Impact of Psychosocial Factors in Patients with Chronic Low Back Pain

SEPTEMBER 12, 2013
Amber N. Mitchell, MD

Commentary from Dr. Mitchell
Low back pain due to various musculoskeletal etiologies is a major burden on quality of life as well as on the economy. Due to the dramatic lifetime prevalence of low back pain in the general population of nearly 50% 2, this article is very relevant. Statistical analysis was thorough, with multivariate and univariate logistic regression used to control for variables. The study explored how occupational factors and personal qualities impact the perception and response to pain. In this study, it was determined that pain catastrophizing and acquisition of negative beliefs about one’s pain are associated with lower back pain. Low job satisfaction and high job support are independently associated with work leave for low back pain. It is necessary to continue this study longitudinally to observe if these trends persist, as a 12-month duration is suboptimal to draw definitive conclusions.
Of course this study is not externally valid given the parochial nature of the study population—middle-aged, female nurses from Australia. There may be underlying factors intrinsic to the field of nursing that render them especially vulnerable to the psychosocial impact of pain. Nurses often care for patients complaining of back pain in the hospital. Health care workers, in general, are susceptible to factitious disorder, malingering, and somatization given the nature of their work. They witness the benefits of infirmity, the proverbial “sick role,” as many of their patients take leave of work and receive the attention of loved ones. Different professions require different amounts of manual labor. The field of nursing is not only vulnerable to mirroring of the “sick role,” but requires more manual labor than other professions, which limits the extrapolation of the data. In addition, men, who are generally more physically active than women, were not studied. The differences in perceptions and prevalence of low back pain amongst different professions should be studied further.
The low responder rate of 38% is another limitation of this study. Low back pain and work leave may be underreported due to severe debility that precludes participation in the study or busy work scheduling.The work attrition due to work-related low-back pain and/or individual psychosocial stressors may be an underestimate as the study favors those out of work with ample time and motivation to complete the questionnaire. There may be a subset of nurses who suffer from work-related low-back pain, yet are resilient enough to withstand it and continue to work. This same population may be too busy to complete the questionnaire as it is not mandatory. Also, the retrospective design leaves the study open to recall bias amongst the limited responders. Given that greater than 50% of the data is unknown and prone to such memory bias, we should apply the data judiciously.
Each individual brings his or her own experiences to a situation. In any study, it is difficult to anticipate and control for the variability of personal qualities and circumstances. Chronic pain syndromes are created by the complex interaction of genetic and environmental factors. Various genetic polymorphisms causing aberrant signaling within the serotonergic and adrenergic pathways have been associated with susceptibility to musculoskeletal pain.8 In addition, individual differences in mental schemata and coping strategies will no doubt influence the way in which the body reacts to occupational stress. Undue emotional distress, somatic awareness, psychosocial stress, and catastrophizing amplify pain mechanisms.8 The mental schema of thinking something is worse than it actually is the basis of catastrophizing, which can influence occupation attrition rates. Catastrophizing is the process of entering an experience with negative expectations, which often results in poor outcomes due to poor coping and self-fulfilling prophecy of one’s own doom.Maladaptive processing of an external conflict, such as job-related stress, often leads toaberrant signaling transduction that leads to increased release of inflammatory cytokines and vulnerability to somatization and pain.2 Somatization has been found in several studies to be associated with development of chronic back pain.4 Biofeedback, cognitive-behavioral therapy, and physical exercise are possible conservative means of managing stress and averting somatization and pain.5-7,9
Thus, as genetically diverse creatures, humans carry the burden of diverse, unexpected reactions to environmental stressors. For this reason, pain management is not a field of systematic protocols, but one of individualization, patient-focused care. Identification of an adverse work environment, as well as faulty mental coping mechanisms, may be the first steps in averting the pathogenesis of chronic pain and limiting occupational attrition rates.
Amber N. Mitchell is a neurology resident at Albany Medical Center Hospital
1. Urquhart DM, Kelsall HL, Hoe VC, Cicuttini FM, Forbes AB, Sim MR. Are Psychosocial Factors Associated With Low Back Pain and Work Absence for Low Back Pain in an Occupational Cohort? Clin J Pain. 2013 Jan 30. [Epub ahead of print].
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7. Chandler C, Bodenhamer-Davis E, Holden JM, Evenson T, Bratton S. Enhancing personal wellness in counselor trainees using biofeedback: an exploratory study. Appl Psychophysiol Biofeedback. 2001 Mar;26(1):1-7.
8. Diatchenko L, Fillingim RB, Smith SB, Maixner W. The phenotypic and genetic signatures of common musculoskeletal pain conditions. Nat Rev Rheumatol. 2013 Apr 2. doi: 10.1038/nrrheum.2013.43. [Epub ahead of print].
9. Henschke N, Ostelo RW, van Tulder MW, Vlaeyen JW, Morley S, Assendelft WJ, Main CJ. Behavioural treatment for chronic low-back pain. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002014.

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