Disability,pain catastrophizing and stress coping of patients with low back pain in rehabilitation practice in Latvia

1. Introduction

It is known that pain has emotional and behavioral consequences that influences development of the problems and outcome of the treatment [1]. Exaggerated psychosocial response to acute pain is maladaptive and may intensify the pain experience and impede recovery. Patients’ attitudes and coping mechanisms seem to play a causal role in the chronification of low back pain (LBP) and augment a cycle of chronic pain and disability [2]. There is some evidence that catastrophizing as a cognitive response or ongoing coping strategy might lead to delayed recovery [3].

Patients who do not participate in activities due to expectations of pain possibly experience a considerable rise in functional disability over time. Such behavior may potentially increase sensitivity to pain, muscle atrophy and weight gain. This cycle of increasing negative expectancies and avoidance behaviors is likely to contribute to maintaining chronic pain and decrease in functioning over time [4].

There are studies that show that pain catastrophizing, fear of movement or reinjury and general emotional distress are related to pain and disability [5].

Sullivan et al. found significant correlation of pain catastrophizing with reported pain intensity and perceived disability [6].

According to Lazarus and Folkman’s stress appraisal model, individual assesses pain stressor relevance and levels of harm as the primary appraisal, then continues to reflect upon the coping options and formulate the possibility of success as the secondary appraisal. Investigators suggest that pain catastrophizing magnification and rumination domain stems from a dysfunctional focus and evaluation in the primary appraisal stage, while helplessness is a maladaptive and negative secondary appraisal [7].

Catastrophizing had originally been construed as a way of coping and may serve as a coping function by eliciting supportive or solicitous responses from others [8].

Furthermore, catastrophizing has also been linked to adverse pain outcomes [9, 10] and it can therefore be surmised that a reduction in pain catastrophizing will lead to a reduction in pain and disability [11].

There are studies reporting a reduction in fear avoidance and disability in patients who had acute low back pain and were treated by physical therapists when emotional and cognitive aspects were addressed [12].

This highlights the importance of a multifactorial approach to pain management with biopsychosocial model and holistic approaches to treating chronic pain [13].

2. Objective

To examine pain catastrophizing, stress coping strategies and disability among patients with low back pain in rehabilitation practice in Latvia.

3. Methods

The study included all patients who were sent for rehabilitation and entered the rehabilitation center “Vaivari” from 1 September 2015 until 1 April 2016 and complied with the inclusion criteria of the study. Study participants included 74 patients with clinical diagnosis: lumbar and other intervertebral disc disorders with radiculopathy and spondylosis (according to ICD-10 M51.1 and M 47); aged 18 + years; had no comorbid malignant/terminal diseases, had no severe psychopathological disorders (schizophrenia, bipolar disorder, major depression with suicidal intention and substance misuse) and agreed to participate in the research.

Eligible patients were given an information sheet explaining the study with assurance of anonymity and were informed that a refusal to participate in the study would not affect any further treatment. Written informed consent was obtained. The design of the study protocol was approved by the National Rehabilitation Center Ethics Committee.

In the study five research tools were used: Demographic questionnaire, Pain Catastrophizing Scale (Sullivan et al. 1995), Visual Analogue Scale (VAS); “The Ways of Coping scale” (Folkman & Lazarus, 1985); The Oswestry Low Back Disability Questionnaire (Fairbanks et al., 1980).

The Pain Catastrophizing Scale consists of 13 questions (thoughts and feelings) and question participants about past painful experiences and indicate the degree to which they experienced each of the 13 feelings or thoughts. These questions are measured in a 5-point Likert scale from 0 (not at all) to 4 (all the time). All questions were divided into three subscales: Rumination, magnification and helplessness [14]. The scale demonstrated high internal consistency, Cronbach’s Alpha 0.92.

Using the Visual Analogue Scale (VAS), patients were asked to mark on the 10-cm long line the intensity of pain at the moment. Using a ruler, the score was determined by measuring the distance (mm) on the 10-cm line between “no pain” and “severe pain”, providing a range of scores from 0–100. According to results VAS ratings of 0 to 4 mm indicates “no pain”; 5 to 44 mm – “mild pain”; 45 to 74 mm – “moderate pain”; and 75 to 100 mm – “severe pain” [15].

“The Ways of Coping scale” consists of 66 items which are divided into eight subscales. Confrontive coping, seeking social support and planful problem solving corresponds to Problem- oriented stress coping, whereas Distancing, self-controlling, accepting responsibility, escape-avoidance and positive reappraisal refers to emotional-oriented stress coping. A 4-point rating scale was used where 0 indicated “never use,” 1 indicated “use sometimes,” 2 indicated “use often enough,” and 3 indicated “use frequently” The Scale had high level of internal consistency (0.93).

The Oswestry Low Back Disability Questionnaire examines perceived level of disability in 10 everyday activities: pain, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life and travelling. All activities are scored from 0 to 5 with the first statement scoring 0 through to the last at 5. The sum of the section scores is transformed to a percentage score. The total possible score ranges 0–100 and a higher score indicates worse function. Results indicates the level of disability and it ranges from 0–20% – minimal disability; 21–40% – moderate disability; 41–60% – severe disability; 61–80% – crippled and 80–100% complete disability [16]. The Questionnaire showed good internal consistency and reliability (0.78).

All data analyses were performed using SPSS, version 20. Descriptive statistics were performed for the entire sample, including demographic factors, pain characteristics and self-report measurements. According to the distribution of the obtained data further analysis was performed based on non-parametric methods. Correlations between the scores of the different scales were obtained through Spearman’s correlation coefficient. Homogeneity between groups was assessed using Leven’s test. For all tests P value 0.05 was considered statistically significant.

4. Results

The characteristics of the participants are presented in Table 1. The mean age of participants was 48.4 years with the majority being female – 57.7%. According to The Oswestry Low Back Disability Questionnaire most of the respondents – 65.8% had moderate disability (21%–40%) –, which means that these patients experienced more pain and difficulty during sitting, lifting and standing. Travel and social life were more difficult and they could be disabled in work. Personal care, sexual activity and sleeping were not grossly affected, whereas minimal disability (0–20%) had 28.9% of the participants and severe disability (41%–60%) – 5.3% of the patients. The disability index ranged from 2% to 48.89%, with mean value 25.69% which corresponds to moderate disability overall.

The mean value of Visual Analogue Scale (31.4 mm) on the other hand refers to mild pain. According to the mean values of “The Ways of Coping scale”, emotional-oriented stress coping of patients with low back pain were higher than problem-oriented stress coping (Table 2).

There were statistically significant correlations between low back pain disability and rumination ( r = 0.489), magnification ( r = 0.326) and helplessness ( r = 0.519). Statistically significant correlations were found between problem-oriented stress coping and magnification ( r = 0.283). Emotion-oriented stress coping correlated significantly significant with VAS ( r = 0.298) and magnification ( r = 0.257) (Table 3).

There are statistically significant correlations between catastrophizing and confrontive coping ( r = 0.310), escape-avoidance ( r = 0.402) and emotion-oriented stress coping ( r = 0.242). Also, between rumination and escape-avoidance ( r = 0.299). While magnification has statistically significant correlation with confrontive coping ( r = 0.319), seeking social support ( r = 0.302), accepting responsibility ( r = 0.238), escape-avoidance ( r = 0.467), problem-oriented stress coping ( r = 0.283) and emotion-oriented stress coping ( r = 0.257). According to the helplessness subscale we can see statistically significant correlations with confrontive coping ( r = 0.292) and escape-avoidance ( r = 0.383) (Table 4).

There were statistically significant differences in ways of coping and pain severity. Patients with no or mild pain tended to use less confrontive coping, self-controlling, accepting responsibility, escape-avoidance and emotion-oriented stress coping than patients with moderate and severe pain (Table 5).

Patients with minimal disability had lower mean values in rumination, helplessness and catastrophizing than study participants with moderate disability. There were statistically significant correlations between groups in rumination and helplessness subscales ( 0.01) (Table 6).

No statistically significant differences were found in catastrophizing and stress coping strategies between participants with different gender, visit number, in-patients or out-patients, living alone or in relationship, level of education and smoking. No correlations were found between disability and stress coping strategies.

This study examined pain catastrophizing, stress coping strategies and disability and their interrelations among patients with low back pain. Sociodemographic and medical data of patients with low back pain of the patients in the sample: these patients were married/cohabitant (77%), with higher education (43.2%), non-smokers (70.5%), they had been complaining about mild low back pain for six or more years, most of them are women (57.7%). Our results demonstrated similar findings with other studies, which reported the gender-associated LBP to be more common among women – several studies had shown that women were more likely to suffer from chronic pain and were more susceptible to it than men [17, 18]. It is well established that gender differences in pain exists, but the specific underlying mechanisms contributing to this are not clear [19]. Our obtained data about education level of patients in our sample are contradictory with other researcher’s findings, although further studies are necessary in Latvian population.

According to our data there were strong interrelationships of disability and pain catastrophizing in all subscales. The research data showed significantly higher scores of pain catastrophizing in patients with more severe disability.

It was also noted the following link, patients with relatively more intense pain, had relatively higher scores of stress coping ways. The most significant differences in ways of coping strategies between patients with no pain and moderate/severe pain were following: Accepting responsibility, escape-avoidance and confrontive coping. It is important to mention that the emotion-oriented stress coping strategy statistically significant increased with the intensity of the pain.

Our study showed that emotion-oriented coping strategy showed correlation with pain catastrophizing in magnification subscale, but confrontive coping accordingly with magnification and helplessness. It is important to note that the escape-avoidance coping statistically significant correlated with all pain catastrophizing scales – rumination, magnification and helplessness. Catastrophizing could be as an exaggerated negative interpretation of pain that may occur during an actual or anticipated pain experience and together with previous mentioned stress coping strategies might influence the level of disability through emotions [20, 21].

There are study data that patients with chronic pain who have higher pain catastrophizing, feel more disabled by their pain and endure more psychological distress than those who have lower pain catastrophizing [22]. The pain related fear model adapted from Vlaeyen and Linton shows that fear of pain develops because of cognitive interpretation of pain as pain catastrophizing which leads to avoidance behavior followed by disability. Escape and avoidance behaviors contribute to the cycle of chronic pain [4].

Avoidance behavior is maladaptive response and if it persists, it can convey to extended fear, restricted activity and other physical and psychological consequences that leads to disability and persistence of pain [13]. Furthermore, studies show that worry and fear of the movement and avoidance strategy are better predictors of functional limitations than biomedical markers or pain severity [23, 24]. Taking into consideration that people believe in vulnerability of the spine and the need to avoid activities (Fear avoidance beliefs) appear to be strong predictor of prolonged pain, delayed recovery and work absence [25].

It should be noted that most of the our study participants with low back pain had back pain duration 2 years and more and for 28.4% it was over 10 years.

This corresponded to the fear avoidance model of chronic pain which included affective and behavioral components or avoidance with catastrophic interpretation of pain. Therefore it is necessary to address and correct these maladaptive beliefs. Few studies showed that addressing these issues in the primary care setting reduced disability in pacients with back pain [26, 27].

The present study has a number of limitations. The study did not use any objective indices, but confide on a self-report measure. Patients were asked to describe their level of disability as it related to various forms of activities of daily living, their attitudes and beliefs. As a limitation shoud be mentioned relatively low study participants number.

6. Conclusion

Achieved results highlight the importance of a multifactorial approach to pain management and the enourmous significance of pain catastrophizing in patients with low back pain. It is critical to recognise these factors in both the acute and chronic pain patients in order to understand which aspects of their pain are a barrier to their recovery. The biopsychosocial approach view illness as the result of the dynamic interaction between psychologic and social factors and is widely accepted, but unfortunately not fully implemented. Therefore there is a necessity of the development of interdisciplinary pain management and rehabilitation approach programs for patients with low back pain.