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. 2001 Jul;55(7):455–468. doi: 10.1136/jech.55.7.455

Formal education and back pain: a review

C Dionne 1, M Von Korff 1, T Koepsell 1, R Deyo 1, W Barlow 1, H Checkoway 1
PMCID: PMC1731944  PMID: 11413174

Abstract

OBJECTIVES—To summarise the scientific evidence on the relation between educational status and measures of the frequency and the consequences of back pain and of the outcomes of interventions among back pain patients, and to outline possible mechanisms that could explain such an association if found.
DESIGN—Sixty four articles published between 1966 and 2000 that documented the association of formal education with back pain were reviewed.
MAIN RESULTS—Overall, the current available evidence points indirectly to a stronger association of low education with longer duration and/or higher recurrence of back pain than to an association with onset. The many reports of an association of low education with adverse consequences of back pain also suggest that the course of a back pain episode is less favourable among persons with low educational attainment. Mechanisms that could explain these associations include variations in behavioural and environmental risk factors by educational status, differences in occupational factors, compromised "health stock" among people with low education, differences in access to and utilisation of health services, and adaptation to stress. Although lower education was not associated with the outcomes of interventions in major studies, it is difficult, in light of the current limited available evidence, to draw firm conclusions on this association.
CONCLUSION—Scientific evidence supports the hypothesis that less well educated people are more likely to be affected by disabling back pain. Further study of this association may help advance our understanding of back pain as well as understanding of the relation between socioeconomic status and disease as a general phenomenon.


Keywords: back pain; educational status

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Selected References

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  1. Alaranta H., Hurme M., Miettinen M. L. Handicap 1 year following surgery for lumbar disc herniation: special reference to social and vocational factors. Int Rehabil Med. 1986;8(1):39–43. doi: 10.3109/03790798609166510. [DOI] [PubMed] [Google Scholar]
  2. Armenian H. K., Halabi S. S., Khlat M. Epidemiology of primary health problems in Beirut. J Epidemiol Community Health. 1989 Dec;43(4):315–318. doi: 10.1136/jech.43.4.315. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Astrand N. E., Isacsson S. O. Back pain, back abnormalities, and competing medical, psychological, and social factors as predictors of sick leave, early retirement, unemployment, labour turnover and mortality: a 22 year follow up of male employees in a Swedish pulp and paper company. Br J Ind Med. 1988 Jun;45(6):387–395. doi: 10.1136/oem.45.6.387. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Badley E. M., Ibañez D. Socioeconomic risk factors and musculoskeletal disability. J Rheumatol. 1994 Mar;21(3):515–522. [PubMed] [Google Scholar]
  5. Barnekow-Bergkvist M., Hedberg G. E., Janlert U., Jansson E. Determinants of self-reported neck-shoulder and low back symptoms in a general population. Spine (Phila Pa 1976) 1998 Jan 15;23(2):235–243. doi: 10.1097/00007632-199801150-00017. [DOI] [PubMed] [Google Scholar]
  6. Bergenudd H., Nilsson B. Back pain in middle age; occupational workload and psychologic factors: an epidemiologic survey. Spine (Phila Pa 1976) 1988 Jan;13(1):58–60. doi: 10.1097/00007632-198801000-00014. [DOI] [PubMed] [Google Scholar]
  7. Bergenudd H., Nilsson B. The prevalence of locomotor complaints in middle age and their relationship to health and socioeconomic factors. Clin Orthop Relat Res. 1994 Nov;(308):264–270. [PubMed] [Google Scholar]
  8. Biering-Sørensen F., Thomsen C. Medical, social and occupational history as risk indicators for low-back trouble in a general population. Spine (Phila Pa 1976) 1986 Sep;11(7):720–725. doi: 10.1097/00007632-198609000-00011. [DOI] [PubMed] [Google Scholar]
  9. Blumer D., Heilbronn M. Chronic pain as a variant of depressive disease: the pain-prone disorder. J Nerv Ment Dis. 1982 Jul;170(7):381–406. doi: 10.1097/00005053-198207000-00001. [DOI] [PubMed] [Google Scholar]
  10. Boshuizen H. C., Verbeek J. H., Broersen J. P., Weel A. N. Do smokers get more back pain? Spine (Phila Pa 1976) 1993 Jan;18(1):35–40. doi: 10.1097/00007632-199301000-00007. [DOI] [PubMed] [Google Scholar]
  11. Burdorf A. Exposure assessment of risk factors for disorders of the back in occupational epidemiology. Scand J Work Environ Health. 1992 Feb;18(1):1–9. doi: 10.5271/sjweh.1615. [DOI] [PubMed] [Google Scholar]
  12. COHART E. M. Socioeconomic distribution of cancer of the female sex organs in New Haven. Cancer. 1955 Jan-Feb;8(1):34–41. doi: 10.1002/1097-0142(1955)8:1<34::aid-cncr2820080104>3.0.co;2-f. [DOI] [PubMed] [Google Scholar]
  13. Callahan L. F., Cordray D. S., Wells G., Pincus T. Formal education and five-year mortality in rheumatoid arthritis: mediation by helplessness scale score. Arthritis Care Res. 1996 Dec;9(6):463–472. doi: 10.1002/art.1790090608. [DOI] [PubMed] [Google Scholar]
  14. Callahan L. F., Pincus T. Education, self-care, and outcomes of rheumatic diseases: further challenges to the "biomedical model" paradigm. Arthritis Care Res. 1997 Oct;10(5):283–288. doi: 10.1002/art.1790100502. [DOI] [PubMed] [Google Scholar]
  15. Callahan L. F., Pincus T. Formal education level as a significant marker of clinical status in rheumatoid arthritis. Arthritis Rheum. 1988 Nov;31(11):1346–1357. doi: 10.1002/art.1780311102. [DOI] [PubMed] [Google Scholar]
  16. Cassel J. The contribution of the social environment to host resistance: the Fourth Wade Hampton Frost Lecture. Am J Epidemiol. 1976 Aug;104(2):107–123. doi: 10.1093/oxfordjournals.aje.a112281. [DOI] [PubMed] [Google Scholar]
  17. Cats-Baril W. L., Frymoyer J. W. Identifying patients at risk of becoming disabled because of low-back pain. The Vermont Rehabilitation Engineering Center predictive model. Spine (Phila Pa 1976) 1991 Jun;16(6):605–607. doi: 10.1097/00007632-199106000-00001. [DOI] [PubMed] [Google Scholar]
  18. Croft P. R., Rigby A. S. Socioeconomic influences on back problems in the community in Britain. J Epidemiol Community Health. 1994 Apr;48(2):166–170. doi: 10.1136/jech.48.2.166. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Cunningham L. S., Kelsey J. L. Epidemiology of musculoskeletal impairments and associated disability. Am J Public Health. 1984 Jun;74(6):574–579. doi: 10.2105/ajph.74.6.574. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Cypress B. K. Characteristics of physician visits for back symptoms: a national perspective. Am J Public Health. 1983 Apr;73(4):389–395. doi: 10.2105/ajph.73.4.389. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Deyo R. A., Cherkin D., Conrad D., Volinn E. Cost, controversy, crisis: low back pain and the health of the public. Annu Rev Public Health. 1991;12:141–156. doi: 10.1146/annurev.pu.12.050191.001041. [DOI] [PubMed] [Google Scholar]
  22. Deyo R. A., Diehl A. K. Psychosocial predictors of disability in patients with low back pain. J Rheumatol. 1988 Oct;15(10):1557–1564. [PubMed] [Google Scholar]
  23. Deyo R. A., Tsui-Wu Y. J. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976) 1987 Apr;12(3):264–268. doi: 10.1097/00007632-198704000-00013. [DOI] [PubMed] [Google Scholar]
  24. Deyo R. A., Tsui-Wu Y. J. Functional disability due to back pain. A population-based study indicating the importance of socioeconomic factors. Arthritis Rheum. 1987 Nov;30(11):1247–1253. doi: 10.1002/art.1780301107. [DOI] [PubMed] [Google Scholar]
  25. Dionne C., Koepsell T. D., Von Korff M., Deyo R. A., Barlow W. I., Checkoway H. Formal education and back-related disability. In search of an explanation. Spine (Phila Pa 1976) 1995 Dec 15;20(24):2721–2730. doi: 10.1097/00007632-199512150-00014. [DOI] [PubMed] [Google Scholar]
  26. Doxey N. C., Dzioba R. B., Mitson G. L., Lacroix J. M. Predictors of outcome in back surgery candidates. J Clin Psychol. 1988 Jul;44(4):611–622. doi: 10.1002/1097-4679(198807)44:4<611::aid-jclp2270440419>3.0.co;2-g. [DOI] [PubMed] [Google Scholar]
  27. Ernst E. Smoking, a cause of back trouble? Br J Rheumatol. 1993 Mar;32(3):239–242. doi: 10.1093/rheumatology/32.3.239. [DOI] [PubMed] [Google Scholar]
  28. Feinstein J. S. The relationship between socioeconomic status and health: a review of the literature. Milbank Q. 1993;71(2):279–322. [PubMed] [Google Scholar]
  29. Fishbain D. A., Cutler R. B., Rosomoff H. L., Khalil T., Steele-Rosomoff R. Impact of chronic pain patients' job perception variables on actual return to work. Clin J Pain. 1997 Sep;13(3):197–206. doi: 10.1097/00002508-199709000-00004. [DOI] [PubMed] [Google Scholar]
  30. Franks P., Boisseau V. Educational status and health. J Fam Pract. 1980 Jun;10(6):1029–1034. [PubMed] [Google Scholar]
  31. Fredrickson B. E., Trief P. M., VanBeveren P., Yuan H. A., Baum G. Rehabilitation of the patient with chronic back pain. A search for outcome predictors. Spine (Phila Pa 1976) 1988 Mar;13(3):351–353. doi: 10.1097/00007632-198803000-00022. [DOI] [PubMed] [Google Scholar]
  32. Frymoyer J. W. Back pain and sciatica. N Engl J Med. 1988 Feb 4;318(5):291–300. doi: 10.1056/NEJM198802043180506. [DOI] [PubMed] [Google Scholar]
  33. Frymoyer J. W., Pope M. H., Costanza M. C., Rosen J. C., Goggin J. E., Wilder D. G. Epidemiologic studies of low-back pain. Spine (Phila Pa 1976) 1980 Sep-Oct;5(5):419–423. doi: 10.1097/00007632-198009000-00005. [DOI] [PubMed] [Google Scholar]
  34. Garg A., Moore J. S. Epidemiology of low-back pain in industry. Occup Med. 1992 Oct-Dec;7(4):593–608. [PubMed] [Google Scholar]
  35. Guck T. P., Meilman P. W., Skultety F. M., Dowd E. T. Prediction of long-term outcome of multidisciplinary pain treatment. Arch Phys Med Rehabil. 1986 May;67(5):293–296. [PubMed] [Google Scholar]
  36. Harreby M., Hesselsøe G., Kjer J., Neergaard K. Low back pain and physical exercise in leisure time in 38-year-old men and women: a 25-year prospective cohort study of 640 school children. Eur Spine J. 1997;6(3):181–186. doi: 10.1007/BF01301433. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Harreby M., Kjer J., Hesselsøe G., Neergaard K. Epidemiological aspects and risk factors for low back pain in 38-year-old men and women: a 25-year prospective cohort study of 640 school children. Eur Spine J. 1996;5(5):312–318. doi: 10.1007/BF00304346. [DOI] [PubMed] [Google Scholar]
  38. Hart L. G., Deyo R. A., Cherkin D. C. Physician office visits for low back pain. Frequency, clinical evaluation, and treatment patterns from a U.S. national survey. Spine (Phila Pa 1976) 1995 Jan 1;20(1):11–19. doi: 10.1097/00007632-199501000-00003. [DOI] [PubMed] [Google Scholar]
  39. Hazard R. G., Bendix A., Fenwick J. W. Disability exaggeration as a predictor of functional restoration outcomes for patients with chronic low-back pain. Spine (Phila Pa 1976) 1991 Sep;16(9):1062–1067. doi: 10.1097/00007632-199109000-00009. [DOI] [PubMed] [Google Scholar]
  40. Heck K. E., Pamuk E. R. Explaining the relation between education and postmenopausal breast cancer. Am J Epidemiol. 1997 Feb 15;145(4):366–372. doi: 10.1093/oxfordjournals.aje.a009114. [DOI] [PubMed] [Google Scholar]
  41. Heistaro S., Vartiainen E., Heliövaara M., Puska P. Trends of back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors. Am J Epidemiol. 1998 Oct 1;148(7):671–682. doi: 10.1093/aje/148.7.671. [DOI] [PubMed] [Google Scholar]
  42. Henry J. P., Cassel J. C. Psychosocial factors in essential hypertension. Recent epidemiologic and animal experimental evidence. Am J Epidemiol. 1969 Sep;90(3):171–200. doi: 10.1093/oxfordjournals.aje.a121062. [DOI] [PubMed] [Google Scholar]
  43. Hubert H. B., Bloch D. A., Fries J. F. Risk factors for physical disability in an aging cohort: the NHANES I Epidemiologic Followup Study. J Rheumatol. 1993 Mar;20(3):480–488. [PubMed] [Google Scholar]
  44. Hurme M., Alaranta H. Factors predicting the result of surgery for lumbar intervertebral disc herniation. Spine (Phila Pa 1976) 1987 Nov;12(9):933–938. doi: 10.1097/00007632-198711000-00016. [DOI] [PubMed] [Google Scholar]
  45. Hurwitz E. L., Morgenstern H. Correlates of back problems and back-related disability in the United States. J Clin Epidemiol. 1997 Jun;50(6):669–681. doi: 10.1016/s0895-4356(97)00018-8. [DOI] [PubMed] [Google Scholar]
  46. Jacobsson L., Lindgärde F., Manthorpe R., Ohlsson K. Effect of education, occupation and some lifestyle factors on common rheumatic complaints in a Swedish group aged 50-70 years. Ann Rheum Dis. 1992 Jul;51(7):835–843. doi: 10.1136/ard.51.7.835. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Jayson M. I. Why does acute back pain become chronic? BMJ. 1997 Jun 7;314(7095):1639–1640. doi: 10.1136/bmj.314.7095.1639. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Jenkins C. D. Low education: a risk factor for death. N Engl J Med. 1978 Jul 13;299(2):95–97. doi: 10.1056/NEJM197807132990210. [DOI] [PubMed] [Google Scholar]
  49. Katzman R. Education and the prevalence of dementia and Alzheimer's disease. Neurology. 1993 Jan;43(1):13–20. doi: 10.1212/wnl.43.1_part_1.13. [DOI] [PubMed] [Google Scholar]
  50. Kearney J. R. The work incapacity and reintegration study: results of the initial survey conducted in the United States. Soc Secur Bull. 1997;60(3):21–32. [PubMed] [Google Scholar]
  51. Keel P. J., Wittig R., Deutschmann R., Diethelm U., Knüsel O., Löschmann C., Matathia R., Rudolf T., Spring H. Effectiveness of in-patient rehabilitation for sub-chronic and chronic low back pain by an integrative group treatment program (Swiss Multicentre Study). Scand J Rehabil Med. 1998 Dec;30(4):211–219. [PubMed] [Google Scholar]
  52. Kelsey J. L., White A. A., 3rd Epidemiology and impact of low-back pain. Spine (Phila Pa 1976) 1980 Mar-Apr;5(2):133–142. doi: 10.1097/00007632-198003000-00007. [DOI] [PubMed] [Google Scholar]
  53. Kleinke C. L., Spangler A. S., Jr Predicting treatment outcome of chronic back pain patients in a multidisciplinary pain clinic: methodological issues and treatment implications. Pain. 1988 Apr;33(1):41–48. doi: 10.1016/0304-3959(88)90201-1. [DOI] [PubMed] [Google Scholar]
  54. Kokan P. J., Wing P. C., Thompson W. J. Factors associated with failure of lumbar spine fusion. Can J Surg. 1974 Sep;17(5):294–298. [PubMed] [Google Scholar]
  55. Kubzansky L. D., Kawachi I., Sparrow D. Socioeconomic status, hostility, and risk factor clustering in the Normative Aging Study: any help from the concept of allostatic load? Ann Behav Med. 1999 Fall;21(4):330–338. doi: 10.1007/BF02895966. [DOI] [PubMed] [Google Scholar]
  56. Kushi L. H., Folsom A. R., Jacobs D. R., Jr, Luepker R. V., Elmer P. J., Blackburn H. Educational attainment and nutrient consumption patterns: the Minnesota Heart Survey. J Am Diet Assoc. 1988 Oct;88(10):1230–1236. [PubMed] [Google Scholar]
  57. La Vecchia C., Negri E., Pagano R., Decarli A. Education, prevalence of disease, and frequency of health care utilisation. The 1983 Italian National Health Survey. J Epidemiol Community Health. 1987 Jun;41(2):161–165. doi: 10.1136/jech.41.2.161. [DOI] [PMC free article] [PubMed] [Google Scholar]
  58. Lacroix J. M., Powell J., Lloyd G. J., Doxey N. C., Mitson G. L., Aldam C. F. Low-back pain. Factors of value in predicting outcome. Spine (Phila Pa 1976) 1990 Jun;15(6):495–499. doi: 10.1097/00007632-199006000-00012. [DOI] [PubMed] [Google Scholar]
  59. Lancourt J., Kettelhut M. Predicting return to work for lower back pain patients receiving worker's compensation. Spine (Phila Pa 1976) 1992 Jun;17(6):629–640. doi: 10.1097/00007632-199206000-00002. [DOI] [PubMed] [Google Scholar]
  60. Lanier D. C., Stockton P. Clinical predictors of outcome of acute episodes of low back pain. J Fam Pract. 1988 Nov;27(5):483–489. [PubMed] [Google Scholar]
  61. Lantz P. M., House J. S., Lepkowski J. M., Williams D. R., Mero R. P., Chen J. Socioeconomic factors, health behaviors, and mortality: results from a nationally representative prospective study of US adults. JAMA. 1998 Jun 3;279(21):1703–1708. doi: 10.1001/jama.279.21.1703. [DOI] [PubMed] [Google Scholar]
  62. Latza U., Kohlmann T., Deck R., Raspe H. Influence of occupational factors on the relation between socioeconomic status and self-reported back pain in a population-based sample of German adults with back pain. Spine (Phila Pa 1976) 2000 Jun 1;25(11):1390–1397. doi: 10.1097/00007632-200006010-00011. [DOI] [PubMed] [Google Scholar]
  63. Lee P. W., Chow S. P., Lieh-Mak F., Chan K. C., Wong S. Psychosocial factors influencing outcome in patients with low-back pain. Spine (Phila Pa 1976) 1989 Aug;14(8):838–843. doi: 10.1097/00007632-198908000-00011. [DOI] [PubMed] [Google Scholar]
  64. Lehmann T. R., Spratt K. F., Lehmann K. K. Predicting long-term disability in low back injured workers presenting to a spine consultant. Spine (Phila Pa 1976) 1993 Jun 15;18(8):1103–1112. doi: 10.1097/00007632-199306150-00023. [DOI] [PubMed] [Google Scholar]
  65. Leigh J. P. An empirical analysis of self-reported, work-limiting disability. Med Care. 1985 Apr;23(4):310–319. doi: 10.1097/00005650-198504000-00003. [DOI] [PubMed] [Google Scholar]
  66. Leigh J. P., Sheetz R. M. Prevalence of back pain among fulltime United States workers. Br J Ind Med. 1989 Sep;46(9):651–657. doi: 10.1136/oem.46.9.651. [DOI] [PMC free article] [PubMed] [Google Scholar]
  67. Leino-Arjas P., Hänninen K., Puska P. Socioeconomic variation in back and joint pain in Finland. Eur J Epidemiol. 1998 Jan;14(1):79–87. doi: 10.1023/a:1007448402954. [DOI] [PubMed] [Google Scholar]
  68. Leino P., Magni G. Depressive and distress symptoms as predictors of low back pain, neck-shoulder pain, and other musculoskeletal morbidity: a 10-year follow-up of metal industry employees. Pain. 1993 Apr;53(1):89–94. doi: 10.1016/0304-3959(93)90060-3. [DOI] [PubMed] [Google Scholar]
  69. Leino P. Symptoms of stress predict musculoskeletal disorders. J Epidemiol Community Health. 1989 Sep;43(3):293–300. doi: 10.1136/jech.43.3.293. [DOI] [PMC free article] [PubMed] [Google Scholar]
  70. Liberatos P., Link B. G., Kelsey J. L. The measurement of social class in epidemiology. Epidemiol Rev. 1988;10:87–121. doi: 10.1093/oxfordjournals.epirev.a036030. [DOI] [PubMed] [Google Scholar]
  71. Liira J. P., Shannon H. S., Chambers L. W., Haines T. A. Long-term back problems and physical work exposures in the 1990 Ontario Health Survey. Am J Public Health. 1996 Mar;86(3):382–387. doi: 10.2105/ajph.86.3.382. [DOI] [PMC free article] [PubMed] [Google Scholar]
  72. Mackenbach J. P. Socio-economic health differences in The Netherlands: a review of recent empirical findings. Soc Sci Med. 1992 Feb;34(3):213–226. doi: 10.1016/0277-9536(92)90264-q. [DOI] [PubMed] [Google Scholar]
  73. Magora A. Investigation of the relation between low back pain and occupation. IMS Ind Med Surg. 1970 Nov;39(11):465–471. [PubMed] [Google Scholar]
  74. Magora A., Taustein I. An investigation of the problem of sick-leave in the patient suffering from low back pain. IMS Ind Med Surg. 1969 Nov;38(11):398–408. [PubMed] [Google Scholar]
  75. Marmot M. G., McDowall M. E. Mortality decline and widening social inequalities. Lancet. 1986 Aug 2;2(8501):274–276. doi: 10.1016/s0140-6736(86)92085-4. [DOI] [PubMed] [Google Scholar]
  76. McMahon L. F., Jr, McLaughlin C. G., Petroni G. R., Tedeschi P. J. Small area analysis of hospital discharges for musculoskeletal diseases in Michigan: the influence of socioeconomic factors. Am J Med. 1991 Aug;91(2):173–178. doi: 10.1016/0002-9343(91)90011-l. [DOI] [PubMed] [Google Scholar]
  77. Mitchell J. M., Burkhauser R. V., Pincus T. The importance of age, education, and comorbidity in the substantial earnings losses of individuals with symmetric polyarthritis. Arthritis Rheum. 1988 Mar;31(3):348–357. doi: 10.1002/art.1780310306. [DOI] [PubMed] [Google Scholar]
  78. Murphy K. A., Cornish R. D. Prediction of chronicity in acute low back pain. Arch Phys Med Rehabil. 1984 Jun;65(6):334–337. [PubMed] [Google Scholar]
  79. Mäkelä M., Heliövaara M. Prevalence of primary fibromyalgia in the Finnish population. BMJ. 1991 Jul 27;303(6796):216–219. doi: 10.1136/bmj.303.6796.216. [DOI] [PMC free article] [PubMed] [Google Scholar]
  80. Mäkelä M., Heliövaara M., Sievers K., Impivaara O., Knekt P., Aromaa A. Prevalence, determinants, and consequences of chronic neck pain in Finland. Am J Epidemiol. 1991 Dec 1;134(11):1356–1367. doi: 10.1093/oxfordjournals.aje.a116038. [DOI] [PubMed] [Google Scholar]
  81. Mäkelä M., Heliövaara M., Sievers K., Knekt P., Maatela J., Aromaa A. Musculoskeletal disorders as determinants of disability in Finns aged 30 years or more. J Clin Epidemiol. 1993 Jun;46(6):549–559. doi: 10.1016/0895-4356(93)90128-n. [DOI] [PubMed] [Google Scholar]
  82. Natvig H. Sociomedical aspects of low back pain causing prolonged sick leave. A retrospective study. Acta Sociomed Scand. 1970;2(2):117–126. [PubMed] [Google Scholar]
  83. Nilsson P. M., Johansson S. E., Sundquist J. Low educational status is a risk factor for mortality among diabetic people. Diabet Med. 1998 Mar;15(3):213–219. doi: 10.1002/(SICI)1096-9136(199803)15:3<213::AID-DIA569>3.0.CO;2-#. [DOI] [PubMed] [Google Scholar]
  84. Nosek M. A., Parker R. M., Larsen S. Psychosocial independence and functional abilities: their relationship in adults with severe musculoskeletal impairments. Arch Phys Med Rehabil. 1987 Dec;68(12):840–845. [PubMed] [Google Scholar]
  85. Nykvist F., Hurme M., Alaranta H., Miettinen M. L. Social factors and outcome in a five-year follow-up study of 276 patients with sciatica. Scand J Rehabil Med. 1991;23(1):19–26. [PubMed] [Google Scholar]
  86. Oostdam E. M., Duivenvoorden H. J. Predictability of the result of surgical intervention in patients with low back pain. J Psychosom Res. 1983;27(4):273–281. doi: 10.1016/0022-3999(83)90049-1. [DOI] [PubMed] [Google Scholar]
  87. Orvieto R., Rand N., Lev B., Wiener M., Nehama H. Low back pain and body mass index. Mil Med. 1994 Jan;159(1):37–38. [PubMed] [Google Scholar]
  88. Papageorgiou A. C., Macfarlane G. J., Thomas E., Croft P. R., Jayson M. I., Silman A. J. Psychosocial factors in the workplace--do they predict new episodes of low back pain? Evidence from the South Manchester Back Pain Study. Spine (Phila Pa 1976) 1997 May 15;22(10):1137–1142. doi: 10.1097/00007632-199705150-00014. [DOI] [PubMed] [Google Scholar]
  89. Pappas G., Queen S., Hadden W., Fisher G. The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986. N Engl J Med. 1993 Jul 8;329(2):103–109. doi: 10.1056/NEJM199307083290207. [DOI] [PubMed] [Google Scholar]
  90. Park C. H., Wagener D. K., Winn D. M., Pierce J. P. Health conditions among the currently employed. Vital Health Stat 10. 1993 Jul;(186):1–67. [PubMed] [Google Scholar]
  91. Pierce J. P., Fiore M. C., Novotny T. E., Hatziandreu E. J., Davis R. M. Trends in cigarette smoking in the United States. Educational differences are increasing. JAMA. 1989 Jan 6;261(1):56–60. [PubMed] [Google Scholar]
  92. Pincus T., Brooks R. H., Callahan L. F. Prediction of long-term mortality in patients with rheumatoid arthritis according to simple questionnaire and joint count measures. Ann Intern Med. 1994 Jan 1;120(1):26–34. doi: 10.7326/0003-4819-120-1-199401010-00005. [DOI] [PubMed] [Google Scholar]
  93. Pincus T., Callahan L. F. Associations of low formal education level and poor health status: behavioral, in addition to demographic and medical, explanations? J Clin Epidemiol. 1994 Apr;47(4):355–361. doi: 10.1016/0895-4356(94)90156-2. [DOI] [PubMed] [Google Scholar]
  94. Pincus T., Callahan L. F., Burkhauser R. V. Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population. J Chronic Dis. 1987;40(9):865–874. doi: 10.1016/0021-9681(87)90186-x. [DOI] [PubMed] [Google Scholar]
  95. Pincus T., Callahan L. F. Formal education as a marker for increased mortality and morbidity in rheumatoid arthritis. J Chronic Dis. 1985;38(12):973–984. doi: 10.1016/0021-9681(85)90095-5. [DOI] [PubMed] [Google Scholar]
  96. Pincus T., Callahan L. F. Taking mortality in rheumatoid arthritis seriously--predictive markers, socioeconomic status and comorbidity. J Rheumatol. 1986 Oct;13(5):841–845. [PubMed] [Google Scholar]
  97. Pincus T., Esther R., DeWalt D. A., Callahan L. F. Social conditions and self-management are more powerful determinants of health than access to care. Ann Intern Med. 1998 Sep 1;129(5):406–411. doi: 10.7326/0003-4819-129-5-199809010-00011. [DOI] [PubMed] [Google Scholar]
  98. Pincus T. Formal educational level--a marker for the importance of behavioral variables in the pathogenesis, morbidity, and mortality of most diseases? J Rheumatol. 1988 Oct;15(10):1457–1460. [PubMed] [Google Scholar]
  99. Polatin P. B., Gatchel R. J., Barnes D., Mayer H., Arens C., Mayer T. G. A psychosociomedical prediction model of response to treatment by chronically disabled workers with low-back pain. Spine (Phila Pa 1976) 1989 Sep;14(9):956–961. doi: 10.1097/00007632-198909000-00007. [DOI] [PubMed] [Google Scholar]
  100. Porter R. W., Oakshott G., Oakshot G [corrected to Oakshott G. ]. Spinal stenosis and health status. Spine (Phila Pa 1976) 1994 Apr 15;19(8):901–903. doi: 10.1097/00007632-199404150-00006. [DOI] [PubMed] [Google Scholar]
  101. Reisbord L. S., Greenland S. Factors associated with self-reported back-pain prevalence: a population-based study. J Chronic Dis. 1985;38(8):691–702. doi: 10.1016/0021-9681(85)90023-2. [DOI] [PubMed] [Google Scholar]
  102. Roncarati A., McMullen W. Correlates of low back pain in a general population sample: a multidisciplinary perspective. J Manipulative Physiol Ther. 1988 Jun;11(3):158–164. [PubMed] [Google Scholar]
  103. Rowe M. L. Low back pain in industry. A position paper. J Occup Med. 1969 Apr;11(4):161–169. doi: 10.1097/00043764-196904000-00001. [DOI] [PubMed] [Google Scholar]
  104. Ruberman W., Weinblatt E., Goldberg J. D., Chaudhary B. S. Psychosocial influences on mortality after myocardial infarction. N Engl J Med. 1984 Aug 30;311(9):552–559. doi: 10.1056/NEJM198408303110902. [DOI] [PubMed] [Google Scholar]
  105. Saraste H., Hultman G. Life conditions of persons with and without low-back pain. Scand J Rehabil Med. 1987;19(3):109–113. [PubMed] [Google Scholar]
  106. Skovron M. L. Epidemiology of low back pain. Baillieres Clin Rheumatol. 1992 Oct;6(3):559–573. doi: 10.1016/s0950-3579(05)80127-x. [DOI] [PubMed] [Google Scholar]
  107. Smith A. M., Baghurst K. I. Public health implications of dietary differences between social status and occupational category groups. J Epidemiol Community Health. 1992 Aug;46(4):409–416. doi: 10.1136/jech.46.4.409. [DOI] [PMC free article] [PubMed] [Google Scholar]
  108. Smith G. R., Jr, O'Rourke D. F. Return to work after a first myocardial infarction. A test of multiple hypotheses. JAMA. 1988 Mar 18;259(11):1673–1677. [PubMed] [Google Scholar]
  109. Spengler D. M., Bigos S. J., Martin N. A., Zeh J., Fisher L., Nachemson A. Back injuries in industry: a retrospective study. I. Overview and cost analysis. Spine (Phila Pa 1976) 1986 Apr;11(3):241–245. doi: 10.1097/00007632-198604000-00010. [DOI] [PubMed] [Google Scholar]
  110. Stronks K., van de Mheen H., van den Bos J., Mackenbach J. P. The interrelationship between income, health and employment status. Int J Epidemiol. 1997 Jun;26(3):592–600. doi: 10.1093/ije/26.3.592. [DOI] [PubMed] [Google Scholar]
  111. Svensson H. O., Andersson G. B. Low back pain in forty to forty-seven year old men. I. Frequency of occurrence and impact on medical services. Scand J Rehabil Med. 1982;14(2):47–53. [PubMed] [Google Scholar]
  112. Svensson H. O. Low back pain in forty to forty-seven year old men. II. Socio-economic factors and previous sickness absence. Scand J Rehabil Med. 1982;14(2):55–60. [PubMed] [Google Scholar]
  113. Syme S. L., Berkman L. F. Social class, susceptibility and sickness. Am J Epidemiol. 1976 Jul;104(1):1–8. doi: 10.1093/oxfordjournals.aje.a112268. [DOI] [PubMed] [Google Scholar]
  114. Tate D. G. Workers' disability and return to work. Am J Phys Med Rehabil. 1992 Apr;71(2):92–96. doi: 10.1097/00002060-199204000-00006. [DOI] [PubMed] [Google Scholar]
  115. Tsoi W. F., Kua E. H. Predicting the outcome of schizophrenia ten years later. Aust N Z J Psychiatry. 1992 Jun;26(2):257–261. [PubMed] [Google Scholar]
  116. Tunturi T., Pätiälä H. Social factors associated with lumbosacral fusion. Scand J Rehabil Med. 1980;12(1):17–23. [PubMed] [Google Scholar]
  117. Viikari-Juntura E., Vuori J., Silverstein B. A., Kalimo R., Kuosma E., Videman T. A life-long prospective study on the role of psychosocial factors in neck-shoulder and low-back pain. Spine (Phila Pa 1976) 1991 Sep;16(9):1056–1061. doi: 10.1097/00007632-199109000-00008. [DOI] [PubMed] [Google Scholar]
  118. Volinn E., Van Koevering D., Loeser J. D. Back sprain in industry. The role of socioeconomic factors in chronicity. Spine (Phila Pa 1976) 1991 May;16(5):542–548. doi: 10.1097/00007632-199105000-00010. [DOI] [PubMed] [Google Scholar]
  119. Von Korff M., Deyo R. A., Cherkin D., Barlow W. Back pain in primary care. Outcomes at 1 year. Spine (Phila Pa 1976) 1993 Jun 1;18(7):855–862. doi: 10.1097/00007632-199306000-00008. [DOI] [PubMed] [Google Scholar]
  120. Von Korff M., Le Resche L., Dworkin S. F. First onset of common pain symptoms: a prospective study of depression as a risk factor. Pain. 1993 Nov;55(2):251–258. doi: 10.1016/0304-3959(93)90154-H. [DOI] [PubMed] [Google Scholar]
  121. Von Korff M., Parker R. D. The dynamics of the prevalence of chronic episodic disease. J Chronic Dis. 1980;33(2):79–85. doi: 10.1016/0021-9681(80)90031-4. [DOI] [PubMed] [Google Scholar]
  122. Vucetic N., Astrand P., Güntner P., Svensson O. Diagnosis and prognosis in lumbar disc herniation. Clin Orthop Relat Res. 1999 Apr;(361):116–122. doi: 10.1097/00003086-199904000-00016. [DOI] [PubMed] [Google Scholar]
  123. Vucetic N., de Bri E., Svensson O. Clinical history in lumbar disc herniation. A prospective study in 160 patients. Acta Orthop Scand. 1997 Apr;68(2):116–120. doi: 10.3109/17453679709003991. [DOI] [PubMed] [Google Scholar]
  124. Vällfors B. Acute, subacute and chronic low back pain: clinical symptoms, absenteeism and working environment. Scand J Rehabil Med Suppl. 1985;11:1–98. [PubMed] [Google Scholar]
  125. Waddell G. Simple low back pain: rest or active exercise? Ann Rheum Dis. 1993 May;52(5):317–319. doi: 10.1136/ard.52.5.317. [DOI] [PMC free article] [PubMed] [Google Scholar]
  126. Walsh K., Cruddas M., Coggon D. Low back pain in eight areas of Britain. J Epidemiol Community Health. 1992 Jun;46(3):227–230. doi: 10.1136/jech.46.3.227. [DOI] [PMC free article] [PubMed] [Google Scholar]
  127. Weinblatt E., Ruberman W., Goldberg J. D., Frank C. W., Shapiro S., Chaudhary B. S. Relation of education to sudden death after myocardial infarction. N Engl J Med. 1978 Jul 13;299(2):60–65. doi: 10.1056/NEJM197807132990202. [DOI] [PubMed] [Google Scholar]
  128. Westrin C. G., Hirsch C., Lindegård B. The personality of the back patient. Clin Orthop Relat Res. 1972 Sep;87:209–216. [PubMed] [Google Scholar]
  129. Wilfling F. J., Klonoff H., Kokan P. Psychological, demographic and orthopaedic factors associated with prediction of outcome of spinal fusion. Clin Orthop Relat Res. 1973 Jan-Feb;(90):153–160. [PubMed] [Google Scholar]
  130. Woo J., Leung S. S., Ho S. C., Sham A., Lam T. H., Janus E. D. Influence of educational level and marital status on dietary intake, obesity and other cardiovascular risk factors in a Hong Kong Chinese population. Eur J Clin Nutr. 1999 Jun;53(6):461–467. doi: 10.1038/sj.ejcn.1600777. [DOI] [PubMed] [Google Scholar]
  131. Zant J. L., Dekker-Saeys A. J., Van den Burgh I. C., Kolman A., Van der Stadt R. J. Sthenia, ambition and educational level in patients suffering from ankylosing spondylitis: a controlled study of personality features as compared to rheumatoid arthritis and unspecified low back pain. Clin Rheumatol. 1982 Dec;1(4):243–250. doi: 10.1007/BF02032082. [DOI] [PubMed] [Google Scholar]

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