Review article (meta-analysis)| Volume 97, ISSUE 9, P1573-1587, September 2016

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Psychological Distress in Acute Low Back Pain: A Review of Measurement Scales and Levels of Distress Reported in the First 2 Months After Pain Onset

Published:February 24, 2016DOI:



      To characterize the measurement scales and levels of psychological distress reported among published studies of acute low back pain (LBP) in the scientific literature.

      Data Sources

      Peer-reviewed scientific literature found in 8 citation index search engines (CINAHL, Embase, MANTIS, PsycINFO, PubMed, Web of Science, AMED, and Academic Search Premier) for the period from January 1, 1966, to April 30, 2015, in English, Danish, Norwegian, and Swedish languages.

      Study Selection

      Cross-sectional, case-control, cohort, or randomized controlled trials assessing psychological distress and including participants drawn from patients and workers (or an identifiable subset) with acute LBP (<8wk). Three researchers independently screened titles, abstracts, and full-length articles to identify peer-reviewed studies according to established eligibility criteria.

      Data Extraction

      Descriptive data (study populations, definitions of LBP, distress measures) were systematically extracted and reviewed for risk of bias. Distress measures were described, and data were pooled in cases of identical measures. Reported levels of distress were contextualized using available population norms, clinical comparison groups, and established clinical cutoff scores.

      Data Synthesis

      Of 10,876 unique records, 23 articles (17 studies) were included. The most common measures were the Beck Depression Inventory, the modified version of the Zung Self-Rated Depression Scale, the Center for Epidemiologic Studies-Depression Scale, and the Medical Outcomes Study 12-Item Short-Form Health Survey and Medical Outcomes Study 36-Item Short-Form Health Survey. Pooled results for these scales showed consistent elevations in depression, but not anxiety, and reduced mental health status in comparison with the general population.


      Based on the high consistency across studies using valid measures with a low to moderate risk of bias, there is strong evidence that psychological distress is elevated in acute LBP.


      List of abbreviations:

      BDI (Beck Depression Inventory), CES-D (Center for Epidemiologic Studies-Depression), CI (confidence interval), LBP (low back pain), SF-12 (Medical Outcomes Study 12-Item Short-Form Health Survey), SF-36 (Medical Outcomes Study 36-Item Short-Form Health Survey), ZSRDS (Zung Self-Rating Depression Scale)
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        • Linton S.J.
        A review of psychological risk factors in back and neck pain.
        Spine (Phila Pa 1976). 2000; 25: 1148-1156
        • Burton A.K.
        • Tillotson K.M.
        • Main C.J.
        • Hollis S.
        Psychosocial predictors of outcome in acute and subchronic low back trouble.
        Spine (Phila Pa 1976). 1995; 20: 722-728
        • Pincus T.
        • Burton A.K.
        • Vogel S.
        • Field A.P.
        A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
        Spine (Phila Pa 1976). 2002; 27: E109-E120
        • da C Menezes Costa L.
        • Maher C.G.
        • Hancock M.J.
        • McAuley J.H.
        • Herbert R.D.
        • Costa L.O.
        The prognosis of acute and persistent low-back pain: a meta-analysis.
        CMAJ. 2012; 184: E613-E624
        • Heuch I.
        • Foss I.S.
        Acute low back usually resolves quickly but persistent low back pain often persists.
        J Physiother. 2013; 59: 127
        • Vroman K.
        • Warner R.
        • Chamberlain K.
        Now let me tell you in my own words: narratives of acute and chronic low back pain.
        Disabil Rehabil. 2009; 31: 976-987
        • Itz C.J.
        • Geurts J.W.
        • van Kleef M.
        • Nelemans P.
        Clinical course of non-specific low back pain: a systematic review of prospective cohort studies set in primary care.
        Eur J Pain. 2013; 17: 5-15
        • Suri P.
        • Rainville J.
        • Fitzmaurice G.M.
        • et al.
        Acute low back pain is marked by variability: an internet-based pilot study.
        BMC Musculoskelet Disord. 2011; 12: 220
        • Chou R.
        • Shekelle P.
        Will this patient develop persistent disabling low back pain?.
        JAMA. 2010; 303: 1295-1302
        • Pillastrini P.
        • Gardenghi I.
        • Bonetti F.
        • et al.
        An updated overview of clinical guidelines for chronic low back pain management in primary care.
        Joint Bone Spine. 2012; 79: 176-185
        • Moore J.E.
        Chronic low back pain and psychosocial issues.
        Phys Med Rehabil Clin N Am. 2010; 21: 801-815
        • Linton S.J.
        • Nicholas M.K.
        • MacDonald S.
        • et al.
        The role of depression and catastrophizing in musculoskeletal pain.
        Eur J Pain. 2011; 15: 416-422
        • Bair M.J.
        • Robinson R.L.
        • Katon W.
        • Kroenke K.
        Depression and pain comorbidity: a literature review.
        Arch Intern Med. 2003; 163: 2433-2445
        • van Tulder M.
        • Becker A.
        • Bekkering T.
        • et al.
        Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care.
        Eur Spine J. 2006; 15: S169-S191
      1. Institute for Clinical Systems Improvement. Low back pain, adult acute and subacute. Available at: Accessed March 14, 2016.

        • Chou R.
        • Qaseem A.
        • Snow V.
        • et al.
        Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491
        • Sterne J.
        • Gavaghan D.
        • Egger M.
        Publication and related bias in meta-analysis: power of statistical tests and prevalence in literature.
        J Clin Epidemiol. 2000; 53: 1119-1129
        • Mirowsky J.
        • Ross C.E.
        Social causes of psychological distress.
        2nd ed. Aldeine Transaction, New York2003
        • Philips H.
        • Grant L.
        Acute back pain: a psychological analysis.
        Behav Res Ther. 1991; 29: 429-434
        • Gatchel R.J.
        • Polatin P.B.
        • Mayer T.G.
        The dominant role of psychosocial risk factors in the development of chronic low back pain disability.
        Spine (Phila Pa 1976). 1995; 20: 2702-2709
        • Fritz J.M.
        • George S.Z.
        Identifying psychosocial variables in patients with acute work-related low back pain: the importance of fear-avoidance beliefs.
        Phys Ther. 2002; 82: 973-983
        • Coste J.
        • Lefrancois G.
        • Guillemin F.
        • Pouchot J.
        Prognosis and quality of life in patients with acute low back pain: insights from a comprehensive inception cohort study.
        Arthritis Rheum. 2004; 51: 168-176
        • Wand B.M.
        • Bird C.
        • McAuley J.H.
        • Dore C.J.
        • MacDowell M.
        • De Souza L.H.
        Early intervention for the management of acute low back pain: a single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise.
        Spine (Phila Pa 1976). 2004; 29: 2350-2356
        • Grotle M.
        • Vøllestad N.K.
        • Veierød M.B.
        • Brox J.I.
        Fear-avoidance beliefs and distress in relation to disability in acute and chronic low back pain.
        Pain. 2004; 112: 343-352
        • Grotle M.
        • Brox J.I.
        • Veierod M.B.
        • Glomsrod B.
        • Lonn J.H.
        • Vollestad N.K.
        Clinical course and prognostic factors in acute low back pain: patients consulting primary care for the first time.
        Spine (Phila Pa 1976). 2005; 30: 976-982
        • Hay E.M.
        • Mullis R.
        • Lewis M.
        • et al.
        Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice.
        Lancet. 2005; 365: 2024-2030
        • van der Windt D.A.
        • Kuijpers T.
        • Jellema P.
        • van der Heijden G.J.
        • Bouter L.M.
        Do psychological factors predict outcome in both low-back pain and shoulder pain?.
        Ann Rheum Dis. 2007; 66: 313
        • Newell D.
        • Field J.
        Who will get better? Predicting clinical outcomes in a chiropractic practice.
        Clinical Chiropractic. 2007; 10: 179-186
        • Shaw W.S.
        • Pransky G.
        • Patterson W.
        • Linton S.J.
        • Winters T.
        Patient clusters in acute, work-related back pain based on patterns of disability risk factors.
        J Occup Environ Med. 2007; 49: 185-193
        • Shaw W.S.
        • Pransky G.
        • Winters T.
        The Back Disability Risk Questionnaire for work-related, acute back pain: prediction of unresolved problems at 3-month follow-up.
        J Occup Environ Med. 2009; 51: 185-194
        • Gurcay E.
        • Bal A.
        • Eksioglu E.
        • Esen Hasturk A.
        • Gurhan Gurcay A.
        • Cakci A.
        Acute low back pain: clinical course and prognostic factors.
        Disabil Rehabil. 2009; 31: 840-845
        • Hiebert R.
        • Campello M.A.
        • Weiser S.
        • Ziemke G.W.
        • Fox B.A.
        • Nordin M.
        Predictors of short-term work-related disability among active duty US Navy personnel: a cohort study in patients with acute and subacute low back pain.
        Spine J. 2012; 12: 806-816
        • Melloh M.
        • Elfering A.
        • Salathe C.R.
        • et al.
        Predictors of sickness absence in patients with a new episode of low back pain in primary care.
        Ind Health. 2012; 50: 288-298
        • Reme S.
        • Shaw W.
        • Steenstra I.
        • Woiszwillo M.
        • Pransky G.
        • Linton S.
        Distressed, immobilized, or lacking employer support? A sub-classification of acute work-related low back pain.
        J Occup Rehabil. 2012; 22: 541-552
        • Shaw W.S.
        • Reme S.E.
        • Pransky G.
        • Woiszwillo M.J.
        • Steenstra I.A.
        • Linton S.J.
        The pain recovery inventory of concerns and expectations: a psychosocial screening instrument to identify intervention needs among patients at elevated risk of back disability.
        J Occup Environ Med. 2013; 55: 885-894
        • Carstens J.K.
        • Shaw W.S.
        • Boersma K.
        • Reme S.E.
        • Pransky G.
        • Linton S.J.
        When the wind goes out of the sail - declining recovery expectations in the first weeks of back pain.
        Eur J Pain. 2014; 18: 269-278
        • Elfering A.
        • Käser A.
        • Melloh M.
        Relationship between depressive symptoms and acute low back pain at first medical consultation, three and six weeks of primary care.
        Psychol Health Med. 2014; 19: 235-246
        • Melloh M.
        • Elfering A.
        • Stanton T.R.
        • et al.
        Low back pain risk factors associated with persistence, recurrence and delayed presentation.
        J Back Musculoskel Rehabil. 2014; 27: 281-289
        • Leresche L.
        • Turner J.A.
        • Saunders K.
        • Shortreed S.M.
        • Von Korff M.
        Psychophysical tests as predictors of back pain chronicity in primary care.
        J Pain. 2013; 14: 1663-1670
        • Hirsch O.
        • Strauch K.
        • Held H.
        • et al.
        Low back pain patient subgroups in primary care: pain characteristics, psychosocial determinants, and health care utilization.
        Clin J Pain. 2014; 30: 1023-1032
        • Slepian P.
        • Bernier E.
        • Scott W.
        • Niederstrasser N.G.
        • Wideman T.
        • Sullivan M.
        Changes in pain catastrophizing following physical therapy for musculoskeletal injury: the influence of depressive and post-traumatic stress symptoms.
        J Occup Rehabil. 2014; 24: 22-31
        • Beck A.T.
        • Ward C.H.
        • Mendelson M.
        • Mock J.
        • Erbaugh J.
        An inventory for measuring depression.
        Arch Gen Psychiatry. 1961; 4: 561-571
        • Beck A.T.
        • Steer R.A.
        • Garbin M.G.
        Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation.
        Clin Psychol Rev. 1988; 8: 77-100
        • Thombs B.D.
        • Magyar-Russell G.
        • Bass E.B.
        • et al.
        Performance characteristics of depression screening instruments in survivors of acute myocardial infarction: review of the evidence.
        Psychosmatics. 2007; 48: 185-194
        • Zung W.W.
        A self-rating depression scale.
        Arch Gen Psychiatry. 1965; 12: 63-70
        • Main C.J.
        • Wood P.L.
        • Hollis S.
        • Spanswick C.C.
        • Waddell G.
        The Distress and Risk Assessment Method: a simple patient classification to identify distress and evaluate the risk of poor outcome.
        Spine (Phila Pa 1976). 1992; 17: 42-52
        • Radloff L.S.
        The CES-D Scale: a self-report depression scale for research in the general population.
        Appl Psych Meas. 1977; 1: 385-401
        • Ware J.
        • Kosinski M.
        • Bjorner J.
        • Turner-Bowker D.
        • Gandek B.
        • Maruish M.
        User's manual for the SF-36v2 Health Survey.
        2nd ed. QualityMetric, Lincoln2007
        • Ware J.E.
        • Kosinski M.
        • Keller S.D.
        A 12-item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity.
        Med Care. 1996; 34: 220-233
        • McHorney C.A.
        • Ware Jr., J.E.
        • Raczek A.E.
        The MOS 36-item Short-Form Health Survey (SF-36): II. Pyschometric and clinical tests of validity in measuring physical and mental health constructs.
        Med Care. 1993; 31: 247-263
        • Nielsen A.C.
        • Williams T.A.
        Depression in ambulatory medical patients.
        Arch Gen Psychiatry. 1980; 37: 999-1004
        • Triffaux J.M.
        • Wauthy J.
        • Albert A.
        • et al.
        Psychological distress of surgical patients after orthotopic heart transplantation.
        Transplant Int. 2001; 14: 391-395
        • Wilder Schaaf K.P.
        • Artman L.K.
        • Peberdy M.A.
        • et al.
        Anxiety, depression, and PTSD following cardiac arrest: a systematic review of the literature.
        Resuscitation. 2013; 84: 873-877
        • Thombs B.D.
        • Taillefer S.S.
        • Hudson M.
        • Baron M.
        Depression in patients with systemic sclerosis: a systematic review of the evidence.
        Arthritis Rheum. 2007; 57: 1089-1097
        • Anderson R.J.
        • Clouse R.E.
        • Freedland K.E.
        • Lustman P.J.
        The prevalence of comorbid depression in adults with diabetes: a meta-analysis.
        Diabetes Care. 2001; 24: 1069-1078
        • Daubs M.D.
        • Norvell D.C.
        • McGuire R.
        • et al.
        Fusion versus nonoperative care for chronic low back pain: do psychological factors affect outcomes?.
        Spine (Phila Pa 1976). 2011; 36: S96-S109
        • Misterska E.
        • Jankowski R.
        • Gtowacki M.
        Chronic pain coping styles in patients with herniated lumbar discs and coexisting spondylotic changes treated surgically: considering clinical pain characteristics, degenerative changes, disability, mood disturbances, and beliefs about pain control.
        Med Sci Monit. 2013; 19: 1211-1220
        • Ojala T.
        • Piirainen A.
        • Suutama T.
        • Hakkinen A.
        Reliability and validity study of the Finnish version of the Chronic Pain Acceptance Questionnaire (CPAQ).
        Disabil Rehabil. 2013; 35: 306-314
        • Hobby J.L.
        • Lutchman L.N.
        • Powell J.M.
        • Sharp D.J.
        The Distress and Risk Assessment Method (DRAM): failure to predict the outcome of lumbar discectomy.
        J Bone Joint Surg Br. 2001; 83: 19-21
        • Lundberg M.
        • Frennered K.
        • Hagg O.
        • Styf J.
        The impact of fear-avoidance model variables on disability in patients with specific or nonspecific chronic low back pain.
        Spine (Phila Pa 1976). 2011; 36: 1547-1553
        • Carleton R.N.
        • Thibodeau M.A.
        • Teale M.J.
        • et al.
        The center for epidemiological studies depression scale: a review with a theoretical and empirical examination of item content and factor structure.
        PLoS One. 2013; 8: e58067
        • Farmer M.E.
        • Locke B.Z.
        • Moscicki E.K.
        • Dannenberg A.L.
        • Larson D.B.
        • Radloff L.S.
        Physical activity and depressive symptoms: the NHANES I epidemiologic follow-up study.
        Am J Epidemiol. 1988; 128: 1340-1351
        • Seeher K.
        • Low L.F.
        • Reppermund S.
        • Brodaty H.
        Predictors and outcomes for caregivers of people with mild cognitive impairment: a systematic literature review.
        Alzheimers Dement. 2013; 9: 346-355
        • Fann J.R.
        • Thomas-Rich A.M.
        • Katon W.J.
        • et al.
        Major depression after breast cancer: a review of epidemiology and treatment.
        Gen Hosp Psychiat. 2008; 30: 112-126
        • Wang H.
        • Ahrens C.
        • Rief W.
        • Gantz S.
        • Schiltenwolf M.
        • Richter W.
        Influence of depression symptoms on serum tumor necrosis factor-alpha of patients with chronic low back pain.
        Arthritis Res Ther. 2010; 12: R186
        • Di lorio A.
        • Abate M.
        • Guralnik J.M.
        • et al.
        From chronic low back pain to disability, a multifactorial mediated pathway: The InCHIANTI study.
        Spine (Phila Pa 1976). 2007; 32: E809-E815
        • Parker S.L.
        • Godil S.S.
        • Shau D.N.
        • Mendenhall S.K.
        • McGirt M.J.
        Assessment of the minimum clinically important difference in pain, disability, and quality of life after anterior cervical discectomy and fusion: clinical article.
        J Neurosurg Spine. 2013; 18: 154-160
        • Hopman W.M.
        • Harrison M.B.
        • Friedberg E.
        • Buchanan M.
        • Vandenkerkhof E.G.
        Associations between chronic disease, age and physical and mental health status.
        Chronic Dis Can. 2009; 29: 108-116
        • Adogwa O.
        • Parker S.L.
        • Shau D.N.
        • et al.
        Preoperative Zung depression scale predicts patient satisfaction independent of the extent of improvement after revision lumbar surgery.
        Spine J. 2013; 13: 501-506
        • Iolascon G.
        • Gimigliano F.
        • Malavolta N.
        • et al.
        Effectiveness of teriparatide treatment on back pain-related functional limitations in individuals affected by severe osteoporisis: a prospective pilot study.
        Clin Cases Miner Bone Metab. 2012; 9: 161-165
        • Hoffman D.L.
        • Dukes E.M.
        The health status burden of people with fibromyalgia: a review of studies that assessed health status with the SF-36 or the SF-12.
        Int J Clin Pract. 2007; 62: 115-126
        • Schlenk E.A.
        • Erlen J.A.
        • Denbar-Jacob J.
        • et al.
        Health-related quality of life in chronic disorders: a comparison across studies using the MOS SF-36.
        Qual Life Res. 1998; 7: 57-65
        • Tavafian S.S.
        • Jamshidi A.
        • Mohammad K.
        • Montazeri A.
        Low back pain education and short term qualify of life: a randomized trial.
        BMC Musculoskelet Disord. 2007; 8: 21
        • Licciardone J.C.
        • Gatchel R.J.
        • Kearns C.M.
        • Minotti D.E.
        Depression, somatization, and somatic dysfunction in patients with nonspecific chronic low back pain: results from the OSTEOPATHIC trial.
        J Am Osteopath Assoc. 2012; 112: 783-791
        • van Wijk R.M.
        • Geurts J.W.
        • Lousberg R.
        • et al.
        Psychological predictors of substantial pain reduction after minimally invasive radiofrequency and injection treatments for chronic low back pain.
        Pain Med. 2008; 9: 212-221
        • Nicholas M.K.
        • Linton S.J.
        • Watson P.J.
        • Main C.J.
        • “Decade of the Flags” Working Group
        Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal.
        Phys Ther. 2011; 91: 737-753
        • Cifuentes M.
        • Webster B.S.
        • Genevay S.
        • Pransky G.
        The course of opioid prescribing for a new episode of disabling low back pain: opioid features and dose escalation.
        Pain. 2010; 151: 22-29
        • Webster B.S.
        • Bauer A.Z.
        • Choi Y.
        • Cifuentes M.
        • Pransky G.
        Iatrogenic consequences of early magnetic resonance imaging in acute, work-related, disabling low back pain.
        Spine (Phila Pa 1976). 2013; 38: 1939-1946