Increased Pain Tolerance
This study examined retrospective data from a
as an Indicator of Return
to Work in Low-Back
Injuries After Work
Hardening
Jennifer M. Joy, Jamie Lowy,
Jim K. Mansoor
Key Words: injured worker • rehabilitation
Jennifer M. Joy, PT, is Physical Therapist, Fit-to-Work
Rehabilitation Clinic, Cameron Park, California.
Jamie Lowy, PT, is Physical Therapist, Fit-to-Work
Rehabilitation Clinic, Cameron Park, California.
Jim K. Mansoor, PhD, is Assistant Professor, Physical Therapy
Department, School of Pharmacy and Health Sciences,
University of the Pacific, 3601 Pacific Avenue, Stockton,
California 95211; jmansoor@uop.edu.
This article was accepted for publication March 17, 2000.
200
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Objective.
multidisciplinary work-hardening program that compared
patients who did and did not return to work after low-
back injury. The objective of this study was to identify dif-
ferences between these groups to better guide
work-hardening programs and return-to-work decisions.
Method. Retrospective data from patients with low-
back injuries (n = 115) who participated in a northern
California work-hardening program were analyzed. Using
two-way analysis of variance, male and female patients
who did and did not return to work were compared.
Results. No significant differences were found between
men and women for any of the variables studied. Patients
who did and did not return to work were not significantly
different in age, length of injury, and subjective pain at the
beginning or end of the work-hardening program or in
activity tolerance (p = .08). Patients who returned to work
perceived a significantly (p ≤ .05) greater improvement in
pain tolerance by the end of the work-hardening program
than those who did not return to work.
Conclusion. The results of this study suggest that reha-
bilitation emphasis should not be placed on the reduction
of subjective pain but, rather, on strategies to cope with
existing pain while improving functional ability.
Joy, J. M., Lowy, J., & Mansoor, J. K. (2001). Increased pain tol-
erance as an indicator of return to work in low-back injuries after work
hardening. American Journal of Occupational Therapy, 55, 200–205.
D
etermining whether a patient is able to return to
work after an occupational low-back injury can be
a difficult decision, particularly if the person has
been off work for a long period. Studies have shown that
the longer a person is off work due to injury, the less likely
that person will return to work (McGill, 1969; Milhous et
al., 1989; Waddell, 1987), especially when the person is
being compensated financially. Additionally, age, gender,
and time from injury to therapeutic intervention have all
been examined as predictors of return to work (Ash &
Goldstein, 1995; Beissner, Saunders, & McManis, 1996;
Caruso, Chan, & Chan, 1987; Hazard et al., 1989;
Hildebrandt, Pfingsten, Saur, & Jansen, 1997; Niemeyer,
Jacobs, Reynolds-Lynch, Bettencourt, & Lang, 1994).
Frequently, however, physicians and other health care
providers will ask the patient whether he or she feels ready
to return to work, and the response is often based on the
patient’s pain. Patients with back injuries frequently have
pain that lasts beyond the expected level and duration of
the healing process (Vasudevan & Lynch, 1991); they often
have no demonstrable objective cause for the pain
(Nachemson, 1983); and they have no anatomically verifi-
March/April 2001, Volume 55, Number 2
 able lesion (Haig & Penha, 1991). Physicians and other
members of the health care team often become frustrated
when attempting to decide whether persistent pain com-
plaints should delay return to work. Should the determina-
tion of whether a patient is able to return to work be based
on self-reported pain levels or on other factors?
Several studies have examined subjective pain levels as
they relate to return-to-work rates. Roland and Morris
(1983) found that self-reports of pain were actually better
predictors of return to work than length of time off work.
Lefort and Hannah (1994) found in their prospective clin-
ical study of persons with low-back injuries that the return-
to-work group showed significant improvement in pain
measures, whereas the group that did not return to work
showed no change in pain. Alternatively, Hazard, Bendix,
and Fenwick (1991) noted that although initial patient
self-reports of pain intensity in a 3-week functional restora-
tion program were lower for program graduates than for
dropouts, the self-assessments did not predict eventual
return to work. Likewise, Ambrosius, Kremer, Herkner,
Dekraker, and Bartz (1995) showed that the group that
had the greatest decrease in pain after a work-hardening
program had a slightly lower return-to-work rate than the
group who had no significant change in pain level. These
studies indicate that pain level may not be the best indica-
tor in return-to-work decisions.
The purpose of this study was to examine differences
between patients with low-back injuries who eventually
returned to work and those who did not return to work.
In particular, we wanted to determine whether a relation-
ship existed between subjective pain level, pain tolerance,
and activity tolerance and return to work among patients
who participated in a work-hardening program. Addi-
tional factors examined were gender, age, length of time
since injury, and length of time spent in the work-harden-
ing program.
Method
Sample
All data used in this study were analyzed retrospectively
from records of patients with low-back injuries (n = 115)
referred to a work-hardening program in northern
California from March 1989 to August 1996. They were
referred to the program by various sources, including
physicians, rehabilitation nurses, insurance companies, and
employers. At the time of referral to the program, all had
been off work for 2 months or more since injury or surgery.
For acceptance into the work-hardening program, patients
were required to be ambulatory and authorized to attend
by their workers’ compensation insurance carrier. All
patients were entitled to workers’ compensation benefits.
Data from patients referred to the work-hardening pro-
gram for reasons other than low-back injury were excluded
from the study (n = 117).
The American Journal of Occupational Therapy
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Work-Hardening Program
The work-hardening program used a multidisciplinary
approach for treating injured workers. The treatment staff
was made up of an occupational therapist, physical thera-
pist, vocational counselor, psychologist, and workroom
foreman, with the occupational therapist and physical ther-
apist working full time with the patients. Both the occupa-
tional therapist and the physical therapist were involved
with the initial intake evaluation, daily activity schedules,
case management, and discharge planning. The physical
therapist instructed patients in daily low-back exercises and
injury-prevention training, whereas the occupational ther-
apist worked with patients in pain-management techniques
and supervised individual work-simulation activities.
Patients were expected to attend the work-hardening pro-
gram 5 days a week for 6 hours per day.
All patients were treated at the same work-hardening
facility in northern California. The physical space consist-
ed of a 2,000-sq ft warehouse-like area with a variety of job-
related simulations; an adjoining 2,000-sq ft gym shared
with traditional outpatient occupational and physical ther-
apy services; and a smaller room used for multiple purpos-
es, including classes, intake and exit conferences, stretching
exercises, and lunch. Additionally, an outside area was used
for simulating outdoor activities, including gardening and
various types of materials handling.
Treatment consisted of job-specific work simulations,
physical conditioning, and education. Work simulations
were set up to match activities that injured workers did on
the job. For example, an old, unused car was a permanent
fixture at the facility and provided a simulation station for
automechanics. Injured electricians worked on wiring
while in a crawl space under a mock-up framed structure
built in one corner of the workroom. Grocery store work-
ers restocked mock grocery items on shelving set to varying
heights. The facility also had a telephone pole installed in
the outside area behind the building for climbing activities
for linemen. Each day began with a 1-mile group warm-up
walk around the facility, which was followed by stretching
exercises for the lower extremities and low back as well as
floor exercises, such as abdominal strengthening. Much of
the day was scheduled for work-simulation activities. One-
hour classes on the anatomy of the spine, proper posture,
body mechanics, and pain and stress management were
also provided during the course of the week. These classes
were taught by the occupational and physical therapists
and involved slides, handouts, lectures, and group discus-
sions. The patients spent the final hour of the day per-
forming aerobic and strengthening exercises in the gym. An
aerobic period of 20 min to 30 min included activities on
a treadmill, stair stepper, and stationary bicycle. Eagle® and
Nautilus® exercise equipment was used for the strengthen-
ing exercises.
Each patient’s treatment plan was individualized on
201
 the basis of injury, job description, and case goals. The pri-
mary goal for treatment was to facilitate safe return to the
workforce. The program helped to identify whether a
patient had the functional capacity to return to a previous
job or whether limitations in functional abilities required
that the patient return to alternate work.
Data Collection
At the time of referral, each patient participated in an
intake evaluation that consisted of a questionnaire to be
completed by the patient, an interview with one of the staff
members, a physical assessment, and a functional abilities
assessment. The questionnaire collected information on
age, gender, date of injury, education, occupation, job
description, and psychosocial-related topics. In addition,
the patient completed a pain drawing to indicate where he
or she felt pain. The interview portion of the evaluation
collected information about the patient’s medical history
and the present injury. During this time, the patient was
asked to report current pain level using a simple numerical
scale from 0 to 10 with verbal expressions as anchors. On
the pain level scale, 0 was equivalent to no pain and 10 was
equivalent to excruciating pain. The pain level scale was
similar to category ratio scales used to measure perceived
exertion and perceived pain (Borg, 1990; Borg, Holmgren,
& Lindblad, 1981). The physical assessment followed the
interview to establish general range of motion, strength,
and sensation. Functional abilities testing established the
patient’s baseline capacities for 16 physical demands,
including lifting, carrying, standing, walking, and other
tasks generally evaluated in work-hardening programs.
On the day of discharge from the program, each
patient completed an exit questionnaire that again asked
for a current self-rating of pain level using the pain level
scale. Additionally, the patient was asked to rate on a scale
of 0% to 100% improvement in pain tolerance and activi-
ty tolerance since starting the work-hardening program.
Pain tolerance was defined as the ability to continue work
despite the presence of pain symptoms. Activity tolerance
was defined as an increase in the amount of work or
non–work-related activities that the patient could tolerate
at the end of the work-hardening program compared with
the start of the program.
Return-to-work status was determined by contacting
the patients at 1, 6, 12, and 24 months after discharge from
the program. If the patient had returned to work either part
time or full time to either the original or an alternative job
at the time of the follow-up phone calls, the patient was
considered to have successfully returned to work. The date
of return to work was then recorded in the patient’s chart.
After this point, no further contact was made with the
patient. For those patients who successfully returned to
work, the average time from discharge from the work-hard-
ening program to return to work was 4 months. After 24
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months, no further follow-up phone calls were made to
patients.
Statistical Analysis
Retrospective data were analyzed using a two-way analysis
of variance (ANOVA), with gender as one independent fac-
tor and work status (did not return to work vs. returned to
work) as the other. Dependent variables included age,
length of injury, days spent in the work-hardening program,
pain level at the start and end of the program, and pain tol-
erance and activity tolerance. All data are presented showing
means and standard errors of the mean.
Results
Overall Participant Characteristics
The age of the patients in the work-hardening program
ranged from 19 years to 61 years (M = 37.8 ± .9 years). The
average length of time since injury was 274 ± 24 days.
Patients spent an average of 12.6 ± .5 days in the work-
hardening program. Little overall change in pain level from
the start to the end of the work-hardening program was
reported, with average pain ratings (on a scale of 1 to 10)
of 4.1 ± .2 at the start and 4.2 ± .2 at the end of the pro-
gram. Overall, by the end of the work-hardening program,
pain tolerance improved 35.5 ± 2.4%, and activity toler-
ance improved 43.3 ± 2.6%.
Gender and Work Status Findings
The results of the two-way ANOVA with gender and work
status (did not return to work, returned to work) as inde-
pendent factors are presented in Table 1 and Figure 1. Note
that no main effects for gender for any of the variables stud-
ied were found, indicating that men and women had simi-
lar characteristics before the work-hardening program and
responded similarly to the program. Additionally, no main
effects for work status were found for age, length of injury,
days spent in the work-hardening program, or change in
pain level from the start to the end of the program. This
finding indicates that both groups had similar average ages,
lengths of injury, and days spent in the work-hardening pro-
gram (see Table 1). Interestingly, measurements of pain lev-
els for the group that did not return to work and the group
that did return to work showed virtually no change from the
start of the program to the end of the program (see Figure
1a). Pain tolerance, however, showed significant (p ≤ .05)
improvement by the end of the program for the group that
returned to work (see Figure 1b). Activity tolerance also
improved in the group that returned to work (p = .08) but
not significantly (see Figure 1c). Finally, no significant inter-
action effects were found between gender and work status.
Discussion
The purpose of this study was to examine the differences
between patients with low-back injuries who did and did
March/April 2001, Volume 55, Number 2
 Table 1
Descriptive Statistics of Participants in a Work-Hardening Program
Did Not Return to Work Returned to Work
Variable Women Men Women Men
Number of participants 14 28 25 48
Age (years) 38.0 ± 2.7 39.3 ± 2.0 35.7 ± 2.2 38.0 ± 1.1
Length of injury (days) 268 ± 70 295 ± 52 240 ± 30 280 ± 42
Time in program (days) 13 ±1 13 ± 1 12 ± 1 13 ± 1
a
Pain level
Start of program 4.2 ± 0.6 4.0 ± 0.4 5.0 ± 0.5 3.7 ± 0.3
End of program 4.5 ± 0.6 4.5 ± 0.5 4.7 ± 0.5 3.8 ± 0.3
Pain tolerance (% improvement) 24.2 ± 5.6 26.8 ± 3.8 39.1 ± 5.0* 42.0 ± 4.1*
Activity tolerance (% improvement) 33.1 ± 7.4 38.4 ± 5.4 40.0 ± 5.0 51.0 ± 4.0
Note. Values presented as means ± standard errors of the mean.
a
Scale of 1 (no pain) to 10 (excruciating pain).
*Significant (p ± .05) main effect for work status.

not return to work after a work-hardening program. In par-
ticular, we wanted to determine whether a relationship
existed among subjective pain level, activity tolerance, and
pain tolerance and return to work. When comparing the
group that returned to work with the group that did not,
no significant differences were found due to age, gender,
length of injury, days spent in the work-hardening pro-
gram, or change in pain level between the start and end of
Figure 1. Changes in (a) perceptions of pain levels, (b) per-
cent improvement in pain tolerance, and (c) percent improve-
ment in activity tolerance in men and women who did and did
not return to work after a work-hardening program. Note.
WH=work hardening; RTW = return to work. *Significantly dif-
ferent (p ≤ .05) from patients who did not return to work.
the program. Activity tolerance showed greater improve-
ment in the group that returned to work, but the change
was not significant (p = .08). Changes in pain tolerance
after the work-hardening program were found to be signif-
icant (p ≤ .05) when comparing patients who returned to
work with those who did not.
Our results indicate that age and gender were not pre-
dictors of return to work. These findings are consistent
with those of Ash and Goldstein (1995), Hildebrandt et al.
(1997), and Niemeyer et al. (1994) but differed from those
of Beissner et al. (1996), Hazard et al. (1989), and Caruso
et al. (1987). Beissner et al. and Hazard et al. found that
older patients (i.e., 50–60 years of age) were less likely to
return to work after injury than their younger counterparts
(i.e., 19–30 years of age). The mean age of the patients in
our study was in the mid to high 30s (see Table 1), indi-
cating that age may not be a factor in determining return
to work when the injured worker’s age falls between young
and old. Beissner et al. found that women were initially
more likely to return to work up to 3 months after com-
pleting a work-hardening program. However, this differ-
ence was not apparent 1 year after completing the program.
Caruso et al. also found that women were more likely to
return to work immediately after a work-hardening pro-
gram. In our study, we considered return to work up to 2
years after completing the work-hardening program suc-
cessful, with the mean time to return to work for our sam-
ple being 4 months. Our results did not show any gender
differences in return to work rates, indicating that at 4
months post–work-hardening program, gender may not
play a role as a predictor of return to work.
Our finding that length of time in a work-hardening
program was not a predictor of return to work is consistent
with research by Beissner et al. (1996) and Niemeyer et al.
(1994). Several studies also backed our finding that length
of injury was not a significant factor in determining return-
to-work rates (Ash & Goldstein, 1995; Beissner et al., 1996;
Hazard et al., 1989). Other studies, however, have support-
ed length of time off work (length of injury) as a strong pre-
dictor of return to work (Bigos et al., 1986; Burke,
Harms-Constas, & Aden, 1994; Frymoyer, 1992;
Hildebrandt et al., 1997; Lancourt, 1992; Peterson, 1995;

The American Journal of Occupational Therapy 203

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 Robert, Blide, McWhorter, & Coursey, 1995). In our study,
the average length of injury before the work-hardening pro-
gram was 8.7 months for the group that returned to work
and 9.4 months for the group that did not return to work.
This indicates homogeneity between our groups. The
length of injury of our sample was similar to that of the
Robert et al.’s (1995) and Hildebrandt et al.’s (1997). Why
some researchers have found length of time off work as a
predictor of return to work and others have not is unknown.
However, the type of work-hardening program may play a
role.
Although subjective pain is often used as an important
factor in making return-to-work decisions, our study
showed that pain level was not a factor in determining
return-to-work status. Rather, pain tolerance, and activity
tolerance were more important factors in determining
whether a patient with a low-back injury returned to work.
This finding indicates that perhaps rehabilitation emphasis
should not be placed on the reduction of subjective pain
but on strategies to cope with existing pain while improv-
ing functional ability. Although other researchers have
found that self-reports of pain are good predictors of
return-to-work outcome (Hildebrandt et al., 1997; Lefort
& Hannah, 1994; Roland & Morris, 1983), many cite
patients’ perceptions of their functional abilities as being
critical to their ability to return to work rather than their
overall pain levels (Callahan, 1993; Deardorff, Rubin, &
Scott, 1991; Fordyce, Roberts, & Sternbach, 1985; Keane
& Saal, 1991; Long, 1995; Rainville, Ahern, Phalen,
Childs, & Sutherland, 1992).
Multidisciplinary programs, such as work-hardening
and functional restoration programs, may be of benefit in
helping the patient identify and resolve issues that often
contribute to reports of high pain levels and disability exag-
geration. Contributing factors to disability exaggeration
may include fear of reinjury, overly protective spouses,
physician warnings against painful activity, sick role famil-
iarity, anxiety, and depression. These factors may lead
patients to unconsciously overreport symptoms or perform
poorly on functional tests (Hazard et al., 1991). Addition-
ally, many patients’ perceptions of their disabilities may
represent an avoidance strategy that is influenced by the
patient’s belief about the severity of the disease, by the
belief that pain represents tissue damage, and by concern
about receiving adequate treatment (Waddell, Newton,
Henderson, Somerville, & Main, 1993).
Work-hardening and functional restoration programs
focus on functional retraining of patients and often include
counseling that may be of benefit in addressing these
underlying patient concerns. The work-hardening program
in which the patients in this study participated emphasized
individual patient–therapist interactions that encouraged
patients to address issues specifically dealing with return-
to-work barriers, such as unrealistic expectations of treat-
ment results (“I need to be 100% cured before returning to
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work,” “I need to be pain free before I return to work”) or
financial gain (“I will get retrained and make more money
in my new job,” “The longer I am off work, the larger the
workers’ compensation settlement will be”). Hazard et al.
(1991) emphasized that by integrating components stress-
ing cognitive behavioral therapy into treatment programs,
a patient’s feeling of helplessness can be reduced and feel-
ings of competence increased, leading to greater return-to-
work success independent of any changes in a patient’s
overall pain level. Indeed, numerous studies have addressed
the helpfulness of work-hardening and functional restora-
tion programs in addressing both physical and nonphysical
barriers that injured workers face (Brewer & Storms, 1993;
Burke et al., 1994; Edwards et al., 1992; Greenberg &
Bello, 1996; Hazard et al., 1989; Hazard et al., 1991;
Hildebrandt et al., 1997; Mayer et al., 1987; Mitchell &
Carmen, 1990; Niemeyer et al., 1994; Ricke, Chara, &
Johnson, 1992). By de-emphasizing impairment and sub-
jective pain levels and addressing unresolved issues and
helping patients refocus on improving their pain tolerance
and performance of functional tasks, multidisciplinary pro-
grams can play an important role in maximizing injured
workers’ potential for being able to return to work.
The decision about whether a patient is ready to return
to work is complex and involves many variables. Tradition-
ally, the health care community and patients have tended to
fixate on the goal of pain relief as a measure of improve-
ment. Our study suggests that although physicians, occupa-
tional therapists, physical therapists, and other health care
providers should not discount pain self-reports, the rehabil-
itation focus should not be on pain levels but on improving
pain tolerance and activity tolerance. Our study, however, is
limited by its retrospective nature, which does not allow for
control of the variables measured. Future prospective
research with greater internal validity should be conducted
to examine further the role that pain tolerance and activity
tolerance play in successful return to work. ▲
Acknowledgment
We thank Candice Hoffman for her assistance in this study.
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