Fear-Avoidance Beliefs in Patients With Neck and Back Pain
Fear-Avoidance Beliefs in Patients With Neck and Back Pain
In this study, the psychological and social work factors were significantly and relatively strongly associated with fear–avoidance beliefs about work. These factors, in addition to disability and psychological distress, explained 39% of fear–avoidance beliefs in patients on sick leave due to neck or back pain.
Description of psychological and social factors at work and possible association with neck or back pain, have mainly been studied in worker populations. In a review from 2004, Hartvigsen et al. concluded that LBP was not significantly associated with demand and control. Furthermore, moderate evidence for no association between social support and LBP is reported. However, later studies have shown associations between psychological and social factors at work and neck and back pain. The present population reported a lower level of most aspects of demand, control, support, and reward, whereas effort and overcommitment were reported at a higher level than the reference population, although the differences were small. The relationship between psychological and social factors at work and pain may change with duration of disability and transition into patient status. The variety of work places among the present patients may also influence the results. The perceived higher support from co-workers and family and friends by female patients are consistent with data in the reference population. However, the higher quantitative demands, effort and overcommitment as reported by men than women, are not consistent with reference population.
The study population reported higher demand for physical endurance than the reference population. It is well known that physical work demands are associated with LBP prevalence in specific occupational populations and in the general worker population. In our population, we did not have information about the physical workload to which it was actually exposed. Nevertheless, half of the population reported a demand for physical endurance. It may be that being troubled by pain makes one perceive the work situation to be more physically demanding than usual.
The mean pain score of 5–6 in the study population was comparable to that in other studies on sick-listed workers with chronic LBP in secondary care. Computer workers with neck pain, but not sick-listed, have reported a lower pain level than in our population, whereas neck pain patients with more permanent work disabilities were characterised by even higher pain level than in the present study. The average ODI score reported in the present study was slightly higher than that reported in primary care populations and slightly lower than in patients recruited from secondary care populations. However, our inclusion criteria demanding duration of sick leave < 1 year may have rendered us with a slightly less chronic LBP cohort.
Psychological distress in our study population, reported by HSCL-10, was much higher than in the general population. However, a similar level of psychological distress has been reported by Brox et al. in chronic LBP. In our population, 54% of the patients reported values above the recommended cut-off level, which indicates experience of significant psychological distress.
To the best of our knowledge, the impact of psychosocial work factors on fear–avoidance beliefs has not been evaluated previously. The factors underlying fear–avoidance beliefs are important to capture because these beliefs are a major predictor of work loss and disability. It is well known that medical factors such as pain and disability, along with more personal factors such as depressive symptoms and anxiety, are associated with fear–avoidance beliefs. We also know that perceived psychosocial factors at work are closely associated with anxiety and depression. However, in our study, emotional distress continued to make a unique contribution to fear–avoidance beliefs, in addition to psychosocial factors at work. Similarly, our analysis showed that both gender and disability still provide their own contribution to fear–avoidance beliefs about work. The association with disability is generally known, whereas the association with gender varies between studies. In our model, pain did not contribute to fear–avoidance beliefs. This is consistent with other studies that found low or no correlation between fear–avoidance beliefs about work and pain intensity. Our findings emphasise the importance of identifying psychological and social work factors and including them in the assessment of prognosis for recovery or work loss, in addition to medical and emotional factors.
The present cohort was recruited from individuals in specialised care, and selected regarding language skills. The similar age and gender distributions among the consenters and non-consenters and the screening of all referred patients for eligibility precluded a representative patient cohort. However, these patients had a wide variety of occupations, which may have concealed potential differences from the reference population. The perceived burden of work may have been influenced by LBP. Furthermore, the lack of more objective assessment of exposure was a limitation, along with most studies conducted in this field.
The reference populations had a greater proportion of women and greater proportions with higher educational level or white-collar workers than the study population. This may have contributed to the difference regarding perception of demands for physical endurance.
The regression analyses were performed with women and men together, and this may have concealed different associations for men and women. Although performing a stratified analysis resulted in reduction of power, we clearly saw that disability was of significance for men only. None of the significant associations showed diverging directions for men compared with women in this analysis.
The use of a cross-sectional study design limited the analyses to explore associations, and not to draw any inference of causality in the associations found. The results imply a focus on the social and psychological factors at work in treatment and rehabilitation. However, as the actual prognostic value of the demand, control, and support in work for return to work in this patient population could not be established due to the cross-sectional design, a prospective study would be preferable as a basis for advices of implementation.
Discussion
In this study, the psychological and social work factors were significantly and relatively strongly associated with fear–avoidance beliefs about work. These factors, in addition to disability and psychological distress, explained 39% of fear–avoidance beliefs in patients on sick leave due to neck or back pain.
Description of psychological and social factors at work and possible association with neck or back pain, have mainly been studied in worker populations. In a review from 2004, Hartvigsen et al. concluded that LBP was not significantly associated with demand and control. Furthermore, moderate evidence for no association between social support and LBP is reported. However, later studies have shown associations between psychological and social factors at work and neck and back pain. The present population reported a lower level of most aspects of demand, control, support, and reward, whereas effort and overcommitment were reported at a higher level than the reference population, although the differences were small. The relationship between psychological and social factors at work and pain may change with duration of disability and transition into patient status. The variety of work places among the present patients may also influence the results. The perceived higher support from co-workers and family and friends by female patients are consistent with data in the reference population. However, the higher quantitative demands, effort and overcommitment as reported by men than women, are not consistent with reference population.
The study population reported higher demand for physical endurance than the reference population. It is well known that physical work demands are associated with LBP prevalence in specific occupational populations and in the general worker population. In our population, we did not have information about the physical workload to which it was actually exposed. Nevertheless, half of the population reported a demand for physical endurance. It may be that being troubled by pain makes one perceive the work situation to be more physically demanding than usual.
The mean pain score of 5–6 in the study population was comparable to that in other studies on sick-listed workers with chronic LBP in secondary care. Computer workers with neck pain, but not sick-listed, have reported a lower pain level than in our population, whereas neck pain patients with more permanent work disabilities were characterised by even higher pain level than in the present study. The average ODI score reported in the present study was slightly higher than that reported in primary care populations and slightly lower than in patients recruited from secondary care populations. However, our inclusion criteria demanding duration of sick leave < 1 year may have rendered us with a slightly less chronic LBP cohort.
Psychological distress in our study population, reported by HSCL-10, was much higher than in the general population. However, a similar level of psychological distress has been reported by Brox et al. in chronic LBP. In our population, 54% of the patients reported values above the recommended cut-off level, which indicates experience of significant psychological distress.
To the best of our knowledge, the impact of psychosocial work factors on fear–avoidance beliefs has not been evaluated previously. The factors underlying fear–avoidance beliefs are important to capture because these beliefs are a major predictor of work loss and disability. It is well known that medical factors such as pain and disability, along with more personal factors such as depressive symptoms and anxiety, are associated with fear–avoidance beliefs. We also know that perceived psychosocial factors at work are closely associated with anxiety and depression. However, in our study, emotional distress continued to make a unique contribution to fear–avoidance beliefs, in addition to psychosocial factors at work. Similarly, our analysis showed that both gender and disability still provide their own contribution to fear–avoidance beliefs about work. The association with disability is generally known, whereas the association with gender varies between studies. In our model, pain did not contribute to fear–avoidance beliefs. This is consistent with other studies that found low or no correlation between fear–avoidance beliefs about work and pain intensity. Our findings emphasise the importance of identifying psychological and social work factors and including them in the assessment of prognosis for recovery or work loss, in addition to medical and emotional factors.
Limitations and Strengths
The present cohort was recruited from individuals in specialised care, and selected regarding language skills. The similar age and gender distributions among the consenters and non-consenters and the screening of all referred patients for eligibility precluded a representative patient cohort. However, these patients had a wide variety of occupations, which may have concealed potential differences from the reference population. The perceived burden of work may have been influenced by LBP. Furthermore, the lack of more objective assessment of exposure was a limitation, along with most studies conducted in this field.
The reference populations had a greater proportion of women and greater proportions with higher educational level or white-collar workers than the study population. This may have contributed to the difference regarding perception of demands for physical endurance.
The regression analyses were performed with women and men together, and this may have concealed different associations for men and women. Although performing a stratified analysis resulted in reduction of power, we clearly saw that disability was of significance for men only. None of the significant associations showed diverging directions for men compared with women in this analysis.
The use of a cross-sectional study design limited the analyses to explore associations, and not to draw any inference of causality in the associations found. The results imply a focus on the social and psychological factors at work in treatment and rehabilitation. However, as the actual prognostic value of the demand, control, and support in work for return to work in this patient population could not be established due to the cross-sectional design, a prospective study would be preferable as a basis for advices of implementation.
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