Identifying beliefs that delay or reduce time to return to work (RTW) can help save businesses a lot on their insurance premiums. Ideally, businesses should be looking to identify these beliefs as soon as possible after an injury and then targeting the beliefs that can be modified with appropriate treatment. It is important to note that the although uncovering the beliefs of the injured worker is vital to successfully rehabilitating them and obtaining a successful return to work outcome,  the beliefs of their managers, employers, insurers and even their treating health professionals can significantly impact the outcome. Past research into so called “prognostic indicators” of delayed RTW have identified non-modifiable barriers such as age, gender, industry and level of education.1 However, more recent research has cast doubts on these findings.2

Recent scientific research has identified a number of beliefs that can have a significant impact on a successful RTW outcome for injured workers.3,4 What makes these factors even more important is that they can be identified early after an injury has occurred and when identified early, they can be amenable to change. These factors are:

  • Fear avoidance beliefs
  • Recovery expectations/Catastrophising
  • Self-efficacy
  • Workplace involvement

Fear Avoidance Beliefs

Fear avoidance beliefs (FAB), sometimes referred to as kinesiophobia, i.e. fear of movement, is one of the biggest beliefs that can impact an injured workers return to work progress. Fear of movement is often linked to the pain (actual or expected) associated with movement and can therefore possibly be more accurately described as a fear of pain.

Fear of pain can be worse than pain itself. Research has shown that individuals who have a high level of fear of pain or fear of re-injury will become more physically and mentally deconditioned due to their pain condition.

Fear of pain is also associated with other predictors of poor outcome such as passive approaches to treatment (relying on others to assist you) and an external locus of control (a belief that events are outside of an individuals’ own control).

FAB’s have been well established as a risk factor for developing chronic pain in a range of musculoskeletal injuries.5 It has been shown to be particularly evident in chronic low back pain suffers.6 Furthermore, Iles et al. (2008) found that there is moderate evidence that FAB’s are predictive of RTW outcome.4 There are a number of questionnaires designed to measure FAB and the fear avoidance beliefs questionnaire has been shown to be a valid and reliable outcome measure.7  Furthermore, FAB have been shown to be amenable to change.8,9

FAB’s are often due to a limited understanding of the factors contributing to their pain. It is now known that changes in the structure of the spine (and other areas of the body, e.g. the shoulder, hip, knee and tendons) and associated imaging (such as disc bulges, loss of cartilage thickness, tendinopathic changes) actually have a low correlation with symptoms. In fact, often people without pain can have structural changes on MRI and these changes relate most closely with age, not pain.10 This suggests these changes are more likely to be part of the normal ageing process, and not a “disease” or an “injury”. We now know that pain should be understood from a biopsychosocial perspective. This means that these are biological, psychological and social factors which work together to produce a unique pain experience.11

Fear of pain is one predictor of poor recovery

Recovery Expectations

Expectations regarding recovery have been shown to be a strong predictor of delayed RTW. It is also very easy to measure and an example questionnaire as described by Gross and Battie (2005) is provided below.12 These authors estimated that every one-point increase in recovery expectations score equated to a 22% reduction in likelihood that time-loss benefits would be suspended within one year. Another related concept is the injured workers perception about injury severity. Within patients with whiplash associated disorders, i.e. neck pain often resulting for motor vehicle accidents, worse injury severity perception is associated with worse recovery expectations and worse injury outcomes.13,14 Again, injury severity perception can be measured with a simple numerical rating scale.


Recovery expectations are also linked with another risk factor for poor return to work outcomes, catastrophising. Catastrophising has been broadly described as an excessive negative orientation toward pain stimuli or pain experience.15 I.e. injured workers who may be catastrophising can report things like “I worry all the time about whether the pain will end” and “It’s terrible and I think it’s never going to get any better”. Injured workers who catastrophise their pain may shift an undue amount of their attention onto painful or potentially painful events. Injured workers who catastrophise are often unable to shift their attention away from painful or potentially painful events. They also tend to be more avoidant and equate pain with damage.16 Pain catastrophising can be measured using a validated and reliable questionnaire, the Pain Catastrophizing Scale.17

Finally, recovery expectations and pain catastrophising are potentially amenable to change with early intervention, appropriate advice and education regarding the normal prognosis for an injury and encouragement to remain active, including remaining at work on suitable duties.


Self-efficacy relates to an individuals’ confidence to be able to perform or complete a set of tasks or activities. When related to pain or an injury, self-efficacy is an injured workers confidence to function despite their pain or injury. Thus it is linked and related to fear avoidance beliefs, recovery expectation, and catastrophising. Self-efficacy has been found to be a potential contributor to the disability of chronic pain and self-efficacy has been associated with RTW outcomes and successful work functioning.18 Injured workers with high self-efficacy are more likely to engage in active rehabilitation, including an appropriate RTW program. Self-efficacy related to pain can be measured using the Pain Self-Efficacy Questionnaire.19

Franche and Krause (2002) suggest self-efficacy can be increased by the successful engagement in the behaviour of interest. Increased self-efficacy can be seen whether the behaviour is partially or fully engaged in.20 Therefore, employers and insurers can help foster increased self-efficacy for injured workers via the implementation of appropriate and achievable suitable duties and the prescription of a gradual RTW program. This RTW program should be commenced as soon as practicably possible, needs to be meaningful to the injured worker, but critically, also achievable. Successful engagement in work tasks will increase the injured workers confidence to function, i.e. increase their self-efficacy, and contribute to a successful RTW outcome.

Workplace Involvement

A review by Carroll et al. (2010) found that stakeholder involvement in the RTW process helped improve RTW outcomes for injured workers.3 They additionally found that workplace-related exercise interventions were beneficial at aiding RTW, but they were no more effective than exercise interventions that occurred away from the workplace. This suggests that a specific type of workplace involvement is required to improve RTW outcomes. Carroll et al. (2010, pp. 617) state very clearly that “Interventions involving active, structured consultation among employee, employer and occupational health practitioners, and agreements regarding subsequent, appropriate work modifications, appear to be more effective at helping people with back pain on long-term sick leave to RTW than interventions that do not possess such components.3

Employers need to be actively involved in the RTW process to obtain successful outcomes for their injured employees.

In contrast to this positive workplace involvement, poor employer and insurer beliefs can also negatively affect the RTW outcome. A common mistake made by employers and insurers is attributing blame to the injured worker, especially early on in the injury process. Even if the worker is at fault, it is almost never the case that the worker was maliciously trying to injure themselves.  Thus, employers and insurers should be focused initially on facilitating and providing the appropriate care for the injured worker. Any attempts in the early stages to attribute blame or reprimand the injured worker will only succeed in setting up an adversarial relationship, where there is no trust between the parties. This will make initiating a collaborative RTW program and obtaining a successful outcome infinitely more difficult to achieve. Further down the line, after adequate medical care has been provided and a rehabilitation program has been started, it may be appropriate to start to educate the injured worker about safe work practices and provide them with additional training to help reduce the risk of another injury. However, this should only be initiated after the workers injury has been acknowledged and care has been provided.

A collaborative RTW program is crucial for optimal outcomes

A number of commonly regarded beliefs have been shown NOT to provide any prognostic indication of RTW outcome. Of these, the most equivocal is compensation, in that there is insufficient evidence to suggest that compensation is predictive of RTW outcome.4 This challenges a commonly held unhelpful belief, that all injured workers are putting it on, or exaggerating their symptoms consciously or maliciously. Although secondary gain is a factor to consider, the number of injured workers who are actively seeking to distort their symptoms in order to gain financial or occupational favour is low.  Furthermore, suggesting that an injured worker is seeking undue financial or occupational favour is likely to set up an adversarial relationship and will create more barriers to a successful return to work outcome, as described above. Finally, the evidence is far clearer on the predictive capacity of depression, stress and anxiety and job satisfaction. These factors are NOT predictive of RTW outcome.4


The beliefs of injured workers, employers and insurers impact the RTW outcome for injured workers. These beliefs can have positive or negative impacts on the RTW outcome, and therefore should be identified early in the recovery process, with interventions targeting facilitation of positive beliefs and amelioration of negative beliefs. The common beliefs that can affect RTW outcome and can be assessed include:

  • Fear avoidance beliefs
  • Recovery expectations/Catastrophising
  • Self-efficacy
  • Workplace involvement

Employers and insurers can help via fostering a collaborative and empathetic relationship with the injured worker, facilitating improved self-efficacy via the implementation of an appropriately timed and paced RTW program. Furthermore, employers can help ameliorate unhelpful beliefs around avoidance, recovery expectations and catastrophising by providing injured workers access to expert medical and rehabilitative care as soon as possible after any injury via early intervention programs, such as onsite physiotherapy services. Investing in these processes will help improve employee health and satisfaction, improve productivity via a healthier workforce and result cost-savings via a reduction in workers compensation premiums.



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