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A Systematic Review of Psychological Factors as Predictors of Chronicity/Disability in Prospective Cohorts of Low Back Pain

Pincus, Tamar, PhD*; Burton, A. Kim, PhD; Vogel, Steve, DO; Field, Andy P., PhD§

Primary Care

Study Design. A systematic review of prospective cohort studies in low back pain.

Objectives. To evaluate the evidence implicating psychological factors in the development of chronicity in low back pain.

Summary of Background Data. The biopsychosocial model is gaining acceptance in low back pain, and has provided a basis for screening measurements, guidelines and interventions; however, to date, the unique contribution of psychological factors in the transition from an acute presentation to chronicity has not been rigorously assessed.

Methods. A systematic literature search was followed by the application of three sets of criteria to each study: methodologic quality, quality of measurement of psychological factors, and quality of statistical analysis. Two reviewers blindly coded each study, followed by independent assessment by a statistician. Studies were divided into three environments: primary care settings, pain clinics, and workplace.

Results. Twenty-five publications (18 cohorts) included psychological factors at baseline. Six of these met acceptability criteria for methodology, psychological measurement, and statistical analysis. Increased risk of chronicity (persisting symptoms and/or disability) from psychological distress/depressive mood and, to a lesser extent, somatization emerged as the main findings. Acceptable evidence generally was not found for other psychological factors, although weak support emerged for the role of catastrophizing as a coping strategy.

Conclusion. Psychological factors (notably distress, depressive mood, and somatization) are implicated in the transition to chronic low back pain. The development and testing of clinical interventions specifically targeting these factors is indicated. In view of the importance attributed to other psychological factors (particularly coping strategies and fear avoidance) there is a need to clarify their role in back-related disability through rigorous prospective studies.

From the *Department of Psychology, Royal Holloway, University of London, London, UK, the †Spinal Research Unit, University of Huddersfield, Huddersfield, UK, the ‡British School of Osteopathy, London, UK, and the §School of Cognitive & Computer Science, University of Sussex, Sussex, UK.

Funded by a grant from BackCare, the National Organisation for Healthy Backs.

Acknowledgment date: June 23, 2000.

First revision date: October 10, 2000.

Acceptance date: January 8, 2001.

Address correspondence to

Dr. Tamar Pincus

Department of Psychology

Royal Holloway, Egham

United Kingdom


The manuscript submitted does not contain information about medical devices.

No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject or this manuscript.

© 2002 Lippincott Williams & Wilkins, Inc.