Introduction
Evidence & Methods
Somatization has long been felt to adversely impact outcomes in the setting of low back pain, as well as other musculoskeletal disorders. The role of somatization as an impediment to recovery from debilitating low back pain (and capacity to work) warrants further exploration. The authors performed an investigation of this effect, using data collected as part of a randomized prospective trial.
Perhaps not surprisingly, the authors maintain that the presence of multiple somatic symptoms was negatively correlated with return to work. Likewise, the duration of absence from work was significantly longer for those individuals with the highest levels of multiple somatic symptoms.
The results of this study reinforce concepts long maintained to be true regarding the impact of somatization on work-capacity and functional outcomes in the setting of spinal disorders. As a post-hoc analysis of data collected during a randomized clinical trial, it should be recognized that this study was not specifically designed to detect differences between patients with different levels of somatization. In addition, the fact that patients in this study were randomized to different treatments, irrespective of their somatization level, may have biased some of the results presented here. Finally, as with all studies conducted in a different ethno-cultural context, the findings of this study and its conclusions might not necessarily be generalizable to patients with back pain in the United States or elsewhere.
—The Editors
Patients with high levels of so-called medically unexplained somatic symptoms are frequent in both primary care and hospital outpatient populations [1], [2], [3], and persons with many of these symptoms are often not working [4]. The prevalence of severe somatic symptoms was 15% in a sick-listed population, and 15% to 30% of the patients with multiple symptoms did not recover or got worse during sick-listing [5]. Multiple somatic symptoms are commonly associated with illness worry (health anxiety) and poor functional status [6]. Common somatic symptoms include musculoskeletal pain, fatigue, dizziness, and noncardiac chest pain. It has been reported that multiple somatic symptoms are associated with disability independent of comorbidity and that health anxiety contributes to a longer duration of sickness absence (SA) [5]. In the literature, a high level of multiple somatic symptoms is also referred to as bodily distress [7], [8].
High levels of multiple somatic symptoms are diagnosed differently by different medical specialities; these syndromes (eg, chronic fatigue, irritable bowel, fibromyalgia) are very alike based on subjective complaints, and they are not well explained by traditional medical methods [7], [8]. Within rheumatology, “low back pain (LBP)” is often used as a diagnostic label for nonspecific symptoms. However, LBP is at times associated with specific anatomic and structural disease; therefore LBP may not be classified as medically unexplained. Still, structural changes can explain the pain in only a fraction of LBP patients [9].
Patients with LBP often do not return to work (RTW) and knowledge of factors associated with RTW failure should be identified to inform due interventions. Psychological distress has been documented as a risk factor for RTW [10], and an overlap between multiple somatic symptoms and psychological distress measured by the “General Health Questionnaire” has been documented [11].
The overall rate of RTW in our first study including sick-listed LBP patients with radiculopathy and specific and nonspecific disorders in the secondary health care system was 73.5% during the first year [12].
The primary aim of the present study was to explore whether multiple somatic symptoms at baseline in a subset of patients with nonspecific LBP was associated with SA, RTW, unemployment, or social benefits throughout the first 2 years after a sick-listing episode. Secondary aims were to investigate whether multiple somatic symptoms decreased after intervention and whether there were any differences between the intervention groups.