Best Practice & Research Clinical Rheumatology 27 (2013) 637–648

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevierhealth.com/berh

Effects of workplace, family and cultural

influences on low back pain: What opportunities
exist to address social factors in general
consultations?
William S. Shaw, Ph.D. a, b, *, Paul Campbell, Ph.D. c,1,
Candace C. Nelson, Sc.D. a, d, 2, Chris J. Main, Ph.D. c, 3,
Steven J. Linton, Ph.D. e, 4
a
Liberty Mutual Research Institute for Safety, 71 Frankland Road, Hopkinton, MA 01748, USA
b
University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
c
Arthritis Research UK Primary Care Centre, Primary Care Sciences, Keele University, Staffordshire ST5 5BG,
UK
d
Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
e
Örebro University, CHAMP, School of Law, Psychology and Social Work, Örebro SE-701 82, Sweden

s u m m a r y
Keywords:
Low back pain Social factors are widely acknowledged in behavioural models of
Social factors
pain and pain management, but incorporating these factors into
Organisational support
general medical consultations for low back pain (LBP) can be
Social support
Back disability 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 organ-
isational support may be an effective strategy to reduce the
negative lifestyle consequences of LBP. For clinicians to address

* Corresponding author. Liberty Mutual Research Institute for Safety, 71 Frankland Road, Hopkinton, MA 01748, USA. Tel.: þ1
508 497 0253; fax: þ1 508 435 8136.
E-mail addresses: william.shaw@libertymutual.com (W.S. Shaw), p.campbell@keele.ac.uk (P. Campbell), cnelson@hsph.
harvard.edu (C.C. Nelson), profcmain@gmail.com (C.J. Main), steven.linton@oru.se (S.J. Linton).
1
Tel.: þ44 (0) 1782 734828; fax: þ44 (0) 1782 733911.
2
Tel.: þ1 617 632 5602; fax: þ1 508 435 8136.
3
Tel.: þ44 (0) 1614 489955; fax: þ44 (0) 1782 733911.
4
Tel.: þ46 (0) 1930 3505.

1521-6942/$ – see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.berh.2013.09.012
638 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648

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.
Ó 2013 Elsevier Ltd. All rights reserved.

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 [1–3]. 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
[4,5]. Because the aetiology of LBP is often unclear, and because no biomedical cure is in sight for the
large majority of chronic LBP sufferers [6], much LBP research has been redirected to secondary pre-
vention: 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 [7,8], 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 in-
fluence 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 [9–12] may apply to LBP as well. Fig. 1 highlights a
number of social variables within the domains of workplace, home, clinic and sociocultural background

Fig. 1. Potential social factors influencing pain and disability outcomes.

 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648 639

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 V12 billion per year [13]. Similar statistics and figures can be found in the United States
and Australia [14,15]. LBP is one of the most frequently reported reasons for sickness absence [16], with
evidence of high recurrence and difficulties in returning to work (RTW) for a small but significant
group of those with LBP [17,18]. 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 [19].
Social factors are prominent in theoretical models of occupational health and wellness. The systems
model of work disability proposed by Loisel and colleagues [20] 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 [21,22]. 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)
[23]. The Model of Human Occupation similarly stresses the importance of social groups in the
workplace to accommodate or mitigate disabling health conditions [24].
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 [25]. 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 pro-
gramme [26]. Efforts by reviewers [27–32] 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 [29,30], whereas others [27,28,31,32] 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 [29,32]. Evidence for the prognosis of LBP, however, is
mixed. Two systematic reviews [30,32] 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 [27,28,31,32]. 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 [33]. 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
640 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648

relationships and compromise levels of support. While there is evidence of a detrimental consequence
of LBP on marital satisfaction, partner emotions and relationship quality [34], there are also beneficial
effects of spousal support on LBP coping and function [34,35]. 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 [34,36–38]. 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 [34,38] involving empathy, understanding, communication and congruence between partners/
family members [39]. Two recent qualitative studies on the impact of LBP on the family [40,41] 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 [30,42], and there is ample evidence of this from the general medical rehabilitation
literature [43–45] and in general health studies [46–48]. Systematic reviews in LBP have concluded
that social isolation produces longer work absences when these variables are pooled [30] and that
family social factors mediate negative psychological reactions to pain [42].

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 [49,50]. 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 [51]. 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 out-
comes and greater patient satisfaction [52–55], 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 [56]; 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 [57,58].
Longitudinal studies of LBP prognosis typically include demographic assessments of age, gender, in-
come, 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 [59–63], but some studies report no such effects [64,65]. 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 [60,61,66–69], but other studies report no associations [64,65,68,70].
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
 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648 641

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 [71,72] 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 psycho-
social 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.) [28,30,71–76] (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) [77], the Job
Content Questionnaire [78] and the Work Organisation Assessment Questionnaire (WOAQ) [79]; but
there can be practical difficulties in integrating these measures into routine clinical assessment [80].
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 coor-
dinator [80–83]. RTW coordination efforts have been shown to reduce the length of work absences for
musculoskeletal conditions [84]. Also important is the level of agreement and consensus present be-
tween employer and employee about the illness and the strategies to facilitate RTW [80,85,86]. Other
studies have shown the benefits of adding workplace communication and involvement to standard
clinical treatments for LBP [87,88]. 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 [89]. A small amount of evidence thus far has shown some beneficial effects when partners and

Table 1
Occupational factors included in the “flags” assessment strategy developed by Main and colleagues [71,72]. For a detailed
synthesis of the evidence on occupational factors, (see literature reviews by Shaw [28,73,80]), Steenstra [30], Hartvigsen [76],
Crook [74], and Waddell [75].

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
642 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648

family members are included in treatments [90,91]. While research on pain empathy and the inter-
personal–intrapersonal process between couples appears promising [34], 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 [34,39]. 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 [92]. In a recent systematic review of Internet-based counselling in-
terventions, a sub-analysis showed evidence for peer social support and social networking as elements
that led to improved pain and function [93]. 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 [94].
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 [42,95]. The mecha-
nisms 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 [93] and the overall assessment of the quality of advice from the Internet concerning the
management of LBP is low [96]. Further work is required to understand the mechanisms and com-
plexities 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 qualifi-
cations necessary to help patients deal with the social complications of LBP should be addressed [97].
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.

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 [4,5]. 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 [6]. An alternative is psychological in-
terventions, which offer similar benefits and fewer side effects [7,8], but their uptake and availability in
general medical settings have been slow [97,98].
Apart from providing psychotherapy services to patients, another option is to integrate psycho-
logically informed treatment strategies into physical treatments and consultations [97]. While the
 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648 643

Table 2
Illustrations of possible social problems in LBP recovery and function in relation to conventional LBP treatment paradigms.

Prevailing LBP treatment paradigms

Exclusive biomedical Decision-making based Reliance on biomechanical Watching and

focus on diagnostic algorithms explanations waiting
Co-worker A non-specific or RTW plans are not likely Co-workers may questionCo-workers may be
support fluctuating biomedical to consider issues why LBP has persisted sceptical that the
diagnosis may raise pertaining to production individual should be
despite medical evaluation
doubts among co- units and the speed and and treatment. out of work for more
workers. distribution of work. than a few days.
Organisational Organisations cede Frontline supervisors The individual may feel The organisation may
support responsibility for and workers are not their organisation is feel that a prompt
disability prevention included in planning questioning whether the RTW is being delayed
to medical providers. efforts for RTW and jobpain is real and demanding unnecessarily by
modification. validation. medical providers.
Partner support Partners may foster a Partners may feel that Partners may feel that the Partners may become
repeated (and often cause of LBP has not been outraged that more is
the patients are not being
fruitless) search for a given an adequate voiceaccurately or correctly not being done in the
biomedical cure. or autonomy. diagnosed. first few weeks of LBP.
Family conflict Medical providers may Treatment scheduling The family may perceive Uncertainty of
overlook social factors may fail to consider social
that the patient is being treatment plans and
if the focus is to explain ramifications at work and
denied necessary health delays may upset
signs, symptoms, and home. care or disability benefits to family roles, schedules
aetiology. deal with distress and and activities.
hardship.
Social Some patients may be Some may feel threatened Standardised physical Some patients may be
disadvantage unfamiliar with medical by insurance and testing may not take into less able to modify
jargon and have fewer regulatory systems account cultural differences caregiving and job
options for LBP treatment governing treatment and and language difficulties. demands and provide
and support. sickness absence. self-care during the
early stages of LBP.

RTW ¼ return to work; LBP ¼ low back pain.

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, communi-
cation 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 [99].

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,
644 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648

RTW coordinator or social worker can improve LBP outcomes [33,81,82,84,100], 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 pa-
tients report high psychological distress and fears about the future in a confidential pre-examination
survey [55,56]. 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 [101–103]. 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 [104]. 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 [105].
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 [28,55,56]. While
psychosocial screening coupled with matched treatment options has been shown to improve outcomes
and increase the cost-effectiveness of LBP treatment [106], 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.

Summary

In conclusion, there is evidentiary support for a number of social factors in the prognosis of LBP,
especially co-worker support, organisational support from an employer, spousal support, family con-
flict and social disadvantage. Identifying and addressing these issues in routine clinical care and case
management can be challenging given traditional paradigms for LBP treatment and disability man-
agement. While more research is needed, improving social and organisational support may be an
effective strategy to improve LBP outcomes. Incorporating these strategies, however, requires that LBP
assessments include psychosocial screening alongside physical examinations, that clinicians recognise
the need for individualised communication and problem solving and that treatment decision making
 W.S. Shaw et al. / Best Practice & Research Clinical Rheumatology 27 (2013) 637–648 645

be based on more than just diagnostic injury classifications and the usual signs and symptoms.
Whether these changes can be implemented on a wide scale remains an unanswered question.

Practice points

 Patients with LBP may experience poorer outcomes due to a lack of workplace organisational
support, poor spousal support, family conflict and social disadvantage.
 Adopting more patient-centred and communication-focussed clinical care strategies may
help to identify social factors that are impacting LBP recovery and return to work.
 Applying more psychologically informed and individualised treatment plans may help to
counter negative social factors, but integrating these strategies may require a philosophical
shift away from prevailing models based on biomechanical evaluation only.
 Treatment decision making and return-to-work planning need to incorporate the personal
views and circumstances of the patient.

Research agenda

 Social constructs as they relate to LBP recovery and coping should be more precisely defined
and measured so that causal linkages and mechanisms can be more clearly understood.
 More emphasis should be placed on the efficacy and cost-effectiveness of clinical and
workplace interventions emphasising communication, individual problem solving and RTW
coordination.
 Further development and testing of specific tools, assessment methods and communication
strategies are needed, especially with respect to their cost-effectiveness.
 Psychological theories of pain should be expanded to include the influence of social factors on
pain beliefs and pain behaviour.
 Analytic strategies to assess the impact of social factors should be more closely tied to
theoretical models linking social support to health outcomes.

Conflict of interest

The authors declare no financial or personal relationships with people or organisations that could
inappropriately influence the content of this article.

Funding acknowledgement

Development of this article was partially funded with travel support from a 2006 International
Association for the Study of Pain (IASP) research grant funded by the Scan/Design Foundation by Inger
and Jens Bruun (Linton/Shaw).

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