1.1

Introduction

Chronic low back pain (cLBP) is a public health issue in most industrialised countries. The incidence has been continually increasing over the past 20 years in industrialized countries . In France, cLBP constitutes about 7–10% of all forms of low back pain but costs 70–80% of total spending for this condition . This includes direct costs which are stable but also indirect costs (sick leave, compensation, loss of earnings, loss of spending power), thus having important economical repercussions (tax returns, company productivity level) . Since the study by Mayer et al. , many studies have suggested that functional programs are effective in the management of cLBP , as well as for sub-acute pain . However, the long-term maintenance of these benefits is linked to the regular practice of a physical activity .

The patient’s perception of his condition and the potential effect of treatment has a large impact on treatment effectiveness . Fear of pain and related avoidance behaviour are precursors for pain-related disability to set in . The results of many studies have confirmed the benefits of psychobehavioural management of pain associated with fitness training . This type of management is even more effective if it begins early following the onset of pain or even as prevention . Scales designed to measure the effects of different psychobehavioural approaches as well as the functional impact of chronic pain have been validated in French . A review of the literature only found transcultural studies of scale validation or measures in industrialized countries (non emerging) . However, no study has attempted to compare these outcome measures and their results as a function of culture, economic level and customs within different French-speaking countries. The aim of this study was to evaluate pain and its repercussions on cLBP patients in four French-speaking countries by studying transverse and longitudinal correlations between parameters such as pain, function, anxiety, depression, fears and beliefs regarding return to work and physical activity and coping strategy (psychological defence strategies which patients may use when facing a painful stress).

1.2

Materials and methods

This study is a prospective open study comparing a population of cLBP patients in four French-speaking countries with different economical levels and cultures.

1.3

Results

During the year of inclusions, 278 patients were included: 83 in France, 75 in the Ivory Coast, 84 in Tunisia and 36 in Morocco. Demographic and clinical data of the population are presented in Tables 1 and 2 .

The Anova was used to evaluate the “country effect”, i.e. if the country has an impact on the results. No “country effect” was found for the duration of the low back pain (F = 1.145; p = 0.24) or for the Quebec function index (F = 0.577; p = 0.53). A “country effect” was found for pain (F = 2.707; p < 0.001), anxiety (F = 3.467; p < 0.001), depression (F = 5.137; p < 0.001), fear of return to work FABQ Work (F = 1.974; p < 0.001) and fear of physical activity FABQ Phys (F = 5.076; p < 0.001). Regarding coping strategies, a “country effect” was found for distraction (F = 5.256; p < 0.001), dramatisation (F = 4.830; p < 0.001), reinterpretation (F = 5.716; p < 0.01), efforts to ignore the pain (F = 5.017; p < 0.001), praying (F = 18.725; p < 0.001) and seeking social support (F = 7.120; p < 0.001).

Paired comparisons for the significant values of the “country effect” gave the following results:

• •
  

  for pain level, mean VAS score in Morocco was significantly higher than that of the Ivory Coast (+7.1; p = 0.02), France (+8.9; p = 0.03) and Tunisia (+13.4; p = 0.04). Mean pVAS was significantly higher than that of Tunisia (+18.6; p < 0.01). There was no significant difference between the Ivory Coast and France (0.52; p = 0.9). The pVAS for the Ivory Coast was significantly higher than that of Tunisia (+16.84; p < 0.01);

  
  
• •
  

  for the anxiety scale, the HAD-A for Tunisia was respectively greater than that for the Ivory Coast (+0.02; p = 0.98), France (0.91; p = 0.24) and Morocco (+2.42; p ≤ 0.01). The HAD-A score for the Ivory Coast was significantly higher than that for France (+1.41; p = 0.02) and Morocco (+1.78; p = 0.08). The score for France was significantly higher than for Morocco (+1.64; p = 0.04);

  
  
• •
  

  for the depression scale, the HAD-D score for Tunisia was respectively greater than that of Morocco (+1.42; p = 0.12), the Ivory Coast (+2.12; p = 0.01) and France (+2.95; p < 0.01). The score for Morocco was higher than that of the Ivory Coast (+1.97; p = 0.02) and France (+1.92; p = 0.02). The score for the Ivory Coast was higher than that of France (+1.12; p = 0.04);

  
  
• •
  

  for the apprehension regarding return to work scale, the FABQ Work score was respectively significantly higher in the Ivory Coast than in France (+3.51; p = 0.03), Tunisia (+18.94; p < 0.01) and Morocco (+23.78; p < 0.01). It was greater in France than Tunisia (+1.15; p = 0.64) and Morocco (+5.81; p = 0.01). This score was greater in Tunisia than in Morocco (+5.4; p = 0.03);

  
  
• •
  

  for the scale of apprehension of a return to physical activities, the FABQ Phys score was respectively higher in Tunisia than the Ivory Coast (+0.67; p = 0.92), France (+7.8; p = 0.18) and Morocco (+2.23; p = 0.16). The FABQ Phys score for the Ivory Coast was higher than that for France (+8.25; p < 0.01) and Morocco (+6.42; p < 0.01). The score for France was higher than for Morocco (+0.14; p = 0.92).

For coping strategies:

• •
  

  the distraction strategy was respectively more used in the Ivory Coast than in Morocco (+1.47; p = 0.09), Tunisia (+1.68; p = 0.03) and France (+3.53; p < 0.01). Its use was greater in Morocco than Tunisia (+0.38; p = 0.73) and France (+0.56; p = 0.55). It was more used in Tunisia than France (1.82; p = 0.03);

  
  
• •
  

  the strategy of dramatisation was respectively more used in the Ivory Coast than in France (+2.11; p < 0.01), Tunisia (+2.30; p ≤ 0.01) and Morocco (+3.81; p < 0.01). This strategy was used more in France than Tunisia (+0.26; p = 0.76) and Morocco (+1.86; p = 0.05). It was used more in Tunisia than Morocco (+2.06; p = 0.05);

  
  
• •
  

  the strategy of reinterpretation was respectively more used in Tunisia than Morocco (+0.29; p = 0.78), the Ivory Coast (0.56; p = 0.47) and France (+1.64; p = 0.02). This strategy was more used in Morocco than the Ivory Coast (+0.42; p = 0.61) and France (+1.44; p = 0.14). It was more used in the Ivory Coast than France (+1.08; p = 0.02);

  
  
• •
  

  no significant differences for the strategy of ignoring the pain were found. The strategy tended to be respectively more used in Morocco than Tunisia (+0.09; p = 0.9), the Ivory Coast (+0.08; p = 0.9) and France (+0.58; p = 0.41). It was more used in Tunisia than the Ivory Coast (+0.26; p = 0.63) and France (+0.76; p = 0.53). It was more used in the Ivory Coast than France (+0.31; p = 0.53);

  
  
• •
  

  the strategy of prayer was respectively more used in the Ivory Coast than Tunisia (+1.60; p < 0.01), Morocco (+1.58; p < 0.01) and France (+5.73; p < 0.01). This strategy was more used in Tunisia than Morocco (+0.38; p = 0.61) and France (+4.15; p < 0.01). It was more used in Morocco than France (+3.92; p < 0.01);

  
  
• •
  

  the strategy of finding social support was respectively more used in the Ivory Coast than Tunisia (+1.62; p = 0.06), Morocco (+1.53; p = 0.14) and France (+8.39; p < 0.01). This strategy was more used in Tunisia than Morocco (+0.50; p = 0.68) and France (+6.02; p < 0.01). It was more used in Morocco than France (+5.81; p < 0.01).

1.4

Discussion

This study revealed a “country effect” (effect which could result from the country of birth and the country in which the person is living with the symptoms) on the parameters of pain, anxiety, depression, avoidance behaviour and psychobehavioural adaptations but not for function. It is known that the patient’s perception of his illness and of the potential benefit of treatment is decisive for improvement and compliance with treatment for both sub-acute and cLBP . Based on this knowledge, an approach was developed in order to predetermine the profile of patients who suffer from this pathology. Five predictive factors of chronicity in industrialised countries were found: personal, medicolegal, socioeconomical, professional and psychological .

Among the personal factors, only age above 45 years is significant . This factor was not found in our study, the mean age for all the countries being below 45 years except for Morocco (45.2 years). Moreover, analysis of demographic criteria showed that there were few differences between the countries studied with regard to age, weight, height and BMI.

Regarding the medicolegal factors, the notion of compensation is a high risk factor for pain to become chronic (RR > 5) .

With regard to socioeconomic factors, low socioeconomic status and poor level of education (independent factors) are the most common . In our study, it is probable that variations in social criteria, even if they are complex are important. They are only indirectly measured by the number of work-related accidents and the duration of sick leave. France has the highest number of pathologies linked to work-related accidents. This is probably because these accidents are covered by the social security system rather than because working conditions are more dangerous. The duration of sick leave in France is also longer. Similarly, financial compensation during the sick leave may not incite patients to return to work. In the Ivory Coast, little physiotherapy is offered. In the other participating countries, this type of treatment appears to be as well developed as in France but the number of sessions of therapy per patient is higher in France. This can be explained by differences in social security cover.

With regard to professional factors, the boring nature of the job is not a predictive factor of cronicity (in contrast with acute LBP ), however, low job status and poor physical condition relative to work constraints are predictive factors. Our findings showed that apprehension regarding return to work (FABQ Work) was greater in the Ivory Coast than France, Tunisia or Morocco. The difference between the Ivory Coast and the other countries was very large. This result is different to that for recommencing physical activity (FABQ Phys): for this parameter, Tunisia has the highest apprehension score compared with the Ivory Coast, France and Morocco.

Lastly, with regard to psychological factors, an anxious-depressive or hysterical nature is recognised as being a predictive factor for chronicity . It is difficult to know if these are primary or secondary factors relating to the lumbar pathology. Similarly, patients with cLBP tend to have a more hypochondriac personality than the general population (higher hospital admittance for other pathologies such as gastric ulcers, pain syndromes…) . Anxiety was found to be higher in Tunisia than in other countries. Morocco had the lowest anxiety level. With regard to depression, the mean HAD-D score was highest in Tunisia, compared with the Ivory Coast, Morocco then France.

The CSQ was used to evaluate patients’ defence strategies against pain. Tunisia had high repercussions of low back pain (HAD-A, HAD-D, FABQ Phys), however, it had the lowest level of pain. The most used compensatory strategies were reinterpretation (positive) and prayer (negative). The Ivory Coast also had high repercussions from the pathology (FABQ Work). The most used compensatory strategies in this country were distraction and dramatisation (negative) and seeking social support (positive). The highest level of pain was in Morocco (pVAS). The most used compensatory strategy was ignoring the pain (positive).

Many studies have evaluated the psychological approach to chronic pain. Indeed, Feurstein and Beattie in 1995 defined four types of phychological high-risk behaviours : the patient presents all pathology as serious; he finds all pathology which is unexplained or resistant to treatments very serious; the patient is incapable of managing his pain and he underestimates his true physical capacity. Based on the conclusions of Fordyce et al. , Lethem et al. developed the concept of “fear-avoidance-exaggerated response to pain”. Linton then went on to conclude that there are two possible responses to a painful stimulus . The first is conditioned, automatic and always the same (sympathetic response with fear, anxiety and muscle tension). The second is acquired and defined as a learning of avoidance behaviour in order to decrease fears, anxiety and muscle tension. These responses have limited effectiveness and reinforce these attitudes, leading to a vicious circle responsible for a progressive deconditioning. This is characterized by a decrease in physical activity with loss of muscle endurance (especially spinal and abdominal) with repercussions on morale (increased sensation of being seriously ill) and modifications in pain tolerance. Vlaeyen and Linton established the current model of “fear-avoidance” based on his work and the notion of “kinesiphobia” defined by Kori et al. . In this concept, the patient chooses between confrontation (adapted) and avoidance (pathological). Subjects who adopt the second strategy have a poorer prognosis, regardless of the type of therapeutic programme . Early, effective therapeutic management can change behaviour, thus rapidly improving function . In a prospective study, Klenerman et al. showed that the psychological concept occurs very early and that rapid evaluation and management are the best predictive factors for return to work. This model of “fear-avoidance behaviour” has been validated for all painful pathologies (cLBP, post-herpes nerve pain, algodystrophy…) .

Our results help to orientate specific management strategies for cLBP depending on the cultural and socioeconomic particularities of the population. There is, however, a selection bias in our study regarding the recruitment of patients who understand and can read French. The reason for this was so that we could use scales validated in this language, however, African patients who fit this criterion may not be representative of the general population of their respective countries.

A longitudinal cross-cultural study of cLBP using scales which have been translated and validated for each individual country seems justified in order to ensure a representative sample. This could lead to different treatment approaches being used within a country which has a population of people of varied backgrounds.

1.5

Conclusion

The results of this study show that there is not a “country effect” for functional ability but that there are many variations regarding pain, anxiety, depression, avoidance behaviour and psychobehavioural adaptations. An analysis of explanatory factors deduced from a prospective longitudinal study is warranted.

2.1

Introduction

La lombalgie chronique pose un problème de santé publique dans la majorité des pays industrialisés. Son incidence est en constante augmentation ces 20 dernières années dans les pays industrialisés . En France, les formes chroniques, qui ne représentent que 7 à 10 % des lombalgies, occasionnent 70 à 80 % des dépenses globales pour les lombalgiques . Ces dernières sont constituées de coûts directs, stables , mais aussi indirects plus ou moins mesurables (arrêts de travails, indemnisations, perte de salaire, de pouvoir d’achat) entraînant des répercussions économiques importantes (rentrées fiscales, taux de productivité des entreprises) . De nombreuses études depuis celle de Mayer et al. en 1985 suggèrent que les programmes de restauration fonctionnelle sont efficaces dans la prise en charge des lombalgies chroniques mais aussi subaiguës . Cependant, la persistance des bénéfices à long terme semble être étroitement liée à la pratique d’une activité physique .

La perception du malade sur son état et sur le potentiel du traitement sont décisifs pour l’amélioration de l’observance du traitement . Les peurs de la douleur et les conduites d’évitement induites se révèlent prépondérantes dans l’initiation puis le maintien de l’incapacité liée à cette douleur . De nombreux travaux ont confirmé l’intérêt de la prise en charge psychocomportementale de la douleur associée aux programmes de reconditionnement à l’effort . Cette prise en charge serait d’autant plus efficace qu’elle est pratiquée tôt dans l’anamnèse de la lombalgie, voire en préventif . Les échelles permettant de mesurer ces différentes approches psychocomportementales ainsi que le retentissement fonctionnel de la douleur chronique ont été validées en français . L’analyse de la littérature ne retrouve que des études transculturelles de validation d’échelles ou de mesure dans des pays industrialisés (non émergeants) . Mais aucune étude n’a tenté de comparer ces outils de mesure et leurs résultats en fonction des cultures, du niveau économique, des us et des coutumes de différents pays francophones. L’objectif de cette étude est l’évaluation de la douleur et de son retentissement chez les patients atteints de lombalgie chronique dans quatre pays francophones en étudiant les corrélations transversales et longitudinales entre les paramètres évaluant la douleur, la fonction, l’anxiété, la dépression, les peurs et des croyances face à la reprise d’une activité professionnelle et physique et la stratégie de coping (stratégies de défenses psychologiques qu’utilise un patient face à un stress douloureux).

2.2

Matériels et méthodes

Ce travail est une étude prospective ouverte comparant une population de lombalgiques chroniques commune dans quatre pays francophones de niveaux économiques et culturels différents.

2.3

Résultats

Sur ce délai d’un an, 278 patients ont été inclus : 83 en France, 75 en Côte d’Ivoire, 84 en Tunisie et 36 au Maroc. Les données démographiques et cliniques de la population sont représentées par pays dans les Tableaux 3 et 4 .

Tableau 1

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