ABSTRACT

BACKGROUND AND OBJECTIVES:

Psychosocial factors may be associated with multisite pain, which is characterized by pain symptoms in more than one part of the body. The aim of the present study was to determine associations between psychosocial factors and multisite pain in a population of workers.

METHODS:

A cross-sectional study was conducted involving 195 workers (educators, administrative technicians, healthcare workers, cleaners, and zookeepers). Psychosocial factors were evaluated using the short form of the second version of the Copenhagen Psychosocial Questionnaire. Multisite pain was identified using the Nordic Musculoskeletal Questionnaire.

RESULTS:

Multisite pain was associated with quantitative demands (OR=1.31; 95% CI: 1.06-1.63), work pace (OR=1.20; 95% CI: 1.01-1.43), emotional demands (OR=1.39; 95% CI: 1.18-1.63), commitment to the workplace (OR=0.75; 95% CI: 0.62-0.91), predictability (OR=0.86; 95% CI: 0.76-0.99), job satisfaction (OR=0.53; 95% CI: 0.32-0.88), work-family conflict (OR=1.37; 95% CI: 1.16-1.62), justice (OR=0.81; 95% CI: 0.69-0.94), general health perception (OR=0.54; 95% CI: 0.38-0.76), burnout (OR=1.41; 95% CI: 1.17-1.69), and stress (OR=1.41; 95% CI: 1.18-1.68).

CONCLUSION:

Several psychosocial factors were associated with multisite pain, indicating that these factors could be considered in the multisite pain management.

Keywords:
Burnout psychological; Chronic pain; Stress psychological; Working environment

RESUMO

JUSTIFICATIVA E OBJETIVOS:

Fatores psicossociais podem estar associados à dor multirregional, caracterizada por sintomas de dor em mais de uma parte do corpo. O objetivo do presente estudo foi determinar associações entre fatores psicossociais e dor multirregional em uma população de trabalhadores.

MÉTODOS:

Foi realizado um estudo transversal com 195 trabalhadores (professores, técnicos administrativos, profissionais de saúde, faxineiros e funcionários de zoológicos). Os fatores psicossociais foram avaliados por meio da versão abreviada da segunda versão do Copenhagen Psychosocial Questionnaire. A dor multirregional foi identificada por meio do Nordic Musculoskeletal Questionnaire.

RESULTADOS:

A dor multirregional foi associada com demandas quantitativas (OR=1,31; IC 95%: 1,06-1,63), ritmo de trabalho (OR=1,20; IC 95%: 1,01-1,43), demandas emocionais (OR=1,39; IC 95%: 1,18- 1,63), compromisso com o local de trabalho (OR=0,75; IC 95%: 0,62-0,91), previsibilidade (OR=0,86; IC 95%: 0,76-0,99), satisfação no trabalho (OR=0,53; IC 95%: 0,32-0,88), conflito trabalho-família (OR=1,37; IC 95%: 1,16-1,62), justiça (OR=0,81; IC 95%: 0,69-0,94), percepção geral de saúde (OR=0,54; IC 95%: 0,38-0,76), burnout (OR=1,41; IC 95%: 1,17-1,69) e estresse (OR=1,41; IC 95%: 1,18-1,68).

CONCLUSÃO:

Vários fatores psicossociais foram associados à dor multirregional, indicando que estes devem ser abordados no manejo da dor.

Descritores:
Ambiente de trabalho; Dor crônica; Esgotamento psicológico; Estresse psicológico

INTRODUCTION

Psychosocial work factors refer to the interaction between the workplace and human factors and can influence health, performance, and job satisfaction¹1 MacDonald W. The impact of job demands and workload on stress and fatigue. Aust Psychol. 2003;38:2:102-17.,²2 Martinez MC, Fischer FM. Fatores psicossociais no trabalho hospitalar: situações vivenciadas para desgaste no trabalho e desequilíbrio entre esforço e recompensa. Rev Bras Saúde Ocup. 2019;44:e12.. Workers with high work demands, limited control, and little support from supervisors and coworkers have higher levels of psychosocial stress in the workplace¹1 MacDonald W. The impact of job demands and workload on stress and fatigue. Aust Psychol. 2003;38:2:102-17.. Moreover, psychosocial stress at work is associated with the development of chronic pain³3 Bongers PM, de Winter CR, Kompier MA, Hildebrandt VH. Psychosocial factors at work and musculoskeletal disease. Scand J Work Environ Health. 1993;19(5):297-312..

Musculoskeletal pain is quite common in the working population and has been associated with both high work demands and a low level of control⁴4 Boden LI, Sembajwe G, Tveito TH, Hashimoto D, Hopcia K, Kenwood C, Stoddard AM, Sorensen G. Occupational injuries among nurses and aides in a hospital setting. Am J Ind Med. 2012;55(2):117-26.

5 Ihlebaek C, Eriksen HR. Occupational and social variation in subjective health complaints. Occup Med (Lond). 2003;53(4):270-8.-⁶6 Waters TR. Introduction to ergonomics for healthcare workers. Rehabil Nurs. 2010;35(5):185-91.. There is evidence that pain in one body region increases the chance of pain occurring in other locations, which is known as multisite pain⁷7 Kamaleri Y, Natvig B, Ihlebaek CM, Bruusgaard D. Localized or widespread musculoskeletal pain: does it matter? Pain. 2008;138(1):41-6.. Workers with multisite pain are at greater risk of developing work disability⁸8 Miranda H, Kaila-Kangas L, Heliövaara M, Leino-Arjas P, Haukka E, Liira J, et al. Musculoskeletal pain at multiple sites and its effects on work ability in a general working population. Occup Environ Med. 2010;67(7):449-55.. Furthermore, a greater number of pain sites leads to a greater level of disability as well as worse physical and psychological health⁹9 Croft P. The question is not “have you got it”? But “how much of it have you got”? Pain. 2009;141(1-2):6-7..

Studies have identified an association between multisite pain and psychosocial factors. Low social support is the most frequent factor associated with multisite pain¹⁰10 Solidaki E, Chatzi L, Bitsios P, Markatzi I, Plana E, Castro F, et al. Work-related and psychological determinants of multisite musculoskeletal pain. Scand J Work Environ Health. 2010;36(1):54-61.

11 Haukka E, Leino-Arjas P, Ojajärvi A, Takala EP, Viikari-Juntura E, Riihimäki H. Mental stress and psychosocial factors at work in relation to multiple-site musculoskeletal pain: a longitudinal study of kitchen workers. Eur J Pain. 2011;15(4):432-8.

12 Sembajwe G, Tveito TH, Hopcia K, Kenwood C, O’Day ET, Stoddard AM, et al. Psychosocial stress and multi-site musculoskeletal pain: a cross-sectional survey of patient care workers. Workplace Health Saf. 2013;61(3):117-25.

13 Fernandes RCP, Pataro SMS, de Carvalho RB, Burdorf A. The concurrence of musculoskeletal pain and associated work-related factors: a cross sectional study. BMC Public Health. 2016;16:628.

14 Oakman J, de Wind A, van den Heuvel SG, van der Beek AJ. Work characteristics predict the development of multi-site musculoskeletal pain. Int Arch Occup Environ Health. 2017;90(7):653-61.

15 Dragioti E, Gerdle B, Larsson B. Longitudinal associations between anatomical regions of pain and work conditions: a study from The SwePain cohort. Int J Environ Res Public Health. 2019;16(12):2167.

16 Larsen LB, Ramstrand N, Fransson EI. Psychosocial job demand and control: multi-site musculoskeletal pain in Swedish police. Scand J Public Health. 2019;47(3):318-25.-¹⁷17 Vleeshouwers J, Knardahl S, Christensen JO. Effects of psychosocial work factors on number of pain sites: the role of sleep quality as mediator. BMC Musculoskelet Disord. 2019;20(1):595.. However, high work demands¹²12 Sembajwe G, Tveito TH, Hopcia K, Kenwood C, O’Day ET, Stoddard AM, et al. Psychosocial stress and multi-site musculoskeletal pain: a cross-sectional survey of patient care workers. Workplace Health Saf. 2013;61(3):117-25.

13 Fernandes RCP, Pataro SMS, de Carvalho RB, Burdorf A. The concurrence of musculoskeletal pain and associated work-related factors: a cross sectional study. BMC Public Health. 2016;16:628.

14 Oakman J, de Wind A, van den Heuvel SG, van der Beek AJ. Work characteristics predict the development of multi-site musculoskeletal pain. Int Arch Occup Environ Health. 2017;90(7):653-61.

15 Dragioti E, Gerdle B, Larsson B. Longitudinal associations between anatomical regions of pain and work conditions: a study from The SwePain cohort. Int J Environ Res Public Health. 2019;16(12):2167.-¹⁶16 Larsen LB, Ramstrand N, Fransson EI. Psychosocial job demand and control: multi-site musculoskeletal pain in Swedish police. Scand J Public Health. 2019;47(3):318-25.,¹⁸18 Herin F, Vézina M, Thaon I, Soulat JM, Paris C; ESTEV group. Predictive risk factors for chronic regional and multisite musculoskeletal pain: a 5-year prospective study in a working population. Pain. 2014;155(5):937-43. and low level of control¹¹11 Haukka E, Leino-Arjas P, Ojajärvi A, Takala EP, Viikari-Juntura E, Riihimäki H. Mental stress and psychosocial factors at work in relation to multiple-site musculoskeletal pain: a longitudinal study of kitchen workers. Eur J Pain. 2011;15(4):432-8.,¹⁵15 Dragioti E, Gerdle B, Larsson B. Longitudinal associations between anatomical regions of pain and work conditions: a study from The SwePain cohort. Int J Environ Res Public Health. 2019;16(12):2167.,¹⁷17 Vleeshouwers J, Knardahl S, Christensen JO. Effects of psychosocial work factors on number of pain sites: the role of sleep quality as mediator. BMC Musculoskelet Disord. 2019;20(1):595. are also cited. Other authors report that job satisfaction¹⁰10 Solidaki E, Chatzi L, Bitsios P, Markatzi I, Plana E, Castro F, et al. Work-related and psychological determinants of multisite musculoskeletal pain. Scand J Work Environ Health. 2010;36(1):54-61.,¹⁹19 Neupane S, Miranda H, Virtanen P, Siukola A, Nygård CH. Multi-site pain and work ability among an industrial population. Occup Med. 2011;61(8):563-9., team spirit¹⁹19 Neupane S, Miranda H, Virtanen P, Siukola A, Nygård CH. Multi-site pain and work ability among an industrial population. Occup Med. 2011;61(8):563-9., work influence¹²12 Sembajwe G, Tveito TH, Hopcia K, Kenwood C, O’Day ET, Stoddard AM, et al. Psychosocial stress and multi-site musculoskeletal pain: a cross-sectional survey of patient care workers. Workplace Health Saf. 2013;61(3):117-25.,¹⁸18 Herin F, Vézina M, Thaon I, Soulat JM, Paris C; ESTEV group. Predictive risk factors for chronic regional and multisite musculoskeletal pain: a 5-year prospective study in a working population. Pain. 2014;155(5):937-43.,¹⁹19 Neupane S, Miranda H, Virtanen P, Siukola A, Nygård CH. Multi-site pain and work ability among an industrial population. Occup Med. 2011;61(8):563-9., and emotional demands¹⁴14 Oakman J, de Wind A, van den Heuvel SG, van der Beek AJ. Work characteristics predict the development of multi-site musculoskeletal pain. Int Arch Occup Environ Health. 2017;90(7):653-61. are predictive factors for multisite pain. However, most of these studies have evaluated psychosocial factors using the demand, control, and social support model¹⁷17 Vleeshouwers J, Knardahl S, Christensen JO. Effects of psychosocial work factors on number of pain sites: the role of sleep quality as mediator. BMC Musculoskelet Disord. 2019;20(1):595., according to which the combination of high work demand and low control increases the risk of health problems and diminished wellbeing¹1 MacDonald W. The impact of job demands and workload on stress and fatigue. Aust Psychol. 2003;38:2:102-17..

The Copenhagen Psychosocial Questionnaire (COPSOQ) is another instrument for the assessment of psychosocial factors. This questionnaire includes several concepts and theories and is not based on a single theoretical explanatory model of the relationship between psychosocial risk, workplace, and health²⁰20 Kristensen TS, Hannerz H, Høgh A, Borg V. The Copenhagen Psychosocial Questionnaire-a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health. 2005;31(6):438-49.

21 Nübling M, Stößel U, Hasselhorn HM, Michaelis M, Hofmann F. Measuring psychological stress and strain at work - evaluation of the COPSOQ Questionnaire in Germany. Psychosoc Med. 2006;3:Doc05.-²²22 Fernandes C, Pereira A. Exposição a fatores de risco psicossocial em contexto de trabalho: revisão sistemática. Rev Saúde Pública. 2016;50:24.. The COPSOQ addresses relevant dimensions for investigation²²22 Fernandes C, Pereira A. Exposição a fatores de risco psicossocial em contexto de trabalho: revisão sistemática. Rev Saúde Pública. 2016;50:24., enabling a more comprehensive assessment of psychosocial factors and may therefore allow focusing interventions on more specific factors, possibly increasing the effectiveness of such interventions at preventing and controlling multisite pain.

There is a need to study the relationship between psychosocial factors and multisite pain through an instrument that enables a more comprehensive evaluation of psychosocial factors, beyond the work demands and control. Thus, the aim of the present study was to determine associations between psychosocial factors and multisite pain in a population of workers using the short version of the COPSOQ II. The hypothesis is that there are associations between specific psychosocial factors and multisite pain.

METHODS

The present observational, cross-sectional study was reported in accordance with the recommendations of the STROBE initiative (Strengthening the Reporting of Observational Studies in Epidemiology)²³23 Malta M, Cardoso LO, Bastos FI, Magnanini MMF, Silva CMFPD. Iniciativa STROBE: subsídios para a comunicação de estudos observacionais. Rev Saúde Pública. 2010;44(3):559-65..

The inclusion criteria were individuals aged between 18 and 65 years old, working at the same function for at least six months, and having a minimum work routine of 20 hours per week²⁴24 Korshøj M, Krustrup P, Jørgensen MB, Prescott E, Hansen ÅM, Kristiansen J, et al. Cardiorespiratory fitness, cardiovascular workload and risk factors among cleaners; a cluster randomized worksite intervention. BMC Public Health. 2012;12:645.. The exclusion criterion was not having information on musculoskeletal symptoms.

Participants were recruited through social media, e-mails, and visits to their workplaces. The sample was composed of 195 workers: civil servants and service providers in the fields of education, health, administration, human resources, general services (cleaners and conservation), maintenance, and repair (building assistants and zookeepers) (Figure 1).

The occupations were grouped into blue-collar workers (healthcare workers, general services, maintenance, and repair) and white-collar workers (educators, healthcare professionals, administration staff, and human resources staff) following the classification²⁵25 Basu S, Ratcliffe G, Green M. Health and pink-collar work. Occup Med. 2015;65(7):529-34..

This study received approval from the local institutional review board. All volunteers received clarifications regarding the purpose of the study and those who agreed to participate signed a Free and Informed Consent Term (FICT).

Data collection was performed with the aid of the following instruments: Sociodemographic questionnaire addressing personal data (age, gender, marital status, and schooling) and occupational data (function, job seniority, and hours of work per day); COPSOQ II-Br: short version of COPSOQ II-Br was used to assess psychosocial factors²⁶26 Gonçalves JS, Moriguchi CS, Chaves TC, Sato TO. Cross-cultural adaptation and psychometric properties of the short version of COPSOQ II-Brazil. Rev Saude Publica. 2021;55:69.. This questionnaire consists of 40 items²⁷27 Pejtersen JH, Kristensen TS, Borg V, Bjorner JB. The second version of the Copenhagen Psychosocial Questionnaire. Scand J Public Health. 2010;38(3 Suppl):8-24. distributed among the following domains: demands at work, influence and development, meaning and commitment, interpersonal relationships, leadership, job satisfaction, work-family conflict, values in the workplace, general health, burnout and stress, and offensive behavior.

The items are scored on a Likert scale (0 = never/hardly ever, 1 = seldom, 2 = sometimes, 3 = often, 4 = always; or 0 = to a very small extent, 1 = to a small extent, 2 = somewhat, 3 = to a large extent, 4 = to a very large extent). Item 1B is the only one with an inverted score (0 = always, 1 = often, 2 = sometimes, 3 = seldom, 4 = never/hardly ever). The total score is the sum of the items of each domain, except for the offensive behavior domain²⁰20 Kristensen TS, Hannerz H, Høgh A, Borg V. The Copenhagen Psychosocial Questionnaire-a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health. 2005;31(6):438-49. and Nordic Musculoskeletal Questionnaire (NMQ) administered to identify musculoskeletal symptoms in nine regions of the body in the previous seven days and 12 months, as well as investigate functional limitations and having sought health care due to these symptoms²⁸28 de Barros EN, Alexandre NM. Cross‐cultural adaptation of the Nordic musculoskeletal questionnaire. Int Nurs Rev. 2003;50(2):101-8.,²⁹29 Pinheiro FA, Tróccoli BT, Carvalho CVD. Validação do Questionário Nórdico de Sintomas Osteomusculares como medida de morbidade. Rev Saúde Pública. 2002;36(3):307-12..

Participants reported the presence/absence (dichotomous characteristic) of musculoskeletal symptoms, such as pain, numbness, or discomfort in each region of the body. Multisite pain was defined by the sum of the number of regions with pain in the previous 12 months. The body regions were grouped into 1) neck and shoulders; 2) thoracic and lumbar region; 3) upper limbs (elbow and wrist/hand), and 4) lower limbs (hip, knee, and ankle/foot). If a worker had pain in two or more regions, multisite pain was recorded¹⁹19 Neupane S, Miranda H, Virtanen P, Siukola A, Nygård CH. Multi-site pain and work ability among an industrial population. Occup Med. 2011;61(8):563-9.,³⁰30 Pensola T, Haukka E, Kaila-Kangas L, Neupane S, Leino-Arjas P. Good work ability despite multisite musculoskeletal pain? A study among occupationally active Finns. Scand J Public Health. 2016;44(3):300-10..

Procedures

Data collection took place from October 2016 to September 2018. The questionnaires were available in paper and online formats (Google Forms™).

The questionnaire in paper format was administered by a researcher at the workplace. The participants signed the FICT prior to participating in the study. Questionnaires were then distributed to the participants with a previous explanation about the questions and the assurance of confidentiality in the answers.

For the online questionnaire, the participants first had access to the FICT and those who agreed to the terms of the FICT proceeded to complete the questionnaires. The invitation with the link to complete the questionnaires was available on social and institutional media. If the participants had any questions, they could contact the researcher through an email address that was provided. The answering of the questionnaires did not lead to any additional hours of work or reduced wages.

This study was approved by the Institution Ethics Committee for Human Research (CAAE: 64255917.7.000).

Statistical analysis

Descriptive data analysis was performed using mean, standard deviation, and frequency values for the total and stratified sample of the study according to the occurrence of multisite pain.

Binomial logistic regression was performed to obtain odds ratios (OR) and 95% confidence intervals (CI) for estimates of the strength of the associations between psychosocial factors and multisite pain. The assumptions for the binomial logistic regression analysis were tested to investigate the occurrence of multicollinearity and outliers. No multicollinearity between the independent variables or any significant outliers were found. The confounding factors incorporated into the regression models were gender, age, and type of work. All statistical analyses were performed using IBM SPSS Statistics 21 (IBM Corp, Armonk, NY, USA).

RESULTS

Most workers were female (72%), 39% had completed post-graduation, and 86% worked during the day (Table 1).

Prevalence of multisite pain was 61.5% (95% CI: 54.6 to 68.1%). Symptoms were most frequent in the neck/shoulders and thoracic/lumbar region (Table 2).

Multisite pain was associated with several domains of the COPSOQ II. Association was direct (OR > 1) for some domains and inverse (OR < 1) for others. Domains with a direct association were demands at work, work-family conflict, burnout, and stress. Domains with an inverse association were meaning and commitment, predictability, job satisfaction, justice, and general health perception. Unadjusted and adjusted models presented similar results (Table 3).

DISCUSSION

The present study found associations between psychosocial factors and multisite pain among workers. The hypothesis was confirmed, as the results indicate significant associations between multisite pain and specific domains of the COPSOQ II. These findings are in line with data reported in other studies indicating that multisite pain is associated with psychosocial factors¹⁰10 Solidaki E, Chatzi L, Bitsios P, Markatzi I, Plana E, Castro F, et al. Work-related and psychological determinants of multisite musculoskeletal pain. Scand J Work Environ Health. 2010;36(1):54-61.

11 Haukka E, Leino-Arjas P, Ojajärvi A, Takala EP, Viikari-Juntura E, Riihimäki H. Mental stress and psychosocial factors at work in relation to multiple-site musculoskeletal pain: a longitudinal study of kitchen workers. Eur J Pain. 2011;15(4):432-8.

12 Sembajwe G, Tveito TH, Hopcia K, Kenwood C, O’Day ET, Stoddard AM, et al. Psychosocial stress and multi-site musculoskeletal pain: a cross-sectional survey of patient care workers. Workplace Health Saf. 2013;61(3):117-25.

13 Fernandes RCP, Pataro SMS, de Carvalho RB, Burdorf A. The concurrence of musculoskeletal pain and associated work-related factors: a cross sectional study. BMC Public Health. 2016;16:628.

14 Oakman J, de Wind A, van den Heuvel SG, van der Beek AJ. Work characteristics predict the development of multi-site musculoskeletal pain. Int Arch Occup Environ Health. 2017;90(7):653-61.

15 Dragioti E, Gerdle B, Larsson B. Longitudinal associations between anatomical regions of pain and work conditions: a study from The SwePain cohort. Int J Environ Res Public Health. 2019;16(12):2167.

16 Larsen LB, Ramstrand N, Fransson EI. Psychosocial job demand and control: multi-site musculoskeletal pain in Swedish police. Scand J Public Health. 2019;47(3):318-25.

17 Vleeshouwers J, Knardahl S, Christensen JO. Effects of psychosocial work factors on number of pain sites: the role of sleep quality as mediator. BMC Musculoskelet Disord. 2019;20(1):595.

18 Herin F, Vézina M, Thaon I, Soulat JM, Paris C; ESTEV group. Predictive risk factors for chronic regional and multisite musculoskeletal pain: a 5-year prospective study in a working population. Pain. 2014;155(5):937-43.-¹⁹19 Neupane S, Miranda H, Virtanen P, Siukola A, Nygård CH. Multi-site pain and work ability among an industrial population. Occup Med. 2011;61(8):563-9..

Multisite pain was associated with high demands at work, specifically with quantitative demands, work pace, and emotional demands. High work demand has been mentioned by other authors¹²12 Sembajwe G, Tveito TH, Hopcia K, Kenwood C, O’Day ET, Stoddard AM, et al. Psychosocial stress and multi-site musculoskeletal pain: a cross-sectional survey of patient care workers. Workplace Health Saf. 2013;61(3):117-25.

13 Fernandes RCP, Pataro SMS, de Carvalho RB, Burdorf A. The concurrence of musculoskeletal pain and associated work-related factors: a cross sectional study. BMC Public Health. 2016;16:628.

14 Oakman J, de Wind A, van den Heuvel SG, van der Beek AJ. Work characteristics predict the development of multi-site musculoskeletal pain. Int Arch Occup Environ Health. 2017;90(7):653-61.

15 Dragioti E, Gerdle B, Larsson B. Longitudinal associations between anatomical regions of pain and work conditions: a study from The SwePain cohort. Int J Environ Res Public Health. 2019;16(12):2167.-¹⁶16 Larsen LB, Ramstrand N, Fransson EI. Psychosocial job demand and control: multi-site musculoskeletal pain in Swedish police. Scand J Public Health. 2019;47(3):318-25.,¹⁸18 Herin F, Vézina M, Thaon I, Soulat JM, Paris C; ESTEV group. Predictive risk factors for chronic regional and multisite musculoskeletal pain: a 5-year prospective study in a working population. Pain. 2014;155(5):937-43.,³¹31 Oakman J, Stevens M, Karstad K, Hallman DM, Rugulies R, Holtermann A. Do organisational and ward-level factors explain the variance in multi-site musculoskeletal pain in eldercare workers? A multi-level cross-sectional study. Int Arch Occup Environ Health. 2020;93(7):891-8.. A recent meta-analysis of longitudinal cohort studies confirmed that job strain (i.e., high demand and low level of control) is a risk factor for musculoskeletal pain (risk ratio: 1.62; 95% CI: 1.22 to 2.15)³²32 Amiri S, Behnezhad S. Is job strain a risk factor for musculoskeletal pain? A systematic review and meta-analysis of 21 longitudinal studies. Public Health. 2020;181:158-67.. Emotional demands were identified as a predictive factor for developing multisite pain across the four-year measurement period (OR: 1.38; 95% CI: 1.21 to 1.56) in a population of 5136 employees from the prospective cohort Study on Transitions in Employment, Ability and Motivation (STREAM) in the Netherlands¹⁴14 Oakman J, de Wind A, van den Heuvel SG, van der Beek AJ. Work characteristics predict the development of multi-site musculoskeletal pain. Int Arch Occup Environ Health. 2017;90(7):653-61..

Workers with multisite pain had less commitment to the workplace, less job satisfaction, a lower sense of justice, and less predictability. Authors¹⁰10 Solidaki E, Chatzi L, Bitsios P, Markatzi I, Plana E, Castro F, et al. Work-related and psychological determinants of multisite musculoskeletal pain. Scand J Work Environ Health. 2010;36(1):54-61.,¹⁹19 Neupane S, Miranda H, Virtanen P, Siukola A, Nygård CH. Multi-site pain and work ability among an industrial population. Occup Med. 2011;61(8):563-9. found that job satisfaction was a protective factor for multisite pain. Accordingly, an overview of systematic reviews found that low job satisfaction was associated with back pain³³33 Macfarlane GJ, Pallewatte N, Paudyal P, Blyth FM, Coggon D, Crombez G, et al. Evaluation of work-related psychosocial factors and regional musculoskeletal pain: results from a EULAR Task Force. Ann Rheum Dis. 2009;68(6):885-91.. Justice is an important human value in the workplace and has a considerable impact on worker well-being. Study³⁴34 Elovainio M, Kivimäki M, Helkama K. Organization justice evaluations, job control, and occupational strain. J Appl Psychol. 2001;86(3):418-24. showed that lack of organizational justice is a source of stress and negative emotional reactions at work that can lead to health problems.

Work-family conflict was also associated with the outcome. Study³⁵35 Nützi M, Koch P, Baur H, Elfering A. Work-family conflict, task interruptions, and influence at work predict musculoskeletal pain in operating room nurses. Safety Health Work. 2015;6(4):329-37. found a significant positive association between work-family conflict and lumbar/cervical pain. There was an association between work-private life conflict and the number of pain sites in a two-year prospective study³⁶36 Vleeshouwers J, Knardahl S, Christensen JO. A prospective study of work-private life conflict and number of pain sites: moderated mediation by sleep problems and support. J Behav Med. 2019b;42(2):234-45.. Work-family conflict can be defined as an inter-role conflict, in which role pressures from work and family are not compatible³⁷37 Amstad FT, Meier LL, Fasel U, Elfering A, Semmer NK. A meta-analysis of work-family conflict and various outcomes with a special emphasis on cross-domain versus matching-domain relations. J Occup Health Psychol. 2011;16(2):151-69.. This aspect is considered a potential source of stress and has negative effects on well-being. General health perception was also inversely associated with multisite pain. People with chronic widespread pain report having a poorer perception of their health status³⁸38 Sylwander C, Larsson I, Andersson M, Bergman S. The impact of chronic widespread pain on health status and long-term health predictors: a general population cohort study. BMC Musculoskelet Disord. 2020;21(1):36..

Burnout and stress were associated with multisite pain. These are the psychosocial aspects addressed most in the literature due to the greater negative impact on physical and mental health³⁹39 Murofuse NT, Abranches SS, Napoleão AA. Reflexões sobre estresse e burnout e a relação com a enfermagem. Rev Latino-Am Enferm. 2005;13(2):255-61.. A systematic review of prospective studies showed a significant association between burnout and musculoskeletal disorders⁴⁰40 Salvagioni D, Melanda FN, Mesas AE, González AD, Gabani FL, Andrade SM. Physical, psychological and occupational consequences of job burnout: a systematic review of prospective studies. PloS One. 2017;12(10):e0185781..

Another important result of the present study was that about 62% of workers had complaints of pain in more than two parts of the body, the most affected of which were the neck/shoulders (88%) and thoracic/lumbar region (90%). This finding agrees with data described in previous studies reporting the prevalence of multisite pain among different working populations¹⁰10 Solidaki E, Chatzi L, Bitsios P, Markatzi I, Plana E, Castro F, et al. Work-related and psychological determinants of multisite musculoskeletal pain. Scand J Work Environ Health. 2010;36(1):54-61.,³¹31 Oakman J, Stevens M, Karstad K, Hallman DM, Rugulies R, Holtermann A. Do organisational and ward-level factors explain the variance in multi-site musculoskeletal pain in eldercare workers? A multi-level cross-sectional study. Int Arch Occup Environ Health. 2020;93(7):891-8.,⁴¹41 Neupane S, Nygård CH, Oakman J. Work-related determinants of multi-site musculoskeletal pain among employees in the health care sector. Work. 2016;54(3):689-97.,⁴²42 Christensen JO, Nielsen MB, Finne LB, Knardahl S. Comprehensive profiles of psychological and social work factors as predictors of site-specific and multi-site pain. Scand J Work Environ Health. 2018;44(3):291-302..

A very relevant aspect of the present study was the high prevalence of multisite pain among workers. This underscores the importance of pain assessments to identify affected regions of the body and seek causes. Organizational interventions may be relevant to the management of multisite pain.

This study has some limitations that should be considered. The cross-sectional design does not enable establishing causal relationships between psychosocial factors and multisite pain. Other limitations are the different number of workers in each occupational group and the lack of assessments of somatization and sleep, which have been shown to be associated with multisite pain¹⁰10 Solidaki E, Chatzi L, Bitsios P, Markatzi I, Plana E, Castro F, et al. Work-related and psychological determinants of multisite musculoskeletal pain. Scand J Work Environ Health. 2010;36(1):54-61.,¹⁷17 Vleeshouwers J, Knardahl S, Christensen JO. Effects of psychosocial work factors on number of pain sites: the role of sleep quality as mediator. BMC Musculoskelet Disord. 2019;20(1):595.,⁴³43 Aili K, Nyman T, Svartengren M, Hillert L. Sleep as a predictive factor for the onset and resolution of multi-site pain: a 5-year prospective study. Eur J Pain. 2015;19(3):341-9..

CONCLUSION

The present study identified associations between several psychosocial factors and multisite pain in workers, indicating that these factors could be considered in the multisite pain management.

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