European Spine Journal

https://doi.org/10.1007/s00586-022-07404-7

ORIGINAL ARTICLE

Positive lifestyle behaviours and emotional health factors are

associated with low back pain resilience
K. E. Roberts1   · P. R. Beckenkamp2   · M. L. Ferreira3   · G. E. Duncan4   · L. Calais‑Ferreira5   · J. M. Gatt6   ·
P. Ferreira7 

Received: 4 June 2022 / Revised: 18 August 2022 / Accepted: 23 September 2022

© The Author(s) 2022

Abstract
Purpose  To evaluate the relationship between lifestyle behaviours, emotional health factors, and low back pain (LBP)
resilience.
Methods  This retrospective longitudinal study utilised 1,065 twins with a recent history of LBP from the Washington State
Twin Registry. A lifestyle behaviour score was built using variables of body mass index, physical activity engagement, sleep
quality, smoking status, and alcohol consumption. An emotional health score was built using variables of the absence of
depressed mood, perceived stress, and active coping. The main outcome was LBP resilience, assessed as recovery (“bounc-
ing back”), and sustainability (maintaining high levels of function despite LBP).
Results  After adjusting for covariates, there was no relationship between the lifestyle behaviour score (OR 1.05, 95% CI 0.97–
1.15, p = 0.218) and the emotional health score (OR 1.08, 95% CI 0.98–1.19, p = 0.142) with the likelihood of recovering from
LBP. There was however, evidence of a positive association between the lifestyle behaviour score (β 0.20, 95% CI 0.04–0.36,
p = 0.013), the emotional health score (β 0.22, 95% CI 0.00–0.43, p = 0.049), and greater levels of sustainability. These results
were confirmed by a within-pair analysis (lifestyle behaviour score: β 1.79, 95% CI 0.05–3.53, p = 0.043) and (emotional health
score: β 0.52, 95% CI 0.09–0.96, p = 0.021) adjusting for genetic and early shared environmental confounding.
Conclusion  Findings from this study suggest that people who adopt optimal lifestyle behaviours and positive emotional
factors are more likely to be resilient and maintain high levels of function despite suffering from LBP.

Keywords  Low back pain · Resilience · Positive · Lifestyle behaviours

Introduction USA and Australia [2], with direct medical costs for LBP
averaging $315 billion/year from 2012 to 2014 in the USA
Low back pain (LBP) is the main cause of years lived with [3] and $3.4 billion from 2018 to 2019 in Australia [4].
disability (YLD) globally [1]. The associated economic bur- Up to two-third of people report persistent pain at twelve
den is high, especially in high income countries such as the months [5], following an episode of LBP [6]. One-third of

5
* K. E. Roberts Centre for Epidemiology and Biostatistics, Melbourne
[email protected] School of Population and Global Health, The University
of Melbourne, Melbourne, VIC, Australia
1
Faculty of Medicine and Health, The University of Sydney, 6
Neuroscience Research Australia and the School
Sydney, NSW 2006, Australia
of Psychology, The University of New South Wales, Sydney,
2
School of Health Sciences, Faculty of Medicine and Health, NSW, Australia
The University of Sydney, Sydney, NSW, Australia 7
School of Health Sciences, Charles Perkins Centre, Faculty
3
Sydney Musculoskeletal Health, Kolling Institute, School of Medicine and Health, The University of Sydney, Sydney,
of Health Sciences, Faculty of Medicine and Health, The NSW, Australia
University of Sydney, Sydney, NSW, Australia
4
Washington State Twin Registry, Elson S Floyd College
of Medicine, Washington State University Health Sciences
Spokane, Spokane, USA

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those who recover will report another episode within one primarily recruited through the Washington State Depart-
year of the previous episode [7]. Given the limited efficacy ment of Licensing (DOL) records. Details about the WSTR’s
in commonly used treatments for LBP (e.g. paracetamol and prior recruitment procedures and additional information are
anti-inflammatories) [8, 9], attention has shifted towards reported elsewhere [30–32]. Twins included in this study
helping patients to adopt healthy lifestyles and be pain resil- completed baseline surveys between 2010 and 2018 with
ient [5]. Healthy and positive lifestyle behaviours such as follow-up surveys sent to participants every two to three
smoking cessation, improvements in sleep quality, engage- years.
ment in moderate to high physical activity, healthy BMI,
and moderate to low alcohol consumption have been asso-
Participants
ciated with lower risk of chronic LBP (e.g. 11% lower risk
in those engaging in adequate leisure time physical activity
Data from twins who had completed at least two surveys
[10]) and improvements in LBP intensity (e.g. OR 4.30, 95%
were included in this study, resulting in 2334 participants
CI 2.21–8.5 in those with better sleep quality) [11].
(1167 complete twin pairs). Previous exposure to LBP was
Positive emotional health factors are also thought to influ-
considered to be the stressor that may or may not lead to
ence coping responses [12] and the capacity to overcome
participants’ recovery or sustainability. As such, all 1065
adversity [13, 14]. Positivity, optimism, and active coping
participants who reported, at baseline, having LBP that
have been found to be associated with less intensity of pain
lasted for at least one day in the previous three months were
in people with arthritis [15], fibromyalgia [16], and knee
included in the analyses.
osteoarthritis [17], whilst optimism has been associated with
This resulted in 1065 participants (487 individual twin
less experimental pain intensity in pain-free subjects (mean
members of an incomplete pair and 578 twin members of a
46.40/100 vs. 53.59/100) [18] and may be important con-
complete pair) who had a history of LBP. Follow-up surveys
tributors to LBP resilience.
that contained the variables of interest were included, result-
Resilience is recognised as a dynamic process and an out-
ing in a mean time between surveys of four years. (Partici-
come of adaptation and adjustment to adversity [19] result-
pant flowchart is included as Supplementary digital content.)
ing in either recovery or sustainability [19, 20]. The concept
of resilience is appealing in LBP because it shifts the focus
away from the negative aspects of the condition (e.g. high Variables used and data collection
disability, low recovery rates), to positive aspects, potentially
explaining why some people recover from, or continue to Predictors of LBP resilience
function well in the presence of LBP.
Familial factors and early environmental factors have We investigated two sets of predictors of LBP resilience:
been found to explain population differences in obesity [21, lifestyle factors and emotional health factors (Table 1).
22], sleep quality [23], smoking status [24], alcohol use [25], Lifestyle factors included were BMI, smoking status, lei-
and physical activity [26], with genetic factors also account- sure time physical activity, sleep quality, and alcohol con-
ing for 21–67% of the variability of LBP [27]. Twin study sumption (Table 1) and were based on previous studies that
designs are instrumental to control for unobserved confound- investigated the impact of lifestyle behaviours on self-rated
ing variables such as genetics and the early familial environ- health [33], life expectancy [34], chronic diseases [35], LBP
ment [28, 29] in the relationship between risk or prognostic [6], and overall health [36, 37].
factors and clinical outcomes. This study, therefore, aimed Emotional health factors included were depressed mood,
to evaluate the relationship between lifestyle behaviours and perceived stress, and active coping (Table 1) and were based
emotional health factors on LBP resilience assessed through on available data and variables that have been shown to
recovery and sustainability. Our secondary aim was to con- impact on psychological resilience [15, 19] and LBP [38,
firm the results with a within-pair analysis, controlling for 39].
genetic and early environmental factors. Each factor was given a score of optimal (two points),
intermediate (one point), or poor (zero points) [35], with a
total lifestyle behaviour and emotional health score being
Methods computed (Table 1). This created a continuous scale span-
ning from the lowest positive/healthy score with lowest
Study design potential for resilience to highest positive/healthy score with
greatest potential for resilience [35]. The scale also allows
This retrospective longitudinal cohort study included par- the examination of the impact of the accumulation of posi-
ticipants from the Washington State Twin Registry (WSTR). tive lifestyle behaviours and emotional health factors rather
The WSTR is a community-based registry of twin pairs than individual factors alone [33].

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Table 1  Scoring system used Lifestyle behaviours Emotional health factors

for computing lifestyle and
emotional health scores Body Mass Index/BMI a
Depressed mood/PHQ2f
 Optimal ≤ 25 Optimal = 0
 Intermediate = 25–30 Intermediate = 1 or 2
 Poor =  ≥ 30 Poor = ≥ 3
Smokingb Stress Scale/Cohen P­ SSg
 Optimal = non Optimal = 0–13
 Intermediate = former Intermediate = 14–26
 Poor = occasional or current Poor = 27–40
Leisure time physical a­ ctivityc Active coping/resilient ­copingh
 Optimal =  ≥ 150 min mod or 75 min vig Optimal = 17–20
 Intermediate = 60–150 min mod or 20–70 min vig Intermediate = 14–16
 Poor =  < 60 min mod Poor = 4–13
Sleepd
 Optimal = ≥ 8 h per night
 Intermediate = 6–8 h per night
 Poor =  < 6 h per night
Alcohol ­Consumptione
 Optimal = 0
 Intermediate = 1–7
Poor =  > 8
Total lifestyle behaviour score: 0–10 Total emotional health score: 0–6
a 2
 Body mass index (BMI, kg/m ), calculated as weight (in kilograms) divided by height (in metres squared)
[35, 60]
b
 Smoking status [35] measured as non-smoker, former, occasional, or current
c
 Leisure time physical activity, measured as total minutes spent in moderate or vigorous activity per week
[61]
d
 Sleep, measured as the total number of hours of sleep per night [62, 63]
e
 Alcohol consumption, measured with the Alcohol Use Disorders Identification Test (AUDIT) [64]
f
 Depressed mood, measured with the Patient Health Questionnaire-2 (PHQ-2) [65]
g
 Perceived stress, measured with the Cohen Perceived Stress Scale) [66, 67]
h
 Active coping, measured with the Brief Resilient Coping Scale [68]
The cut-off points used were derived from previous studies using similar lifestyle and emotional health
scales as well as recognised recommendations [35, 61, 62, 64, 65, 67, 68]

Outcomes of LBP resilience Each question was scored from one to five, and scores
were added to provide a total function score ranging from
LBP resilience was assessed through two outcome measures 3 to 15 (n = 375).
that describe resilience: recovery and sustainability. Recov-
ery is thought to best describe a successful response to an
acute struggle, and sustainability to describe a successful Covariates
response to a more chronic stressor [20] and as such, both
outcomes were considered for this analysis (Table 2). The following variables were considered for inclusion in
Recovery was defined as the absence of LBP in the previ- the analysis as covariates because they have been associ-
ous 3 months, assessed at follow-up. ( x = 4 years, n = 906). ated with both LBP and physical/mental health in previous
Sustainability was assessed through a function score research: sex [40], age [41], educational attainment [42],
based on the level of pain interference in participants’ annual household income [42], presence of comorbid mus-
physical or work activities. Participants had to report expe- culoskeletal conditions [27], and mental health conditions
riencing LBP in the previous three months, at follow-up, [5], in addition to the time difference between baseline and
in combination with a function score built utilising three follow-up survey completion.
questions from the WSTR survey at follow-up (Table 2).

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Table 2  Variables used to create the outcomes of recovery and sustainability

Recovery ( x = 4 years, n = 906)

In the past 3 months have you had back pain that lasted for at least one day?
Sustainability (n = 375)
During the past 4 weeks, have you accom- During the past 4 weeks, were you limited in During the past 4 weeks, how much did
plished less than you would like as a result of the kind of work or other activities as a result pain interfere with your normal work?
your physical health? of your physical health?
No none of the time 5 No none of the time 5 Not at all 5
Yes, a little of the time 4 Yes, a little of the time 4 A little bit 4
Yes, some of the time 3 Yes, some of the time 3 Moderately 3
Yes, most of the time 2 Yes, most of the time 2 Quite a bit 2
Yes, all of the time 1 Yes, all of the time 1 Extremely 1
Total function score: 3–15

A score of three represents low levels of function (with disruption to work and physical activities due to pain), whilst a score of 15 represents
very high levels of function (with minimal disruption to work and physical activities due to pain)

Statistical analyses Results

A descriptive statistical analysis was performed to sum- Baseline characteristics

marise the data. Logistic regression models were built
to assess the relationship between lifestyle behaviours, Baseline characteristics of the 1065 participants included in
emotional health factors, and recovery with odds ratios the study are summarised in Table 3, whilst study sample
and 95% confidence intervals (CI) used to quantify the resilience outcomes are summarised in Table 4.
association between the predictor and the outcome. Lin-
ear regression models were built to assess the relationship LBP resilience: recovery outcome
between lifestyle behaviours, emotional health factors, and
sustainability with a correlation coefficient and 95% CI After adjusting for covariates, there was no relationship
used to quantify the association between the predictors and between the combined lifestyle behaviour score and the
the outcome. All analyses were adjusted for dependency of likelihood of people recovering from LBP at follow-up (OR
data to accommodate for the use of twin data. Univariate 1.05, 95% CI 0.97–1.15, p = 0.218). In addition, after adjust-
analyses were performed on all potential confounding vari- ment, there was no relationship between the cumulative
ables and p-values of < 0.2 were used to determine inclu- emotional health score with recovery from LBP at follow-up
sion in the multivariate model [43]. Secondary confirma- (1.08, 95% CI 0.98–1.19, p = 0.142) (Table 5).
tory within-pair analysis was performed when the original The sensitivity analysis revealed a statistically significant
models revealed a statistical association at the 0.05 level, relationship between combinations of fewer lifestyle behav-
by regressing twin-pair differences of predictors on out- iours and recovery. However, no relationship was found
comes [44]. Univariate analyses were performed on all between the fewer combinations of emotional health factors
previous covariates to determine inclusion in the within- and recovery (Supplementary Table 1).
pair model. Only complete twin pairs were included in
the confirmatory within-pair analysis which adjusts for LBP resilience: sustainability outcome
genetic and shared environmental factors. Secondary sen-
sitivity analyses were performed on different combinations After adjusting for covariates, there was a positive asso-
of lifestyle behaviour categories and emotional health cat- ciation between sustainability (i.e. physical function in the
egories. No adjustments for multiple tests in the sensitivity presence of pain) and lifestyle behaviours (β 0.20, 95% CI
analysis were performed to reduce the likelihood of type 2 0.04–0.36, p = 0.013) (Table 6). This twins-as-individuals
errors [45]. Participants with missing data were excluded association was supported by the within-pair analysis (β
and a complete case analysis was performed as missing 1.79, 95% CI 0.05–3.53, p = 0.043).
data was considered independent of the outcome. After adjusting for covariates, there was a positive asso-
Statistical analyses were performed using stata SE 16.1. ciation between sustainability and emotional health factors
All p-values were two-sided, and CIs were set at 95%. (β 0.22, 95% CI 0.00–0.43, p = 0.049) (Table 6), with the
STROBE guidelines were used for accuracy of reporting association being confirmed by the within-pair analysis (β
[46]. 0.52, 95% CI 0.09–0.96, p = 0.021).

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Table 3  Study sample demographics (β 0.28, 95% CI 0.08 to 0.48, p = 0.005) (Supplementary

Characteristics n (%) unless
Table 2). Only one combination of emotional health factors
otherwise (perceived stress/depressive thoughts) showed a relationship
stated with sustainability (β 0.47, 95% CI 0.19–0.76, p = 0.001).
Sex
 Male 337 (31.64)
Zygosity
Discussion
 Dizygotic 363 (34.08)
Findings of this study revealed that greater levels of sustain-
 Monozygotic 702 (65.92)
ability in LBP (i.e. maintenance of high levels of function)
Sex of the pair
are associated with an increased number of healthy lifestyle
 MM 257 (24.13)
behaviours (adequate sleep and physical activity, optimal
 FF 658 (61.78)
BMI, non-smoking, and minimal alcohol consumption) as
 MF 150 (14.08)
well as with healthy emotional factors (lack of depressive
 Age (years) [mean, SD] 43.78 (15.90)
thoughts, low perceived stress, and resilient coping). This
 BMI (h/m2) [mean, SD] 26.32 (5.61)
relationship was confirmed when familial and genetic con-
Marriage status
founders were controlled for in the within-pair analyses. This
 Single, never married 228 (21.41)
study also found that there was no relationship between the
 Married 603 (56.62)
lifestyle behaviour score or the emotional health score with
 Widowed 19 (1.78)
recovery from LBP.
 Divorced 96 (9.01)
Resilience describes the process of successful adaptation
 Separated 18 (1.69)
[19], with physical resilience referring to optimising func-
 Living with partner 86 (8.08)
tion [47], or resisting functional decline [48] following a
Highest level of education at baseline
stressor. It embodies factors that impact on recovering from
 Grades 1–8 2 (0.19)
episodes of pain or enable maintenance of function [12],
 Grades 9–11 12 (1.13)
 Grade 12/high school grad/GED 100 (9.39)
consisting of resilience resources (stable personal charac-
 Some college 266 (24.98)
teristics), and resilience mechanisms (thoughts or behav-
 Associates degree 102 (9.58)
iours that support recovery or function) [12]. Our findings
 Bachelors’ degree 337 (31.64)
suggest that these positive lifestyle behaviours and positive
 Master’s degree 244 (22.91)
emotional health factors may be important resilience mecha-
 Professional degree beyond masters 0 (0)
nisms for promoting high levels of function in the presence
 Doctoral degree 0 (0)
of LBP.
Household income USD (at baseline)
People’s lifestyles may have a significant impact on their
 Less than $20,000 97 (9.11)
physical health, with engagement in sufficient physical activ-
 $20,000–$29,999 70 (6.57)
ity, minimal alcohol consumption, non-smoking habits, and
 $30,000–$39,999 98 (9.20)
healthy diet, associated with a decreased risk of chronic
 $40,000–$49,999 110 (10.33)
disease [35], increased functional health [49], and reduced
 $50,000–$59,999 90 (8.45)
incidence of LBP [50]. Sleep was also included in our life-
 $60,000–$69,999 91 (8.54)
style behaviour score given the protective impact of higher
 $70,000–$79,999 81 (7.61)
levels of sleep quality on the development of LBP [51, 52].
 $80,000–$89,999 408 (38.31)
The findings of this study indicate that the healthier lifestyle
 $90,000 or more 0 (0)
behaviours people adopt, the more likely they are to main-
tain high levels of function despite having LBP, suggest-
Study sample of 1065 participants who reported a history of low back ing that people with LBP may benefit from accumulating
pain that lasted for at least one day in the previous 3 months at base-
resources that support the maintenance of function.
line
Positive affect, extraversion [17], and active coping have
been shown to be associated with improvements in pain and
The sensitivity analysis revealed a relationship between disability associated with arthritis [53] as well as physi-
most of the combinations of four lifestyle behaviour catego- cal activity in people with osteoporosis [54]. Positive psy-
ries and sustainability, with the exception of sleep/physi- chological factors have also been shown to correlate with
cal activity/smoking and alcohol. Of the alternative com- physical functioning and pain tolerance in people with fibro-
binations analysed, the strongest relationship was found myalgia [16] and knee osteoarthritis [17]. Our emotional
for sleep/physical activity/BMI/and alcohol consumption health score, which combined the concepts of absence of

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Table 4  Study sample resilience outcomes and lifestyle behaviour and emotional health scores
Variable Category Individuals with low Individuals who have Individuals who have
back pain at baseline recovered at follow-up sustained at follow-
up*
n= 1065 n= 421 n = 216

Age range (years) 18–85 18–85 18–74

Age (years) [mean, SD] 43.77 (15.9) 44.36 (16.63) 41.5 (14.5)
Recovered at follow-up 421 (45%)
Sustainability score at follow-up 375 (55%)
1st quartile 216 (58%)
2nd quartile 97 (26%)
3rd quartile 46 (12%)
4th quartile 16 (4%)
BMIa [n, %] Optimal (< 25) 489 (46%) 267(46%) 118 (55%)
Intermediate (25–30) 351 (33%) 196(34%) 56 (26%)
Poor ( ≥ 30) 217 (21%) 112(19%) 40 (19%)
Smoking status Optimal (non-smoker) 691 (53%) 374(65%) 144 (67%)
Intermediate (former) 269 (25%) 160(28%) 51(24%)
Poor (occasional or current) 103 (10%) 45(8%) 21 (10%)
Physical activity Optimal ( ≥ 150 min mod or 75 min 322 (30%) 190(33%) 72 (33%)
vig)
Intermediate (60–150 min mod or 504 (47%) 274(47%) 101 (47%)
20–70 min vigorous)
Poor (< 60 min mod) 239 (22%) 116(20%) 43 (20%)
Sleep status Optimal ( ≥ 7 h) 358 (34%) 206(36%) 64 (30%)
Intermediate (6–7 h) 523 (49%) 295(51%) 112(52%)
Poor (< 6 h) 180 (17%) 79(14%) 40 (19%)
Alcohol intake Optimal (audit = 0) 189 (18%) 91(16%) 31(14%)
Intermediate (audit = 1–7) 835 (78%) 474(32%) 175(81%)
Poor (audit > 8) 41 (4%) 15(3%) 10 (5%)
Lifestyle behaviour score
0 0 0 0
1 5 (1%) 2(0%) 1(0.5%)
2 23 (2%) 11(2%) 1(0.5%)
3 42 (4%) 12(2%) 8(4%)
4 94 (9%) 37(6%) 12(6%)
5 158 (15%) 64(11%) 26(12%)
6 254 (24%) 105(18%) 38(18%)
7 230 (22%) 130(23%) 49(23%)
8 179 (17%) 137(24%) 54(25%)
9 58 (6%) 64(11%) 25(12%)
10 8 (1%) 10(2%) 1(0.5%)
Depressed mood/PHQ2b Optimal (O) 565 (53%) 330(57%) 126(58%)
Intermediate (1 or 2) 404 (38%) 211(36%) 76(35%)
Poor ( ≥ 3) 96 (9%) 39(7%) 14(6%)
­ SSc
Perceived stress/Cohen P Optimal (0–13) 574 (54%) 338(59%) 120(56%)
Intermediate (14–26) 447 (42%) 221(38%) 89(41%)
Poor (27–40) 44 (4%) 21(4%) 7(3%)
Resilient coping/BRCSd Optimal (17–20) 259 (24%) 152(26%) 42(19%)
Intermediate (14–16) 421 (40%) 226(39%) 98(45%)
Poor (4–13) 383 (36%) 201(935%) 76(35%)
Emotional health score 0 24 (2%) 9(2%) 4(2%)

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Table 4  (continued)
Variable Category Individuals with low Individuals who have Individuals who have
back pain at baseline recovered at follow-up sustained at follow-
up*
n= 1065 n= 421 n = 216

1 44 (4%) 17(3%) 7(3%)

2 147 (14%) 75(13%) 24(11%)
3 203 (19%) 109(19%) 41(19%)
4 261 (25%) 138(24%) 66(31%)
5 235 (22%) 138(24%) 47(22%)
6 149 (14%) 93(16%) 27(13%)
a
 BMI = Body Mass Index
b
 PHQ2 = Patient Health Questionnaire 2
c
 Cohen PSS = Cohen Perceived Stress Scale
d
 BRCS = Brief Resilient Coping Scale
*Sustained at follow-up describes the people who continue to report low back pain at follow-up and have scores in the top quartile of function on
the sustainability scale

Table 5  Logistic regression of lifestyle behaviour score, emotional depressive thoughts, low levels of perceived stress, and high
health score, and recovery levels of resilient coping, extends this research [16, 17, 53,
Variable OR (95% CI) p value 54], suggesting the more positive emotional health factors
people have, the more likely they are to maintain high levels
Twins-as-individuals of function when faced with LBP.
 Lifestyle behaviour score 1.05 (0.97–1.15) 0.218 n = 857 In the current study no relationship was found between
 Emotional health score 1.08 (0.98–1.19) 0.142 n  = 865 the positive lifestyle behaviour score or the positive emo-
Positive lifestyle behaviour model adjusted for sex, highest level of tional health score and recovery from LBP. Whilst this may
education, household income, musculoskeletal variables, and mental be a limitation of the data that was available (e.g. absence
health variables of LBP as a measure of recovery), it may also suggest that
Positive emotional health model adjusted for sex, highest level of for people who experience LBP, maintenance of function
education, household income, musculoskeletal variables, and mental despite pain may be more important than the absence of
health variables

Table 6  Linear regression Variable Coeff (95% CI) p value R2

of lifestyle behaviour score,
emotional health score, and Positive lifestyle behaviours
sustainability
Twins-as-individuals
 Lifestyle behaviour score 0.20 (0.04–0.36) 0.013* 0.247 n  = 349
Within-pair
 Lifestyle behaviour score 1.79 (0.05–3.53) 0.043* 0.052 n  = 220
Positive emotional health factors
Twins-as-Individuals
 Emotional health score 0.22 (0.00–0.43) 0.049* 0.249 n  = 354
Within-pair
 Emotional health score 0.52 (0.09–0.96) 0.021* 0.069 n = 152

Positive lifestyle behaviour model adjusted for age at baseline, highest level of education, household
income, musculoskeletal variables, and mental health variables. Within-pair model—adjusted for the men-
tal health variable
Positive emotional health model adjusted for age at baseline, sex, highest level of education, household
income, musculoskeletal variables, and mental health variables. Within-pair model—no adjustment
required
*Indicates statistical significance of p < 0.05

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pain. In fact, people with LBP tend not to describe recovery caution and future research should include multiple timepoints
as the absence of pain [55]. Given that LBP is thought to to more thoroughly assess the impact of positive factors on
be a long-lasting condition [5], sustainability may therefore LBP resilience. Future research should attempt to confirm the
be the most effective way to describe how people cope and results of this study through the implementation of inception
adapt, potentially informing how LBP should be effectively cohort studies that use LBP specific outcome measures (e.g.
managed. LBP disability) and more frequent follow-ups to reduce pos-
The World Health Organisation recognises the impor- sible risk of bias and to address the generalisability. Further
tance of empowering people to manage their health and analysis of the twin data—that is, the estimation of between-
well-being through lifestyle behaviour change [56]. Consid- pair, as well as within-pair, associations between lifestyle
ering 75% of those with LBP suffer other comorbid condi- behaviours and LBP resilience would also allow important
tions such as heart and lung disease and diabetes [57], adopt- conclusions to be drawn about the role of heritability (i.e.
ing these positive lifestyle behaviours and emotional health genetics), as well as both shared and non-shared environmen-
factors may impact not only on their LBP but also their tal factors on LBP resilience.
general health and quality of life [58]. Whilst adopting the
five positive lifestyle behaviours analysed may be difficult Clinical implications
for those with LBP, the findings suggest these changes are
likely to be important for maintaining high levels of physical The findings of this study provide important clinical implica-
and work-related function. Given the number of sensitivity tions for targeting lifestyle behaviours and emotional health
analyses conducted and the potential for some of the tests to factors that can impact the sustainability of people who pre-
be underpowered, these results should be viewed with cau- sent with LBP. Using the results of the regression model for
tion. However, the results also showed that combinations of sustainability (β 0.20, 95% CI 0.04–0.36, p = 0.013), if people
four lifestyle behaviours had a greater positive relationship with LBP cease smoking, improve their sleep from less than
with sustainability than fewer factors, supporting the main six hrs/night to eight hrs/night, increase physical activity to
finding that greater numbers of positive lifestyle behaviours more than 20 min/day, consume minimal to no alcohol, and
might be important in people’s capacity to maintain high improve their BMI from 30 to 25, they may improve their
levels of function in LBP. function score on average by two points (out of 15). Using the
function scale, this could reduce the impact of pain on their
Strengths and limitations daily lives from a category of “all of the time” to a category of
“some of the time”, or from a category of “some of the time”
This study has several strengths. The use of a sample of to a category of “none of the time”, with this impact poten-
twins allowed the control of unobserved confounding vari- tially being regarded as clinically meaningful. Moreover, using
ables such as genetics and the early familial environment the results of the regression model for sustainability (β 0.22,
[28, 29], in addition to the adjustment of observed multiple 95% CI 0.00–0.43, p = 0.049), improving emotional health
covariates in the analyses. The longitudinal nature of this from poor to optimal through managing depressive thoughts
study also provides important insights into people’s long- and feelings as well as decreasing stress levels and improv-
term adaptation and coping with LBP. Follow-up surveys ing resilient coping may also reduce the impact of pain on
asked participants how they felt on the average day and at their daily lives from a category of “a little of the time” to a
most, in the past month to minimise recall bias. Further to category of “none of the time”, or from a category of “most of
this, as resilience changes with time, it is expected that the the time” to a category of “some of the time”. This study has
resilience outcomes relate to how the participants felt at the focussed on positive lifestyle factors and positive emotional
time of completing the surveys and not in the period between health factors that impact on recovery and function with LBP.
baseline and follow-up. More importantly, these factors are modifiable and the findings
This study also has some limitations. The lack of repre- highlight the potential benefits of managing lifestyle behav-
sentation of participants from lower socio-economic groups iours and the emotional well-being of people who present with
and less educated people impacts on the generalisability of the ongoing LBP as opposed to promoting the use of traditional,
results. The study participants were largely within intermediate medicalised approaches that often offer little to no value to
to optimal levels of individual lifestyle behaviours which may patients with LBP [59].
also impact on the generalisability of the results. In addition,
the requirements of the twin analysis meant the within-pair
analysis involved small numbers of twin pairs. Despite this, the
twin analysis confirmed the robustness of the results obtained
in the whole cohort, individual analysis. Whilst the sensitivity
analysis was pre-planned, the results should be viewed with

13
European Spine Journal

Conclusion References

To our knowledge, this study was the first to investigate the 1. GBD 2019 Diseases and Injuries Collaborators (2020) Global bur-
den of 369 diseases and injuries in 204 countries and territories,
associations between combinations of positive, rather than 1990–2019: a systematic analysis for the Global Burden of Dis-
negative, factors and LBP resilience, assessed through the ease Study 2019. Two page summary: low back pain. The Lancet.
outcomes of recovery and sustainability. People who adopt 396(10258): S168–S169. https://d​ oi.o​ rg/1​ 0.1​ 016/S
​ 0140-6​ 736(20)​
optimal lifestyle behaviours such as engaging in moderate 30925-9.
2. Sebbag E, Felten R, Sagez F, Sibilia J, Devilliers H, Arnaud L
physical activity, adequate sleep, non-smoking, minimal (2019) The world-wide burden of musculoskeletal diseases: a
alcohol consumption, and maintaining a healthy BMI, as systematic analysis of the World Health Organization Burden of
well as positive emotional factors, are more likely to be resil- Diseases Database. Ann Rheum Dis 78(6):844–848. https://​doi.​
ient and have higher levels of function despite their LBP. org/​10.​1136/​annrh​eumdis-​2019-​215142
3. United States Bone and Joint Initiative. The Burden of Mus-
This has important implications for both clinical guidelines culoskeletal Diseases in the United States (BMUS). Low back
and practice, where encouragement to adopt simple, positive and neck pain 2020 [cited 2021 22nd October]; Available
lifestyle behaviours and emotional health factors may have a from: https://​www.​bonea​ndjoi​ntbur​den.​org/​fourth-​editi​on/​iia0/​
significant impact on LBP management. low-​back-​and-​neck-​pain.
4. Australian Institute of Health and Welfare (2021) Disease
expenditure in Australia 2018–2019, n. Cat, HWE 81 (editor).
Supplementary Information  The online version contains supplemen-
AIHW, Canberra. https://​doi.​org/​10.​25816/​r2ya-​6406
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 00586-0​ 22-0​ 7404-7.
5. Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML,
Genevay S, Hoy D, Karppinen J, Pransky G, Sieper J, Smeets
Acknowledgements  The authors thank the Washington State Twin
RJ, Underwood M, Buchbinder R, Hartvigsen J, Cherkin D,
Registry for making their data available for this research.
Foster NE, Maher CG, Underwood M, van Tulder M, Anema
JR, Chou R, Cohen SP, Menezes Costa L, Croft P, Ferreira M,
Author contributions  All authors contributed to the drafts and read and
Ferreira PH, Fritz JM, Genevay S, Gross DP, Hancock MJ, Hoy
approved the submitted version of this manuscript.
D, Karppinen J, Koes BW, Kongsted A, Louw Q, Öberg B, Peul
WC, Pransky G, Schoene M, Sieper J, Smeets RJ, Turner JA,
Funding  Open Access funding enabled and organized by CAUL and its
Woolf A (2018) What low back pain is and why we need to pay
Member Institutions. This research did not receive any specific fund-
attention. The Lancet 391(10137):2356–2367. https://​doi.​org/​
ing from funding agencies in the public, commercial, or not-for-profit
10.​1016/​s0140-​6736(18)​30480-x
sectors.
6. Parreira PCS, Maher CG, Ferreira ML, Machado GC, Blyth FM,
Naganathan V, Waite LM, Seibel MJ, Handelsman D, Cumming
Data availability  The datasets presented in this article are not readily
RG (2017) A longitudinal study of the influence of comorbidi-
available because data is available from the Washington State Twin
ties and lifestyle factors on low back pain in older men. Pain
Registry after application and approval for use. Requests to access the
158(8):1571–1576. https://​doi.​org/​10.​1097/j.​pain.​00000​00000​
datasets should be directed to [email protected].
000952
7. da Silva T, Mills K, Brown BT, Herbert RD, Maher CG, Han-
Declarations  cock MJ (2017) Risk of recurrence of low back pain: a system-
atic review. J Orthop Sports Phys Ther 47(5):305–313. https://​
Conflict of interest  JMG is a stockholder in MAP Biotech Pty Ltd. The doi.​org/​10.​2519/​jospt.​2017.​7415
authors have no other conflicts of interest to declare. 8. Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel
Shaheed C, Maher CG (2016) Paracetamol for low back pain.
Ethical approval  Participants provided written informed consent Cochrane Database Syst Rev. https://​doi.​org/​10.​1002/​14651​858.​
using procedures approved by the Washington State University IRB CD012​230
(#14547). 9. Enthoven WT, Roelofs PD, Deyo RA, van Tulder MW, Koes
BW (2016) Non-steroidal anti-inflammatory drugs for chronic
Open Access  This article is licensed under a Creative Commons Attri- low back pain. Cochrane Database Syst Rev. 2:12087. https://​
bution 4.0 International License, which permits use, sharing, adapta- doi.​org/​10.​1002/​14651​858.​CD012​087
tion, distribution and reproduction in any medium or format, as long 10. Shiri R, Falah-Hassani K (2017) Does leisure time physical
as you give appropriate credit to the original author(s) and the source, activity protect against low back pain? Systematic review
provide a link to the Creative Commons licence, and indicate if changes and meta-analysis of 36 prospective cohort studies. Br J
were made. The images or other third party material in this article are Sports Med 51(19):1410–1418. https://​doi.​org/​10.​1136/​bjspo​
included in the article's Creative Commons licence, unless indicated rts-​2016-​097352
otherwise in a credit line to the material. If material is not included in 11. Kovacs FM, Seco J, Royuela A, Betegon JN, Sanchez-Herraez S,
the article's Creative Commons licence and your intended use is not Meli M, Martinez Rodriguez ME, Nunez M, Alvarez-Galovich
permitted by statutory regulation or exceeds the permitted use, you will L, Moya J, Sanchez C, Luna S, Borrego P, Moix J, Rodriguez-
need to obtain permission directly from the copyright holder. To view a Perez V, Torres-Unda J, Burgos-Alonso N, Gago-Fernandez I,
copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. Gonzalez-Rubio Y, Abraira V (2018) The association between
sleep quality, low back pain and disability: a prospective study
in routine practice. Eur J Pain 22(1):114–126. https://​doi.​org/​10.​
1002/​ejp.​1095

13
 European Spine Journal

12. Sturgeon JA, Zautra AJ (2010) Resilience: a new paradigm for 29. Vitaro F, Brendgen M, Arseneault L (2009) The discordant MZ-
adaptation to chronic pain. Curr Pain Headache Rep 14(2):105– twin method: one step closer to the holy grail of causality. Int J
112. https://​doi.​org/​10.​1007/​s11916-​010-​0095-9 Behav Dev 33(4):376–382. https://​doi.​org/​10.​1177/​01650​25409​
13. Ong AD, Bergeman CS, Boker SM (2009) Resilience comes of 340805
age: defining features in later adulthood. J Pers 77(6):1777–1804. 30. Afari N, Noonan C, Goldberg J, Edwards K, Gadepalli K, Oster-
https://​doi.​org/​10.​1111/j.​1467-​6494.​2009.​00600.x man B, Evanoff C, Buchwald D (2006) University of Washington
14. Ong AD, Zautra AJ, Reid MC (2015) Chronic pain and the adap- Twin Registry: construction and characteristics of a community-
tive significance of positive emotions. Am Psychol 70(3):283– based twin registry. Twin Res Hum Genet 9(6):1023–1029.
284. https://​doi.​org/​10.​1037/​a0038​816 https://​doi.​org/​10.​1375/​18324​27067​79462​543
15. Smith BW, Zautra AJ (2008) Vulnerability and resilience in 31. Duncan GE, Avery AR, Strachan E, Turkheimer E, Tsang S (2019)
women with arthritis: test of a two-factor model. J Consult Clin The Washington State Twin Registry: 2019 update. Twin Res
Psychol 76(5):799–810. https://d​ oi.​org/​10.​1037/0​ 022-​006X.​76.5.​ Hum Genet 22(6):788–793. https://​doi.​org/​10.​1017/​thg.​2019.​36
799 32. Strachan E, Hunt C, Afari N, Duncan G, Noonan C, Schur E, Wat-
16. Furlong LV, Zautra A, Puente CP, Lopez-Lopez A, Valero PB son N, Goldberg J, Buchwald D (2013) University of Washington
(2010) Cognitive-affective assets and vulnerabilities: two factors Twin Registry: poised for the next generation of twin research.
influencing adaptation to fibromyalgia. Psychol Health 25(2):197– Twin Res Hum Genet 16(1):455–462. https://d​ oi.o​ rg/1​ 0.1​ 017/t​ hg.​
212. https://​doi.​org/​10.​1080/​08870​44080​20746​56 2012.​124
17. Johnson-Wright L, Zautra AJ, Going S (2008) Adaptation to early 33. Harrington J, Perry IJ, Lutomski J, Fitzgerald AP, Shiely F,
knee osteoarthritis: the role of risk, resilience, and disease severity McGee H, Barry MM, Van Lente E, Morgan K, Shelley E (2010)
on pain and physical functioning. Ann Behav Med 36(1):70–80. Living longer and feeling better: healthy lifestyle, self-rated
https://​doi.​org/​10.​1007/​s12160-​008-​9048-5 health, obesity and depression in Ireland. Eur J Public Health
18. Hanssen MM, Peters ML, Vlaeyen JWS, Meevissen YMC, Van- 20(1):91–95. https://​doi.​org/​10.​1093/​eurpub/​ckp102
cleef LMG (2013) Optimism lowers pain: evidence of the causal 34. Li Y, Pan A, Wang DD, Liu X, Dhana K, Franco OH, Kaptoge
status and underlying mechanisms. Pain 154(1):53–58. https://d​ oi.​ S, Di Angelantonio E, Stampfer M, Willett WC, Hu FB (2018)
org/​10.​1016/j.​pain.​2012.​08.​006 Impact of healthy lifestyle factors on life expectancies in the US
19. Zautra A, Hall J, Murray K (2010) Resilience. A new definition population. Circulation 138(4):345–355. https://​doi.​org/​10.​1161/​
of health for people and communities. In: Reich J, Zautra A, Hall CIRCU​LATIO​NAHA.​117.​032047
S (eds) Handbook of adult resilience. Guildford Press, New York, 35. Nyberg ST, Singh-Manoux A, Pentti J, Madsen IEH, Sabia S,
pp 3–29 Alfredsson L, Bjorner JB, Borritz M, Burr H, Goldberg M, Heik-
20. Zautra AJ (2009) Resilience: one part recovery, two parts sustain- kila K, Jokela M, Knutsson A, Lallukka T, Lindbohm JV, Nielsen
ability. J Pers 77(6):1935–1943. https://​doi.​org/​10.​1111/j.​1467-​ ML, Nordin M, Oksanen T, Pejtersen JH, Rahkonen O, Rugulies
6494.​2009.​00605.x R, Shipley MJ, Sipila PN, Stenholm S, Suominen S, Vahtera J,
21. Nielsen LA, Nielsen TR, Holm JC (2015) The impact of familial Virtanen M, Westerlund H, Zins M, Hamer M, Batty GD, Kivi-
predisposition to obesity and cardiovascular disease on childhood maki M (2020) Association of healthy lifestyle with years lived
obesity. Obes Facts 8(5):319–328. https://​doi.​org/​10.​1159/​00044​ without major chronic diseases. JAMA Intern Med. https://​doi.​
1375 org/​10.​1001/​jamai​ntern​med.​2020.​0618
22. Brandkvist M, Bjorngaard JH, Odegard RA, Asvold BO, Sund 36. Poortinga W (2007) The prevalence and clustering of four major
ER, Vie GA (2019) Quantifying the impact of genes on body mass lifestyle risk factors in an English adult population. Prev Med
index during the obesity epidemic: longitudinal findings from the 44(2):124–128. https://​doi.​org/​10.​1016/j.​ypmed.​2006.​10.​006
HUNT Study. BMJ 366:l4067. https://​doi.​org/​10.​1136/​bmj.​l4067 37. Conry MC, Morgan K, Curry P, McGee H, Harrington J, Ward
23. Madrid-Valero JJ, Rubio-Aparicio M, Gregory AM, Sanchez- M, Shelley E (2011) The clustering of health behaviours in Ire-
Meca J, Ordonana JR (2020) Twin studies of subjective sleep land and their relationship with mental health, self-rated health
quality and sleep duration, and their behavioral correlates: system- and quality of life. BMC Public Health 11:692. https://​doi.​org/​10.​
atic review and meta-analysis of heritability estimates. Neurosci 1186/​1471-​2458-​11-​692
Biobehav Rev 109:78–89. https://​doi.​org/​10.​1016/j.​neubi​orev.​ 38. Pinheiro MB, Ferreira ML, Refshauge K, Maher CG, Ordonana
2019.​12.​028 JR, Andrade TB, Tsathas A, Ferreira PH (2016) Symptoms of
24. Avenevoli S, Merikangas KR (2003) Familial influences on ado- depression as a prognostic factor for low back pain: a systematic
lescent smoking. Addiction 98:1–20. https://​doi.​org/1​ 0.​1046/j.​ review. Spine J 16(1):105–116. https://​doi.​org/​10.​1016/j.​spinee.​
1360-​0443.​98.​s1.2.x 2015.​10.​037
25. Enoch MA (2012) The influence of gene-environment interac- 39. Puschmann AK, Driesslein D, Beck H, Arampatzis A, Moreno
tions on the development of alcoholism and drug dependence. Catala M, Schiltenwolf M, Mayer F, Wippert PM (2020) Stress
Curr Psychiatry Rep 14(2):150–158. https://​doi.​org/​10.​1007/​ and self-efficacy as long-term predictors for chronic low back
s11920-​011-​0252-9 pain: a prospective longitudinal study. J Pain Res 13:613–621.
26. Aasdahl L, Nilsen TIL, Meisingset I, Nordstoga AL, Evensen https://​doi.​org/​10.​2147/​JPR.​S2238​93
KAI, Paulsen J, Mork PJ, Skarpsno ES (2021) Genetic variants 40. Hoy D, Bain C, Williams G, March L, Brooks P, Blyth F, Woolf
related to physical activity or sedentary behaviour: a systematic A, Vos T, Buchbinder R (2012) A systematic review of the global
review. Int J Behav Nutr Phys Act 18(1):15. https://​doi.​org/​10.​ prevalence of low back pain. Arthritis Rheum 64(6):2028–2037.
1186/​s12966-​020-​01077-5 https://​doi.​org/​10.​1002/​art.​34347
27. Ferreira PH, Beckenkamp P, Maher CG, Hopper JL, Ferreira ML 41. Hoy D, March L, Brooks P, Blyth F, Woolf A, Bain C, Williams G,
(2013) Nature or nurture in low back pain? Results of a systematic Smith E, Vos T, Barendregt J, Murray C, Burstein R, Buchbinder
review of studies based on twin samples. Eur J Pain 17(7):957– R (2014) The global burden of low back pain: estimates from the
971. https://​doi.​org/​10.​1002/j.​1532-​2149.​2012.​00277.x Global Burden of disease 2010 study. Ann Rheum Dis 73(6):968–
28. Turkheimer E, Harden KP, Reis HT, Judd CM (2013) Behavior 974. https://​doi.​org/​10.​1136/​annrh​eumdis-​2013-​204428
genetic research methods. In: Handbook of research methods in 42. Shmagel A, Foley R, Ibrahim H (2016) Epidemiology of Chronic
social and personality psychology, pp 159–187. https://​doi.​org/​ low back pain in US adults: data from the 2009–2010 national
10.​1017/​CBO97​80511​996481.​012

13
European Spine Journal

health and nutrition examination survey. Arthritis Care Res 56. World Heath Organisation (2022) Health promotion and disease
68(11):1688–1694. https://​doi.​org/​10.​1002/​acr.​22890 prevention through population-based interventions, including
43. Thabane L, Mbuagbaw L, Zhang S, Ye C, Thabane M, Giangrego- WHO EMRO.
rio L, Dennis B, Kosa D (2013) A tutorial on sensitivity analyses 57. Australian Institute of Health and Welfare. Back problems.
in clinical trials: the what, why, when and how. BMC Med Res Reports and Data Cat.no:PHE231 2020 [cited 2022; Available
Methodol 13(92):1–12. https://​doi.​org/​10.​1186/​1471-​2288-​13-​92 from: https://​www.​aihw.​gov.​au/​repor​ts/​chron​ic-​muscu​loske​letal-​
44. Carlin JB, Gurrin LC, Sterne JA, Morley R, Dwyer T (2005) condi​tions/​back-​probl​ems/​conte​nts/​what-​are-​back-​probl​ems
Regression models for twin studies: a critical review. Int J Epi- 58. Yang H, Haldeman S (2018) Behavior-related factors associated
demiol 34(5):1089–1099. https://​doi.​org/​10.​1186/​1471-​2288-​13-​ with low back pain in the US adult population. Spine 43(1):28–34.
9210.​1093/​ije/​dyi153 https://​doi.​org/​10.​1097/​BRS.​00000​00000​001665
45. Perneger T (1998) What’s wrong with Bonferroni adjustments? 59. Traeger AC, Buchbinder R, Elshaug AG, Croft PR, Maher CG
Br Med J 316(7139):1236–1238 (2019) Care for low back pain: Can health systems deliver? Bull
46. von Elm E, Altman D, Egger M, Pocock S, Gøtzsche P, Vanden- World Health Organ 97(6):423–433. https://d​ oi.o​ rg/1​ 0.2​ 471/B ​ LT.​
broucke J, Initiative S (2008) The Strengthening the Reporting 18.​226050
of Observational Studies in Epidemiology (STROBE)statement: 60. World Health Organisation. Body mass index - BMI. Health Top-
guidelines for reporting observational studies. J Clin Epidemiol ics 2021 [cited 2021 20.12.2021]; Available from: https://​www.​
61(4):344–349. https://​doi.​org/​10.​1016/j.​jclin​epi.​2007.​11.​008 euro.w ​ ho.i​ nt/e​ n/h​ ealth-t​ opics/d​ iseas​ e-p​ reven​ tion/n​ utrit​ ion/a-h​ ealt​
47. Resnick B, Galik E, Dorsey S, Scheve A, Gutkin S (2011) Reli- hy-​lifes​tyle/​body-​mass-​index-​bmi
ability and validity testing of the physical resilience measure. Ger- 61. World Health Organisation, Global Recommendations on Physical
ontologist 51(5):643–652. https://​doi.​org/​10.​1093/​geront/​gnr016 Activity for Health. 2010: Geneva. https://w ​ ww.w ​ ho.i​ nt/p​ ublic​ atio​
48. Whitson HE, Duan-Porter W, Schmader KE, Morey MC, Cohen ns/i/​item/​97892​41599​979
HJ, Colon-Emeric CS (2016) Physical resilience in older adults: 62. Watson NF, Badr MS, Belenky G, Bliwise DL, Buxton OM,
systematic review and development of an emerging construct. J Buysse D, Dinges DF, Gangwisch J, Grandner MA, Kushida C,
Gerontol A Biol Sci Med Sci 71(4):489–495. https://​doi.​org/​10.​ Malhotra RK, Martin JL, Patel SR, Quan SF, Tasali E (2015) Rec-
1093/​gerona/​glv202 ommended amount of sleep for a healthy adult: a joint consensus
49. Myint PK, Surtees PG, Wainwright NW, Wareham NJ, Bingham statement of the American Academy of sleep medicine and sleep
SA, Luben RN, Welch AA, Smith RD, Harvey IM, Khaw KT research society. Sleep 38(6):843–844. https://​doi.​org/​10.​5665/​
(2007) Modifiable lifestyle behaviors and functional health in the sleep.​4716
European Prospective Investigation into Cancer (EPIC)-Norfolk 63. Buysse D, Reynolds C, Monk T, Brmna S, Kupfer D (1989) The
population study. Prev Med 44(2):109–116. https://​doi.​org/​10.​ Pittsburgh sleep quality index: a new instrument for psychiatric
1016/j.​ypmed.​2006.​09.​007 practice and research. Psychiatry Res 28:193–213. https://d​ oi.o​ rg/​
50. Bohman T, Alfredsson L, Jensen I, Hallqvist J, Vingard E, Skill- 10.​1016/​0165-​1781(89)​90047-4
gate E (2014) Does a healthy lifestyle behaviour influence the 64. Mental Health Commission of Western Australia. AUDIT Alcohol
prognosis of low back pain among men and women in a gen- Screening Tool. 2018 [cited 2021 13.5.2021]; Available from:
eral population? A population-based cohort study. BMJ Open https://w​ ww.m ​ hc.w ​ a.g​ ov.a​ u/m
​ edia/2​ 607/a​ lcoho​ l-a​ udit-s​ creen​ ing-​
4(12):e005713. https://​doi.​org/​10.​1136/​bmjop​en-​2014-​005713 tool-​mk4.​pdf.
51. Alsaadi S, McAuley J, Hush J, Lo S, Bartlett D, Grunstein R, 65. Kroenke KS, Williams RJ (2003) The Patient Health Question-
Maher C (2014) The bidirectional relationship between pain inten- naire-2 validity of a two-item depression screener. Med Care.
sity and sleep disturbance/quality in patients with low back pain. https://​doi.​org/​10.​1097/​01.​MLR.​00000​93487.​78664.​3C
Clin J Pain 30(9):755–765. https://​doi.​org/​10.​1097/​AJP.​00000​ 66. Kamarck T, Mermelstein R, Cohen S (1983) A global measure of
00000​000055 perceived stress. J Health Soc Behav 24(4):385–396. https://​doi.​
52. Seelig AD, Jacobson IG, Donoho CJ, Trone DW, Crum-Cianflone org/​10.​2307/​21364​04
NF, Balkin TJ (2016) Sleep and health resilience metrics in a large 67. New Hamsphire Government (2021) Percieved stress scale. In:
military cohort. Sleep 39(5):1111–1120. https://​doi.​org/​10.​5665/​ State of New Hampshire Employee Assisstance Program. New
sleep.​5766 Hampshire government: New Hampshire. https://d​ as.n​ h.g​ ov/w ​ elln​
53. Fisher MN, Snih SA, Ostir GV, Goodwin JS (2004) Positive affect ess/​docs/​perci​eveds​tress​scale.​pdf
and disability among older Mexican Americans with arthritis. 68. Sinclair VG, Wallston KA (2004) The development and psycho-
Arthritis Rheum 51(1):34–39. https://​doi.​org/​10.​1002/​art.​20079 metric evaluation of the Brief Resilient Coping Scale. Assessment
54. Pasco JA, Jacka FN, Williams LJ, Brennan SL, Leslie E, Berk M 11(1):94–101. https://​doi.​org/​10.​1177/​10731​91103​258144
(2011) Don’t worry, be active: positive affect and habitual physical
activity. Aust N Z J Psychiatry 45(12):1047–1052. https://d​ oi.o​ rg/​ Publisher's Note Springer Nature remains neutral with regard to
10.​3109/​00048​674.​2011.​621063 jurisdictional claims in published maps and institutional affiliations.
55. Hush JM, Refshauge K, Sullivan G, De Souza L, Maher CG,
McAuley JH (2009) Recovery: what does this mean to patients
with low back pain? Arthritis Rheum 61(1):124–131. https://​doi.​
org/​10.​1002/​art.​24162

13