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Medical Factors
Will an episode of low back pain become a long-term problem? Our psychology is important in deciding.

At a glance:
A person's psychology, as well as their physical symptoms, can influence whether an episode of back pain will be a “one-off' (acute condition) or become a long-term (chronic) condition. Psychological distress
Severe suffering, pain, anxiety or sorrow
 and/or depressed mood increase the chances that 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 conditions will become chronic.
An episode of back pain might be a one-off or the beginning of an ongoing condition. People who are more distressed or depressed are more likely to have ongoing problems. This is not an unexpected result, since doctors already know that people who are more anxious about their condition do not recover as well.

There might be a few explanations for this: When people are anxious about back pain, they tend to restrict their activities. While this avoids some things that could harm them, it also limits their rehabilitation. People who are confident, on the other hand, tend to return to their normal activities more quickly.

Make sure you understand your condition and that your questions are answered. When you have the information that you need, you can make a good plan, be more confident of your strategies and your ability to cope. 

If there are barriers that prevent you from returning to your normal activities, discuss them with your treater, family, or other people you trust.

Others can help, but is your personal beliefs, attitudes and way of thinking that make the real difference.
When someone is distressed about their condition, it adds emotional suffering to the physical difficulties they are having.

It can be hard to help people who are distressed. They may be less responsive to your approaches, challenging to communicate with, and they may take longer to return to work. This can be frustrating.

It is important to support people who are distressed. Simple things like making yourself available to them can make a difference.

People who are distressed may need a more focused approach on return to work and mapping out a clear rehabilitation
The process of helping a person back to their former abilities and quality of life (or as close as possible) after injury or a medical condition.
 path. Remaining off work and avoiding normal activities doesn't usually help.  Employees need clear advice about the system they are operating in, and especially about your expectations of them. People need to feel confident that they will be listened to if they have issues that need discussion, or problems with return to work.

People with distress need more time, more communication, and a more active planning approach to rehabilitation.
Treating practitioners generally know that distressed patients have worse outcomes despite spending more time in the health care system and receiving more treatment.

Managing the distress requires more time, more communication and more energy. It is important to ensure that all the players are working together to focus on rehabilitation.
Patients who are fearful, distressed, or worried are more likely to have a back pain episode that becomes a chronic
continuing a long time or recurring frequently
 condition. It is difficult to know whether this means they have higher levels of pain, or are more likely to have increased problems with the same level of back pain.

This group needs more communication in the early stages, to make sure they understand their condition and the system in which they are working. Communications may need to be repeated on a few occasions, and the person's fears need to be addressed. When people are more confident about managing the condition they have better outcomes. Improving communication with the case manager and the workplace can be helpful.
Original Article, Authors & Publication Details:
T. Pincus1, A. K. Burton2, S. Vogel3 and A. P. Field4 (2002). 

systematic review
systematic review
A comprehensive review of research studies in a particular area. The review follows guidelines to ensure the studies included are valid.
 of psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 factors as predictors of chronicity/disability in prospective cohorts of low back pain.
  Spine; 27(5):E109-E120

1Department of Psychology, Royal Holloway, University of London, London, UK.
2Spinal Research Unit, University of Huddersfield, Huddersfield, UK
3British School of Osteopathy, London, UK
4School of Cognitive
relating to the mental processes of perception, memory, judgment, and reasoning
 & Computer Science, University of Sussex, Sussex, UK.
Background, Study Objectives, How It Was Done:
An episode of back pain may be a one-off occurrence (an acute condition) or the beginning of a long term (chronic) condition. Psychological factors are important in determining which outcome occurs.

The authors of this review wished to identify the most important psychological factors in chronic disease, and investigate whether these only become important in certain environments or groups.

Studies to be included in this review were identified by database
Store of information (e.g. published research articles). Information can be retrieved by searching (e.g. for key words, authors, or titles).
 searching (in October 1999).

25 papers were identified which investigated the effect of psychological factors in the transition of low back pain from acute to chronic.

Some papers were based on findings from the same group of participants, so there were a total of 18 studies in the 25 papers. The reviewers considered how each study had been done, whether the psychological factors had been measured well, and whether data had been analysed appropriately.

Some studies did not take into account other factors that affect whether back pain will continue into the long term, making it impossible to estimate the contribution made by psychological factors alone. Some did not complete adequate follow up to avoid bias.
Study Findings:
The research papers used different measures to determine if a person's back pain persisted. Measures included how much pain the patient reported (after 1 week, 3 months and 12 months), whether the patient had returned to work by 6 months, and the total time taken off work due to back pain over 12 months.

The most commonly measured psychological factor was “distress.' In some studies the psychological factor was undefined, or factors were combined to produce an overall score.

Psychological distress/depressive mood:

People who are distressed are more likely to develop a chronic back condition, particularly in the primary care setting. This effect was independent of physical factors such as pain and level of function. This evidence came from four studies of acceptable quality.


Somatisation is when anxiety causes physical symptoms such as pain. Evidence from two studies of acceptable quality linked somatisation
Conversion of anxiety into physical symptoms. Common examples include headaches and heartburn.
 with the development of chronic back pain.


One study of acceptable quality reported that a personality test (the Minnesota Multiphasic Personality Inventory subscale of hysteria) could predict whether a person with low back pain would return to work. However, the authors of this review considered that this result was not statistically reliable.

Thinking style:

One study of acceptable quality reported that when patients had a poor or avoidant coping style (measured by the Coping Strategies Questionnaire) their low back pain was more likely to become chronic.
This review investigated the role of psychological factors in the progression of a back condition from acute to chronic by reviewing research in the area.

There is strong evidence that psychological distress and/or depressive mood increases the likelihood that a patient with acute back pain will develop chronic back pain.
PubMed Abstract
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