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Table of Contents
Year : 2019  |  Volume : 18  |  Issue : 1  |  Page : 13-17

Coping mechanisms as predictor of stress in patients with chronic low back pain: A Nigerian Study

1 Department of Orthopaedic Surgery and Traumatology, University of Calabar, Calabar, Nigeria
2 Spine Unit, National Orthopaedic Hospital, Igbobi, Lagos, Nigeria
3 Clinical and Research Unit, Federal Neuropsychiatric Hospital, Calabar, Nigeria

Date of Web Publication26-Jul-2019

Correspondence Address:
Dr. Joseph Asuquo
Department of Orthopaedic Surgery and Traumatology, Faculty of Medicine, College of Medical Science, University of Calabar, PMB 1115, Calabar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njot.njot_5_19

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Introduction: Chronic low back pain (LBP) is one of the most common musculoskeletal conditions worldwide. It can be quite severe, affecting physical, social, occupational and even psychological well-being. This study describes the coping mechanisms commonly employed in patients with chronic LBP and its relationship to perceived stress. Methods: In this descriptive hospital-based study, Brief Cope Scale and the Perceived Stress Scale (PSS) were administered to 100 patients with chronic LBP. Variables analysed were sociodemographic characteristics, dimensions of the Brief Cope Scale and the PSS. Logistic regression was used to determine predictors of perceived stress. Data were analysed using IBM SPSS version 20, and the threshold for statistical significance was set at 0.05. Results: Sample was comprised of 59 females and 41 males with an age range of 18–72 years (= 42.7 ± 16.2). The most common spinal pathologies were lumbar spondylosis (n = 39), canal stenosis (n = 18) and facet joint arthritis (n = 16). The average perceived stress score for the entire sample was 28 (standard deviation [SD] = 6.94), and the coping mechanisms most employed were religion ( = 6.9, SD = 1.77), planning ( = 6.4, SD = 1.34) and emotional support (= 6.0, SD = 1.54). After logistic regression, instrumental support, self-blame, active coping, religion, positive reframing and venting emerged as predictors of perceived stress. Conclusion: Coping styles are an important determinant of perceived stress in patients with chronic LBP. Due consideration should be given to the stress experienced by patients with chronic LBP, and their clinical care should include stress management to improve outcome.

Keywords: Chronic, coping mechanisms, low back pain, perceived stress

How to cite this article:
Asuquo J, Abang I, Anisi C, Toluse A, Essien E, Edet B, Agweye P. Coping mechanisms as predictor of stress in patients with chronic low back pain: A Nigerian Study. Niger J Orthop Trauma 2019;18:13-7

How to cite this URL:
Asuquo J, Abang I, Anisi C, Toluse A, Essien E, Edet B, Agweye P. Coping mechanisms as predictor of stress in patients with chronic low back pain: A Nigerian Study. Niger J Orthop Trauma [serial online] 2019 [cited 2024 Feb 25];18:13-7. Available from: https://www.njotonline.org/text.asp?2019/18/1/13/263522

  Introduction Top

Pain has been experienced by everyone regardless of age, gender and socioeconomic status. It can be described as an unfavourable experience which if severe or chronic could have a lasting emotional and disabling effect. Pain as defined by the International Association for the Study of Pain is 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage'.[1] It can be regarded as a vital or warning sign and also one of the universal types of stress. Brennan et al. proposed that pain management should be considered a fundamental human right.[2]

The psychological response of an individual is important as regards the ability to cope with pain. Pain catastrophising, for example, is 'the tendency to focus on and exaggerate the threat value of painful stimuli and negatively evaluate one's own ability to deal with pain'.[3] The individual's specific mindset as regards the experience of pain can have a direct impact on behaviour, adaptation, functional ability and quality of life.[4]

Chronic pain is a continuous or long term, lasting more than 3–6 months after the expected healing period.[5] It may be continuous or intermittent, poorly understood, complex and sometimes difficult to manage. Causes may be life-threatening or non-life-threatening and may persist for life. Those with chronic pain exhibit changes in behaviour due to the adaptability of the body to persistent impulses. Numerous studies suggest sex-based differences in the experience of pain. Proposed explanations are debated, but it is possible that pain is processed differently by both sexes.[6],[7] The prevalence of chronic pain in the general population ranges from 2% to 40% or 7% to 55.2% depending on the definition of chronic pain used.[8] Between 40% and 60% of patients with chronic pain have comorbid depression, an association that has been referred to as the 'pain–depression dyad'. When chronic low back pain (LBP) is comorbid with depression, patients tend to have poorer outcome. The scientific relationship between the two is poorly understood.[9],[10],[11],[12]

Coping mechanism can be defined as 'the cognitive and behavioural efforts made to master, tolerate or reduce external and internal demands and conflicts amongst them'.[13] Coping has been classified into problem-focussed coping (PFC) and emotional-focussed coping (EFC). In PFC, attempts are made to change the stressful situations through problem-solving, decision-making and direct action, whereas in EFC, attempts are made to regulate the distressing emotion by changing the meaning of the situation cognitively without real change. Coping can sometimes be effective/positive or ineffective/negative; likewise, stress can be positive or negative, but the relationship between them is somewhat complex.[14],[15]

Few African and even fewer Nigerian studies have looked at coping mechanisms in patients with chronic LBP. In this study, we describe coping mechanisms and perceived stress in patients with chronic LBP and also determine which coping mechanisms are predictors of perceived stress.

  Methods Top

This study is a descriptive study conducted amongst patients in the spine clinics of the University of Calabar Teaching Hospital, Calabar, and National Orthopaedic Hospital, Igbobi, Lagos. These institutions are located in the South-South and Southwest regions of Nigeria, respectively. The sample size was one hundred (n = 100) patients, recruited using convenience sampling method. Inclusion criteria were patients with LBP <6 months and patients aged 18 years and above who gave consent. Patients with traumatic conditions were excluded from the study. Ethical approval was obtained from the Institutional Ethics and Research Committee of both the establishments.

All patients completed a sociodemographic questionnaire with variables such as age, sex, tribe and ethnicity. Diagnosis was extracted from patient medical records. Data were collected from February to December 2017.

The coping behaviours were assessed using the Brief Cope Scale (BCS) which is an abbreviated version of the Cope Inventory.[16] This consists of 14 major subscales which include denial, substance abuse, self-blame, emotional support, instrument support, active coping, self-distraction, venting, positive reframing, humour, planning, acceptance, religion and behavioural disengagement. Each subscale requires a response to 2 questions in the questionnaire, making a total of 28 coping behaviours, rated on a frequency of 1 (1 = I have not been doing this at all) to 4 (4 = I have been doing this a lot). These can be stratified into problem-focussed (active coping, instrument support and planning) and emotional-focussed (the remaining eleven) coping mechanisms as found in the literature.[14]

The Perceived Stress Scale (PSS) consists of 14 questions assessing the respondent's feelings and thoughts over the preceding month.[17] It measures how stressful they perceived their life to be. The client is presented with questions such as How often have you felt nervous and 'stressed'? and How often have you felt that things were going your way? The response format is on a 5-point Likert scale from 0 (0 = 'never') to 4 (4 = 'very often'). High scores signify a perceived stressful life over the preceding month.

The study instruments were administered to the patients by the research assistants and the authors. Time spent administering the instrument was about 15 min. All the patients gave written informed consent.

The data collected (sociodemographic, Brief cope and PSS) were analysed using IBM SPSS Statistics Version 20 (IBM Corp., Armonk, NY, USA). The threshold for statistical inference was 0.05. The age range, mean and standard deviation (SD) of the age, male-to-female ratio, frequency distribution of the various tribes and diagnosis were established. The mean and SD of the subscales of the BCS were determined. The mean and SD of PSS were determined as well. Logistic regression was used to determine which coping mechanisms were predictors of perceived stress.

  Results Top

The patients were Nigerians from different tribes and religions and the three major tribes in Nigeria were represented.

The age range of respondents was 18–72 years, with a mean (SD) of 42.7 ± 16.2. The sample comprised 59 females and 41 males (male-to-female ratio = 1:1.4). The Yoruba ethnic group had the largest representation in the group (n = 46), followed by the Igbo tribe (n = 26) [Table 1].
Table 1: Sociodemographic data of respondents

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Regarding the diagnosis, the most common spinal pathologies were lumbar spondylosis (n = 39), canal stenosis (n = 18) and facet joint arthritis (n = 16) [Table 1].

The coping mechanisms most employed were religion ( = 6.6, SD = 1.77), planning ( = 6.4, SD = 1.34), emotional support ( = 6.0, SD = 1.84) and active coping ( = 5.9, SD = 1.58) amongst others. The least employed coping mechanisms are substance use ( = 2.5, SD = 1.10) and behavioural disengagement ( = 3.7, SD = 1.54) [Table 2].
Table 2: The mean scores of the Perceived Stress Scale and the 14 subscales of the Brief Cope scale

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The mean perceived stress score was 28 (SD = 6.94) [Table 2].

After logistic regression, the coping styles found to be predictors of perceived stress amongst the 14 subscales of the BCS were religion, instrumental support, positive reframing, venting, self-blame and active coping [Table 3].
Table 3: Logistic regression showing predictors of perceived stress

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  Discussion Top

This study aimed to determine the pattern of coping mechanisms as well as the relationship between coping mechanism and perceived stress as measured by the PSS amongst patients with LBP. Chronic LBP could result in significant life dysfunction in sufferers by limiting mobility, occupational function, earning ability and even social activities. It has also been associated with poorer quality of life and poorer mental health outcome. Chronic pain, therefore, affects various dimensions of life and can be an important stressor.[18]

The use of religion, planning and emotional support were the most frequently used coping strategies in our sample. This is similar to another Nigerian study amongst fishermen with LBP where the most frequently used coping styles were religion, use of emotional support and acceptance.[19] Nigeria has been identified as one of the most religious countries in the world, with as high as 96% describing themselves as religious.[20] It is, therefore, not surprising that Nigerians would easily turn to their religious beliefs for succour from stressful life experiences. Substance abuse and behavioural disengagement were the least used coping styles in the Nigerian study amongst fishermen, and our study replicated that finding as well. In general, as regards the use of coping, both studies had convergent findings.

Coping styles which increased the risk for perceived stress were instrumental support, self-blame and active coping, whereas protective factors included religion, positive reframing and venting.

Instrumental support involves getting help and advice from other people as a means to cope. The finding that this increases risk for perceived stress feels counterintuitive and goes against expectations. Studies that compare coping against perceived stress amongst LBP patients are very scarce, limiting our ability to compare findings. One study by Sirois et al. which aimed to determine the relationship between coping and perceived stress in a mixed sample comprising patients with arthritis and inflammatory bowel disease did not find any relationship between instrumental support and perceived stress.[21] Another study amongst patients with Crohn's disease found a significant inverse correlation between instrumental support and perceived stress.[22] Our finding suggests that getting advice from others is not always advantageous. Perhaps, this may relate to the quality of advice given, as misinformation could possibly worsen stress.

Self-blame has been consistently found to worsen perceived stress, as replicated in our study.[21],[22],[23] Active coping, where an individual has been 'taking action to try to make the situation better' (Item 7, Brief cope), was found to predict higher levels of perceived stress, contrary to findings by Sirois et al. who found a significant negative correlation between active coping and perceived stress.[21] This may suggest that this coping style is not helpful in patients with LBP.

Religious coping, characterised by 'trying to find comfort in my religion or spiritual beliefs' (Item 22) or 'praying and meditating' (Item 27), was the most used coping style in our sample and was also found to be a protective factor against perceived stress. As previously noted, studies that compare coping and perceived stress in chronic LBP are scarce and limit our ability for comparisons. Our finding was, however, in keeping with a study which found religiousness to be protective against perceived stress amongst HIV-positive women.[24] Our findings were, however, differed from the study by Bussell and Naus (amongst breast cancer survivors) and Darnopiha (amongst patients with Crohn's disease), which found no relationship between religious coping and perceived stress.[22],[23] Nigeria is a very religious country, and it is understandable why in our context, religious belief would be adaptive.

Positive reframing, in which an individual tries to look at the stressful situation from a different, more optimistic perspective, was also found to protect against stress. This was in keeping with findings by Sirois et al. and Bussell and Naus.[21],[23] Venting which allows expression of negative feelings was found to protect against perceived stress as well, but this was not consistent the report by Sirois et al. and Bussell and Naus.[21],[23] It is possible that venting may be appropriate in persons with LBP but not in other conditions. Local sociocultural factors which possibly play a role in how emotions are handled could also be a factor.

  Conclusion Top

Patients with chronic LBP used more of religion, planning and emotional support as coping skills and less of substance abuse and behavioural disengagement. Furthermore, some coping styles (instrumental support, self-blame, active coping, religion, positive reframing and venting) emerged as significant predictors of perceived stress amongst patients with LBP.

Even though the PSS does not measure the experience of stress that is directly due to LBP, it could be seen as a general indictor of psychosocial well-being amongst respondents in the context of LBP. We expect that patients who have good coping will have lower level of perceived stress in the face of life stressors, including LBP.

In developing a treatment plan for such patients, consideration should be given to their psychological well-being, as well as their ability to cope not only with life stress on the whole but also with their physical condition. There is also a need to screen patients to determine their coping styles and associated level of stress. Therapies such as coping skills training are available and could be instituted in cases of poor coping. This will make for a more holistic approach to patient care and could possible improve overall outcome as well as patient satisfaction.


This study was conducted in Southern Nigeria; these findings may only be applicable within the region. Our use of convenience sampling could have resulted in sample selection bias. We were also unable to rule out other important conditions associated with stress such as depression, which may better account for some of our findings. We did not correlate our findings with the intensity of pain, and it is possible that pain severity may be an important confounder of perceived stress.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3]


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