Summary
Social factors are widely acknowledged in behavioural models of pain and pain management, but incorporating these factors into general medical consultations for low back pain (LBP) can be challenging. While there is no compelling evidence that social factors contribute to LBP onset, these factors have been shown to influence functional limitation and disability, especially the effects of organisational support in the workplace, spousal support, family conflict and social disadvantage. A number of barriers exist to address such social factors in routine medical encounters for LBP, but there is emerging evidence that improving social and organisational support may be an effective strategy to reduce the negative lifestyle consequences of LBP. For clinicians to address these factors in LBP treatment requires a clearer psychosocial framework in assessment and screening, more individualised problem-solving efforts, more patient-centred interventions involving family, peers and workplace supports and a less biomechanical and diagnostic approach.
The high prevalence and ubiquitous nature of low back pain (LBP) has made it one of the most disabling and costly health conditions in the modern world . Plentiful treatment options exist, but there are considerable controversies about which pharmacological, surgical, physical or psychological treatments are most effective and whether these are superior to conservative care and reassurance . Because the aetiology of LBP is often unclear, and because no biomedical cure is in sight for the large majority of chronic LBP sufferers , much LBP research has been redirected to secondary prevention: understanding the complexity of factors that affect LBP recovery, chronicity and recurrence. While there is some progress in developing psychological theories and interventions to address maladaptive pain beliefs and behaviours , less is known about the broader social, organisational and family context of pain and how best to incorporate these factors into clinical practice.
Unlike psychological constructs that assess differences in pain attitudes, beliefs and emotional responses (e.g., pain catastrophising), social factors are the external facts and circumstances that influence or control an individual’s behaviour or attitudes related to pain. Thus, social factors include socio-demographic factors as well as characteristics of the psychosocial environment at home, clinic and the workplace. Although not routinely assessed in a general consultation for LBP, social factors may play a significant role in coping and functional recovery. While the causal pathways and mechanisms relating social factors to LBP outcomes are no doubt complex and bidirectional, the well-documented positive effect of social support on physical health may apply to LBP as well. Fig. 1 highlights a number of social variables within the domains of workplace, home, clinic and sociocultural background that have been hypothesised to affect LBP outcomes. In the following sections, we summarise the existing research evidence from each of these domains.
Evidence for the influence of social factors at work
One very significant outcome of LBP is its effect on the ability to maintain work role functioning. Evidence from a large Pan-European project has shown that 25% of workers report LBP at any one time (point prevalence), and costs of lost productivity due to LBP and other musculoskeletal disorders are estimated at €12 billion per year . Similar statistics and figures can be found in the United States and Australia . LBP is one of the most frequently reported reasons for sickness absence , with evidence of high recurrence and difficulties in returning to work (RTW) for a small but significant group of those with LBP . The high cost of back disability has naturally led to questions about the best ways to bolster workplace social and organisational support for workers with LBP .
Social factors are prominent in theoretical models of occupational health and wellness. The systems model of work disability proposed by Loisel and colleagues reflects multiple levels of individual, workplace, health-care and societal factors. In occupational stress research, the well-known Karasek Demand–Control Model suggests that job strain and subsequent illness (such as LBP) are manifest in jobs where demands on the employee are high, and where the employee has little or no control in the management of those demands . A moderating influence in this model is the extent to which an employee receives social support within the workplace environment (interaction and support from co-workers, interaction and support from employers/supervisors and occupational aspects of support) . The Model of Human Occupation similarly stresses the importance of social groups in the workplace to accommodate or mitigate disabling health conditions .
A number of LBP prognostic studies have considered the effects of workplace social support, but most rely on a restricted repertoire of questions focussed on generic supervisor or co-worker support, with no inclusion of subdomains that might have special relevance for overcoming workplace pain and disability. Even with these limitations, there is evidence of the influence of workplace social factors. For example, in a prospective cohort of 295 patients with acute LBP, those reporting less social support from co-workers were 1.55 times more likely to have an incomplete recovery after 8 weeks . In another cohort of 273 workers with LBP for more than 4 weeks, those reporting more supervisor support were 1.20 times more likely to show functional improvement after a 12-week exercise programme . Efforts by reviewers to synthesise results in this area, however, have led to different conclusions depending on the scope of the review: some reviewers have limited workplace support to social support from co-workers or supervisors , whereas others have included broader aspects of organisational support (e.g., proactive disability management practices).
One area of agreement among reviews is that co-worker, supervisor or general workplace social support has little, if any, effect on LBP incidence . Evidence for the prognosis of LBP, however, is mixed. Two systematic reviews have concluded that lower levels of co-worker support, but not supervisor support, are associated with longer duration of sickness absence. When a broader definition of workplace support is applied (including proactive disability management, organisational support and psychosocial workplace environment), reviewers report a consistent effect of lower levels of workplace support increasing time until RTW, and less support is associated with more functional difficulties at work . This finding is consistent with the literature supporting employers’ efforts to offer modified duty work, maintain contact with ill workers and adopt more proactive return-to-work programmes . To improve on past research, future studies should identify more specific elements and mechanisms of workplace social support and test indirect pathways and interactions of support on LBP outcomes.
Evidence for the influence of social factors outside work
Social factors at home
Support at home can be another factor in LBP recovery and functional improvement. This is likely a reciprocal relationship, as LBP can also disrupt family roles and responsibilities, cause stress to family relationships and compromise levels of support. While there is evidence of a detrimental consequence of LBP on marital satisfaction, partner emotions and relationship quality , there are also beneficial effects of spousal support on LBP coping and function . Most of the research on family support and LBP has focussed on‘ spousal ’communication and emotional support, with a focus on operant-conditioning models whereby pain behaviour elicits a communicative interpretation and reaction from partners, and this either reinforces or extinguishes pain behaviours . If pain behaviour appears to be reinforced by overly sympathetic (solicitous) responses from the patients’ partner or family, perhaps this issue could be addressed in the lifestyle advice provided by clinicians.
The current evidence of the impact of LBP on families is more descriptive than explanatory, but it suggests that family interactions are more complex than those described by the operant-conditioning model involving empathy, understanding, communication and congruence between partners/family members . Two recent qualitative studies on the impact of LBP on the family report an associated reduction in shared leisure activities and time spent with family, changes in the parent and child role (e.g., children having to assist in daily duties due to parents’ disability), changes in traditional gendered roles (e.g., the wife now works full-time because the husband cannot work), anger and frustration expressed by family members and financial strain (e.g., being out of work due to LBP). Generally, social support (from family, friends and social groups) has been shown to facilitate a more rapid recovery , and there is ample evidence of this from the general medical rehabilitation literature and in general health studies . Systematic reviews in LBP have concluded that social isolation produces longer work absences when these variables are pooled and that family social factors mediate negative psychological reactions to pain .
Social factors in health communications
One element of social support not commonly recognised in the LBP literature is the empathy and understanding of clinicians who may provide social support through patient education and advice. In the majority of LBP cases with no identifiable aetiology or complication, clinicians play a critical role in allaying patient fears, making lifestyle recommendations, promoting activity resumption and providing realistic expectations for recovery . While the psychological impacts of chronic LBP are well documented, patients with acute episodes or exacerbations of LBP can similarly report elevated levels of psychological distress . Thus, the reassurance and support provided by clinicians is a factor in LBP recovery. More patient-centred interviewing strategies and more proactive efforts of clinicians to address lifestyle and workplace concerns have been associated with improved LBP outcomes and greater patient satisfaction , though the research in this area is generally sparse. Even highly distressed patients appear unlikely to volunteer their frustration and lifestyle concerns in an initial consult for LBP ; hence, more deliberate efforts may be needed to evaluate psychological distress along with a physical examination. More research is needed to determine the extent to which this provider-based variety of social support can be effectively leveraged to support improved LBP outcomes in general consultations.
Social disadvantage
Although social disadvantage is not frequently cited as a social factor in LBP disability, social and economic disadvantage is certainly associated with poorer outcomes in other health domains . Longitudinal studies of LBP prognosis typically include demographic assessments of age, gender, income, education and race/ethnicity, and these variables might be considered as a general metric of social standing. The majority of LBP studies report older age and female gender as risk factors for poorer LBP outcomes , but some studies report no such effects . Studies of socioeconomic status and LBP (including income, education and occupation) have also had mixed results. There are frequent reports that lower income, less education and employment in manual occupations is associated with increased pain and disability , but other studies report no associations . There is very little research examining the association between race/ethnicity and LBP. In summary, though results vary by population setting and location, there is evidence that social disadvantage is a factor in LBP recovery and functional improvement. Although issues of social disadvantage may not represent modifiable risk factors in the usual sense, clinicians can nevertheless take these factors into account when making lifestyle recommendations, evaluating coping resources and assessing the prognosis for recovery.
Opportunities for addressing workplace social factors
The ‘Flags’ model of psychosocial screening would appear to be a helpful conceptual framework for understanding, conceptualising and addressing social factors in LBP, including those in the workplace. Using a colour-coded screening algorithm, clinicians are prompted to assess psychosocial factors from a number of domains: ‘red’ flags are medical signs of potential serious pathology, ‘yellow’ flags are important psychological beliefs, ‘blue’ flags are an employee’s perceptions of RTW obstacles and ‘black’ flags are job traits and employment conditions. The perception of workplace social support is included within the black and blue flag categories, alongside other important employment factors (job satisfaction, fear of re-injury caused by job, demands of job, job type, work environment, etc.) (see Table 1 ). Self-report measures are also available to assess psychosocial factors at the workplace. Examples include the Obstacles to Return to Work Questionnaire (ORQ) , the Job Content Questionnaire and the Work Organisation Assessment Questionnaire (WOAQ) ; but there can be practical difficulties in integrating these measures into routine clinical assessment .
| Blue flags (subjective perceptions and beliefs about work) |
| Perceptions of heavy work |
| Inability to modify work |
| Job stress |
| Workplace social support |
| Job satisfaction |
| Expectation for return to work |
| Fear of re-injury |
| Black flags (factual circumstances surrounding work) |
| Rates of pay |
| Negotiated entitlements |
| Sickness certification policies |
| Wage reimbursement rates |
| Availability of modified duty |
| Management style |
| Labour union involvement |
| Employer size |
| Organisational structure |
| Work schedules and shifts |
| Heavy physical loads |
To address issues of workplace support, clinicians might engage in more in-depth problem solving with patients, communicate more directly with the employer or supervisor or assign an RTW coordinator . RTW coordination efforts have been shown to reduce the length of work absences for musculoskeletal conditions . Also important is the level of agreement and consensus present between employer and employee about the illness and the strategies to facilitate RTW . Other studies have shown the benefits of adding workplace communication and involvement to standard clinical treatments for LBP . Overall, there is evidence that workplace support can be improved, and this has benefits to workers with LBP.
Opportunities for addressing social factors outside the workplace
Interest is growing on the influence of the social context in clinical practice, with consideration of the inclusion of family members (e.g., partners) in the treatment of those with chronic illnesses such as LBP . A small amount of evidence thus far has shown some beneficial effects when partners and family members are included in treatments . While research on pain empathy and the interpersonal–intrapersonal process between couples appears promising , more research is needed to understand how congruence, empathy and communication about pain can be built between patient, family and practitioner to facilitate shared goals of recovery . Although sparse, there have been some evidence-based experimental studies focussed on expanding social support for patients in clinical settings. For example, one study employing a peer-led on-line self-management programme for patients with chronic diseases showed an improvement in health status and a reduction in health-care utilisation after 1 year . In a recent systematic review of Internet-based counselling interventions, a sub-analysis showed evidence for peer social support and social networking as elements that led to improved pain and function . In another study assessing the benefits of a ‘back school’ programme (integrating physical and educational components), those patients who were provided extra social interaction with other patients reported less pain-related disability at follow-up .
From a methodological perspective, a number of complexities remain within this field of research. For example, the definition of social support is variable; studies have shown that different types of support can be detrimental or favourable depending on who offers the support . The mechanisms by which a partner or spouse might affect change in the patient, within a treatment paradigm, are not clear and further research is needed to understand such processes. Additionally, whilst the use of ‘online’ support for LBP is growing (e.g., e-mail and Internet), controlled trials have shown mixed effects and the overall assessment of the quality of advice from the Internet concerning the management of LBP is low . Further work is required to understand the mechanisms and complexities of social factors and how they can be utilised to improve LBP outcomes in a general-practice setting.
The challenge of integrating social factors into usual LBP treatment practices
While social factors are generally recognised as prognostic factors in LBP disability and for transition to chronic pain, a number of barriers exist to systematically integrate these factors into everyday clinic practice, case management and RTW coordination for LBP. Tailoring clinical care, patient education and adjunct services to the social needs of patients requires additional provider time and effort; hence, more research is needed to assess the cost-effectiveness of expanded social problem-solving efforts. Engaging patients with acute LBP about their social support systems may seem invasive or unexpected for some; therefore, patient acceptability is also an issue. To improve implementation, more systematic methods are needed to identify social factors in a patient interview, incorporate valid patient screening tools and develop evidence-based intervention strategies. In addition, the level of training or qualifications necessary to help patients deal with the social complications of LBP should be addressed . Despite the need for more research and development, understanding the social context of LBP and addressing lifestyle issues of patients may help to address an unmet need in LBP care. If social factors are to have a more significant role in LBP evaluation and treatment, conventional care models may need to be altered for: (1) better integration of psychosocial approaches; (2) more problem-solving communication; (3) more patient-centred decision making; and (4) early psychosocial screening. We discuss each of these developments in the following sections, and sample illustrations of challenges are shown in Table 2 .
| Prevailing LBP treatment paradigms | ||||
|---|---|---|---|---|
| Exclusive biomedical focus | Decision-making based on diagnostic algorithms | Reliance on biomechanical explanations | Watching and waiting | |
| Co-worker support | A non-specific or fluctuating biomedical diagnosis may raise doubts among co-workers. | RTW plans are not likely to consider issues pertaining to production units and the speed and distribution of work. | Co-workers may question why LBP has persisted despite medical evaluation and treatment. | Co-workers may be sceptical that the individual should be out of work for more than a few days. |
| Organisational support | Organisations cede responsibility for disability prevention to medical providers. | Frontline supervisors and workers are not included in planning efforts for RTW and job modification. | The individual may feel their organisation is questioning whether the pain is real and demanding validation. | The organisation may feel that a prompt RTW is being delayed unnecessarily by medical providers. |
| Partner support | Partners may foster a repeated (and often fruitless) search for a biomedical cure. | Partners may feel that the patients are not being given an adequate voice or autonomy. | Partners may feel that the cause of LBP has not been accurately or correctly diagnosed. | Partners may become outraged that more is not being done in the first few weeks of LBP. |
| Family conflict | Medical providers may overlook social factors if the focus is to explain signs, symptoms, and aetiology. | Treatment scheduling may fail to consider social ramifications at work and home. | The family may perceive that the patient is being denied necessary health care or disability benefits to deal with distress and hardship. | Uncertainty of treatment plans and delays may upset family roles, schedules and activities. |
| Social disadvantage | Some patients may be unfamiliar with medical jargon and have fewer options for LBP treatment and support. | Some may feel threatened by insurance and regulatory systems governing treatment and sickness absence. | Standardised physical testing may not take into account cultural differences and language difficulties. | Some patients may be less able to modify caregiving and job demands and provide self-care during the early stages of LBP. |
Better integration of psychosocial approaches
Despite major advances in our understanding of the physiology of the spine and nervous system, these scientific advances have failed to explain pain intensity and chronicity in the case of ‘garden variety’ nonspecific LBP . On average, the current array of biomedical treatments for nonspecific LBP offers only small incremental or temporary relief from pain, and some interventions come with a significant risk of side effects or other negative outcomes . An alternative is psychological interventions, which offer similar benefits and fewer side effects , but their uptake and availability in general medical settings have been slow .
Apart from providing psychotherapy services to patients, another option is to integrate psychologically informed treatment strategies into physical treatments and consultations . While the primary focus is to alter dysfunctional pain beliefs and increase physical activity, these treatments also offer opportunities to address social factors influencing LBP management and functional recovery. Problem-solving skills training might be useful to overcome barriers at work and home, communication skills training could improve interpersonal coping and support, behavioural analysis might improve insights about the social impacts of pain at home and assertiveness training could improve effective communication within the workplace. All of these cognitive–behavioural strategies are appropriate for addressing social challenges and promoting behaviour change .
More problem-solving communication strategies
Administrative processes are necessary and important ingredients for systems that provide for quality health care and equitable distribution of disability benefits across working populations. These processes support good medical decision making, ensure fair and uniform treatment and often provide the regular means of communication between health-care providers, insurers, employers and patients. In the case of LBP, however, systematic administrative processes are complicated by: (a) a paucity of objective severity indicators; (b) high variability of patient outcomes; and (c) a complex array of factors contributing to back disability. For these reasons, approaches to medical management that rely exclusively on diagnostic categories, injury classification codes and symptom severity ratings may fail to address the subjective nature, variable course and social influences on LBP (for example illustrations, see Table 2 ).
One way to overcome this problem is to develop more open communication between stakeholders in the care management system. Besides ordering more diagnostics, pharmacotherapies and physical treatments, other options might include increased workplace contact and job accommodation efforts, more detailed patient interviews to understand individual problems and concerns and the provision of adjunct services or case management. These types of ancillary services from a nurse case manager, RTW coordinator or social worker can improve LBP outcomes , but these options are sometimes unavailable to LBP patients in general outpatient medical settings and more studies are needed to determine what level of effort is most cost effective with respect to quality-of-life gains.
More patient-centred decision making
Systems for managing back disability rely heavily on the assessments of medical providers to assess readiness for RTW, to make a careful diagnosis and prognosis for recovery and to make decisions for appropriate care and management. When disagreements arise between the worker, their employer or their insurer about the prospects for RTW, the medico-legal system looks to medical data to provide fair and equitable treatment and benefits. While a purely objective marker of LBP severity would be ideal in these situations, imaging studies and instrumented physical tests have been unable to capture the subjectivity of pain experience, and functional assessments of work ability are often inseparable from individual issues of coping, affect, work style and social and organisational support. Thus, treatment decision making and RTW planning should strive to incorporate the personal views and circumstances of the patient in addition to physical findings. Analysis of recorded visits for LBP suggests that providers are unlikely to register the serious psychosocial concerns of patients, even when patients report high psychological distress and fears about the future in a confidential pre-examination survey . Using more patient-centred interviewing strategies might help to identify and address social factors.
Early psychosocial screening
One recommendation common to existing LBP treatment guidelines is that conservative care and reassurance should be the guiding principle during the first few weeks after LBP onset or after initial consultation onset . This is supported by strong evidence that clinical interventions have little or no effect when offered to all consulters, the majority of whom will experience a rapid pain recovery with or without treatment . A second line of medical evaluation or specialist referral (e.g., physiotherapy, orthopaedic referral and imaging studies) is usually offered only after several weeks of persistent pain and disability. This leaves a period of ‘watching and waiting’ in the first few weeks after LBP consultation that may represent a missed opportunity for individuals reporting a high level of psychological distress, family disruption and an unsupportive working environment. Indeed, it has been shown that delays in intervention may be as important as the type of intervention offered to facilitate rehabilitation .
Several weeks of pain and work absence may further contribute to social isolation, disengagement from the workplace and reduced social activity. In fact, there is evidence that psychosocial factors driving the transition to chronic pain are visible in the first few days after an injury . While psychosocial screening coupled with matched treatment options has been shown to improve outcomes and increase the cost-effectiveness of LBP treatment , most screening measures focus on dysfunctional pain beliefs and not enough on social or organisational circumstances. Early psychosocial assessment could be expanded to include a small number of key organisational and home support factors, such as perceptions of the supervisor and spousal support.
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