Quarterly scientific, online publication by Department of Nursing A,

Technological Educational Institute of Athens

_REVIEW_

Effect of physical and psychosocial factors on occupational low back pain

Emel Yilmaz1, Ozden Dedeli2
1.Assistant Professor , Department of Surgical Disease, Celal Bayar University School of Health, Manisa,
Turkey
2.Assistant Professor Department of Internal Medicine, Celal Bayar University School of Health,
Manisa,Turkey

ABSTRACT
Background: Musculoskeletal pain, in particular low back pain, is one of the most common occupational
health problems and accounts for a large number of workers compensational days and disability in
modern industrialised societies. It is believed that occupational musculoskeletal pain is caused by multiple
factors, generally categorised into physical, psychosocial and lifestyle ones.
Aims: The aim of this review was to evaluate role of psychosocial and physical risk factors in work-related
low back pain in the light of current literature.
Methods and material: The method of this review evaluated both research and review studies in national
and international literature which about role of psychosocial and physical risk factors in work-related low
back pain.
Results: Various physical factors mechanical impacts have been found to be associated with pain in
different body regions. Heavy physical work, heavy or frequent manuel operations, repeated rotation of
the trunk, whole body vibration and prolonged sitting were positively associated with low back pain.
Psychosocial factors at work have also been shown to play important roles in the development of low back
pain. Factors such as work demands, decision latitude, symptoms of stress and social support have been
reported as important psychosocial factors at work. However, the causal and independent contribution of
the work enviroment on the incidence of low back pain is stil debated, especially with regard to
psychosocial factors.
Conclusion: A number of researchers have been examined the evidence for psychosocial factors at work as
risk factors for back pain in recent years. It is recommended to be addressed psychosocial factors as
physical factors as for management of work related low back pain.

Key words: Low back pain, psychological factors, social factors.

CORRESPONDING AUTHOR
Ozden Dedeli,
Celal Bayar,
University School of Health Istasyon Mevkii,
45020 Manisa-Turkey,
Tel:+902362391318
Email: ozdendedeli@yahoo.co.uk

INTRODUCTION

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B
ack disorders encompassa reported between 60-80 %,3,4 and out of
spectrum of condition, from those these incidents in about 80-90% cases
of acute onset and short duration of pain subsides within first 2-3 months rest
lifelong disorders, and include of the patients (around 10-20%) develop
osteoarthritis, disc degeneration, chronic pain syndromes.5 Chronic low
osteoporosis, and common low back back pain patients comprises 73-77% of
pain. Neck pain is an entity in and of all the patients with lower back pain
itself. The prevalence of many of these disorders.6,7 Approximately 90% of cases
disorders increases markedly with age, of back pain have no identifiable cause
and many of the disorders are affected and are designated as nonspecific. Many
by lifestyle factors, such as obesity and doctors order elaborate studies when
certain types of physical activity. nonspecific back pain is presented,
Although the economic and public including radiographs and magnetic
health effects of back disorders and resonance imaging. The results are little
especially low back pain are enormous, guidance to treatment decisions.
epidemiologic research into the problem Inconsistencies remain in the literature
is in a formative stage, is the increasing over the relative contributions of
number of older people throughout the physical and psychological risk factors to
world, the burden on the individual and the occurence of back disorders and
society as a whole is expected to inctease back pain. Relatively little is known
dramatically. While not a disease, back about risk factors for the transition from
pain is a major cause of disability, acute to chronic LBP can be classified as
especially in areas where compensation individual, psychosocial, or occupational
systems take it into cognizance.1,2 factors (Table 1).1
Low back pain (LBP) is usually defined The presence and severity of LBP is
as pain, muscule tension, or stiffness associated with several socio-
localized below the costal magrin and demographic factors, among them sex,
above the inferior gluteal folds, with or age, education level, smoking, and
without leg pain (sciatica).1 LPB is a occupation.8-10 Studies on the
major health problem around the world association between occupational risk
which accounts for considerable factors and low back pain are hampered
socioeconomic and health care burden.2 by the difficulties of measuring specific
The life time incidence of LBP has been exposures. Many studies are limited by

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 Quarterly scientific, online publication by Department of Nursing A,
Technological Educational Institute of Athens

the absence of more quantitative LBP are increasing worldwide.15

measurements of manual material Epidemiologic studies provide some
handling task parameters, and risk of support that psychosocial factors in the
low back injury may be entirely a result work enviroment are in fact related to
of the design of the workplace as LBP. The aim of this paper was to
opposed to individual differences among provide and review of the impact of
11
the workers. Occupational factors be physical, psychosocial factors, and
able to defined as workplace factors and psychological stres on occupational LBP.
others. Workplace factors including
physical and psychosocial factors and Occupational risk factors for low back
their interaction, are strong pain
determinants of back pain. Other factors Musculoskeletal pain, in particular LBP,
such as heavy physical work, night is one of the most common occupational
shifts, lifting, bending, twisting, pulling, health problems and accounts for a large
and pushing have often been associated number of workers compensation days
10,12
with low back pain. Psychological and disability in modern industriablised
variables associated with low back societies. LBP has been found to affect
include stress, distress, mood and more workers and result in higher costs
emotions, cognitive functioning, pain to industry than any other
behavior, and depressive disorder.13 musculoskeletal disorders. Traditionally,
Numerous studies have explored and the most widely investigated
have identified associations between occupational risk factors for LBP have
psychological factors or social factors or been biomechanical demands of the job.
social factors and low back pain. These In more recent years, psychosocial
associations ocur before the fact, i.e. in characteristics of work have been
subjects who have yet to develop back investigated as potential risk factors for
pain, and after the fact, i.e. in patients LBP. Each of these approaches has
who have developed back pain.14 The provided some evidence about the
many publications occupational LBP and complex relationship among work tasks,
have examined risk factors, it is the most work placeenviroment, and LBP. A
expensive source of compensated work conceptual model of the potential
related injury in modern in dust rialised relationships among psychosocial work
countries. Moreover, both the rate and characteristics, biomedical work
the degree of disability accruing from demands, and LBP is presented in Fig 1.

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Psychosocial factors (see pathway a) and research. LBP has been consistently
biomechanical factors (see pathway b) associated with neurotic signs such as
may independently contribute to the depression, anxiety, and heightened
etiology and progression of LBP. somatic awareness in LBP sufferers
Psychosocial factors may also influence drawn from patient populations. While
the relationship between biomechanical several studies have suggested similar
factors and LBP (see pathway c), such associations between psychological
that biomechanical demands have a factors and LBP in nonpatient
greater effect on LBP under poor populations, the findings have not been
psychosocial work conditions. consistent. Aspects of the work
Additionally, poor psychosocial work enviroment and work satisfaction have
characteristics and high biomechanical also been found to be associated with
demands may covary (e.g., tend to LBP in industrial and general popultion
concentrate in smilar jobs and studies. Several studies have reported
occupations). This covariation (see that sufferers of LBP and back injury
pathway a) raises the possibility of claimants are more likely to be
confounding if both types of risk factors dissatisfied with their jobs, attract poor
are not accounted for in risk models. appraisal from supervisors, and be more
Until fairly recently, biomechanical likely to experience a poor psychosocial
demands and psychosocial work work enviroment, but contradictory
characteristics were rarely investigated findings have also been reported.15 Its
as risk factors for LBP within the same believed that occupational LBP is caused
study.16 by multiple factors, generally categorised
into biomechanical and psychosocial
The association of physical and approaches.
nonphysical factors with occupational The biomechanical approach has been
low back pain based on the premise that physical
The association of nonphysical factors aspects of the job contribute to LBP.
with LBP has been one of the more Biomechanical factors have been
robust findings in the literature seporting hypothesized to cause LBP through two
factors associated with LBP. Two factors, mechanisms: excessive load and
psychological state and aspects of work repetitive loading on the spinal
satisfaction, have been the main focus of structures. Excessive loads can result

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 Quarterly scientific, online publication by Department of Nursing A,
Technological Educational Institute of Athens

from lifting heavy loads, awkward might interact to affect the

postures, and high trunk velocities while musculoskeletal system. Chen et al.,19
repetitive loading results from an explored the relation between
evevated number of lifting cycles over psychosocial factors and musculoskeletal
long period time. Biomechanical factors pain in Chinese offshore oil installation
such as lifting, awkward postures, static workers. According to results of this
postures, repetitive trunk motions, study, the prevalence of musculoskeletal
whole-body vibration, and heavy loads pain over the previous 12 months varied
have been found to be risk factors for between 7.5 % for elbow pain and 32 %
LBP. Loads on the spine that accompany for LBP; 56 % workers had at least one
the above risk factors have also been complaint significant associations were
found to be moderately associated with found between various psychosocial
LBP.16 Psychosocial factors at work have factors and musculoskeletal pain in
also been shown to play important roles different body regions after adjusting for
in the development of LBP. Important potential confounding factors.
psychosocial factors included work Occupational stressors, in particular
demands and decision latitude, stres from safety, physical enviroment,
symptoms of stress, social support, type and ergonomics, were
A behaviour, and psychological distress. importantnpredictors of musculoskeletal
After reviewing 59 relevant studies, pain, as was coping by eating behaviour.
Bonger et al.,17 concluded that Eating behaviour coping stkyes as eating,
monotonous work, high perceived drinking alcol/tea/coffee, and smoking.
workload, time pressure, low control on Other coping styles, escaping/abreaction,
the job, lack of social support from external/social, and internal were also
colleagues, and stress symptoms were found to have an impact on pain in
related to musculoskeletal problems. different body regions.
Carayon et al.,18 reviewed work Psychosocial factors at work have also
organisation, job stress, and work related been shown to play important roles in
musculoskeletal disorders, and the development of LBP. Gaffari et al.,20
concluded that work organisation and tested the hypothesis that workplace
psychosocial factors at work could psychosocial factors such as demand,
contribute to upper extremity disorders. control, support, job satisfaction and
They further indicated that work job appreciation can predict the future
organisation and ergonomic factors onset of disabling LBP in Iranian

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Volume 6, Issue 4 (October December 2012)
industrial workers. A total of 744 depression were high. In another study
subjects reported current LBP, a total of determined if there was a relationship
52 new episodes of disabling LBP were between smoking and low back pain.
observed during the 1-year follow-up. Researchers concluded that smoking is
Male employers reported higher not a risk factor for low back pain.23 In
demands, lower control and lower view of the risky physical demands and
support than female employers. psychosocial features of police work,
There are many studies have evaluate policemen are at risk for low back pain.
prevalence, etiology and the association Beyaz & Ketenci24 investigated
of sociodemographic variables with occupational low back pain and
occupational low back pain in Turkey therapeutic approaches in policemen.
but there are limited number of studies Policemen reported causes of LBP; non-
have tested the relationship between ergonomic and worn-out seats, poor
psychosocial factors and occupational physical integration, previous low back
LBP. In a study examined the level of pain, the time spent in the vehicle,
depression and quality of life and their personal occupational heavy equipment
relationship with severity of pain in such as duty belt, stress and occupation
chronic low back pain patients. years. Low back pain is a common
According to researchers the depression problem in textile industry workers. In
level and the pain severity are closely another study investigated the
related in patients with chronic low back prevalence and risk factors of self
pain. Pain severity and the level of reported low back pain among textile
depression negatively affected the life workers. The study population consisted
quality and functional capacity of the of 1153 factory workers of which 84.7%
21 22
patients., Demet et al., investigated were males. Twenty eight percent of the
low back pain of housewives and workers experienced at least once low
determined relationships between back pain during the last six months.
psychological status, education and The prevalence of mechanical low back
physical health in housewives. The pain was 7%. Being female, working
results of this study were the housewives more than ten years in textile industry,
with chronic back pain and do not smoking and working in the office were
exercise regularly limit activities of daily the risk factors for self-reported low
living and, the housewives the level of back pain, and making exercise regularly

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 Quarterly scientific, online publication by Department of Nursing A,
Technological Educational Institute of Athens

was a preventive factor. Workers who of the nurses had experienced an episode
exercise regularly routine reported of of LBP and statistical correlation
low back pain.25-27 Ozcan et al.28 between LBP and working period, sleep
investigated the risk factors and the regime and income level. In another
prevalence of occupational study described musculoskeletal
musculoskeletal pain in workers who problems resulting from work setting
working at metal work. The prevalence and occupation in medical doctors who
of musculoskeletal pain 83.0% in the last work in a hospital. Researchers
12-months. The prevalence of established that 41 of 123 subjects had at
complaints of pain in the last 12-months, least one musculoskeletal problem
64.8% low back, 52.9% back, neck resulting from work setting and working
48.0%. The risk factors of occupational so long time with the same position and
musculoskeletal pain have been found repiting the same activities during wok
that 20 kg load lifting, load-pulling, load- day lead to a risk factor about
carrying. Occupational LBP is a very musculoskeletal problems in medical
31
common complaint in the health care doctor.
professionals. In a study determined the
prevalence of occupational LBP, the Conclusion
association of personal and work related Although there are enough studies
factors with occupational LBP in health related to effect of psychosocial factors
care workers at the university hospitals. on occupational LBP in our country,
The results of this study were yearly psychosocial factors play an important
back pain prevalence was 34.3% and role in low back pain is now well
chronic low back pain prevalence was documented and generally accepted. A
16%. Positive family history and person' ability to recover may be
smoking were found to be related to an determined by such things as motivation,
increased risk of low back pain. Sex, ambitions, social support, attitude at
weight, race, social status, history of work and family dynamics. The
pregnancy or sports activities and daily development of occupational LBP are
living activities were not found to be effective physical factors as well as
related to low back pain.29 Yilmaz & psychosocial factors. According to
Ozkan30 determined the prevalence of findings of review studies may be
LBP in nurses who working at the public suggested that occupational LBP may be
hospitals. Researchers found that 39.9% improved by management of

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psychological distress, provide of social when left untampered. Spine.
support, develop of positive coping 1995; 20(4): 473-477.
styles, evaluate of depression, burnout, 7. Coste J, Delecoeuillerie G. Clinical
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Technological Educational Institute of Athens

ANNEX

Table 1. Risk factors for occurrence of non-specific back pain and chronicity

Occurence Chronicity
Individual Age Obesity
Gender Educational level
Smoking High levels of pain/diability
General health Health care provider attitudes
High birth weight Unemployment
(males)
Psychosocial Stress Distress
factors Pain behavior Depressive mood
Depressive mood Somatization
Cognitive functioning Baseline long duration of pain
Fear-avoidance behavior
Occupational Manual handling of Job dissatisfaction
factors materials
Monotonous tasks Unavailability of light duty
Control at work Lifting for more than three fourths
of the day
Job dissatisfaction
Social support/work relations
Night shifts
Bending and twisting
Whole-body vibration

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Fig. 1. Conceptual model of the relationship between psychosocial and

biomechanical risk factors and LBP (Davids & Heaney, 2000).

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