Manon Truchon

Biopsychosocial Determinants of Chronic Disability and Low-Back Pain: A Review

It is well known that the human and financial costs related to sick leave due to Low-Back Pain (LBP) are substantial in a small percentage of workers. A better understanding of the predictive factors for chronic disability would allow interventions to be adapted and costs to be reduced. This paper is a critical review of recent prospective studies on the biopsychosocial factors predictive of nonreturn to work due to LBP. A sample of 18 prospective studies were systematically analyzed. Despite the limited number of prospective studies and their differences, some factors are promising indicators. These include a previous history of LBP, results of certain clinical tests, a subjective negative appraisal of ones ability to work, and job dissatisfaction. The role of certain psychological variables, including attitudes and beliefs, as well as coping strategies, is also emerging. Additional studies are necessary to confirm the importance of these factors, to specify the nature of the interrelationships among them, and to integrate them into a conceptual framework.

Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model

Purpose : Since the early 1990s, numerous prospective studies have been published on the determinants of chronic disability related to low back pain (LBP) of non-specific origin whose human and financial costs are enormous. The significant contribution of psychosocial factors is being increasingly recognized. However, additional efforts are needed to clarify their role and to improve the interventions. The purpose of this theoretical paper is to propose a coherent organization of the medical and psychosocial determinants identified in prospective studies into a conceptual framework. Method : Several models available in the field of pain and disability as well as in health psychology were reviewed. Results : A recent version of the stress coping model was chosen and adapted to the problem. The adapted model suggests that stress, particularly that caused by the pain associated with LBP, could have a negative impact on the outcome either: (1) indirectly through the negative emotional responses that it produces, which can cause biological or behavioural changes; or (2) directly through the biological or behavioural changes, which can in turn negatively affect the emotional response. Conclusions : The proposed biopsychosocial model assumes that LBP-related chronic disability is possibly, in some cases, a stress-related disorder. Its empirical verification in LBP could particularly improve the understanding of the interrelationships between certain variables.

Predictive validity of the Chronic Pain Coping Inventory in subacute low back pain.

&NA; The Chronic Pain Coping Inventory (CPCI) was developed to assess eight behavioral coping strategies hypothesized to be important for pain adaptation. But the predictive validity of the CPCI has yet to be tested in a longitudinal study. Here, 321 workers on sick leave after a work accident affecting the low back pain (LBP) region completed the CPCI during the subacute stage (T1) of LBP as well as the Catastrophizing scale of the Coping Strategies Questionnaire (CSQ). Disability, pain intensity and depressive mood were assessed simultaneously as well as 6 months later (T2). Work status was also determined at follow‐up. Hierarchical regression analyses revealed that the CPCI (Guarding scale) predicted T1 disability and T2 disability (Relaxation scale), but T1 disability was the best predictor of T2 disability. For T1 pain intensity, the CSQs Catastrophizing dimension was the best predictor and the CPCI Guarding scale added a small contribution. T1 pain intensity was the best predictor of T2 pain intensity. Catastrophizing and Guarding were the most strongly associated with depressive mood at T1 but at T2, only depressive mood at T1 predicted this same variable. Results indicated also that the Guarding and Catastrophizing scales were able to predict future work status. The present study clearly reveals the usefulness of Guarding from the CPCI and Catastrophizing from the CSQ, when predicting different outcomes of adjustment to low back pain.

Low-back-pain related disability: An integration of psychological risk factors into the stress process model

&NA; The purpose of this study was to verify the usefulness of an adaptation of the stress process model in organizing the psychological variables associated with the development of low‐back‐pain related disability. French‐speaking Canadian workers on compensated sick leave (N = 439) due to recent occupational low back pain (LBP) were evaluated during the sub‐acute stage of LBP (between 30 and 83 days after injury). They were assessed for the following factors: life events, injury‐specific cognitive appraisal, emotional distress, avoidance coping, and functional disability. Confirmatory factor analyses were used to test and modify the measurement model. An important modification in the measurement model was the association of catastrophizing with the emotional distress factor. During the sub‐acute stage, path analyses revealed a satisfactory fit of the following model (the following coefficients are standardized): (a) life events (.30) and cognitive appraisal (.42) explained emotional distress (r2 = .30); (b) emotional distress (.42) and cognitive appraisal (.36) explained the use of avoidance coping (r2 = .45); and (c) emotional distress (.24) and avoidance coping (.56) explained functional disability (r2 = .53). The stress model tested here reaffirms the importance of life events in the development of disability through the more established emotional distress factor. Also, cognitive appraisal appears to have an indirect effect on disability through activity avoidance and distress. This adaptation of the stress model makes it possible to integrate risk factors into a reduced set of meaningful factors and proposes a more general adaptation explanation of disability than the specific fear‐avoidance model.

An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project

BackgroundLow-back pain is responsible for significant disability and costs in industrialized countries. Only a minority of subjects suffering from low-back pain will develop persistent disability. However, this minority is responsible for the majority of costs and has the poorest health outcomes. The objective of the Clinic on Low-back pain in Interdisciplinary Practice (CLIP) project was to develop a primary care interdisciplinary practice model for the clinical management of low-back pain and the prevention of persistent disability.MethodsUsing previously published guidelines, systematic reviews and meta-analyses, a clinical management model for low-back pain was developed by the project team. A structured process facilitating discussions on this model among researchers, stakeholders and clinicians was created. The model was revised following these exchanges, without deviating from the evidence.ResultsA model consisting of nine elements on clinical management of low-back pain and prevention of persistent disability was developed. The models two core elements for the prevention of persistent disability are the following: 1) the evaluation of the prognosis at the fourth week of disability, and of key modifiable barriers to return to usual activities if the prognosis is unfavourable; 2) the evaluation of the patients perceived disability every four weeks, with the evaluation and management of barriers to return to usual activities if perceived disability has not sufficiently improved.ConclusionA primary care interdisciplinary model aimed at improving quality and continuity of care for patients with low-back pain was developed. The effectiveness, efficiency and applicability of the CLIP model in preventing persistent disability in patients suffering from low-back pain should be assessed.

Effects of patient--clinician disagreement in occupational low back pain: a pilot study.

Purpose. To determine (1) patient – physical therapist and patient – physician agreement on clinical management of LBP, (2) patient perception of agreement between physical therapist and physician, (3) association between agreement and outcome (return to work, self-perceived disability). Method. Thirty-five workers compensated for LBP responded to a telephone interview within 1 week of referral to physical therapy. They were asked about agreement with the physical therapist and the physician regarding the clinical management of their LBP and whether they thought the physical therapist was providing the treatment the physician would have thought appropriate. They completed a second interview upon returning to work or after 3 months. They answered questionnaires on self-perceived disability, psychological distress, coping strategies, and job satisfaction at both baseline and follow-up. Results. Nearly all patients (97.1%) agreed with the physical therapist and all believed the physical therapist was providing the treatment the physician would have thought appropriate. The 10 (28.6%) patients who disagreed with their physician on medical management of their LBP were less satisfied with the medical care (P = 0.05), technical quality of the visit (P = 0.01), and catastrophized more about their pain (P = 0.03) than those who agreed. Disagreement was not associated with greater time off-work or greater self-perceived disability. Conclusion. Patients who disagreed with their physician were less satisfied with their medical management, and catastrophized more about their pain than those who agreed, but disagreement was not associated with chronicity or disability. Studies with larger sample sizes should investigate the role of other factors, such as patient expectations, in the transition to chronicity.

Psychosocial and socio-demographic factors associated with outcomes for patients undergoing rehabilitation for chronic whiplash associated disorders: a pilot study.

Purpose. Identify psychosocial and socio-demographic factors (measured prior to treatment) that were associated with post-treatment self-perceived pain and disability and two secondary outcomes: psychological distress, and return to work in patients undergoing multidisciplinary rehabilitation for chronic whiplash associated disorders (WAD). Method. Interviews were conducted with 28 patients with chronic WAD at entry to and completion of an intensive rehabilitation program, and a telephone interview was carried out three months later. Participants completed pain and disability, and psychological distress questionnaires, at baseline and at both follow-ups. They also completed psychosocial questionnaires and provided socio-demographic information. The effect of each of the independent variables on the outcomes was first evaluated by simple regressions, and then subsequently by multiple regression analysis. Results. Higher baseline pain and disability predicted higher pain and disability at both follow-ups (p < 0.001), and higher psychological distress at program completion (p = 0.003). Younger age (p = 0.028) and higher baseline psychological distress (p = 0.002) were associated with higher psychological distress three months post-rehabilitation. Greater social support at work was prognostic of return to work at program completion (p = 0.04). Conclusions. Baseline pain and disability was the only factor that affected pain and disability post-rehabilitation. Psychosocial factors played a role in the prognosis of psychological distress and return to work.

Validation of an Adaptation of the Stress Process Model for Predicting Low Back Pain Related Long-term Disability Outcomes : A Cohort Study

Study Design. Twelve-month cohort study. Objective. The aim of the study was to examine the ability of an adaptation of the stress process model to predict different outcomes among low back pain (LBP) sufferers. Summary of Background Data. Recently, the stress process model was adapted and was shown to be useful to partially explain long-term disability related to low back pain, an important occupational health problem. Methods. French-speaking compensated workers on sick leave because of subacute common LBP (N = 439) completed a questionnaire including the adapted stress process models factors: life events and appraisal, cognitive appraisal of LBP, emotional distress, avoidance coping strategies, and functional disability. Six and 12 months later, participants gave information about their work status, number of days of absence, and functional disability. Regression analyses were performed to identify significant predictive factors of these outcomes. Pain intensity, fear of work, gender, and presence of pain radiating below the knee were used as control variables. Results. Number of days of absence, functional disability, and absence from work were predicted at 6 and 12 months by cognitive appraisal of LBP and emotional distress. Functional disability was predicted in addition by functional disability at study entry (T1). When the control variables were considered, number of days of absence was predicted at 6 months by cognitive appraisal, fear of work, and being a male, and, in addition, by emotional distress at 12 months. Functional disability was predicted by functional disability t1, emotional distress, cognitive appraisal of LBP, and fear of work at 6 months, and by the same factors and variables at 12 months, except for functional disability t1. Regarding absence from work, it was predicted at 6 months by fear of work and being a male, and at 12 months by cognitive appraisal of LBP and fear of work. Conclusion. In association with fear of work, 2 factors from the adapted stress process model are significantly useful for predicting LBP related long-term disability outcomes and could be targeted by preventive interventions.

The chronic pain coping inventory: Confirmatory factor analysis of the French version

BackgroundCoping strategies are among the psychosocial factors hypothesized to contribute to the development of chronic musculoskeletal disability. The Chronic Pain Coping Inventory (CPCI) was developed to assess eight behavioral coping strategies targeted in multidisciplinary pain treatment (Guarding, Resting, Asking for Assistance, Task Persistence, Relaxation, Exercise/Stretch, Coping Self-Statements and Seeking Social Support). The present study had two objectives. First, it aimed at measuring the internal consistency and the construct validity of the French version of the CPCI. Second, it aimed to verify if, as suggested by the CPCI authors, the scales of this instrument can be grouped according to the following coping families: Illness-focused coping and Wellness-focused coping.MethodThe CPCI was translated into French with the forward and backward translation procedure. To evaluate internal consistency, Cronbachs alphas were computed. Construct validity of the inventory was estimated through confirmatory factor analysis (CFA) in two samples: a group of 439 Quebecois workers on sick leave in the sub-acute stage of low back pain (less than 84 days after the work accident) and a group of 388 French chronic pain patients seen in a pain clinic. A CFA was also performed to evaluate if the CPCI scales were grouped into two coping families (i.e. Wellness-focused and Illness-focused coping).ResultsThe French version of the CPCI had adequate internal consistency in both samples. The CFA confirmed the eight-scale structure of the CPCI. A series of second-order CFA confirmed the composition of the Illness-focused family of coping (Guarding, Resting and Asking for Assistance). However, the composition of the Wellness-focused family of coping (Relaxation, Exercise/Stretch, Coping Self-Statements and Seeking Social Support) was different than the one proposed by the authors of the CPCI. Also, a positive correlation was observed between Illness and Wellness coping families.ConclusionThe present study indicates that the internal consistency and construct validity of the French version of the CPCI were adequate, but the grouping and labeling of the CPCI families of coping are debatable and deserve further analysis in the context of musculoskeletal and pain rehabilitation.