Psychosocial Risk Factors, Interventions, and Comorbidity in Patients with Non-Specific Low Back Pain in Primary Care: Need for Comprehensive and Patient-Centered Care

Abstract

Non-specific low back pain (LBP) affects many people and has major socio-economic consequences. Traditional therapeutic strategies, mainly focused on biomechanical factors, have had moderate and short-term impact. Certain psychosocial factors have been linked to poor prognosis of LBP and they are increasingly considered as promising targets for management of LBP. Primary health care providers (HCPs) are involved in most of the management of people with LBP and they are skilled in providing comprehensive care, including consideration of psychosocial dimensions. This review aims to discuss three pieces of recent research focusing on psychosocial issues in LBP patients in primary care. In the first systematic review, the patients’ or HCPs’ overall judgment about the likely evolution of LBP was the factor most strongly linked to poor outcome, with predictive validity similar to that of multidimensional scales. This result may be explained by the implicit aggregation of many prognostic factors underlying this judgment and suggests the relevance of considering the patients from biopsychosocial and longitudinal points of view. The second review showed that most of the interventions targeting psychosocial factors in LBP in primary care have to date focused on the cognitive-behavioral factors, resulting in little impact. It is unlikely that any intervention focusing on a single factor would ever fit the needs of most patients; interventions targeting determinants from several fields (mainly psychosocial, biomechanical, and occupational) may be more relevant. Should multiple stakeholders be involved in such interventions, enhanced interprofessional collaboration would be critical to ensure the delivery of coordinated care. Finally, in the third study, the prevalence of psychosocial comorbidity in chronic LBP patients was not found to be significantly higher than in other patients consulting in primary care. Rather than specifically screening for psychosocial conditions, this suggests taking into account any potential comorbidity in patients with chronic LBP, as in other patients. All these results support the adoption of a more comprehensive and patient-centered approach when dealing with patients with LBP in primary care. As this condition is illustrative of many situations encountered in primary care, the strategies proposed here may benefit most patients consulting in this setting.

Risk and protective factors in the clinical rehabilitation of chronic back pain

“…However, predictive quantitative analysis of future pain illustrated that lifestyle factors, for example, demanding physical work, gender and smoking outweighed medical care factors, such as case history, therapy form, iatrogenic factors and type of insurance. Although the frequent use of prescribed pain medications in combination can become undetected medication abuse, a topic that should receive more attention, it is important to note that sociodemographic and lifestyle factors have a huge influence on the medical history of patients 14. Research is beginning to uncover that declared orange flag factors (e.g., substance abuse, gender) are of greater importance than suggested in the current flag catalog and should be respected by health care providers 9,48.…”

“…This helps practitioners to distinguish between individual perception and objective features to then create specific interventions targeted at modifiable risks. In the past, the following factors have been proposed in different flag domains:9 sociodemographic factors such as age, gender, socioeconomic status and cultural conditions,4,10behavioral factors such as fear avoidance, endurance, catastrophizing, anxiety and depression,10–15 andoccupational factors such as employment status/dissatisfaction/expectations/body posture and social support (SS) at the workplace 14,16–18…”

“…For example, work-related stress is often defined as low job satisfaction, demanding physical work, interpersonal stress at work or as “heavy work with little opportunity to modify duties” 7,14,17,19,20. The situation is similar to distress, often operationalized as general stress without considering the type, frequency or impact of a stressor 19.…”

Contribution of occupational factors to the incidence and persistence of chronic low back pain among workers: results from the longitudinal VISAT study

“…The VISAT study emphasises the role of different categories of occupational factors on focused types of LPB and the need to take into consideration the onset time of CLBP. When LBP progresses towards a chronic form, with daily pain and a need for drugs, occupational biomechanical and psycho-organisational factors have to be considered to manage LBP, as suggested in several guidelines53 54 and in a recent review 55…”

The Emotional Brain as a Predictor and Amplifier of Chronic Pain

“…These findings suggest the presence of preexisting functional and morphologic risk factors for the development of chronic back pain, although the preexistence of these factors remains to be proven. It should be noted that earlier clinical studies have identified a long list of risks for chronic pain, such as demographics, affective states, lifestyle, comorbidities, and others (Mayer and Bushnell 2009), yet collectively such parameters account for a relatively small amount of variance for chronic pain (10% to 20%; Hasenbring et al 2012;Ramond-Roquin et al 2015). In contrast, the brain's anatomic and functional properties predict development of chronic pain at 80% to 100% accuracy.…”