Multidisciplinary rehabilitation and workplace interventions for low back pain : an evaluation of the Belgian secondary prevention program for workers with low back pain

Low back pain (LBP) represents a major global health challenge, imposing a significant burden on individuals, healthcare systems, and the broader economy, including costs related to healthcare use, loss of productivity, sickness absence, and work disability. Among workers exposed to high physical demands, the risk of chronicity, long-term work disability, and premature exit from the labor market is particularly pronounced. The transition from acute to chronic LBP is a critical concern, often driven by a complex interplay of biological, psychological, and social factors. In response, the biopsychosocial (BPS) model has become the cornerstone of modern LBP management, advocating for integrated interventions that address the multifaceted nature of the condition. Within this framework, multidisciplinary-based rehabilitation programs, particularly those incorporating vocational components, are recommended to prevent chronicity and facilitate a sustainable return to work (RTW). In Belgium, the Federal Agency for Occupational Risks (FEDRIS) established a secondary prevention program for workers with LBP that combines a multidisciplinary-based rehabilitation program at a hospital or rehabilitation center with an optional ergonomic workplace intervention. The Belgian FEDRIS secondary-prevention program is one of the few large-scale policy initiatives that operationalizes these recommendations by combining a multidisciplinary-based rehabilitation track with an optional workplace intervention. This program, modeled after the Sherbrooke approach, aims to bridge the gap between clinical rehabilitation and occupational health, a critical step towards mitigating the high rates of work disability associated with LBP. Despite its promising design and alignment with international guidelines, the FEDRIS program has not been comprehensively evaluated, leaving a significant gap in our understanding of its real-world effectiveness, implementation fidelity, and cost-effectiveness. This doctoral dissertation was designed to evaluate the national secondary prevention program by FEDRIS through a mixed-methods approach. The objective was to assess the program’s effectiveness in reducing LBP-related disability, promoting sustainable RTW, and improving healthcare efficiency from multiple perspectives. To achieve this, the research was structured around three primary research questions: 1. What is the current evidence base regarding the effectiveness of multidisciplinary BPS interventions—particularly those that include workplace ergonomic components—on pain intensity, functional outcomes, absenteeism, and RTW among workers with (sub)acute LBP? 2. What is the impact of the FEDRIS program on absenteeism, RTW outcomes, and healthcare utilization, and what is its costeffectiveness compared to usual care?. 3. (a) What are the experiences and perceptions of employees and stakeholders regarding the clinical multidisciplinary-based rehabilitation component embedded in the FEDRIS program? (b) What are the experiences and perceptions of employees and stakeholders regarding the ergonomic workplace intervention embedded in the FEDRIS program? This dissertation addressed these three primary research questions through four distinct but complementary studies. The key findings from each chapter are summarized below. Chapter 1 presented a systematic review of the international literature. The findings confirmed with moderate certainty that multidisciplinary-based rehabilitation is superior to usual care (general practitioner only) in improving pain and functional outcomes among workers with subacute LBP. These benefits were consistent across formats and appeared strongest when cognitive–behavioral components were included, as these address maladaptive beliefs, fear avoidance, and catastrophizing. However, effects on work-related outcomes were less consistent. Moreover, more intensive multidisciplinary rehabilitation showed no additional benefits in outcome measures versus less intensive programs. The review also highlighted the very low-certainty evidence base for workplace interventions, with only one study suggesting earlier RTW and reduced sick leave when ergonomic interventions were added to usual care. Importantly, exploratory subgroup analyses pointed toward potentially meaningful predictors of intervention success, including job satisfaction, perceived control over work planning, age, and previous sickness absence. Although tentative, these findings underline the importance of risk-matched approaches tailored to individual risk profiles. Chapter 2 focused on a retrospective population-based evaluation of the Belgian FEDRIS multidisciplinary-based rehabilitation program for workers with LBP. Using linked national databases (2014–2020), the study compared three groups: (A) FEDRIS-sponsored multidisciplinary-based rehabilitation with optional workplace intervention, (B) standard multidisciplinary-based rehabilitation without FEDRIS support or workplace intervention, and (C) usual care without multidisciplinary-based rehabilitation. The usual care group could include ambulatory visits (e.g., general practitioner, physiotherapy), imaging, hospital admissions, or prescribed medication. Outcomes included healthcare utilization, costs, disability days, relapse, and sustained RTW, analyzed through propensity score weighting, regression models, and cost-effectiveness analysis. Among 6,119 participants, the FEDRIS group showed higher total and societal costs (€7,374) and more disability days (~111) than both standard multidisciplinary-based rehabilitation (€4,792; ~65 days) and usual care (€4,803; ~80 days). The workplace intervention within the FEDRIS group significantly reduced disability days, though it did not lower costs. The standard multidisciplinary-based rehabilitation achieved the most favorable cost-effectiveness, with lower costs and higher sustained RTW rates (49%) compared to FEDRIS (37%). Usual care was the least expensive but least effective sustained RTW (35%). Overall, the FEDRIS program did not outperform standard multidisciplinary-based rehabilitation, despite the benefits from its ergonomic component. The findings emphasize the need to optimize patient selection, strengthen workplace integration, and conduct prospective evaluations to ensure cost-effective, sustainable secondary prevention of work-related LBP in Belgium. Chapter 3, article 1, explored the experiences of healthcare professionals and employees through qualitative focus groups, providing a richer understanding of why outcomes varied. Employees described heterogeneous experiences, with some reporting significant improvements in pain and function, while others experienced little to no change. Healthcare professionals, by contrast, generally perceived positive clinical trends. RTW outcomes were more complex and depended heavily on workplace adaptations, employer flexibility, and the physical demands of the job. The multidisciplinary, biopsychosocial approach was widely valued, particularly its combination of education, exercise therapy, and group sessions, which helped to reduce fear of movement and enhance motivation. Yet participants also identified several limitations. These included insufficient psychological support, limited individualization, inadequate real-time feedback, and difficulties in applying clinical skills in demanding work settings. Both employees and healthcare professionals emphasized the importance of continuity of care, noting that benefits often faded once the 36-session program ended. Follow-up sessions, booster treatments, and supportive tools were inconsistently provided, leaving a critical gap in sustaining long-term behavioral change and functional gains. Chapter 3, article 2, examined the role of the workplace intervention in greater detail. The qualitative findings underscored the centrality of workplace adaptations, ergonomic coaching, and employer engagement for achieving durable RTW. Employees valued tailored ergonomic advice and participatory problem-solving, which sometimes uncovered broader issues such as interpersonal conflict or job dissatisfaction. Nevertheless, uptake of the intervention was limited, and administrative delays, employer hesitancy, and a lack of structured follow-up often hampered its implementation. Barriers were particularly pronounced in small companies and in physically demanding occupations, where the feasibility of job modifications was constrained. Many employees and employers were unaware of the intervention, while others were reluctant to engage due to stigma, concerns about feasibility, or financial costs. In practice, the optional nature of the workplace intervention within FEDRIS meant that many workers missed out on potential benefits, thereby undermining the program’s theoretical model, which was based on the Sherbrooke integrated-care framework. The absence of systematic communication between rehabilitation centers, occupational physicians, occupational health services, and employers further reduced impact, as ergonomic recommendations were often not implemented or sustained. Taken together, the three chapters reveal a central paradox. While multidisciplinary-based rehabilitation and workplace interventions for LBP are supported by robust international evidence, the Belgian FEDRIS program failed to deliver consistent improvements in cost, function, or sustainable work participation. This discrepancy can be explained by a combination of factors, including case selection that concentrated on more severe patients in the program, implementation challenges such as administrative delays and variable fidelity, insufficient integration with workplace systems, and a lack of continuity after discharge. Nonetheless, the findings also point to clear opportunities for improvement. The subgroup analyses highlight the potential of risk-matched, individualized care, while the qualitative studies reveal the imp

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