Puin, 22 (1985) 295-307 Elsevier 295 PA1 00752 Environmental Stressors and Chronic Low Back Pain: Life Events, Family and Work Environment Michael Feuerstein *, Susan Suit ** and Manon Houle *** * University of Rochester Medical Center, Rochester. NY 1464 2. ** Unioersitv of Florrdu. Cuinewille. FL 32610 (U.S.A.), and *** Uniuersrp of Western Ontarro, London, Ont; N6A 3K7 (Canudu) (Received 6 June 1984. accepted 16 January 1985) Summary Stressors in the family and job environments have been proposed to play a role in the modulation of pain, yet direct empirical support for such a role is limited. The present study investigated the relationship between general stress, family and work en~ronments (perceived social climate), psycho~o~cal distress (anxiety, depression), and pain experience (sensory, affective, evaluative) in 33 ambulatory chronic low back pain (CLBP) subjects and 35 healthy controls matched for age. sex, socioeco- nomic status (SES), weight, and height. Results indicated that environmental stres- sors/social climate measures, including family conflict, family control, and general stress (Social Readjustment Rating Scale), were greater in the CLBP group. Distress measures were also higher in the CLBP group. Characteristics of the family and work environments were found to be more predictive of the affective and evaluative dimensions of pain. Increased family conflict was associated with increased distress and increased pain, while increased family independence was correlated with less distress and increased pain. Less peer cohesion, less physical comfort, and less job clarity were correlated with increased pain, but not distress. Work pressure was associated with decreased depression and less pain. These findings suggested the presence of both stress and operant mechanisms in the modulation of pain in the family, while operant and distraction mechanisms appear to characterize the rela- tionship among work environment factors and pain. Address correspondence to: Dr. Michael Feuerstein, Division of Behavioral and Psychosocial Medi- cine, Department of Psychiatry, University of Rochester School of Medicine and Dentistry. 300 Crittenden Boulevard. Rochester, NY 14642, U.S.A. 0304-3959/S5/$03.30 0 1985 Elsevier Science Publishers B.V. (BiomedicaI Division)
Transcript
Puin, 22 (1985) 295-307
Elsevier
295
PA1 00752
Environmental Stressors and Chronic Low Back Pain: Life Events, Family and Work Environment
Michael Feuerstein *, Susan Suit ** and Manon Houle *** * University of Rochester Medical Center, Rochester. NY 1464 2. ** Unioersitv of Florrdu. Cuinewille.
FL 32610 (U.S.A.), and *** Uniuersrp of Western Ontarro, London, Ont; N6A 3K7 (Canudu)
(Received 6 June 1984. accepted 16 January 1985)
Summary
Stressors in the family and job environments have been proposed to play a role in the modulation of pain, yet direct empirical support for such a role is limited. The
present study investigated the relationship between general stress, family and work en~ronments (perceived social climate), psycho~o~cal distress (anxiety, depression),
and pain experience (sensory, affective, evaluative) in 33 ambulatory chronic low
back pain (CLBP) subjects and 35 healthy controls matched for age. sex, socioeco- nomic status (SES), weight, and height. Results indicated that environmental stres- sors/social climate measures, including family conflict, family control, and general
stress (Social Readjustment Rating Scale), were greater in the CLBP group. Distress measures were also higher in the CLBP group. Characteristics of the family and work environments were found to be more predictive of the affective and evaluative dimensions of pain. Increased family conflict was associated with increased distress and increased pain, while increased family independence was correlated with less distress and increased pain. Less peer cohesion, less physical comfort, and less job clarity were correlated with increased pain, but not distress. Work pressure was associated with decreased depression and less pain. These findings suggested the presence of both stress and operant mechanisms in the modulation of pain in the family, while operant and distraction mechanisms appear to characterize the rela- tionship among work environment factors and pain.
Address correspondence to: Dr. Michael Feuerstein, Division of Behavioral and Psychosocial Medi-
cine, Department of Psychiatry, University of Rochester School of Medicine and Dentistry. 300
Many biobehavioral factors are thought to contribute to the development, ex-
acerbation, and/or maintenance of chronic low back pain. Psychosocial stressors, such as familial and job-related stress, represent a frequently hypothesized factor. Social learning factors (e.g., familial modeling) have also been suggested to play a
role in chronic pain [9,33]. Clinicaliy, these variables are thought to lead to an increase in intensity or duration of pain or to a change in the quality of pain experienced. Clinical and experimental evidence suggests a relationship between
marital/familial maladjustment and chronic pain [35]. Specific characteristics of families of chronic pain patients, however, have rarely been delineated, nor have
these families been compared to an asymptomatic control group. Furthermore, few
studies have investigated the re~ations~p between ~~upational stress and chronic
pain. An epidemiological study of back pain (type and duration unspecified) indicated
a higher prevalence in those who have lost a spouse through death, divorce, or separation within the previous year than those who have not been exposed to such
stressors [26]. Klein et al. [14] studied the impact of chronic illness (duration greater than 6 months) upon the patient’s spouse. Patients who suffered chronic medical or psychosomatic illnesses and their spouses reported high role tension as measured by the Role Tension Index 17). Additionally, level of role tension correlated significantly with increased somatic symptomology in both marital partners. Kreitman et al. [16]
also investigated familial patterns of chronic ‘hypochondriacal’ patients, 50% of
whom had been ill for over 10 years. Most common sites of symptoms were the head, abdomen, and chest, with chronic pain a frequent complaint. Evaluation
indicated that this group had significantly more marital and sexual dysfunction than
a matched psychiatric control group. Merskey and Spear [Zl] also found that patients with chronic pain reported low marital satisfaction and poor sexual adjust-
ment, as suggested by a high frequency of secondary erectile and preorgasmic
dysfunction. The familial distress reported by pain patients may be related to somatic and
psychological disturbance in the spouse. For example, Shanfield et al. [30] have noted that spouses of chronic pain patients have a tendency toward high levels of psychological distress. Mohamed et al. [22] have found that the spouses of chronic pain patients are also likely to develop pain problems themselves, often in the same loci as their mates. General interactional styles of families of chronic pain patients have not been studied; however, Waring ]34] has suggested that these families often demonstrate an inability to express thoughts and feelings, characteristics often observed in distressed families of patients with classical psychosomatic disorders.
Despite the evidence supporting a relationship between familial/marital malad- justment and chronic pain, increased levels of pain have also been associated with marital satisfaction. Spouses of chronic pain patients (pain duration greater than 1 year and most frequent pain locus in the back, viscera or limbs) who reported a high level of marital satisfaction were observed to behave in a more solicitous manner than relatively unsatisfied spouses [2]. Block et al. 13) have also found that chronic
pain patients whose spouse was solicitous reported significantly higher levels of pain during an interview when observed by their spouse than when observed by a ward clerk. Additionally, the solicitous spouse group reported a significantly longer history of pain (15.5 years) than did the non-solicitous group (4.5 years). It can be hypothesized, therefore, that it is not marital satisfaction per se but rather specific
familial characteristics and/or behavioral responses of family members that may serve to maintain and/or exacerbate chronic pain.
The majority of research on occupation and back pain has involved the identifica-
tion of high risk groups [e.g.. 15,281. Few investigations have been directed at the relationship between pain onset or experience and specific aspects of the work environment. Nagi et al. 1261 found that back pain is associated with increased
vocational stress as indicated by frequent job changes. Kosiak et al. (151 observed
that back pain is most likely to occur during the first year on a job. a time often
associated with frequent adaptations. Svensson and Anderson 1321 recently studied the relationship of low back pain to work history and work environment factors.
Results indicated significant differences between men (40-47 years old) reporting low back pain and those without back pain. Back pain cases reported less overtime work, less concentration needed for work tasks, decreased possibility to influence
work situation with regard to methods and tempo, reduced work satisfaction, more (perceived) monotonous/boring work, more physically heavy work, more frequent
lifting, and less sedentary work. The factors most directly accounting for the occurrence of low back pain were less overtime work, more monotonous/boring
work, and a greater degree of lifting. The relationship between prevalence of back problems and occupation appears to be the result of a complex interaction between risk of injury, exposure to situations of physical and psychological stress. and
reaction to injury [8]. The role of specific work environment factors in the exacerba- tion of pain has not been delineated.
It has been proposed that a number of social/environmental factors, or measures
of ‘social climate’ [13], contribute to pain [8,9,20]. A variety of social climate
measures have been associated with physiological and behavioral changes [ 131 that
could influence an individual’s pain experience. In order to identify the various social/environmental factors in the family and on the job affecting clinical pain, measurements reflecting the multidimensional aspects of these environments are necessary.
The purpose of the present investigation was to further delineate the role of general stressors and perceived social environment (familial and vocational) in the modulation of chronic-episodic low back pain. Specifically, this study was designed to determine whether: (1) low back pain patients experience a different pattern of environmental stressors/social climate than matched healthy controls, (2) low back pain patients experience greater strain or psychological distress in contrast to controls, (3) the distress observed in the back pain subjects is associated with environmental stressor/social climate variables, and (4) aspects of the family and work environments associated with distress differentially contribute to the sensory, affective, and evaluative dimensions of the pain experience.
Method
Su@ecfs
Subjects included 33 ambulatory patients, 17 males and 16 females, diagnosed with chronic mechanical low back pain with or without objective physical findings as
determined by an orthopedic specialist, and 35 healthy controls. All subjects had medical evaluations within the previous 8 months. Selection criteria included: a pain
frequency of at least twice weekly for a minimum period of 6 months; no significant neurological involvement (e.g., sciatica) as determined by orthopedic examination;
no psychophysiological or chronic pain problem other than low back pain; no
significant psychopathology (psychosis, depression}; no worker compensation claim
or ongoing pension; no use of antidepre~ant or anxiolytic medication. Table 1
describes the clinical sample in detail. As Table I indicates, the patient sample does not represent a severely ill group of back pain patients. Pain frequency, duration,
and severity data indicate that the group experiences approximately 5 pain epi- sodes/week of a duration of 4.8 h/episode with an intensity representing a mod- erate level of pain on a lo-point visual analogue scale. These patients also report an 8.4 year mean history of back pain with considerable variability on this measure. Thus, the patient recruited was not the type of patient who would be diagnosed with chronic low back pain syndrome but rather the individual with recurrent prob- lematic episodes of low back pain. It was the intention of this study to investigate the role of stress in this latter group of patients and not the chronic pain syndrome
patient.
TABLE I
PATIENT CHARACTERISTICS
Duration of problem (years)
Onset
Accident (work, home)
Injury
No obvious precipitant
Frequency/week (days)
Duration (h)/episode (maximum 24 h)
Mean intensity
Visual Analogue Scale (l-10)
8.4 (f6.5)
35.7%
7.2%
57.1%
5.4 (k2.2) 4.8 ( + 2.0)
4.4
Mean number of health professiona& consulted for pain
Education (years)
Income a
~5ooo
5-10,000
IO-20,ooo
20- 50,cGO
150,ow
3.8
16.2
3.7%
7.4%
14.8% 48.2%
25.9%
(zk2.3) (zk1.8) (f4.6)
Note: Based on N = 33.
’ Canadian dottars.
299
The 35 healthy controls were matched for age ( + 5 years), height-to-weight ratio,
and sex and socioeconomic status (SES). SES was obtained through a structured interview and matching was based upon income, residence in the same neighbor- hood, equivalent education ( f 2 years), similar lifestyle, leisure activities and cultural (French/English) background. Subjects were mainly Caucasian, middle class Canadians. No significant differences in sex ratio, height-to-weight ratio, income or
education were observed between the two groups. All subjects were recruited from announcements in the Montreal media. Subjects provided full consent to participate in the research *.
Psychometric instruments
Environmental stressors/social climate
Social Readjustment Rating Scale (SRRS). The SSRS measures a cluster of social events requiring change in ongoing life adjustment [12]. The value used in the
present investigation was based upon the product of frequency and relative magni- tude of the life event as reported in Holmes and Rahe fl2]. This scale identifies
changes in family constellation, marriage, occupation, economics, residence. group and peer relations, education, religion. recreation and health. The SRRS provides a general index of life stress.
Family Environment Scale (FES). Form R of the FES was administered to measure the social-environmental characteristics of the family. The FES is comprised of 10 subscales (90 items) which are designed to measure 3 domains or dimensions of
the family: relationship, personal growth, and system maintenance. The relationship dimension is measured by the cohesion, expressiveness, and conflict subscales. The personal growth dimension is measured by the independence, achievement orienta-
tion, intellectual/cultural orientation, active-recreational orientation, and moral-reli- gious subscales. System maintenance dimension is measured by the organization and control subscales. Large normative data have been collected on the scale and
psychometric properties, including internal consistencies for each of the 10 subscales and test-retest reliabilities are all within generally acceptable ranges 1241. The FES was used in the present study to identify specific characteristics within the family
and to relate these to sensory, affective, and evaluative dimensions of pain. Work Environment Scale (WES). Form R of the WES was administered to
measure the social environment of the work setting. The WES consists of 10 subscales (90 items) designed to measure 3 conceptual domains or dimensions of the work environment: relationship, personal growth, and system maintenance and change. The relationship dimension is measured by the involvement, peer cohesion, and supervisor support subscales. The personal growth or goal orientation dimension is assessed by autonomy, task o~entation and work pressure subscales, while the system maintenance and change dimension is measured by the clarity, control. innovation and physical comfort subscales. The scale has been evaluated on a large
* This research was conducted in the Department of Psychiatry, Allan Memorial Institute, and Depart-
ment of Psychology at McGill University.
normative sample and psychometric properties including internal consistency and test-retest reliabilities are all within acceptable limits [23]. The WES was used in the present study to identify specific characteristics within the occupational environment and then to relate these to the pain experience.
Measures of subjective distress are necessary in order to identify whether the social climate measures and environmental stressors are associated with pain via a stressor-distress-pain (stress mechanism) link. Given reports indicating a relationship between negative moods [29] such as anxiety [ll] and depression [4] and chronic low back pain, measures of anxiety and depression were obtained. The measures recorded were designed to evaluate trait or more stable levels of anxiety and depression given the similar focus on measu~ng characteristic, rather than transient, aspects of social environments.
Spielberger State-Trait Anxie<y Inventory (STAZ). The STAI-Trait (STAI-T) Form consists of 20 items designed to measure chronic levels of anxiety [31].
Beck Depression Znuentory (BDZ). The BDI is comprised of 21 items that measure cognitive and endogenous manifestations of depression [l]. Although subjects are requested to describe their ‘current state,’ the scale has relatively high levels of test-retest reliability with reports of r = 0.74 after 3 months [27].
Pain experience McGiN Pain Questionnaire (MPQ). The MPQ consists of 3 major classes of
descriptors - sensory, affective, and evaluative - used to describe a patient’s pain experience [19]. The subscale scores measuring sensory (PRIS), affective (PRIA), and evaluative (PRIE) dimensions of pain, in addition to the pain rating index total (PRIT) which represents the sum of all ratings, were used in the present study as the measure of pain.
Procedure
All subjects completed the Family Environment Scale, Work Environment Scale, and the Social Readjustment Rating Scale. Low back pain subjects were also asked to complete the McGill Pain Questionnaire (MPQ) during a representative pain episode. Prior to completing the questionnaires, each subject signed a consent form that clearly outlined the purpose of the study, and at its completion, subjects were paid for their participation.
Results
Multivariate Hotelling T* tests indicated that low back pain patients experienced si~fic~tly higher levels of general life and family stressors as measured by the SRRS and FES (T2 = 67.95, df = 21, P c 0.05), and silently greater psycho- logical distress as measured by the STAI-T and BDI ( T2 = 12.50, df = 58, P < O.Ol),
301
than control subjects. As shown in Table II, univariate f tests indicated that back
pain subjects had higher scores on the Social Readjustment Rating Scale (t = 2.10, df= 52, P < 0.05), the conflict subscale of the FES (1= 2.42, df= 65, P <: 0.05), the control subscale of the Family Environment Scale (t = 2.69, df= 63, P < O.Ol), the BDI (t = 2.16, df= 53, P < 0.05) and the STAI-T (t = 3.73, df= 65, P < 0.001). Low back pain patients scored lower on the active-recreational subscale of the FES (r = 2.72, df = 64, P < 0.01).
Pearson product-moment correlations were performed among 3 McGill Pain Questionnaire scores (sensory, affective, evaluative), the Social Readjustment Rating
Scale, and subscales of the Family and Work Environment Scales. As can be seen in Table III, significant correlations were obtained among McGill Pain Questionnaire subscale scores, 5 subscales of the Family Environment Scale (conflict. control.
TABLE II
ENVIRONMENTAL STRESSOR/SOCIAL CLIMATE VARIABLES IN CHRONIC LOW BACK
Nore: OveraII Multivariate Hotelling T2 = 67.95, F (21, 29) = 1.93, P i 0.05.
* 0.05. <
** 0.01. i
organization, achievement, and independence), and 5 subscales of the Work En- vironment Scale (peer cohesion, physical comfort, work pressure, clarity, and in- volvement).
In order to determine the relative contribution of these social climate variables in the modulation of the pain experience, stepwise multiple regression analyses were conducted. Analyses were run separately on the sensory, affective, and evaluative MPQ scores. Table IV summarizes the findings from each of the analyses. Less peer cohesion, less physical comfort on the job, and higher family conflict were predictive of higher affective pain ratings ( R2 = 0.48, P < 0.01). Decreased job clarity and
increased family organization were predictive of increased evaluative pain scores ( R2 = 0.44, P -c 0.01). Increased family independence and decreased peer cohesion
TABLE III
CORRELATIONS AMONG ENVIRONMENTAL STRESSOR/SOCIAL CLIMATE DIMENSIONS
SRRS = Social Readjustment Rating Scale; PRIS = Pain Rating Index Sensory; PRIA = Pain Rating
Index Affective; PRIE = Pain Rating Index Evaluative.
303
TABLE IV
STEPWISE MULTIPLE REGRESSION PREDICTING AFFECTIVE, EVALUATIVE. AND
SENSORY PAIN
R2 F P
McGill Pain Quesrionnaire - Affeciive
WES - Peer cohesion 0.238 5.92 0.05
WES - Physical comfort 0.357 4.99 0.05
FES - Conflict 0.476 5.14 0.01
McGill Pain Questionnaire - Evaluative
WES - Job clarity 0.365 10.94 0.01
FES - Organization 0.439 7.05 0.01
McGill Pain Ques~~onnuire - Sensory
FES - Independence 0.123 2.68 0.12
W ES - Peer cohesion 0.309 4.02 0.05
at work were found to be predictive of sensory pain ratings (R* = 0.31, P < 0.05). The mediating role of psychological distress in the exacerbation of pain via
previously identified stressor/social climate variables was identified using Pearson product-moment correlations; these were computed among the BDI, STAl-T, FES subscales (conflict, control, organization, achievement, and independence), and WES subscales (peer cohesion, physical comfort, work pressure, clarity, and involvement).
TABLE V
CORRELATIONS AMONG ENVIRONMENTAL STRESSOR,‘SOCIAL CLIMATE VARIABLES
AND PSYCHOLOGICAL DISTRESS IN LOW BACK PAIN CASES AND CONTROLS
Environmental stressor/
social climate
Chronic low back pain Asymptomatic controls
Anxiety Depression Anxiety Depression
Family d
FES Conflict
FES Control
FES Organization
FES Achievement
FES Independence
Work h
W ES Peer cohesion
WES Physical comfort
WES Work pressure
WES Involvement
0.33 *
0.24
-0.47 **
-0.17
- 0.40 *
-0.34 -0.24
0.19 -0.12
-0.25 - 0.45 *
- 0.27 - 0.26
0.38 + 0.18
- 0.48 **
-0.18
- 0.37 *
0.16
0.05
- 0.20
-0.18
-0.51 **
0.32 - 0.33
0.12
- 0.01
- 0.08
0.03
- 0.05
0.13
- 0.24
0.33
-0.30
0.03
- 0.01
* P<O.O5: ** P <O.Ol.
FES = Family Environment Scale; WES = Work Environment Scale.
* N = 33 (low back pain); N = 35 (controls). h N = 24 (low back pain); N = 23 (controls).
As can be seen in Table V, social climate/environmental stressors reported in the pain group were more frequently associated with psychological distress as compared to controls. Seven corrrelations were significant in the back pain group in contrast to one in the control group. Additionally, certain dimensions in the family and job found to predict pain were associated with an increase in psychological distress while others were correlated in an inverse direction. Specifically, increased family conflict was associated with increased anxiety and depression. Increased family organization and independence were associated with lower levels of anxiety and depression, and increased work pressure was correlated with less depression.
Discussion
The present results, as reflected by the Social Readjustment Rating Scale, indicate that the low back pain group experienced a greater degree of environmental stress over the previous year than matched healthy controls. In addition, greater family conflict and control were observed in the pain group in contrast to controls. The index of family conflict reflects the degree of openly expressed anger, aggression, and conflict among family members. The family control subscafe reflects the extent to which set rules and procedures are used to manage family life. in addition to the increased level of stressors, the pain group also reported higher levels of anxiety and depression, indi not support the $
ting a greater degree of overall distress. However, this pattern does xistence of a simple relationship between stressors, perceived social
climate, subjective distress and pain. While several stressor/social environment measures observed to differ between groups were significantly correlated with dimensions of the pain experience, additional variables (WES - peer cohesion, physical comfort, job clarity; FES - organization, independence) not found to differentiate the groups were also associated with pain. Finally, the ERRS, a measure that differed between groups, was not predictive of pain.
it is often hypothesized that increases in general stress are associated with an exacerbation of pain. The SRRS measure used in the present study does not support such an assumption. In fact, the absence of such a stressor-pain relationship may have been the result of its global nature. The present findings suggest that measures of specific aspects of the family and work environment are more predictive of pain than a general stress index. These findings suggest the importance of measuring specific components of the family and work en~ronments to better determine the relationship between environmental factors and pain. It is also of interest that Leavitt et al. [17], using a similar global measure of stress, did not observe differences between low back cases with and without pathophysiological involve- ment.
A model relating environmental stressors to pain requires empirical evidence that the stressors are associated with increased distress in addition to contributing to the exacerbation of pain. The present results indicate that increased family conflict is correlated with increased anxiety and depression. Greater family organization and family independence are associated with less anxiety and depression.
305
Specific indices of environmental stressors, as measured by the family and work environment scales, were predictive of affective, evaluative, and sensory aspects of pain. Measures of the family and work environments were more predictive of the
affective and evaluative dimensions of pain than the sensory dimension. These findings are consistent with the gate control model’s conceptualization that social environmental factors tend to contribute to affective and evaluative dimensions of
pain to a greater extent than the sensory, which is primarily influenced by sensory input [20]. Family conflict was predictive of pain via increased distress, as would be suggested by a stress-distress-pain model [9,10]. Increased family conflict was associated with increased psychological distress and increased pain. Environmental variables not associated with distress, yet predictive of pain, suggest the presence of
other biobehavioral mechanisms (e.g., operant). The pattern of findings suggests that mechanisms exacerbating pain differ be-
tween the family and work environments. Both stressor/respondent and operant factors appear to exist within the family environment, while operant mechanisms
and distraction appear to be present in the work environment. Specifically, increased
conflict in the family was associated with increased distress and increased pain (i.e., stress mechanisms). Exacerbation of pain in this type of family situation may occur
through an increased physiological stress response [5,6]. In contrast, increased family independence and organization were associated with lower distress and increased pain, suggesting an operant mechanism whereby pain is associated with decreased psychological distress.
Families that score higher on the independence subscale tend to be assertive and self-sufficient and to make decisions that do not involve other family members. Similarly, families high in organization tend to be dependent on familial structure for planning activities and responsibilities. In such environments, pain patients may receive little support and attention, which necessitates pain behavior as a strategy to obtain such support. If the outcome of such behavior is successful in achieving this
goal, it appears reasonable that such social climate variables would be associated with increased pain and decreased psychological distress.
In regard to the work environment, lower peer cohesion, physical comfort, and job clarity were associated with increased pain while increased work pressure was related to lower levels of pain and less depression. It is presently unclear why the
various work environment measures were not related to distress although the absence of such a relationship suggests that distress itself may not directly contribute
to pain as with factors in the family and that operant factors may be present. The
work pressure-less depression-less pain relationship may represent a distraction phenomenon where increased work demands provide a diversion from distress and pain. These mechanisms require empirical validation. The work environment find- ings are consistent with the observations of Svensson and Anderson [32]. The job-related factors in the present study that were associated with increased pain (i.e., low peer cohesion, low physical comfort, and low job clarity) could contribute to reduced job satisfaction and the perception of little influence over work; characteris- tics of the work environment reported by workers with low back pain [32]. Consider- ing the importance of return to work in rehabilitation efforts [25] and the apparent
30h
role of the work environment in the experience of pain, further research on psychosocial work factors and pain appears warranted.
Given the present design. it is unclear as to whether the observed social climate was present prior to the pain disorder. or whether elevated scores are concomitant with or secondary to the pain. The direct causal significance of family conflict and control on pain is also unclear, although the present findings support the role of family conflict in the modulation of pain. Waring et al. [35] have suggested that marital maladjustment exists prior to the onset of the chronic pain syndrome, and that the sick role provides stability to a previously unstable relationship. The results
of Klein et al. [14] contradict this explanation. They found both the patient and spouse independently reported an increase in symptomology and interpersonal tension from pre-illness levels. Longitudinal research measuring family dimensions
of stress prior to the onset of recurrent or chronic low back pain would provide the necessary data for determining the specific etiological role of enviranmental stres-
sors/family climate on low back pain. The present study, however, was directed at identifying the modulating role of environmental stressors/social climate in patients
with a pre-existing pain disorder. While the present findings suggest that specific characteristics of the family and
work environments are associated with pain via different mechanisms, these results require replication. Additionally, given the correlational nature of these data. further experimental investigations of observed interactional patterns within the family and characteristics of the job environments in chronic low back pain cases would provide
more direct support for the existence of stress, operant and distraction mechanisms. These findings do suggest that clinicians might find a more detailed assessment of family and work environments helpful in management efforts directed at this
difficult population.
This research was supported by Grant No. 6605-1716-42, National Health Research and Development Program, Health and Welfare Canada to M. Feuerstein.
Portions of this research were presented at the 5th Annual Meeting of the Society of
Behavioral Medicine, Philadelphia, PA, May 1984. The authors wish to express their appreciation to F.W. Fish, M.D., Royal Victoria
Hospital, Montreal, Que., Canada, for assistance in screening patients.
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Presented at the 2nd World Congress of the International Association for the Study of Pain. Montreal.
