Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 http://www.biomedcentral.com/1471-2474/14/29 RESEARCH ARTICLE Open Access Are religious beliefs and practices of Buddhism associated with disability and salivary cortisol in office workers with chronic low back pain? Annop Sooksawat1, Prawit Janwantanakul1*, Tewin Tencomnao2 and Praneet Pensri1 Abstract Background: Lowback pain (LBP) is common among office workers. A numberof studies have establisheda relationship between Christianityand physical and mental health outcomes among chronic pain patients. The purpose of this study was to examine the relationshipbetween thereligious beliefs and practices of Buddhism and disability and psychological stress inoffice workers with chronic LBP. Methods: A cross-sectional survey was conducted with a self-administered questionnaire delivered by hand to 463 office workers with chronic LBP. Saliva samples were collectedfrom a randomly selected sub-sample of respondents (n=96). Disability due to LBP was assessed using theRoland-Morris Disability Questionnaire and psychological stress was assessed based on salivary cortisol. Two hierarchical regression models were built to determine how much variance indisability and psychological stress could be explained by religious beliefs and practices of Buddhism variables after controllingfor potentialconfounder variables. Results: Only 6% of variance in psychological stress was accounted for by the religious beliefs and practices of Buddhism. Those with high religiousnessexperienced lowerpsychological stress. No association between the religious beliefs and practices ofBuddhismand disability level was found. Depressive symptoms were attributed to both psychologicalstress and disability status inour study population. Conclusions: The findingssuggest that, although being religious may improve thepsychological conditionin workers with chronic LBP, itseffect is insufficient to reduce disability due to illness. Further research should examine therole of depression as a mediator of theeffectof psychological stress on disability in patients with chronic LBP. Background conditions [6]. Baetz and Bowen [7] found that chronic It is well documented that psychosocial factors signifi- painandfatiguesuffererswhowerebothreligiousandspir- cantly influence low back pain (LBP), disability, and per- itual were more likely to have better psychological well- sistent symptoms [1,2]. Psychological stress has been being and use positive coping strategies than non-religious shown to exacerbate pain in women with chronic pain, and non-spiritual sufferers. Abraido-Lanza et al. [8] such as fibromyalgia syndrome [3]. Maladaptive pain reported a positive association between religious coping cognitions, such as pain catastrophizing, cause fear of and psychological well-being in 200 patients with arthritis. movement, which in turn contributes to activity avoid- Also, Baetzetal. [9] surveyed70,884Canadiansandfound ance and functional disability [4]. A systematic review that those who frequently attended worship services had suggests that depression is a strong predictor of poor lowerlevelsofdepressivesymptoms. LBPprognosis[5]. Buddhismisoneofthemajorworldreligionswithmost Previous studies among Christians showed that reli- Buddhists living in Asia, particularly in the East and gion/spirituality wasassociated with positive psychological South-EastAsiaregions.AccordingtotheNationalStatis- ticalOffice,94.2%oftheThaipopulationisBuddhist[10]. *Correspondence:[email protected] Buddhism is a system of teaching aiming to eradicate the 1DepartmentofPhysicalTherapy,FacultyofAlliedHealthSciences, ultimate problem of mental suffering in life. Its teaching ChulalongkornUniversity,Bangkok,Thailand emphasizes the use of one’s own wisdom to attain the Fulllistofauthorinformationisavailableattheendofthearticle ©2013Sooksawatetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsofthe CreativeCommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse, distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited. Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page2of8 http://www.biomedcentral.com/1471-2474/14/29 objectivetruthofnatureandcompletelyeliminatetheori- LBP was defined according to the standardized Nordic gin of mental distress so that the mind can be released questionnaire [21]. Subjects were excluded if they reported once and for all from suffering. Buddhism preaches that pregnancy or had a history of spinal surgery, trauma, or nature is a causally and conditionally interdependent sys- accidents. Subjects who had been diagnosed with congeni- tem of phenomena, including the mind and body of man tal anomaly of the spine, rheumatoid arthritis, infection of [11].Mindfulnessand meditation, whichisthepracticeof thespineanddiscs,ankylosingspondylitis,lumbarspondy- paying attention, on purpose, moment-to-moment, in a lolisthesis, lumbar spondylosis, tumor, systemic lupus waythatisnon-judgmentalandnon-reactive[12],arefun- erythymatosus, or osteoporosis were also excluded from damentally parts of Buddhism. Several studies indicated a thestudy.Inclusionandexclusioncriteriaweredetermined positive effect of mindfulness on pain catastrophizing, byusingaself-reportedquestionnaire. pain-relatedfear,hyper-vigilance,pain-relatedanxietyand, An invitation letter and information about the study physicalandpsychologicalfunctioning[13-15].Significant were sent to a convenience sample of office workers in improvements in pain intensity, pain acceptance, psycho- 11 workplaces in Bangkok, Prachinburi and Singburi logical well-being and physical function have been provinces in Thailand. The enterprises participating in reported in chronic pain patients following mindfulness- this study were those in public transportation, infra- based treatments [12,16]. The practice of continuous structure, energy, healthcare, insurance as well as the mindfulnesshasbeenproposedtofacilitatetheacquisition municipal office and ministerial head office. Those who of adaptive thought and emotion-regulation skills, which expressed interest and who were eligible were invited to reduces psychological inflexibility and expands behavioral participate in the study. A self-administered question- repertoires to provide patients with more healthy options naire was then distributed to each eligible worker by todealwiththeirownproblems[13].Inaddition,mindful- hand and the researcher returned to collect the com- ness enhances physical self-monitoring and body aware- pleted questionnaire 45 minutes later. In addition, saliva ness, possibly leading to improved body mechanics and samples were collected from a sub-sample of respon- self-care[12]. dents, who were randomly selected using a computer- To date, there has been no study on the effect of reli- generated random allocation sequence. Written informed gious beliefs and practices of Buddhism on physical and consent was obtained from all participants and the study mental health outcomes in chronic musculoskeletal wasapprovedbytheUniversityHumanEthicsCommittee. patients, whose physical health is closely related to their psychosocial condition, such as chronic LBP patients. ReligiousbeliefsandpracticesofBuddhismquestionnaire The purpose of this study was to examine the association The religious beliefs and practices of Buddhism ques- between the religious beliefs and practices of Buddhism tionnaire is a reliably validated instrument developed by and disability and psychological stress in office workers a team of Thai researchers [22]. The questionnaire con- with chronic LBP. Psychological stress was measured by sisted of 30 questions divided into three subscales: 10 salivary cortisol, which is routinely used as a biomarker of items on belief in the Buddhist teachings, 10 items on psychologicalstressandrelatedmentalorphysicaldiseases. Buddhistpractice,and10itemsontheBuddhistlifestyle. Salivary cortisol levels are considered a reliable measure of Respondents are asked to what extent these statements hypothalamus-pituitary-adrenal (HPA) axis adaptation to are true for them. Items are scored on a 6-point Likert stress [17]. Evidence suggests that the HPA axis activity scale with responses ranging from 1 (absolutely untrue) may play a role in the association between psychological to 6 (absolutely true). The total score of the test ranges variables and chronicity of pain [18]. It was hypothesized from 30 to 180, with higher scores indicating more spir- that the religious beliefs and practices of Buddhism would itualityorreligiousness(Additionalfile1). be associated with lower levels of disability and psycho- The10itemsonbeliefinBuddhistteachings(Cronbach’s logicalstressinthisgroup. alpha coefficient = .83; Construct validity using the known group technique t-test = 13.29, p < .001; Discrimination Methods t-ratio = 5.25 to 11.08) assess an individual’s belief in the A cross-sectional study was conducted on office work- threebasicteachingsofBuddhismastruth,namely1)belief ers, who were defined as those working in an office en- in the three sources of religious dependence, i.e. the vironment with their main tasks involving using a Buddha,Histeachings,andtheBuddhistmonk,2)beliefin computer, participating in meetings, giving presenta- the law of cause and effect, heaven and hell, and the cycle tions, reading, and phoning [19]. Office workers were of birthanddeath,and3)beliefinNirvanaortheultimate included if they were Buddhist, aged between 18–60 years goalwhichcanbeachievedbyahumanbeing. and had concurrent chronic LBP (i.e. LBP ≥3 months dur- The 10 items on Buddhist practice (Cronbach’s alpha ation either continuously or intermittently such that pain coefficient = .78; Construct validity t-test = 6.02, p < .01; was experienced at least once per week [20]). The area of Discrimination t-ratio = 3.48 to 10.48) measure an Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page3of8 http://www.biomedcentral.com/1471-2474/14/29 individual’s action or restraint as relates to being a good Regarding LBP, subjects were asked about the duration Buddhist,namely1)theactofgiving,whichincludesdona- of LBP, pain intensity using a numerical pain scale, and tions, forgiving and delivering the Buddha’s teachings to radiation ofpaininthepast4weeks. others, 2) the Five Precepts which are the sins of commis- sionbywordsanddeeds,and3)prayingandmeditating. Salivarycortisol The 10 items on Buddhist lifestyle (Cronbach’s alpha co- Anindividual’spsychologicalstresswasassessed basedon efficient=.85;Discriminationt-ratio=6.41to10.87)assess salivary cortisol. Literature suggests that the integrated the extent to which an individual performs the activities of volume of cortisol released over the waking period is posi- everydaylifeconsonantwithBuddhismprinciples. tivelyrelatedtogenerallifestress[26].Participantsreceived written and oral information about sampling details. The Fear-avoidancebeliefsquestionnaire salivary sample was collected on the Wednesday of the The Fear-Avoidance Beliefs Questionnaire (FABQ) Thai week to reduce day-to-day variation in salivary cortisol version is a 16-item instrument containing two sub- by using a salivary sample collection set (IBL-America, scales: 7 items on fear avoidance beliefs about work and Minneapolis, MN, USA). Participants collected two sal- 4 items on fear avoidance beliefs about physical activity. iva samples: at awakening and 30 min after awakening. Itemsarescoredona7-pointLikertscalewithresponses Participants were told not to brush their teeth and to ranging from 0–6 (completely disagree to completely refrain from eating and drinking before the end of sam- agree). The total score of the FABQ work scale ranges pling time. Participants were asked to abstain from from 0 to 42 and the total score of the FABQ physical food, alcohol, caffeine products, juice, and certain med- activities scale ranges from 0 to 24. Higher scores indi- icines (prednisone, dexamethasone, steroids, adrenergic catehigherfearavoidanceattitudes[23]. agonist and antagonist) for at least 3 hours prior to saliva collection. Participants were also asked not to Roland-morrisdisabilityquestionnaire participate in any vigorous activity within 24 hours Disability level associated with LBP was assessed using prior to sample collection. A salivary sample was not the Roland-Morris Disability Questionnaire (RDQ) Thai collected during a menstruation period. The salivary version, which contains 24 yes/no items. Patients are sampleswerestoredina−20°Crefrigeratoruntilassayed. asked whether the statements apply to them that day The free cortisol concentration in saliva was measured (the last 24 hours). The RDQ score is calculated by add- using an enzyme-linked immunosorbent assay (ELISA) ing up the number of “yes” items, ranging from 0 to 24, kit according to the manufacturer’s instructions (IBL- with higher scoresindicatingmoresevere disability[24]. America). All samples were assayed in duplicate and the average was used in analysis. To quantify the cortisol Generalinformationandconfounderquestionnaire awakening response of each subject, the “area under the This questionnaire comprised four sections designed to curve with respect to the ground” (AUC ) was calcu- G gather data on individual, work-related, and psychosocial lated using the formula outlined by Pruessner et al. [27]. factors as well as LBP characteristics. Individual factors In this study, the two cortisol concentration measure- included gender, age, height, body weight, educational ments (i.e. at awakening and 30 min after awakening) level, marital status, frequency and duration of weekly represented M and M and time interval between the 1 2 exercise sessions, and smoking habits. Respondents were measurements was 30 min. Thus, the total AUC canbe G asked if they thought their work was physically demand- calculated as:(M1+M2)/2×30. ing and whether they received work compensation due Before data collection, the test-retest reliability of data to LBP. Information about expectations of treatment or from all questionnaires was assessed using 32 office recoverywasalso sought. workers. Each subject was tested twice on 2 separate Psychosocial factors were measured using the General days with a week lapse between the measurements. The HealthQuestionnaire(GHQ-28) Thaiversion, whichisa intraclass correlation coefficient [ICC (1,1)] was used for 28-item measure of emotional distress in medical set- continuous data. Kendall’s tau-b and Phi were calculated tings.Thequestionsaregroupedintofourareas:somatic forordinalandnominaldata,respectively. symptoms, anxiety and insomnia, social dysfunction, and severe depression. Each area has 7 questions with a Statisticalanalyses scoreof0or1.Thetotalscoreforeacharearangesfrom Descriptive statistics were calculated for all variables. 0 (better or same as usual symptoms for all questions) General characteristics of subjects in the main study to 7 (worse or much worse than usual symptoms for all (n=463) and a randomly selected sub-sample of office questions).Acombinationofscoresfromfourareaswith workers (n=96) were compared using the independent a score of 6 or more indicates a case of psychological t-test and Chi-square for continuous and nominal/ distress [25]. ordinaldata,respectively. Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page4of8 http://www.biomedcentral.com/1471-2474/14/29 Two separate hierarchical regression analyses were con- Associationbetweendisabilityandthereligiousbeliefs ductedtodeterminehowmuchvarianceintheRDQscore andpracticesofBuddhism(n=463) and AUC could be explained by the religious beliefs and A model was constructed to establish the association be- G practicesofBuddhismvariablesaftercontrollingforpoten- tween disability and the religious beliefs and practices of tial confounder variables. Correlational analyses were con- Buddhism (Table 2).Whencorrelational analysis wasused, ducted first to examine the relationships among the LBP duration, pain intensity in the past 4 weeks, radiation religious beliefs and practices of Buddhism and each vari- ofpaininthepast4weeks,expectationoftreatmentorre- able. For dichotomous variables, dummy variables were covery, anxiety, depression, FABQ physical activity and constructed before performing the correlational analysis. FABQ work subscale were significantly correlated with the The variables chosen for inclusion in the regression ana- RDQscore.Thefinalmodelexplained27%ofthetotalvari- lyseswerethosesignificantlycorrelatedwiththeRDQscore ancein disability. Twenty-seven percent of variance in dis- and AUC based on correlational analysis. All variables abilitywasaccountedforbyLBPduration,painintensityin G were entered in the first step and the religious beliefs and thepast4weeks,radiationofpaininthepast4weeks,de- practices of Buddhism variable was entered in the second pression, FABQ physical activity score, and FABQ work step. All statistical analyses were performed using SPSS score.Nofurthervarianceindisabilitywasexplainedbythe statistical software, version 17.0 (SPSS Inc, Chicago, IL, religiousbeliefsandpracticesofBuddhismaftercontrolling USA).Statisticalsignificancewassetatthe5%level. forconfoundervariables. Associationbetweenpsychologicalstressandthe Results religiousbeliefsandpracticesofBuddhism(n=96) Test-retestreliability A model was constructed to establish the association be- The reliability results demonstrated moderate to good tween psychological stress and the religious beliefs and reliability of questionnaire outcomes with the ICC (1,1) practices of Buddhism (Table 3). When correlational ana- scores ranging from 0.75 to 0.92, Kendall’s tau-b ranging lysis was used, gender, age, education and depression were from 0.76to0.87 andPhiranging from 0.85 to1.00. significantly correlated with AUC . The final model G explained 25% of the total variance in psychological stress. Nineteen percent of variance in psychological stress was Subjects’characteristics accounted for by gender, age, education, and depression. There were 2,890 office workers who were approached The religious beliefs and practices of Buddhism accounted to participate in the study with 2,250 accepting the in- for an additional and significant 6% of variance in psycho- vitation (a response rate of 77.8%). Of 2,250 workers, logicalstress,aftercontrollingforconfoundervariables. 519 were eligible, but only 463 agreed to participate in this study. They were asked to complete the self- Discussion administered questionnaire. Of the 463 workers, 102 The analysis of the relationship between the religious wererandomly selected but only 96 agreed to collecting beliefs and practices of Buddhism and disability and psy- their saliva samples (a response rate of 94.1%). Table 1 chological stress in office workers with chronic LBP presents the demographic, LBP, health outcomes, and revealedthatthereligiousbeliefsandpracticesofBuddhism the Buddhist characteristics of the religious beliefs and were significantly associated with psychological stress but practices of the study population. A small number of not with disability. Workers with high religious beliefs and office workers agreed that their job was physically practices of Buddhism had lower psychological stress. The demanding (21.4%) and received work compensation findings confirm the results of previous studies regarding due to their LBP (15.8%). About 52.1% agreed or the effect of religious beliefs and practices of Christianity strongly agreed that their LBP would completely re- onpsychologicalconditions[7-9].Anumberof hypotheses solve itself. Mean cortisol levels at awakening for those havebeenproposedtoexplaintheimprovementofpsycho- with higher and lower/equal to the mean total scores of logical conditions due to religious and spiritual practices. the religious beliefs and practices of Buddhism ques- Thesehypotheseshavefocusedontheinfluenceofreligious tionnaire (132.8) were 5.41 and 6.65 μg/dL, respect- and spiritual practices on neural pathways and social ively. Mean cortisol levels at 30 min after awakening aspects as well as the increase in mindfulness. Positive for those with higher and lower/equal to mean total emotions, such as forgiveness, hope, contentment, love, scores than the mean total scores of the religious may reduce the arousal in the endocrine and immune sys- beliefs and practices of Buddhism questionnaire (132.8) tems and the hypothalamus-pituitary-adrenal axis system, were 7.19 and 8.57 μg/dL, respectively and 30 min after which help increase immune competence and restore awakening were divided into two groups based on physiological stability [28]. Religious or spiritual practices mean total score derived from. provideopportunitiesforfellowship,involvementinformal Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page5of8 http://www.biomedcentral.com/1471-2474/14/29 Table1Demographic,lowbackpain,healthoutcomes,andtheBuddhistcharacteristicsofthereligiousbeliefsand practicesofparticipatingofficeworkerswithchroniclowbackpain Characteristics (n=463) (n=96) N(%) Mean(SD) N(%) Mean(SD) P-value Demographiccharacteristics Age 38.5(10.0) 36.5(9.1) 0.55 Gender 0.69 Male 113(24.4) 32(33.3) Female 350(75.6) 64(66.7) Bodymassindex(kg/m2) 23.1(3.9) 23.8(4.5) 0.16 Education 0.42 LowerthanBachelor’sdegree 80(17.3) 14(14.5) Bachelor’sdegree 298(64.4) 59(61.5) HigherthanBachelor’sdegree 85(18.3) 23(24.0) Exercisefrequencyinthepast12months 0.34 Never 123(26.6) 31(32.3) Occasionally 288(62.2) 52(54.2) Regularly 52(11.2) 13(13.5) Lowbackpaincharacteristics Durationoflowbackpain(months) 28.3(36.9) 27.8(36.9) 0.89 Painintensityinthepast4weeksusingNPS 4.3(1.8) 4.3(1.8) 0.87 Radiationofpaininthepast4weeks 0.74 Yes 137(39.6) 30(31.2) No 326(70.4) 66(68.8) Healthoutcomes RDQ-24 4.8(3.8) 5.1(3.6) 0.40 FABQworksubscale 17.8(7.8) 16.7(7.6) 0.21 FABQphysicalactivitysubscale 14.5(4.5) 14.6(4.4) 0.72 GHQ-28 4.6(5.0) 5.0(5.5) 0.47 Anxietysubscale 1.3(2.0) 1.4(2.2) 0.77 Depressionsubscale 0.2(0.8) 0.4(1.0) 0.13 AUC (cortisol)(μg.min/dL) - 208.2(79.8) - G Cortisollevelatawakening - 6.02(2.5) Cortisollevelat30minafterawakening - 7.87(3.4) ReligiousbeliefsandpracticesofBuddhism Totalscore 135.1(14.9) 132.8(15.1) 0.17 BeliefsinBuddhistteachingsubscale 43.5(6.1) 42.0(6.1) 0.05 Buddhistpracticesubscale 47.6(6.3) 46.4(6.9) 0.09 Buddhistlifestylesubscale 43.9(6.2) 43.3(6.3) 0.63 NPS,numericalpainscale;RDQ-24,theRoland-MorrisDisabilityQuestionnaire;FABQ,Fear-AvoidanceBeliefsQuestionnaire;GHQ-28,theGeneralHealth Questionnaire;AUC ,areaunderthecurvewithrespecttoground. G social programs, and companionship, thus helping reduce However,basedonthe resultsofthepresent study,the both psychological and physical stressors [29]. Religious or effect of religious beliefs and practices of Buddhism on spiritualpracticesmayincreasemindfulness,whichreduces psychological stress was rather subtle (6%). Rippentrop psychological inflexibility through an improvement in et al. [30] conducted a study in chronic musculoskeletal ‘focused attention’ and facilitation of adaptive thought and pain patients with the majority of patients being Christian emotion-regulationskillacquisition[13,14]. and found that 12% of variance in mental health status, Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page6of8 http://www.biomedcentral.com/1471-2474/14/29 Table2Hierarchicalregressionanalysispredicting Otherimportantpsychologicalfactorsthatrelatetothereli- disabilityduetolowbackpain giousbeliefsandpracticesmaybeidentifiedinfuturework. R2 R2 Standard F Several factors were found to significantly associate increment β increment with disability due to LBP, including duration of LBP, forblock pain intensity in the past 4 weeks, radiation of pain Step Potential .27 21.86*** in the past 4 weeks, depression, and fear-avoidance 1 confoundersfor disability beliefs. However, no association between the religious beliefs and practices of Buddhism and disability was LBPduration .16*** found. Johnstone and Yoon [31] found no association Painintensityin .20*** between religiousness/spirituality and physical health thepast4weeks in 118 individuals with chronic disabilities, including Radiationofpain .14** inthepast4weeks traumatic brain injury, cerebral vascular accidents and spinal cord injury. Rippentrop et al. [30] reported that Expectationof -.07 treatmentor only 3% of variance in physical health status, measured recovery by the SF-36, was accounted for by private religious Anxiety .06 practices in chronic musculoskeletal pain patients. The Depression .16** authors hypothesized that patients with poor physical health relied on their faith for comfort and, thus, pri- FABQphysical .09* activitysubscale vate religious activity was a result of increasing phys- ical disability. These findings suggest that, although FABQwork .14** subscale being religious may improve psychological condition, Step Religiousbeliefs .27 .00 0.51 its effect is insufficient to reduce disability due to ill- 2 andpracticesof ness, at least in our sample of office workers with Buddhism chronic LBP. However, our study population of office Totalscale .02 workers with chronic LBP had a low disability level OverallmodelR2=.279(F=19.46,P=.000). (average RDQ scores of 4.8/24), which is in contrast Betasarestandardized.*P<.05;**P<.01;***P<.001. with that of Turner et al. [32] who reported a moder- LBP,lowbackpain;FABQ,Fear-AvoidanceBeliefsQuestionnaire. ate level of disability (the mean RDQ score = 12.7/24) measured by the SF-36, among the study sample was for those workers submitting work compensation accounted for by forgiveness, negative religious coping, claims for work-related back pain. This discrepancy daily spiritual experiences, religious support, and spiritual/ may be due to the difference in subject characteristics religiousnessintensity.Ourfindingsindicatethattheappli- and occupation. In the previous study, the sample was cationofreligiousbeliefsandpracticestotheimprovement workers who ceased working because of their LBPcon- of psychological conditions in the patient population may dition while in the present study the office workers be limited. However, only a few selected psychological fac- were still engaged in their work. Workers who keep tors were examined in the present and previous studies. working should have low disability because it would be difficult for them to remain productive at moderate to high disability levels [33]. Also, the present study only Table3Hierarchicalregressionanalysispredicting recruited office workers while the previous study physiologicalstress included workers from different occupations. Office R2 R2increment Standard F work is sedentary which mainly involves computer use, forblock β increment participation in meetings, giving presentations, read- Step Potential .19 5.50** ing, and phoning [19]. Only 21% of participating office 1 confounders workers reported that their job was physically demand- Gender .24* ing. As a result, we hypothesized that office workers Age .21* were less likely to have moderate to high disability levels because of their limited physical requirements at Education .22* work. Thus, extrapolation of the results to chronic Depression .27** LBP office workers with moderate to high disability Step Religiousbeliefs .25 .06** 7.34** should be undertaken with caution. Different results 2 andpracticesof Buddhism may emerge with those having moderate to high dis- ability levels. Further research on the effect of religion/ Totalscale -.25** spirituality on physical and mental health in those OverallmodelR2=.255(F=6.17,P=.000). Betasarestandardized.*P<.05;**P<.01;***P<.001. seeking treatment is recommended. Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page7of8 http://www.biomedcentral.com/1471-2474/14/29 Interestingly, based on hierarchical multiple regres- Conclusions sion models, we found that depression was only an The current study examined the relationships between investigated variable significantly associated with both the religious beliefs and practices of Buddhism and dis- psychological stress and disability levels in our study ability and psychological stress in office workers with population of office workers with chronic LBP. Office chronic LBP. Disability due to LBP was assessed using workers with high depressive symptoms had high psy- the Roland-Morris Disability Questionnaire and psycho- chological stress and disability levels, which is consist- logical stress was assessed based on salivary cortisol. We ent with the findings from previous studies [34,35]. found that the religious beliefs and practices of Buddhism Nearly 50% of chronic pain patients suffer from serious have a significant effect on psychological stress but not depression [36]. Depression, which is characterized by disability due to LBP. Chronic LBP office workers with low positive affection and loss of self-esteem, poten- high religiousness experienced lower psychological tially decreases the motivation for activity and thus stress. The findings support the notion that religion/ affects productivity and disability [37]. Religion/spiritu- spiritualityisassociatedwithpositivepsychologicalcon- ality, which has a positive effect on mental health, may ditions. We also found that depressive symptoms were partly reduce depression and consequently benefit associated with both psychological stress and disability patients’ physical health. Further research is required to status. Thus,depressionmaybe amediator ofthe effect investigate the long-term effect of reduced psycho- of psychological stress on disability in patients with logical stress on disability level in chronic LBP patients. chronic LBP. The findings from this study add to the The current study has several weak points. First, saliva mounting empirical evidence that the body and mind samples were collected from a randomly selected sub- are inextricably linked and an effective treatment for sample of office workers participating in this study. chronicLBPshouldincorporatebothphysicalandmen- Nevertheless, their characteristics were very similar to a tal health interventions. However, there is much need larger sample of office workers (n = 463) who partici- for continued research to learn about the complex rela- pated in this study. Also, salivary sampling in field stud- tionshipbetweenreligion/spiritualityandhealth. ies relies on the participants themselves to collect their samples. Thus, it is possible that participants did not Additional file collect samples precisely when they were instructed to do so. Second, the cross-sectional study design only Additionalfile1:ReligiousBeliefsandPracticesofBuddhism allows the association between exposure and outcome to Questionnaire. be examined. It is not possible to establish a causal rela- tionship between exposure and outcome. Therefore, a Competinginterests prospective study design is required to validate the find- Theauthorsdeclarethattherearenoconflictsofinterest. ings of this study. Third, this study may be susceptible to the “healthy worker effect”. Office workers suffering Authors’contributions Theauthorshavecontributedinthefollowingways:ASprovided from musculoskeletal injury due to work may move on concept/researchdesign,datacollection,dataanalysisandmanuscript to other jobs and therefore would have been missed dur- writing.PJprovidedconcept/researchdesign,dataanalysisandmanuscript ing the sampling process in the present study. On the writing.TTandPPprovidedconcept/researchdesignandmanuscript writing.Allauthorsreadandapprovedthefinalmanuscript. other hand, those workers remaining may be those who haveexperiencedonlymild tomoderate levels ofdisabil- Acknowledgements ity, which arenot enough towarrant leavingor changing Thisstudywassupportedbythe90thAnniversaryofChulalongkorn the job. Considering the low mean RDQ-24 score in the UniversityFund(RatchadaphiseksomphotEndowmentFund)andthe sample of this study, this is certainly a possibility. Forth, ChulalongkornUniversityCentenaryAcademicDevelopmentProject(#12). WealsowouldliketothankVarapornRakkhitawatthanaforhertechnical disability due to LBP in different occupations is unlikely assistance. to beidenticalbecause the physicalrequirementsfor dif- ferent occupations are different. Thus, the association Authordetails 1DepartmentofPhysicalTherapy,FacultyofAlliedHealthSciences, between the religious beliefs and practices of Buddhism ChulalongkornUniversity,Bangkok,Thailand.2CenterforExcellencein anddisabilitycouldbedifferentamongdifferentworking Omics-NanoMedicalTechnologyDevelopmentProject,Departmentof populations.Generalizationoftheresultsfromthisstudy ClinicalChemistry,FacultyofAlliedHealthSciences,Chulalongkorn University,Bangkok,Thailand. to other populations should be made with caution. Lastly,thepresent study reportedonsocially undesirable Received:28August2012Accepted:14January2013 behavior specifically in terms of the religious beliefs and Published:17January2013 practices, which may have led to bias. Future studies References should consider inclusion of objective information to in- 1. HillJC,FritzJM:Psychosocialinfluencesonlowbackpain,disability,and crease accuracy. responsetotreatment.PhysTher2011,91:712–721. Sooksawatetal.BMCMusculoskeletalDisorders2013,14:29 Page8of8 http://www.biomedcentral.com/1471-2474/14/29 2. ManchikantiL,FellowsB,SinghV,PampatiV:Correlatesof 26. ChidaY,SteptoeA:Cortisolawakeningresponseandpsychosocial Non-PhysiologicalBehaviorinPatientswithChronicLowBackPain. factors:asystematicreviewandmeta-analysis.BiolPsychol2009, PainPhysician2003,6:159–166. 80:265–278. 3. DavisMC,ZautraAJ,ReichJW:Vulnerabilitytostressamongwomenin 27. PruessnerJC,KirschbaumC,MeinlschmidG,HellhammerDH:Twoformulas chronicpainfromfibromyalgiaandosteoarthritis.AnnBehavMed2001, forcomputationoftheareaunderthecurverepresentmeasuresoftotal 23:215–226. hormoneconcentrationversustime-dependentchange. 4. LeeuwM,GoossensME,LintonSJ,CrombezG,BoersmaK,VlaeyenJW:The Psychoneuroendocrionology2003,28:916–931. fear-avoidancemodelofmusculoskeletalpain:currentstateofscientific 28. ThoresenCE:Spiritualityandhealth:istherearelationship? evidence.JBehavMed2007,30:77–94. JHealthPsychol1999,4:291–300. 5. PincusT,VogelS,BurtonAK,SantosR,FieldAP:Fearavoidanceand 29. SeyboldKS,HillPC:TheRoleofReligionandSpiritualityinMentaland prognosisinbackpain:asystematicreviewandsynthesisofcurrent PhysicalHealth.CurrDirPsycholSci2001,10:20–24. evidence.ArthritisRheum2006,54:3999–4010. 30. RippentropEA,AltmaierEM,ChenJJ,FoundEM,KeffalaVJ:Therelationship 6. OmanD,ThoresenCE:'Doesreligioncausehealth?'Differing betweenreligion/spiritualityandphysicalhealth,mentalhealth,and interpretationsanddiversemeanings.JHealthPsychol2002,7:365–380. paininachronicpainpopulation.Pain2005,116:311–321. 7. BaetzM,BowenR:Chronicpainandfatigue:Associationwithreligion 31. JohnstoneB,YoonDP:Relationshipsbetweenthebriefmultidimensional andspirituality.PainResManage2008,13:383–388. measureofreligiousness/spiritualityandhealthoutcomesfora 8. Abraodo-LanzaAF,VasquezE,EcheverroaSE:EnlasManosdeDios[in heterogeneousrehabilitationpopulation.RehabilPsychol2009, God'sHands]:ReligiousandotherformsofcopingamongLatinoswith 54:422–431. arthritis.JConsultClinPsychol2004,72:91–102. 32. TurnerJA,FranklinG,Fulton-KehoeD,SheppardL,WickizerTM,WuR, 9. BaetzM,GriffinR,BowenR,KoenigHG,MarcouxE:Theassociation GluckJV,EganK:Workerrecoveryexpectationsandfear-avoidance betweenspiritualandreligiousinvolvementanddepressivesymptoms predictworkdisabilityinapopulation-basedworkers'compensation inaCanadianpopulation.JNervMentDis2004,192:818–822. backpainsample.Spine(PhilaPa1976)2006,31:682–689. 10. TheNationalStatisticalOffice:StatisticsinThailand.[Online].[cited2011 33. JohnstonV,SouvlisT,JimmiesonNL,JullG:Associationsbetween Dec9];Availablefrom;2009.URL:http://service.nso.go.th/nso/thailand/ individualandworkplaceriskfactorsforself-reportedneckpainand thailand.jsp. disabilityamongfemaleofficeworkers.ApplErgon2008,39:171–182. 11. PayuttoPA:DhammaBilingualized.Bangkok:Panya-pawana;2010. 34. PoleshuckEL,BairMJ,KroenkeK,DamushTM,TuW,WuJ,KrebsEE,Giles DE:Psychosocialstressandanxietyinmusculoskeletalpainpatientswith 12. RosenzweigS,GreesonJM,ReibelDK,GreenJS,JasserSA,BeasleyD: andwithoutdepression.GenHospPsychiatry2009,31:116–122. Mindfulness-basedstressreductionforchronicpainconditions:Variation intreatmentoutcomesandroleofhomemeditationpractice. 35. WobySR,RoachNK,UrmstonM,WatsonPJ:Therelationbetween JPsychosomRes2010,68:29–36. cognitivefactorsandlevelsofpainanddisabilityinchroniclowback painpatientspresentingforphysiotherapy.EurJPain2007,11:869–877. 13. ChoS,HeibyEM,McCrackenLM,LeeSM,MoonDE:Pain-relatedanxietyas 36. RuoffGE:Depressioninthepatientwithchronicpain.JFamPract1996, amediatoroftheeffectsofmindfulnessonphysicalandpsychosocial functioninginchronicpainpatientsinKorea.JPain2010,11:789–797. 43:S25–33. 37. HallAM,KamperSJ,MaherCG,LatimerJ,FerreiraML,NicholasMK: 14. McCrackenLM,Gauntlett-GilbertJ,VowlesKE:Theroleofmindfulnessina Symptomsofdepressionandstressmediatetheeffectofpainon contextualcognitive-behavioralanalysisofchronicpain-relatedsuffering anddisability.Pain2007,131:63–69. disability.Pain2011,152:1044–1051. 15. SchutzeR,ReesC,PreeceM,SchutzeM:Lowmindfulnesspredictspain catastrophizinginafear-avoidancemodelofchronicpain.Pain2010, doi:10.1186/1471-2474-14-29 148:120–127. Citethisarticleas:Sooksawatetal.:Arereligiousbeliefsandpracticesof Buddhismassociatedwithdisabilityandsalivarycortisolinoffice 16. Kabat-ZinnJ,LipworthL,BurneyR:Theclinicaluseofmindfulness workerswithchroniclowbackpain?BMCMusculoskeletalDisorders2013 meditationfortheself-regulationofchronicpain.JBehavMed1985, 14:29. 8:163–190. 17. HellhammerDH,WustS,KudielkaBM:Salivarycortisolasabiomarkerin stressresearch.Psychoneuroendocrinology2009,34:163–171. 18. SudhausS,FrickeB,StachonA,SchneiderS,KleinH,vonDüringM, HasenbringM:Salivarycortisolandpsychologicalmechanismsin patientswithacuteversuschroniclowbackpain. Psychoneuroendocrinology2009,34:513–522. 19. IJmkerS,BlatterBM,vanderBeekAJ,vanMechelenW,BongersPM: Prospectiveresearchonmusculoskeletaldisordersinofficeworkers (PROMO):Studyprotocol.BMCMusculoskeletDisord2006,7:55. 20. BriggsAM,JordanJE,BuchbinderR,BurnettAF,O'SullivanPB,ChuaJY, OsborneRH,StrakerLM:Healthliteracyandbeliefsamongacommunity cohortwithandwithoutchroniclowbackpain.Pain2010,150:275–283. 21. KuorinkaI,JonssonB,KilbomA,VinterbergH,Biering-SorensenF, AnderssonG,JorgensenK:StandardisedNordicquestionnairesforthe analysisofmusculoskeletalsymptoms.ApplErgon1987,18:233–237. 22. BhanthumnavinD,VanindanandaN:ReligiousbeliefandpracticeofThai Submit your next manuscript to BioMed Central Buddhists:Socializationandqualityoflife.Bangkok:NationalResearch and take full advantage of: Council;1997. 23. WaddellG,NewtonM,HendersonI,SomervilleD,MainCJ:AFear- • Convenient online submission AvoidanceBeliefsQuestionnaire(FABQ)andtheroleoffear-avoidance beliefsinchroniclowbackpainanddisability.Pain1993,52:157–168. • Thorough peer review 24. PensriP,BaxterG,McDonoughS:Reliabilityandinternalconsistencyof • No space constraints or color figure charges theThaiversionofRoland-MorrisdisabilityquestionnaireandWaddell disabilityIndexforbackpainpatients.ChulaMedJ2005,49:333–349. • Immediate publication on acceptance 25. NilchaikovitT,SukyingC,SilpakitC:ReliabilityandvalidityoftheThai • Inclusion in PubMed, CAS, Scopus and Google Scholar versionoftheGeneralHealthQuestionaire.JPsychiatrAssocThailand • Research which is freely available for redistribution 1996,41:2–17. Submit your manuscript at www.biomedcentral.com/submit