Sex differences in response to rehabilitation treatment for musculoskeletal pain: the mediating role of post-traumatic stress symptoms

Abstract

Aim: Numerous investigations have revealed sex differences in recovery outcomes in individuals who have sustained work-related musculoskeletal injuries (WRMIs). Previous research has also revealed significant sex differences in the prevalence and severity of post-traumatic stress symptoms (PTSS) following musculoskeletal injury. This study investigated whether PTSS mediated sex differences in recovery outcomes in individuals receiving treatment for a work-related musculoskeletal injury. The recovery outcomes of interest in the present study were pain severity and pain-related disability.

Methods: The study sample included 137 individuals (68 men; 69 women) with WRMIs who were enrolled in a 7-week physical rehabilitation program. Participants completed measures of pain severity, pain disability and PTSS at admission and termination of the physical rehabilitation program.

Results: Consistent with previous research, independent samples t-tests revealed that women obtained significantly higher baseline scores on measures of pain severity (P < 0.01), number of pain sites (P < 0.001), depression (P < 0.001) and PTSS (P < 0.001) compared to men. Also consistent with previous research, the measure of PTSS, assessed at baseline, was prospectively associated with treatment-related disability reduction (P < 0.01), and return to work (P < 0.01). Bootstrap regression analyses revealed that PTSS partially mediated the relation between sex and pain-related disability.

Conclusions: The results of the present study suggest that the experience of PTSS might be one of the factors that explain sex differences in recovery outcomes following a WRMI. The results call for greater attention to the assessment and intervention of PTSS in individuals who have sustained WRMIs.

Keywords

Musculoskeletal injury / pain / disability / post-traumatic stress symptoms / sex differences

References

[1] Jacquier-Bret J, Gorce P. Prevalence of Body Area Work-Related Musculoskeletal Disorders among Healthcare Professionals: A Systematic Review. Int J Environ Res Public Health. 2023; 20: 841.

[2] Nguyen AT, Aris IM, Snyder BD, Harris MB, Kang JD, Murray M, et al. Musculoskeletal health: an ecological study assessing disease burden and research funding. Lancet Reg Health Am. 2024; 29: 100661.

[3] Wuytack F, Evanoff BA, Dale AM, Gilbert F, Fadel M, Leclerc A, et al. Comparison Between Musculoskeletal Pain and Gender-Specific, Non-gendered Job-Exposure Matrix and Self-reported Exposures in CONSTANCES. J Occup Rehabil. 2023;[Epub ahead of print].

[4] Crawford JO, Berkovic D, Erwin J, Copsey SM, Davis A, Giagloglou E, et al. Musculoskeletal health in the workplace. Best Pract Res Clin Rheumatol. 2020; 34: 101558.

[5] Statistiques sur les lesions attribuables aux troubles musculosquelettiques (TMS) en milieu de travail 2019-2022 [Internet]. Commission des normes, de l’équité, de la santé et de la sécurité du travail du Québec; 2023 [cited 2024 Jan 31]. Available from: https://www.cnesst.gouv.qc.ca/sites/default/files/documents/statistiques-lesions-tms_1.pdf

[6] McLeod CB, Reiff E, Maas E, Bültmann U. Identifying return-to-work trajectories using sequence analysis in a cohort of workers with work-related musculoskeletal disorders. Scand J Work Environ Health. 2018; 44: 147-55.

[7] Rysstad T, Grotle M, Aasdahl L, Dunn KM, Tveter AT. Identification and Characterisation of Trajectories of Sickness Absence Due to Musculoskeletal Pain: A 1-Year Population-based Study. J Occup Rehabil. 2023; 33: 277-87.

[8] Lötters F, Burdorf A. Prognostic Factors for Duration of Sickness Absence due to Musculoskeletal Disorders. Clin J Pain. 2006; 22: 212-21.

[9] McGeary DD, Mayer TG, Gatchel RJ, Anagnostis C, Proctor TJ. Gender-related differences in treatment outcomes for patients with musculoskeletal disorders. Spine J. 2003; 3: 197-203.

[10] Carriere JS, Thibault P, Sullivan MJ. The Mediating Role of Recovery Expectancies on the Relation Between Depression and Return-to-Work. J Occup Rehabil. 2015; 25: 348-56.

[11] Gabbe BJ, Simpson PM, Harrison JE, Lyons RA, Ameratunga S, Ponsford J, et al. Return to Work and Functional Outcomes After Major Trauma: Who Recovers, When, and How Well? Ann Surg. 2016; 263: 623-32.

[12] Stock SR, Nicolakakis N, Vézina N, Vézina M, Gilbert L, Turcot A, et al. Are work organization interventions effective in preventing or reducing work-related musculoskeletal disorders? A systematic review of the literature. Scand J Work Environ Health. 2018; 44: 113-33.

[13] Andersen TE, Karstoft KI, Brink O, Elklit A. Pain-catastrophizing and fear-avoidance beliefs as mediators between post-traumatic stress symptoms and pain following whiplash injury - A prospective cohort study. Eur J Pain. 2016; 20: 1241-52.

[14] Keogh E, McCracken LM, Eccleston C. Do men and women differ in their response to interdisciplinary chronic pain management? Pain. 2005; 114: 37-46.

[15] Martin AL, Halket E, Asmundson GJ, Flora DB, Katz J. Posttraumatic Stress Symptoms and the Diathesis-Stress Model of Chronic Pain and Disability in Patients Undergoing Major Surgery. Clin J Pain. 2010; 26: 518-27.

[16] Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. Posttraumatic Stress Disorder in the National Comorbidity Survey. Arch Gen Psychiatry. 1995; 52: 1048-60.

[17] Kilpatrick DG, Resnick HS, Milanak ME, Miller MW, Keyes KM, Friedman MJ. National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-IV and DSM-5 Criteria. J Trauma Stress. 2013; 26: 537-47.

[18] Tolin DF, Foa EB. Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychol Bull. 2006; 132: 959-92.

[19] Soravia LM, Schwab S, Walther S, Müller T. Rescuers at Risk: Posttraumatic Stress Symptoms Among Police Officers, Fire Fighters, Ambulance Personnel, and Emergency and Psychiatric Nurses. Front Psychiatry. 2021; 11: 602064.

[20] Carmassi C, Dell’Oste V, Bertelloni CA, Pedrinelli V, Barberi FM, Malacarne P, et al. Gender and occupational role differences in work-related post-traumatic stress symptoms, burnout and global functioning in emergency healthcare workers. Intensive Crit Care Nurs. 2022; 69: 103154.

[21] Pavilanis A, Truchon M, Achille M, Coté P, Sullivan MJ. Perceived Injustice as a Determinant of the Severity of Post-traumatic Stress Symptoms Following Occupational Injury. J Occup Rehabil. 2023; 33: 134-44.

[22] Wihlke G, Strömmer L, Troëng T, Brattström O. Long-term follow-up of patients treated for traumatic injury regarding physical and psychological function and health-related quality of life. Eur J Trauma Emerg Surg. 2021; 47: 129-35.

[23] Downie WW, Leatham PA, Rhind VM, Wright V, Branco JA, Anderson JA. Studies with pain rating scales. Ann Rheum Dis. 1978; 37: 378-81.

[24] Brunet A, St-Hilaire A, Jehel L, King S. Validation of a French version of the impact of event scale-revised. Can J Psychiatry. 2003; 48: 56-61.

[25] Weiss DS, Marmar CR. The Impact of Event Scale-Revised. In: Wilson JP, Keane TM, editors. Assessing Psychological Trauma and PTSD. The Guilford Press; 1997. pp. 399-411.

[26] Beck JG, Grant DM, Read JP, Clapp JD, Coffey SF, Miller LM, et al. The impact of event scale-revised: psychometric properties in a sample of motor vehicle accident survivors. J Anxiety Disord. 2008; 22: 187-98.

[27] Creamer M, Bell R, Failla S. Psychometric properties of the Impact of Event Scale-Revised. Behav Res Ther. 2003; 41: 1489-96.

[28] Dutta D, Bharati S, Roy C, Das G. Measurement of prevalence of ‘major depressive syndrome’ among Indian patients attending pain clinic with chronic pain using PHQ-9 scale. J Anaesthesiol Clin Pharmacol. 2013; 29: 76-82.

[29] Löwe B, Kroenke K, Herzog W, Gräfe K. Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord. 2004; 81: 61-6.

[30] Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The Pain Disability Index: psychometric and validity data. Arch Phys Med Rehabil. 1987; 68: 438-41.

[31] Tait RC, Chibnall JT, Krause S. The Pain Disability Index: psychometric properties. Pain. 1990; 40: 171-82.

[32] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ. 2007; 335: 806-8.

[33] Scurlock-Evans L, Upton P, Upton D. Evidence-Based Practice in physiotherapy: a systematic review of barriers, enablers and interventions. Physiotherapy. 2014; 100: 208-19.

[34] Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behav Res Methods Instrum Comput. 2004; 36: 717-31.

[35] Côté D, Coutu MF. A critical review of gender issues in understanding prolonged disability related to musculoskeletal pain: how are they relevant to rehabilitation? Disabil Rehabil. 2010; 32: 87-102.

[36] Truchon M. Determinants of chronic disability related to low back pain: Towards an integrative biopsychosocial model. Disabil Rehabil. 2001; 23: 758-67.

[37] Hayes AF. An introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: Guilford Press; 2013.

[38] Fritz MS, Mackinnon DP. Required Sample Size to Detect the Mediated Effect. Psychol Sci. 2007; 18: 233-9.

[39] Giummarra MJ, Cameron PA, Ponsford J, Ioannou L, Gibson SJ, Jennings PA, et al. Return to Work After Traumatic Injury: Increased Work-Related Disability in Injured Persons Receiving Financial Compensation is Mediated by Perceived Injustice. J Occup Rehabil. 2017; 27: 173-85.

[40] Gautschi OP, Corniola MV, Smoll NR, Joswig H, Schaller K, Hildebrandt G, et al. Sex differences in subjective and objective measures of pain, functional impairment, and health-related quality of life in patients with lumbar degenerative disc disease. Pain. 2016; 157: 1065-71.

[41] Stubbs D, Krebs E, Bair M, Damush T, Wu J, Sutherland J, et al. Sex Differences in Pain and Pain-Related Disability among Primary Care Patients with Chronic Musculoskeletal Pain. Pain Med. 2010; 11: 232-9.

[42] Chenot JF, Becker A, Leonhardt C, Keller S, Donner-Banzhoff N, Hildebrandt J, et al. Sex Differences in Presentation, Course, and Management of Low Back Pain in Primary Care. Clin J Pain. 2008; 24: 578-84.

[43] Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009; 10: 447-85.

[44] Murphy JL, Phillips KM, Rafie S. Sex differences between Veterans participating in interdisciplinary chronic pain rehabilitation. J Rehabil Res Dev. 2016; 53: 83-94.

[45] McGinty G, Fox R, Ben-Ezra M, Cloitre M, Karatzias T, Shevlin M, et al. Sex and age differences in ICD-11 PTSD and complex PTSD: An analysis of four general population samples. Eur Psychiatry. 2021; 64: e66.

[46] van Zuiden M, Engel S, Karchoud JF, Wise TJ, Sijbrandij M, Mouthaan J, et al. Sex-differential PTSD symptom trajectories across one year following suspected serious injury. Eur J Psychotraumatol. 2022; 13: 2031593.

[47] Herrera-Escobar JP, El Moheb M, Ranjit A, Weed C, Brasel K, Kasotakis G, et al. Sex differences in long-term outcomes after traumatic injury: A mediation analysis. Am J Surg. 2021; 222: 842-8.

[48] Outcalt SD, Kroenke K, Krebs EE, Chumbler NR, Wu J, Yu Z, et al. Chronic pain and comorbid mental health conditions: independent associations of posttraumatic stress disorder and depression with pain, disability, and quality of life. J Behav Med. 2015; 38: 535-43.

[49] Cohen H, Neumann L, Haiman Y, Matar MA, Press J, Buskila D. Prevalence of post-traumatic stress disorder in fibromyalgia patients: Overlapping syndromes or post-traumatic fibromyalgia syndrome? Semin Arthritis Rheum. 2002; 32: 38-50.

[50] Arnaboldi P, Riva S, Crico C, Pravettoni G. A systematic literature review exploring the prevalence of post-traumatic stress disorder and the role played by stress and traumatic stress in breast cancer diagnosis and trajectory. Breast Cancer (Dove Med Press). 2017; 9: 473-85.

[51] Weathers FW, Marx BP, Friedman MJ, Schnurr PP. Posttraumatic stress disorder in DSM-5: New criteria, new measures, and impliications for assessment. Psychol Inj and Law. 2014; 7: 93-107.

[52] Giummarra MJ, Casey SL, Devlin A, Ioannou LJ, Gibson SJ, Georgiou-Karistianis N, et al. Co-occurrence of posttraumatic stress symptoms, pain, and disability 12 months after traumatic injury. Pain Rep. 2017; 2: e622.

[53] Linnemørken LTB, Granan LP, Reme SE. Prevalence of Posttraumatic Stress Symptoms and Associated Characteristics Among Patients With Chronic Pain Conditions in a Norwegian University Hospital Outpatient Pain Clinic. Front Psychol. 2020; 11: 749.

[54] Andersen TE, Andersen PG, Vakkala MA, Elklit A. The traumatised chronic pain patient-Prevalence of posttraumatic stress disorder - PTSD and pain sensitisation in two Scandinavian samples referred for pain rehabilitation. Scand J Pain. 2012; 3: 39-43.

[55] Boscarino JA, Forsberg CW, Goldberg J. A Twin Study of the Association Between PTSD Symptoms and Rheumatoid Arthritis. Psychosom Med. 2010; 72: 481-6.

[56] Bryant RA. Predictors of post-traumatic stress disorder following burns injury. Burns. 1996; 22: 89-92.

[57] Ravn SL, Hartvigsen J, Hansen M, Sterling M, Andersen TE. Do post-traumatic pain and post-traumatic stress symptomatology mutually maintain each other? A systematic review of cross-lagged studies. Pain. 2018; 159: 2159-69.

[58] Sullivan MJL, Larivière C, Simmonds M. Activity-related summation of pain and functional disability in patients with whiplash injuries. Pain. 2010; 151: 440-6.

[59] Kushnir T, Kasan R. Major sources of stress among women managers, clerical workers, and working single mothers: demands vs. resources. Public Health Rev. 1992; 20: 215-29.

[60] Macpherson RA, Lane TJ, Collie A, McLeod CB. Age, sex, and the changing disability burden of compensated work-related musculoskeletal disorders in Canada and Australia. BMC Public Health. 2018; 18: 758.

[61] Shors TJ, Millon EM, Chang HY, Olson RL, Alderman BL. Do sex differences in rumination explain sex differences in depression? J Neurosci Res. 2017; 95: 711-8.

[62] Ravn SL, Vaegter HB, Cardel T, Andersen TE. The role of posttraumatic stress symptoms on chronic pain outcomes in chronic pain patients referred to rehabilitation. J Pain Res. 2018; 11: 527-36.

[63] Maujean A, Gullo MJ, Andersen TE, Ravn SL, Sterling M. Post-traumatic stress symptom clusters in acute whiplash associated disorder and their prediction of chronic pain-related disability. Pain Rep. 2017; 2: e631.

[64] Sullivan M, Pimentel SD, Paré C. The psychology of pain-related disability: Implications for intervention. In: Wainwright E, Eccleston C, editors. Work, Occupation and Pain Across the Lifespan. Oxford, UK.: Oxford University Press.; 2019. pp. 105-42.

[65] Wong JJ, Côté P, Tricco AC, Watson T, Rosella LC. Joint effects of back pain and mental health conditions on healthcare utilization and costs in Ontario, Canada: a population-based cohort study. Pain. 2022; 163: 1892-904.

[66] Samoborec S, Ruseckaite R, Ayton D, Evans S. Biopsychosocial factors associated with non-recovery after a minor transport-related injury: A systematic review. PLoS One. 2018; 13: e0198352.

[67] Baumeister H, Knecht A, Hutter N. Direct and indirect costs in persons with chronic back pain and comorbid mental disorders-A systematic review. J Psychosom Res. 2012; 73: 79-85.

[68] Gaspar FW, Jolivet DN, Wizner K, Schott F, Dewa CS. Pre-Existing and New-Onset Depression and Anxiety Among Workers With Injury or Illness Work Leaves. J Occup Environ Med. 2020; 62: e567-72.

[69] Liebschutz J, Saitz R, Brower V, Keane TM, Lloyd-Travaglini C, Averbuch T, et al. PTSD in Urban Primary Care: High Prevalence and Low Physician Recognition. J Gen Intern Med. 2007; 22: 719-26.

[70] Sharp TJ, Harvey AG. Chronic pain and posttraumatic stress disorder: mutual maintenance? Clin Psychol Rev. 2001; 21: 857-77.

[71] Asmundson GJ, Coons MJ, Taylor S, Katz J. PTSD and the Experience of Pain: Research and Clinical Implications of Shared Vulnerability and Mutual Maintenance Models. Can J Psychiatry. 2002; 47: 930-7.

[72] Bisson JI, Olff M. Prevention and treatment of PTSD: the current evidence base. Eur J Psychotraumatol. 2021; 12: 1824381.

[73] Friedman MJ, Schnurr PP, Keane TM. Handbook of PTSD: Science and Practice. Edinburgh, UK: Blackwell; 2021.

[74] Stavland H, Refvik C, Eid J, Lockhat R, Hammar Å. A brief intervention for PTSD versus treatment as usual: Study protocol for a non-inferiority randomized controlled trial. Trials. 2021; 22: 737. Erratum in: Trials. 2021; 22:924.

[75] Bongaerts H, Voorendonk EM, Van Minnen A, Rozendaal L, Telkamp BSD, de Jongh A. Fully remote intensive trauma-focused treatment for PTSD and Complex PTSD. Eur J Psychotraumatol. 2022; 13: 2103287.

[76] Sullivan M, Adams H, Ellis T, Clark R, Sully C, Thibault P. Treatment-related reductions in catastrophizing predict return to work in individuals with post-traumatic stress disorder. J Applied Behav Res. 2017; 22: e12087.

[77] Schumann M, Craner J, Kacel E, Morrison E, Gascho K, Gebhard J, et al. The Helplessness Dimension of Pain Catastrophizing Mediates the Relation between PTSD Symptoms and Pain Rehabilitation Measures. Pain Res Manag. 2022; 2022: 2112698.

[78] Pimentel SD, Adams H, Ellis T, Clark R, Sully C, Paré C, et al. The Sequential Relation Between Changes in Catastrophizing and Changes in Posttraumatic Stress Disorder Symptom Severity. J Trauma Stress. 2020; 33: 731-40.