Physiotherapy 90 (2004) 4–11

Influence of benefit type on presenting characteristics and outcomefrom an occupationally orientated rehabilitation programme

for unemployed people with chronic low back pain

Paul J. Watsona,∗, Chris J. Mainb

a Division of Anaesthesia, Pain Management and Critical Care, Leicester General Hospital, University of Leicester, Leicester LE5 4PW, UKb University of Manchester, Manchester, UK

Abstract

Background and purpose High levels of social security benefits in lieu of wages have been suggested as a possible cause of poor outcomefrom vocational rehabilitation programmes for chronic low back pain. Patient groups have also criticised the assessment procedures usedfor qualification for such benefits. We conducted a prospective research project to compare the presenting characteristics and outcome fromtreatment in two groups of unemployed benefit recipients reporting chronic low back pain, one in receipt of a medically determined benefit,incapacity benefit, and a second in receipt of a non-medical benefit, job seekers allowance.Methods Subjects were Employment Services referrals to a rehabilitation programme for people with chronic low back pain. Comparisonswere made of the presenting characteristic of each of the two groups at the start of the programme. The subjects were followed up 6 monthsafter a 6-week occupationally orientated rehabilitation programme, the primary outcome measure was working status.Results Incapacity benefit recipients were younger and more likely to report a traumatic onset of pain, be on opioid medication, have hadsurgery, or been medically dismissed from work, and had received more previous treatment (allP < 0.035 values). There were no significantdifferences in disability, pain report, physical performance, fear avoidance beliefs or psychological distress. At 6 months follow-up there wereno significant differences for employment outcome (chi-squared 1.57,P = 0.264) or positive progress (chi-squared 1.15,P = 0.361).Conclusions Previous and current treatment and mode of onset defined the groups better than disability and pain. This demonstrates that thetype of benefit received may be multiply determined. The possible reasons for this are discussed. Both groups were equally likely to return towork or make positive progress. This demonstrates that in this group, attending an occupational programme, benefit type need not be a barrierto successful outcome.© 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Wage compensation; Low back pain; Rehabilitation; Vocational; Social security

Introduction

Epidemiology and cost of back pain

The percentage of the United Kingdom population con-sulting their general practitioner for back pain in a year isbetween 7%[1] and 9.8%[2]. With respect to work loss as-sociated with back pain, Walsh et al.[3] using self-reportfound that the average 1-year prevalence for work loss due toback pain was 10.6% for men and 6.8% for women. Watsonet al. [4] identified work absence from general practitionersickness records to give an absence rate of 8.2%.

∗ Corresponding author.E-mail address: pjw25@le.ac.uk (P.J. Watson).

Most of those who are absent from work will return within4–6 weeks[4,5] even though they may remain symptomaticfor some time[6]. A small number may develop prolongedwork loss and eventually lose their employment as a result.Once they become unemployed they are significantly disad-vantaged with respect to getting back into the employmentmarket and are likely to spend a long time on State benefitsof one sort or another[7].

Although those with chronic low back pain are few innumber they represent a significant cost to the public purse.Klaber-Moffet et al.[8] estimated the cost of physiotherapyfor back pain in the United Kingdom in 1995 at between24 and 36 million pounds. The overall costs to the NationalHealth Service were estimated as between £265 and £383million. Maniadakis and Gray[9] gave the most recent di-rect (healthcare) cost analysis for the United Kingdom which

0031-9406/$ – see front matter © 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.doi:10.1016/S0031-9406(03)00004-X

P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11 5

was £1623 million. They estimated the cost of NationalHealth Service and private physiotherapy to be £251.2 mil-lion pounds or 37% of the total.

These costs are dwarfed by the indirect costs, includingsickness and incapacity benefits, social care and productionlosses, which were estimated at £10,668 million. This showsthat preventing absence from work and returning to workthose of working age who are no longer economically activeis important.

Wage compensation and return to work

A number of authors have described system problemswhich complicate and may mitigate against successful re-turn to work. These include the absence of appropriateworkplace-based sickness management and the absenceof a system for employer-based vocational rehabilita-tion or absence of modified duties to assist early returnto work [10,11]. Once unemployed, national policy andsocio-economic system barriers include a lack of access tovocational rehabilitation[12], the absence of an integratedapproach across health, benefits and employment agencies,and dependency on benefit payments[7]. However, most ofthe data on wages compensation are from those who wereemployed at the time of the initial absence[7,13,14] andhas often been gathered in countries other than the UnitedKingdom, especially North America, Australia and NewZealand.

Many of these studies report on subjects who are offeredtreatment and wage compensation as part of a health andwelfare benefits package contingent upon their symptomsbeing attributable to their work. Reviews of these systems[15–17]conclude that those compensated take longer to re-turn to work and the rate of return to work appears to beinfluenced by the rate of compensation.

Tito [17], however, cautions us to consider if the ab-sence of a compensation system or lower rates pressurepatients to return to work too early. Different social ben-efit systems make it difficult to draw conclusions aboutthe importance of wages compensation between countries.In the United Kingdom the payment of such benefits isthe responsibility of the employer for the first 6 months,and the amounts paid vary according to local agreements.Once a person has lost his or her employment the Stateis responsible for wage compensation at a fixed rate withthe possibility of add-on benefits for special circumstances[7].

Wages compensation status might also influence the treat-ment or expectations of outcome in healthcare professionals.Simmonds and Kumar[18] found that prior knowledge ofthe wage compensation (benefit) status of a patient, althoughit did not influence clinical findings, negatively influencedphysiotherapists’ rating of the expected outcome. If thera-pists were told that a patient was in receipt of workmen’scompensation payments they rated the expected outcomemore pessimistically.

In the United Kingdom those medically certified tobe unable to work may be in receipt of incapacity ben-efit or severe disability allowance. Movement from suchbenefits into work is extremely low; as few as 3% ofincapacity benefit recipients were observed to move offState benefits in an 18-month period[19]. Some back painsufferers may be symptomatic but medically consideredsuitable for some type of work despite symptom report,and these receive only benefits associated with unemploy-ment (job seekers allowance). Those who do not qualifyfor either of these benefits because of insufficient contri-butions may qualify for basic income support. From therecipient’s point of view, incapacity benefit is preferablebecause it is paid at a higher rate and allows access toother benefits. It might be expected from this that thoseon incapacity benefit would be less likely to return towork.

Aim of study

The aim of this study was to determine:

• Are subjects in receipt of incapacity benefits attendingfor rehabilitation significantly different with respect tolevels of previous history, current treatment, disabil-ity, psychological function and physical performancefrom subjects on job seekers allowance and incomesupport?

• Are people in receipt of incapacity benefit less likely tobe in work or make progress to returning to work at 6months follow-up than those on other benefits followingthe rehabilitation programme?

We hypothesised:

• Subjects on incapacity benefit would demonstrate greaterlimitation, more severe psychological problems and havehad more treatment than those on other benefits.

• Subjects on incapacity benefit would have worse occupa-tional outcomes following intervention.

Methodology

The study was based on a previous investigation by theauthors and reported elsewhere[20]. Subjects were referredby State disability employment advisers or personal advisers(civil servants) who interview and assess people with disabil-ities to advise them on returning to work. Data were gatheredin two locations in the United Kingdom, both of which hadbeen trained in the delivery of the programme. The format ofthe programme and the literature used was standardised. Allsubjects gave informed consent to be included in the studyand local ethical permission to perform the study was soughtand granted from the respective local research ethical com-mittees. Only subjects with back pain and disability wereincluded.

6 P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11

Inclusion criteria

• Symptomatic with mechanical low back pain at assess-ment.

• Duration of symptoms of 6 months or longer.• Roland and Morris Disability Questionnaire Score of

greater or equal to 5 (back pain with disability).• Registered as unemployed for greater than 6 months with

chronic low back pain as the stated reasons for not work-ing.

• In receipt of State disability grant (incapacity benefit orsevere disability allowance) or unemployment benefit (jobseekers allowance, income support).

Exclusion criteria

• Indicators of serious pathology on clinical examination(‘red flags’ [21,22]).

• Pregnancy.• Neoplastic or inflammatory disease.• Severe spinal deformity (i.e. kyphoscoliosis).• Cardiovascular or other disease likely to compromise full

participation with an active rehabilitation approach.• Major psychiatric illness.

Initial assessment

Patients’disability due to back pain was assessed by the24-item Roland and Morris Disability Questionnaire, whichpossesses excellent reliability, validity and responsiveness[23,24]. A score of 5 or greater was chosen as any lesswould not permit the minimum detectable change for thisinstrument[25]. Such a score was deemed to represent painand disability rather than pain alone.

Pain was assessed by a Visual Analogue Scale for painon the day. It has good reliability and reproducibility andpossesses ratio scale properties[26].

Fear avoidance beliefs were assessed by the Tampa Scaleof Kinesiophobia, a 17-item instrument[27]. Each scale hasfour possible levels of agreement with statements about pain,movement and injury.

Psychological distress was assessed by the Modified ZungDepression Index[28], and the Modified Somatic Percep-tion Questionnaire[29] for somatic anxiety. Both measureshave been demonstrated to be predictive of poor outcomefrom interventions in subjects with chronic low back pain[28,30,31].

A series of physical performance measures describedand validated on a chronic pain population by[32] wereassessed:

1. Five-minute walk test—the distance walked in 5 minmeasured in metres.

2. Sit-to stand test—the number of successful sit-to-standmovements performed in 1 min.

3. Step up test—the number of step-ups performed in 1 min.

Procedure

All subjects referred were invited to an introductory dayto explain the purpose of the programme. At this stage onlydata on age, sex and benefit type were collected. Follow-ing the introductory day subjects were invited to opt intothe programme. Participation was voluntary and social se-curity benefits were not at risk if the subjects declined totake part. All subjects underwent clinical, physical func-tion and psychological assessments before inclusion on theprogramme.

Detailed demographic information, medical history, cur-rent treatment, physical function assessment, self-reporteddisability and a comprehensive battery of psychometric datawere collected. Subjects were also asked to give the reasonwhy they had become unemployed.

Programme content

The programme is detailed in previous publications[20].Following assessment, subjects attended an occupationallyoriented pain management programme of 12 half-days over6 weeks with up to 3 h of additional individual vocationalcounselling. In the traditional healthcare settings, health,benefits and employment are dealt with separately; in thisprogramme they were managed concurrently. A specialistvocational counsellor with experience of working with dis-abled people conducted the vocational training component.Subjects were helped to identify occupational goals and thebarriers to success, and were encouraged to set achievableemployment-related goals under the guidance of physiother-apists, psychologists and a vocational trainer with an un-derstanding of the local employment environment. Subjectswere also advised of the potential changes to their wagecompensation if they returned to work. In this way, the sub-jects were able to make a more informed choice about thefeasibility of returning to work and the potential costs andbenefits.

Statistical analysis

Subjects were divided into two groups depending onwhether they were on medically assessed benefit (incapacitybenefit) or other benefits (job seekers allowance and incomesupport). Compensation through medico-legal claims wasrecorded but was not the focus of this research.

The initial presenting characteristics of the two groupswere compared using non-parametric statistics for contin-uous data (Mann–Whitney) and the chi-squared test fordichotomous data. The outcome of interest was employ-ment status 6 months after the programme. Employmentwas defined as in pay-as-you-earn income tax at followup. A secondary outcome, positive occupational outcome,included employment or an employment-related outcome.Positive outcomes included voluntary work, work place-ment or participating in education or training. Those who

P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11 7

failed to complete the programme, were lost to follow-up,or not on one of these outcomes, were classified negativeoutcomes. A chi-squared test was used to compare theoutcome by initial benefit type.

Referred to the Back toWork Programme by DofEE

N = 152

Attended Introductory day

N = 108

3 preferred to stay with

DEA alone

6 declined programme

no reason given.

3 given assessment

appointments failed to

attend

2 started course

Commenced programme N = 86

Accepted onto programme N = 92

1 client fell ill before programme 1 started work 2 clients had child care problems 2 could not travel

Completed programme

N= 84 (97.7%)

Followed up at 3 months

N= 72

(83.7%)

Followed up at 6 months

N= 74

(86.0%)

1 subject failed to complete travel problems1 failed to complete due to

child care problems

2 refused to return questionnaires 2 changed address

10 failed to respond or

unable to contact

2 contacted and refused to give any information by letter or phone 2 changed address

8 unable to contact or failed

to respond to letter or phone

calls

Data from 2 clients excluded – not competent in English. Total number in

analysis pre programme 84 post programme 82, 6 months 72 (85.7% of English

speakers).

Clinical and Psychological assessment

N= 94

2 client excluded on medical grounds 1 due to major

osteoarthritis in knees

1 “red flag”

30 Failed to attend

introductory day no

reason given.

6 unable to attend

because single carer.

8 referred after funding

ceased

Fig. 1. Flow diagram of subjects and reasons for non-attendance/loss to follow-up.

Table 1Comparison of attenders and non-attenders for the Back to Work Programme

Attended for assessmentmean (S.D.) (N = 94)

Did not attend for assessmentmean (S.D.) (N = 58)

Z P

Age 41.5 (8.2) 42.1(7.9) 1.11 0.670Sex (chi-square) (% male) 71.3 69.0 0.811 0.842Benefit (chi-square) (% on incapacity

benefit severe disability allowance)42.5 39.7 1.44 0.497

Results

A total of 152 consecutive subjects were referred to theprogramme, 108 attended the introductory day, 94 opted to

8 P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11

Table 2Back to Work Programme: comparison of subjects by benefits type continuous variables Mann–WhitneyU-test

Incapacity benefitclaimants mean(S.D.) (N = 39)

Not claimingincapacity benefitmean (S.D.) (N = 39)

Z P

Duration (months) 88.96 (111.2) 117.62 (106.4) 1.10 0.273Time since last employed (months) 32.03 (32.3) 41.16(43.6) 1.08 0.294Age 39.40 (7.6) 44.13 (9.3) 2.48 0.015Roland–Morris Disability Questionnaire (N = 84) 14.97 (4.7) 14.36 (3.9) −0.649 0.471Tampa Scale of Kinesiphobia (N = 84) 38.49 (9.4) 39.87 (7.8) 0.728 0.469Modified Zung Depression Index (N = 84) 30.45 (10.5) 31.01(9.5) 0.427 0.670MSPQ (N = 84) 10.21(6.5) 9.62 (6.8) −0.770 0.405Sit-to-stand 1 min 12.24 (6.6) 13.24 (5.7) 0.860 0.4755-min walk 254.78 (112.1) 277.06 (102.3) 0.918 0.362Step-ups 1 min 16.6 (7.8) 17.9 (5.6) 0.713 0.393

Table 3Back to Work Programme: comparison of subjects by benefit type categorical variables (N = 86), chi-squared test

Incapacity benefitclaimants mean (S.D.)

Not claiming incapacitybenefit mean (S.D.)

Chi-square P

Sex (% male) 62 71 0.736 0.481Onset traumatic (% yes) 62 32 7.46 0.008Previous back surgery (% yes) 33 5 11.23 0.001Current/past litigation (% yes) 54 27 6.40 0.014Current/past benefits dispute (% yes) 9 7 0.056 0.812On opioids (% yes) 35 10 8.51 0.007Current care secondary/tertiary (% yes) 43 14 9.25 0.005Previous physiotherapy (% yes) 97 66 12.1 0.001Declared medically unfit for previous job (% yes) 43 19 5.10 0.035

attend the programme subjects and were consented at thispoint, 86 started the programme. The results of two partic-ipants were excluded from the questionnaire data becausethey were not fluent in English, although their data are in-cluded for other analyses. A comparison of those who at-tended the programme and those referred can be seen inTable 1.

Those who attended were not significantly different withrespect to age, sex or benefit type from those who failed toattend. The reasons for non-attendance on the programmeare given inFig. 1.

The results of the initial presenting characteristics of thetwo benefit groups can be seen inTables 2 and 3. No subjectswere receiving severe disability allowance.

There were no significant differences in disability, distressor physical performance between those on incapacity benefitand those on job seekers allowance. However, incapacitybenefits claimants:

• Were younger.• Had received more treatment (physiotherapy, opioids,

surgery, secondary or tertiary care).• Were more likely to report a traumatic onset.• Were more likely to be involved or have been involved in

litigation.• Were more likely to have been declared medically unfit

to do their previous job.

Return to work at 6 months

At 6 months follow-up, 38.4% of all 86 subjects, or 39.3%of the 84 fluent English speakers were in paid employment.

The following results refer only to the 84 fluent Englishspeakers. A summary of the results by outcome can be seenin Table 4.

At 6 months 33 out of 84 people were employed; 16 ofthese 33 people had been on incapacity benefits and 17 hadbeen on other benefits (chi-squared 1.57,P = 0.264). Thiswas not statistically significant.

At the same time 55 people were classified as havinga positive outcome and 29 people were classed as havingnegative outcomes. Once again pre-programme benefit type

Table 4Outcomes by benefit type

Outcome Na Incapacity benefitrecipients (N = 39)

Job seekersallowancerecipients (N = 45)

Employed 33 16 17Work placement 3 1 2Voluntary work 2 2 0Education/training 17 7 10None of the above/not

known29 13 16

a The non-English speakers are excluded from the results.

P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11 9

demonstrated no significant difference between these twogroups (chi-squared 1.15,P = 0.361).

Discussion

The incapacity benefit group was younger than thenon-incapacity benefit group and this contradicts the dataon incapacity benefit that show its recipients to be older[33]. This cannot be easily explained. At the time of thestudy incapacity benefit recipients were invited to attendjob centres for interview but were not compelled to do so.Those who were older may simply have not responded to acall for interview. The referral to the programme was madeby Employment Service staff. There was no requirementon staff to refer to the programme and we were not able tofollow-up every person who might have been appropriatebecause of the issue of informed consent. The EmploymentService personnel may have made a judgement about theappropriateness of referring older people to the programme.Waddell et al.[7] have pointed out that, for some people,incapacity benefit is seen as an proxy for early retirement asthey consider themselves no longer economically active, andfurthermore those within the system collude in this action.

It is particularly interesting that those on incapacity ben-efit were no different from job seekers allowance recipientswith respect to self-report of disability, depressive symp-toms, fear avoidance beliefs or anxiety. It was not the casethat incapacity benefit recipients were not disabled or de-pressed, but those on job seekers allowance were no lessdisabled or depressed. The physical performance testing cor-roborates the findings of the disability self-reports; the per-formance of the two groups was not different.

There are a number of possible explanations for this. First,those who attended the programme may have been those jobseekers allowance recipients who perceived their back painproblem as being significantly limiting. Secondly, those inthe incapacity benefit group may have represented only thosewho were less disabled and who were already investigatingways to return to work. However, the levels of disabilityreported by both groups are as high or higher than normativedata for chronic low back pain subjects[24], demonstratingboth were indeed disabled by their back pain.

The two groups differed considerably with respect toreported onset, medico-legal compensation claims, andamount of previous and current treatment. Incapacity bene-fit recipients were more likely to report a traumatic onset,be pursuing medico-legal compensation and have beendeclared medically unfit for their previous work.

Not all of those on job seekers allowance had been re-ferred for an independent medical assessment and their owngeneral practitioners had not placed these subjects on in-capacity benefit. Although only an anecdotal finding, somesubjects felt that receiving incapacity benefit was likely toreduce their chances of finding work and this merits moreresearch. Ritchie et al[34] and Chew and May[35] identi-

fied the role of a general practitioner as a social resource tolegitimise withdrawal from usual social obligations, and asan economic resource as the gateway to preferential bene-fits, demonstrating that medical assessment is only part ofthe decision process. Waddell et al.[7] also remind us of themultiply determined nature of access to benefits. Althoughthe All Work Test has been demonstrated to have a goodmeasure of reliability[36], Porter[37] reported that unsuc-cessful claimants said it did not fully assess their conditionand was intended to mislead them into giving answers thatdisqualified them.

Members of the incapacity benefit group were morelikely to have had surgery or previous physiotherapy andto be involved currently in secondary or tertiary healthcare(awaiting an appointment with a hospital medical consultant,further investigations, follow-up appointments). They werealso more likely to be on opioid medication. This study wascross-sectional and no comment can be made on the pre-vious severity of the subjects’ back pain which might havewarranted such interventions in the past. Main et al[38] havesuggested that an increased number of interventions is as-sociated with iatrogenic incapacity (caused by contact withthe healthcare professions) and development of chronic in-capacity and social dependency. There is no evidence in thisstudy that increased interventions led to increased disabilityas both groups were equally disabled, but there is a possiblerelationship with increased interventions, continued health-care consulting and maintenance on incapacity benefit. Fur-ther research is required to see if past and current healthcareconsulting is crucially influential in helping medical exam-iners approve access to or continuation on incapacity benefit.

That there was no difference between the two groups inthe percentage returned to work is very surprising in the lightof previous research, even though most of this is from othersocio-economic systems. It is important to remember that nosubject was required to attend. This limits its general extrap-olation to all incapacity benefit and job seekers allowancerecipients, but it demonstrates that where a rehabilitationprogramme is available it can be successful in returning peo-ple to work, or helping those with back pain make progresstowards returning to work. This research cannot commentthe sustainability of employment as a follow-up period of 6months may be too short to predict continued employment.

The observations made about the lack of difference be-tween those on job seekers allowance and incapacity bene-fit are surprising for a benefit that is awarded as a result ofmedical assessment of function. Although the numbers inthis study are small, it suggests that decisions about bene-fit entitlement are complex. This does not imply that thoseon incapacity benefit were not valid claimants, but suggeststhat some people on job seekers allowance experience sig-nificant disability and limitation but are not receiving inca-pacity benefit. The difficulties of accessing work may be thesame for both groups.

Clinically, those managing people with chronic pain whoare on incapacity benefit should not assume that they cannot

10 P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11

be rehabilitated into work if given appropriate help. Addi-tionally, receipt of incapacity benefit does not indicate anunwillingness to work and is certainly not an immovablebarrier to return to work in those who wish to do so.

Key messages

• The type of social support benefit received may bemultiply determined.

• Job seekers allowance recipients with chronic lowback pain may report similar disability, pain and dis-tress to those on incapacity benefit.

• An increased number of medical interventions is moreclosely associated with receipt of incapacity benefitthan level of pain or disability.

• Higher rate benefits need not be a barrier to return towork.

• Further research is required to determine the relativeinfluence of current and past treatment, physical per-formance and subject self-report measures in the de-termination of access to incapacity benefit.

Acknowledgements

The authors wish to acknowledge the contributions ofKerry Booker and Lorraine Moores of Hope Hospital, Sal-ford, and Nick Ambler and Heather Muncey of FrenchayHospital, Bristol.

This project was supported by funding from the NationalDisability Development Initiative.

References

[1] McCormick A, Fleming D, Charlton J. Morbidity statistics from gen-eral practice: Fourth National Study 1991–1992. Office of PopulationCensuses and Surveys, HMSO; 1995.

[2] Thomas E, Silman AJ, Croft PR, Papageorgiou AC, Jayson MI,Macfarlane GJ. Predicting who develops chronic low back pain inprimary care: a prospective study. Br Med J 1999;318:1662–7.

[3] Walsh K, Cruddas M, Coggon D. Low back pain in eight areas inBritain. J Epidemiol Community Health 1992;46:227–30.

[4] Watson P, Main CA, Waddell G, Gales TF, Purcelljones G. Medicallycertified work loss, recurrence and costs of wage compensation forback pain: a follow-up study of the working population of Jersey.Br J Rheumatol 1998;37:82–6.

[5] Waddell G. The back pain revolution. Edinburgh: Churchill Living-stone; 1998.

[6] Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ.Outcome of low back pain in general practice: a prospective study.Br Med J 1998;316:1356–9.

[7] Waddell G, Aylward M, Sawney P. Back pain, incapacity for workand social security benefits: an international literature review andanalysis. London: Royal Society of Medicine Press; 2002.

[8] Klaber-Moffett J, Richardson G, Sheldon T, Maynard A. Back pain:its management and cost to society. Centre for Health Economics,University of York; 1995.

[9] Maniadakis N, Gray A. The economic burden of back pain in theUnited Kingdom. Pain 2000;84:95–103.

[10] Main CJ, Burton AK. Economic and occupational influences on painand disability. In: Main CJ, Spanswick CC, editors. Pain manage-ment: an interdisciplinary approach. Edinburgh: Churchill Living-stone; 2000. p. 63–87.

[11] Bartys S, Tillotson M, Burton K, Main C, Watson PJ, Wright I, etal. Are occupational psychosocial factors related to back pain andsickness absence? In: Hanson M, editor. Contemporary ergonomics.London: Taylor & Francis; 2001. p. 23–8.

[12] British Society of Rehabilitation Medicine. Vocational rehabilitation:the way forward. London: BSRM; 2000.

[13] Loeser JD, Henderlite SE, Conrad DA. Incentive effects of workers’compensation benefits: a literature synthesis. Med Care Res Rev1995;52:34–59.

[14] Fishbain DA, Rosomoff HL, Cutler RB, Rosomoff-Steele R. Sec-ondary gain concept: a review of the scientific evidence. Clin J Pain1995;11:6–21.

[15] Rohling ML, Binder LM, Langhinrichsen-Rohling J. Money matters:a meta-analytical review of the association between financial com-pensation and the experience and treatment of chronic pain. HealthPsychol 1995;14:537–47.

[16] Rainville J, Sobel JB, Hartigan C, Wright A. The effect of com-pensation involvement on the reporting of pain and disability bypatients referred for rehabilitation for chronic low back pain. Spine1997;22:2016–24.

[17] Tito F. The consumer’s perspective. In: Law, money and medicine:Forum on Compensable Disability. Sydney: Royal Australian Collegeof Physicians; 2000.

[18] Simmonds M, Kumar S. Does knowledge of a patient’s workers’compensation status influence clinical judgments. J Occup Rehabil1996;6:93–107.

[19] Rowlingson K, Berthoud R. Disability, benefits and employment.Department of Social Security Research Report 54, HMSO; 1996.

[20] Watson PJ. From back pain to work: final report. Bristol: NationalDisability Development Initiative; 2001.www.le.ac.uk/anaesthesia/lc85/Backtoworkfinalreport.html[accessed 8 December 2003].

[21] Clinical Standards Advisory Group. Back pain: report of a CSAGCommittee on Back Pain. London: HMSO; 1994. p. 1–89.

[22] Royal College of General Practitioners. Clinical guidelines for themanagement of acute low back pain; 2002.www.rcgp.org.uk/rcgp/clinspec/guidelines/[accessed 8 December 2003].

[23] Roland M, Morris R. Study of the natural history of back pain. PartI. Development of a reliable and sensitive measure of disability inlow back pain. Spine 1983;8:141–4.

[24] Roland M, Fairbank J. The Roland–Morris Disability Questionnaireand the Oswestry Disability Questionnaire. Spine 2000;25:3115–24.

[25] Stratford PW, Binkley J, Solomon P, Finch E, Gill C, More-land J. Defining the minimum level of detectable change for theRoland–Morris Questionnaire. Phys Ther 1996;76:359–65.

[26] Price DD, Harkins SW. Psychophysical approaches to pain measure-ment and assessment. In: Turk DC, Melzack R, editors. Handbookof pain assessment. New York: Guildford Press, 1992. p. 111–34.

[27] Kori SH, Miller RP, Todd DD. Kinesiphobia: a new view of chronicpain behavior. Pain Manage 1990;(Jan/Feb):35–43.

[28] Main CJ, Wood PL, Hollis S, Spanswick CC, Waddell G. The distressand risk assessment method: a simple patient classification to identifydistress and evaluate the risk of poor outcome. Spine 1992;17:42–52.

[29] Main CJ. The Modified Somatic Perception Questionnaire. J Psy-chosom Res 1983;27:503–14.

[30] Greenough CG. Recovery from low back pain: 1–5 year follow-up of287 injury-related cases. Acta Orthopaed Scand 1993;254(Suppl):1–34.

[31] Burton AK, Tillotson KM, Main CJ, Hollis S. Psychological predic-tors of outcome in acute and sub-chronic low back trouble. Spine1995;20:722–8.

P.J. Watson, C.J. Main / Physiotherapy 90 (2004) 4–11 11

[32] Harding VR, Williams ACDC, Richardson PH, Nicholas MK, Jack-son JL, Richardson IH, et al. The development of a battery of mea-sures for assessing physical functioning of chronic pain patients.Pain 1994;58:367–75.

[33] Department of Work and Pensions. Incapacity benefit key fact sheet.London: DWP; 2001.

[34] Ritchie J, Ward K, Duldig W. A qualitative study of the role of gene-ral practitioners in the award of-invalidity benefit. Department ofSocial Security Report 18, HMSO; 1993.

[35] Chew C, May C. The benefits of back pain. Fam Pract 1997;14:461–5.

[36] Swales K, Craig P. Evaluation of the incapacity benefit medical test.Department of Social Security Report 26. London: DSS; 1997.

[37] Porter T. Early customer reactions to the delivery of incapacity bene-fits. DSS Report 23. London: Department of Social Security; 1997.

[38] Main CJ, Spanswick CC, Watson PJ. The nature of disability. In:Main CJ, Spanswick CC, editors. Pain management: an interdisci-plinary approach. Edinburgh: Churchill Livingstone; 2000.