Looking upstream to understand low back pain and return to work: psychosocial factors as the product of system issues

Low back pain (LBP) is the most common and expensive musculoskeletal (MSK) disorder in industrialized countries. There is evidence that personal and occupational psychosocial variables play a more important role than spinal pathology or the physical demands of the job. However, it is unclear which psychosocial variables are most important. The objective of this study is to understand which psychosocial variables are deemed most important to various workplace stakeholders involved in the process of returning a worker with LBP to work. Nine focus groups were convened with injured workers, small and large employers, unions, health and safety associations, physicians and non-physician clinicians, return to work coordinators and compensation board representatives in Ontario, Canada. A qualitative grounded theory approach was applied to explore, from their perspectives, important psychosocial factors that prevent the promotion of early and safe return to work (RTW) for individuals with LBP. While the study began by asking questions related to the various psychosocial factors and their association to LBP and RTW, it took an interesting turn. The majority of study participants described how psychosocial factors were the product of larger systemic/organizational issues. Rather than focusing solely on individual psychosocial factors, respondents described how the context of a much larger system, and the complex interplay between the many different components of that system, contributes directly or indirectly to the treatment of LBP and RTW. It is the interrelationships between these systems that determine the process of returning an injured worker with LBP back to work. Although it is important to understand how psychosocial factors affect RTW, organizational structures within our social context seem to play a role in shaping how all stakeholders see and emotionally respond to LBP and RTW, as well as the degree to which they can envision taking action on them. We need to consider moving beyond a psychosocial conceptualization of LBP and RTW into a sociopolitical and economic conceptualization. This reconceptualization provides insight into the "upstream factors" associated with LBP and RTW.