OVERCOMING THE BARRIER AND ADAPTIVE BEHAVIOUR BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

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.

CONCLUSION AND FUTURE

RECOMMENDATIONS

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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