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People Factors
Understanding the person's state of mind helps you help them

At a glance:
  • Back pain treatment is helped by taking note of how people view their pain and work environment, and tailoring treatment accordingly.
  • Most people with back pain recover with little or no treatment. Around 10% - 15% are at risk for chronic
    continuing a long time or recurring frequently
     pain and disability.
  • Simple self assessments of pain and work readiness are useful in choosing treatment and return to work programs.
This article divides people with back pain into groups based on their understanding and expectations about their injury. The authors of the paper advise that people in certain groups need more advice and explanation about their condition.

To find out which group you belong to, choose a number between 1 and 10 (where 10 is Really Bad, 5 is Moderate and 1 is Not a Problem) for each of the questions below:

Q1. How upset are you about this injury?

Q2. How strong is your pain?

Q3. How much are you limiting movement to avoid pain or further damage?

Q4. How helpful and supportive is your employer going to be when you return to work?

Q5. What are your expectations for full recovery from this injury?

Compare your results to the groups in the table below and then talk to your treating health professional and employer about the treatment and support you need.

People worry about their pain and what will happen to them if the pain does not get better. A high level of worry and fear can lead a person to avoid activity. In turn this can make the person isolated, and even depressed. If you have a tendency to be worried or depressed you need to get support from family, friends and work. It is particularly important to get support if you are young and in a new job.
Some people are at risk of longer work absences from back pain.

This study found that people were at risk of becoming disabled if they believed there wasn't much chance of getting their work activities or workplace adjusted to accommodate their injury while they recovered. Young, single, low-paid workers in new jobs are likely to be at high risk due to a lack of support networks.

An active outreach by supervisors in the early days of back injury is likely to help people to get back to work sooner and reduce their pain.

A central element of successful return to work is being able to respond to the employees own view of what they are capable of and what they think will assist in reducing pain and preventing recurrence of injury.
The study finds that brief screening tools may identify which patients are at risk of chronic pain and work disability, and match the best treatment strategies to each patient. However, studies to investigate the effectiveness of interventions which are targeted based on screening have not yet been completed.

In the meantime, the important results of this study are that patients who focus on severe pain, are fearful of their pain and don't expect to fully recover have the worst recovery outcomes. The group of patients who were emotionally distressed also had poor outcomes. The group with concerns that their workplace may not be adjusted for them had better outcomes than the previous two, but poorer outcomes than the “low risk' group, who were not worried.

This article found that people with back pain can be asked several simple questions to determine their risk of disability:

Q1. How upset are you about this injury?

Q2. How strong is your pain?

Q3. How much are you limiting movement to avoid pain or further damage?

Q4. How helpful and supportive is your employer going to be in you returning to work?

Q5. What are you expectations for full recovery from this injury?

The interaction of pain and mood is complex but clearly pain can influence mood and depressed mood can increase pain. People with a tendency to worry will need more explanation, reassurance and support. For some people treatment for depression
A symptom of mood disorder characterized by intense feelings of loss, sadness, hopelessness, failure, and rejection. Major depression is likely to interfere significantly with everyday activity, with symptoms including insomnia, irritability, weight loss, and a lack of interest in outside events. The disorder may last several months or longer and may recur, but it is generally reversible in the short run.
 will lessen the cycle of pain and low moods, improve health and enable return to work.

Particular support is needed for young people with low incomes in a new job who may not have the support of family and social networks. Work supervisor support in changing the work environment and assisting return to work will also help people to fully recover and return to work.
The study finds that brief screening tools can potentially identify which patients are at risk of long term disability, and the best treatment strategies for each person. In the meantime, the study suggests that simple self reporting of pain, fears and work readiness can help with treatment.

Young, low-paid workers in new jobs are likely to be at high risk of chronic pain due to a lack of support networks.

This study suggests that active outreach by supervisors in the early days of back injury is likely to help people get back to work earlier and recover from pain. An important part of this is the adjusting of the workplace to prevent recurrence of back pain, and responding to the employees own view of what they are capable of and what measures will assist in reducing pain in the future. The study says that a worker's own assessment of their pain and ability to perform tasks is a simple and useful guide as to what to do to help them.
Original Article, Authors & Publication Details:
W. S. Shaw1,2, G. Pransky1,2, W. Patterson3,4, S. Linton5 and T. Winters6 (2006).

Patient clusters in acute, work-related back pain based on patterns of disability risk factors. Journal of Occupational and Environmental Medicine; 48(11):1173-1180

1Liberty Mutual Research Institute for Safety, Center for Disability Research, Hopkinton, Massachusetts
2University of Massachusetts Medical School, Department of Family Medicine & Community Health, Worcester, Massachusetts
3Concentra Health Services, Burlington, Massachusetts
4Boston University, School of Public Health, Boston, Massachusetts
5Orebro University, Department of Behavioral, Social and Legal Sciences—Psychology & Orebro Medical Center Hospital, Department of Occupational and Environmental Medicine, Orebro, Sweden
6Occupational and Environmental Health Network, Waltham, Massachusetts
Background, Study Objectives, How It Was Done:
There are three stages in non specific back pain:
  • acute - symptoms ease in days
  • sub-acute – symptoms remain for weeks
  • chronic – symptoms persist beyond 6 months
According to the authors it is not well understood why different treatments for the same injury produce similar results. One possible explanation is that patients are diverse in their particular needs and expectations so, only a minority benefit from any one type of intervention.

“If patients could be subdivided into groups based on the nature of physical, psychological,
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
and/or organizational barriers to recovery, matching them to appropriate interventions may improve outcomes and reduce costs.'

This study included 568 working adults (183 female, 385 male) with acute, work-related back pain who sought treatment at 8 community-based occupational health clinics in the New England region of the United States.

Each of the patients completed a questionnaire that asked them about factors that have previously been shown to affect whether a person will become disabled from work-related back pain. Many of these factors are possible to vary, and include the level of pain and distress,
Severe suffering, pain, anxiety or sorrow
 job concerns, whether the workplace was likely to provide modified duties, and whether the person expected they could return to work within four weeks.

The individuals were followed up one and three months after completing the questionnaire, and the following were measured:
  • reported level of pain, on a scale from one to ten
  • reported level of function, measured by a specific questionnaire, the Roland-Morris Disability Questionnaire.
  • work status (back at full duties, back at normal duties but working fewer hours due to pain, back at modified tasks, or off work).
The study objective was to identify different groups of patients with work-related acute
A condition develops quickly and is often of short duration. The opposite of acute is chronic, which refers to a long term problem continuing for months to years.
 back pain by comparing the information from the initial questionnaire to the follow up results one and three months later. The researchers were looking to see if different risk groups could be identified in the early stages, as if so specific treatments could be put in place that were most useful for that group.
Study Findings:
The patients were grouped according to their responses to questions about their:
  • Distress
  • Pain
  • Fear/avoidance of returning to work
  • Workplaces inflexibility
  • Expectation of resuming work
Four groups (the authors use the term clusters) of patients with acute back pain were identified:
  1. Severe pain / fear avoidant
  2. Concerns about inflexibility of the workplace
  3. Low risk (good expectations and low concern)
  4. Emotional distress
The following table shows the outcomes for each of these groups. The cluster groups average level of pain, function, and work status is shown, reported one and three months after the initial questionnaire. The table also lists the recommended interventions.

Cluster groups and Interventions

Cluster Group Characteristic Questionnaire Responses

Outcomes and Recommended Intervention
1 – Severe pain / fear avoidant High pain

Poor expectations

Fear/avoidance of work
This group had the poorest return to work outcomes overall.

Suggested interventions:

1. A gradual increase in physical activity to overcome fears about pain and activity.

2. A behavioural intervention
A treatment or management program. Interventions often combine several approaches. In this field approaches include training in problem solving, adaptation of work duties, graded activity, an exercise and stretching program and pain relief.
 to improve coping and problem solving strategies

3. A workplace intervention to improve accommodation efforts by the workplace.

2 – Concerns about job accommodation High perception of work inflexibility Both physical work demands and employer policies and practices have been associated with sickness absence due to back pain.

Suggested interventions:

1. Proactive return to work strategies

2. Improved monitoring of injury related absences.

3. Effective communication between employers, workers and health care providers about job modifications

3 – Low Risk Low
  • Pain
  • Distress
  • Fear/avoidance
  • Perception of work inflexibility
Good expectations

This group returns to work as quickly as they can.

Suggested intervention:

Ongoing assessment by health care providers and employers to ensure the person does not take on too much too early.
4 – Emotional distress

Members of this group are often low paid young people in their first job with little or no family support
High distress

Average pain and fear/avoidance

Moderately poor expectations
Improving supervisor and peer support after the onset of pain may decrease the risk of disability
A condition or function that leaves a person unable to do tasks that most other people can do.
 in this group

Suggested intervention:

Workplace outreach to:

1. Improve accommodation efforts

2. Develop modified duty options

3. Improve supervisor support


A simple self assessment survey in which patients self rate their pain, avoidance, distress, recovery expectations and employers supportiveness between 1 and 10 may help health care providers to recommend the best treatment for a person's back pain.
This is one of a number of studies that has researched whether grouping patients into clusters in the early stages of back pain, to determine which treatment they will best respond to, will help prevent long term suffering and disability. The study identifies a range of factors that can impact the longer term outcomes of back pain. Supporting previous research in this area, the authors found that distress, fear and concerns that the workplace wouldn't/couldn't accommodate the injury can be barriers to a person's recovery.

The authors recommend the best treatment option for each patient “cluster'. Further research should be done to test the effectiveness of the interventions recommended for each of the high risk groups (1, 2 and 4 above) in helping people to recover from low back pain, as this has not yet been done. In the meantime, people who are distressed, or fearful of their pain or situation, should be helped to overcome these negative feelings.

The researchers also showed that a simple patient self assessment survey may be useful, as the brief questionnaire used in this study could predict how likely a person was to return to work.
PubMed Abstract
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