A cross-sectional study of disability and quality of life in patients with low back pain: Focus on sex and gender

Abstract

BACKGROUND:

Sex and gender affect responses to pain, but little is known about disability and quality of life.

OBJECTIVES:

To investigate the effects of sex and gender on disability and health-related quality of life (HRQOL) in patients with low back pain.

METHODS:

Ninety-three patients with low back pain were included in this cross-sectional survey study. Disability, HRQOL and gender identity were respectively assessed with the Oswestry Disability Index, Short Form-36 and Bem Sex Role Inventory. The participants were classified into four gender role orientations (masculinity, femininity, androgyny and undifferentiated). One-way analysis of variance was used to analyze both the sex and the gender role orientation.

RESULTS:

Females had higher disability than males ( $p<$ 0.05), but in gender identity, no significant difference was found. Seven domains of HRQOL were lower than the healthy norms. Males experienced greater impacts than females on vitality and mental health ( $p<$ 0.05). For gender identity, five domains of HRQOL had significant differences ( $p<$ 0.05). Masculinity orientation had the least impact on four domains ( $p<$ 0.05), while undifferentiated orientation had the largest impact on all domains.

CONCLUSION:

Sex and gender effects can be used to analyze disability and HRQOL in patients with low back pain. Females have higher disability, while HRQOL is greatly influenced by different gender role orientations.

Keywords

Disability quality of life low back pain sex gender

1. Background

Back pain is the most frequent musculoskeletal disorder among workers [1]. It can present anytime from childhood to older age [2], and nearly 80 percent of adults experience back pain in their lives [3]. Such pain may lead to disability, which extends beyond pain and can lead to overall health problems, more comorbidities, psychological distress, and poor health-related quality of life (HRQOL) [4]. Patients with chronic back pain also tend to be socioeconomically disadvantaged, with a higher unemployment rate and lower income due to disability [5].

Sex is defined as a biological construct, while gender is defined as a social construct. In the biological sex construct, an individual is defined as being male or female according to genetics, anatomy and physiology [6]. It has been suggested that researchers use the term sex when describing the numbers of males and females, or that they stratify outcomes by males versus females for studies [7]. In the social gender construct, gender identity describes how one sees oneself and is seen by others in the dimensions of femaleness or maleness in a society or across a feminine-masculine continuum. Gender identity affects our feelings and behavior [6, 7]. Gender identity affects many health behaviors, such as diet and physical activity, substance abuse, injury and violence, and preventative health behaviors [8]. Gender mainstreaming is an important concept for health, education, environment, and policy. The World Health Organization recommends that researchers consider the differences between males and females, as well as the socialization of gender and differences in gender role characteristics [9, 10, 11].

Masculine traits are a focus on self, independence and goal achievement, which are related to an instrumental orientation; feminine traits are a focus on communication and the connection of self with others, which are related to an expressive orientation [12, 13]. Traditional positive masculine traits are ambition, self-reliance, independence, and courage; traditional positive feminine traits are affection, gentleness, understanding, sensitivity to the needs of others, and empathy. Masculine and feminine traits are related to psychological well-being and self-rated health [13]. These gender traits can be assessed with the Bem Sex Role Inventory (BSRI). A person with a higher masculine score (MS) exhibits more positive masculine traits, and one with a higher feminine score (FS) manifests more positive feminine traits.

Both sex and gender affect one’s experience of pain. Many studies have reported that men and women differ in their responses to pain; women have greater pain prevalence, and they report pain more frequently than do men [14]. These differences have been ascribed to the interaction of biological, psychological, and sociocultural factors. Among the sociocultural factors, feminine and masculine traits influence pain responses. Males with more masculine and fewer feminine traits have higher pain thresholds than do those with more feminine and fewer masculine traits [15]. Masculinity is positively correlated with pain tolerance, and learned masculinity encourages people to withstand pain [16, 17]. Many studies have explored the effects of sex/gender characteristics on pain, but few have assessed the effects on disability and HRQOL in patients with different diseases. Although feminine traits predict more clinical pain [18], the results on masculinity have not been consistent. For example, a study on chronic prostatitis-like syndrome found no significant correlations of mean masculinity and femininity scores to scores of pain and urinary symptoms [19]. However, in Trudeau et al.’s study, agency/instrumentality, one aspect of masculinity, was found to be associated with better health outcomes; predicted less physical disability, pain, and distress; and was associated with greater life satisfaction in patients with rheumatoid arthritis [20].

To our best knowledge, no studies have focused on their effects on disability and/or quality of life in patients with low back pain. The purpose of this study was to investigate the sex and gender effects on disability and HRQOL in patients with low back pain.

2. Methods

2.1 Subjects

A convenience sample of patients with low back pain was recruited from the outpatient department of the Department of Orthopedics of Kaohsiung Medical University Hospital from October 1, 2012 to December 31, 2014. The research protocol was approved by the Institutional Review Board of Kaohsiung Medical University Hospital (KMUH-IRB-20120026), and written informed consent was obtained from all subjects. Participants were included if they met the following criteria: age of 18 or older; low back pain with or without leg pain; diagnosis of low back pain ascribed to spondylolisthesis, spinal stenosis, degenerative joint disease, herniated intervertebral disc, failed back syndrome, strain and sprain, and compression fracture, as well as non-specific back pain; the ability to read traditional Chinese; and the absence of physical limitations affecting the ability to complete the self-administered questionnaire. The exclusion criteria included other types of pain, such as knee osteoarthritis and soft tissue trauma of the lower leg, and general absence of low back pain. The treatment programs were not changed after the patients agreed to participate in the study.

2.2 Procedures

After receiving an explanation of the research program, each patient was asked to complete a questionnaire booklet containing the Oswestry Disability Index (ODI) for assessing disability, the MOS short form 36 (SF-36) for assessing HRQOL, the BSRI for assessing gender identity, the Visual Analog Scale (VAS) for back and leg pain severity, and demographic questions. The patients were subdivided according to sex and gender type.

2.3 Instruments

2.3.1 Disability

Disability was measured with the ODI. The ODI is a questionnaire containing 10 items on the degree of severity to which back (or leg) trouble affects the patient’s ability to manage in everyday life [21]. Each item is scored on a 6-point scale (0–5), with 0 representing no limitation and 5 representing maximal limitation. The raw score is the sum of the item scores (0–50), and the score is commonly transformed to a scale of 0 to 100 to indicate a percentage of patient-perceived disability (0–100%). The functional levels of the patients with low back pain were commonly assessed with a validated translated version of the ODI [22]. The Chinese ODI 2.1 is a well-developed questionnaire with good reliability and validity [23]. The raw scores can be translated into logit scores with a norm table developed by Rasch analysis from a large sample of patients with back pain [24]. A score of zero logits indicates a disability level equal to the mean disability of the norm. A more positive logit score indicates more disability, and a more negative logit score indicates less disability. The reliability was high (reliability coefficient $=$ 0.89) and the test information curve (maximum test information ${>}$ 12, indicating very small standard error) indicated precise estimation of dysfunction.

2.3.2 HRQOL

HRQOL was measured with the SF-36. The SF-36 has 8 health domains: physical functioning (PF), role limitations due to physical health problems (Role-physical, RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role limitations due to emotional problems (Role-emotional, RE), and mental health (MH). The transformed score of each domain ranges from 0 to 100, with higher scores indicating better HRQOL [25]. The Taiwan version of the SF-36 has been shown to have good reliability and validity [26]. The normative values were derived from the 2001 Health Interview Survey of 17,515 subjects and is available with age and sex stratification [27]. The scores in the 8 health domains of the patients with low back pain were compared with the normative values of the SF-36 Taiwan version.

2.3.3 Gender identity

Gender identity was classified with the BRSI. The BRSI has 60 items on masculine, feminine and neutral personality characteristics. The items are rated on a Likert-type scale of 1 (never true) to 7 (always true). The masculinity score (MS) is the average score of the masculine items, and the femininity score (FS) is the average score of the feminine items [28]. All items on the BSRI are positively valued personality aspects. The types of gender identity (masculinity, femininity, androgyny, and undifferentiated) are classified by the values of the MS and FS. Both MS and FS scores being equal to or above the medians indicates androgyny, while both scores being below the medians indicates undifferentiated identity. Only the MS score being equal to or above the median indicates masculinity, and only the FS score being equal to or above the median indicates femininity.

2.4 Data management and statistical analyses

The Chi-square test was used to assess the different distributions of males and females in the four gender role orientations, marital status, education level and occupation. For the disability conditions, both the percentage of disability and the logit score were used for analysis. One-way analysis of variance (ANOVA) was used to analyze both the sex and the gender role orientation, and the post hoc Tukey’s honestly significant difference test was used for gender role orientation. For HRQOL, to determine the magnitude of deviation in the 8 domains versus the general population, the age-/sex-matched normative values were subtracted from the original scores, and the results were taken as the impact scores for each participant [29]. Positive scores indicated better HRQOL, and negative scores indicated poorer HRQOL, than that of age- and sex-matched healthy norms. The $\alpha$ level was set at 0.05. Statistical analyses were performed in SPSS for Windows, release 20.0.

Table 1
Demographic data and clinical characteristics of patients with back pain

	Total		Male ( $n=$ 42)		Female ( $n=$ 51)
	Mean (SD/Range)
Age (years)	59.1	(15.9/21–87)	56.8	(19.5/21–84)	61.0	(12.0/29–87)
Disease duration (months) ${}^{*}$	60.0	(66.9/0–240)	40.5	(46.5/0.1–156)	75.0	(76.2/3–240)
VAS
Back	3.3	(2.5/0–9.2)	3.0	(2.5/0–8.4)	3.5	(2.5/0–9.2)
Leg	2.8	(2.7/0–9.8)	2.6	(2.4/0–9.8)	3.1	(2.9/0–9.4)
	Number (%)
Gender role orientation
Masculinity	20	(21.5%)	12	(28.6%)	8	(15.7%)
Femininity	18	(19.3%)	4	(9.5%)	14	(27.5%)
Androgyny	29	(31.2%)	12	(28.6%)	17	(33.3%)
Undifferentiated	26	(28.0%)	14	(33.3%)	12	(23.5%)
Marital status
Single/widowed	31	(33.3%)	15	(35.7%)	16	(31.4%)
Married	62	(66.7%)	27	(64.3%)	35	(68.6%)
Education ${}^{*}$
Elementary school	31	(33.3%)	8	(19.0%)	23	(45.1%)
High school	34	(36.6%)	14	(33.3%)	20	(39.2%)
University	28	(30.1%)	20	(47.6%)	8	(15.7%)
Occupation ${}^{*}$
Office worker	19	(20.4%)	12	(28.6%)	7	(13.7%)
Laborer	12	(12.9%)	8	(19.0%)	4	(7.8%)
Homemaker	37	(39.8%)	1	(2.4%)	36	(70.6%)
Student	5	(5.4%)	4	(9.5%)	1	(2.0%)
Retired	20	(21.5%)	17	(40.5%)	3	(5.9%)

VAS: Visual Analog Scale. ${}^{*}$ Indicates statistical significance between males and females ( $p=$ 0.025 for disease duration; $p=$ 0.002 for education; $p<$ 0.001 for occupation).

Table 2

Percentage of disability and logit scores of the ODI for patients with back pain ( $n=$ 90)

Sex type	Total		Male ( $n=$ 41)		Female ( $n=$ 49)
Score type (range)			Mean (SD)				$p$
Percentage of disability (0–86%)	32.6%	(20.5)	29.2%	(20.7)	37.3%	(19.7)	0.060
Logit score ( $-$ 5.36–2.56 logits)	$-$ 0.89	(1.33)	$-$ 1.29	(1.60)	$-$ 0.56	(1.07)	0.011
Gender type ${}^{*}$	Masculinity		Femininity		Androgyny		Undifferentiated
Percentage of disability (0–86%)	30.7%	(17.8)	37.8%	(22.2)	30.1%	(21.5)	37.1%	(20.2)
Logit score ( $-$ 5.36–2.56)	$-$ 1.03	(1.03)	$-$ 0.27	(1.26)	$-$ 1.27	(1.56)	$-$ 0.75	(1.38)

ODI: Oswestry Disability Index. ${}^{*}$ : $p$ values were 0.46 and 0.12 for percentage of disability and logit score, respectively.

3. Results

3.1 Study population

The demographic data and clinical characteristics of the patients are shown in Table 1. Participants were excluded if they did not answer the BRSI. A total of 100 patients participated in this study, but seven did not complete all items of the BRSI. Their mean age was 59.1 $\pm$ 15.9 years old. Most of the participants had chronic back problems, with a mean disease duration of about 5 years, and the mean duration for females was longer than that for males ( $p<$ 0.05). Leg pain (VAS $=$ 2.8 $\pm$ 2.7) was less severe than back pain (VAS $=$ 3.3 $\pm$ 2.5). For gender identity, 28% were undifferentiated, and the other gender type percentages were 19.3%, 21.5%, and 31.2% for femininity, masculinity, and androgynous, respectively. The numbers of participants with the various gender identities were not significantly different for males and females. Males tended to have higher educational levels than females. Most males were office workers, laborers or retirees, while most females were homemakers.

Table 3
Original scores of the SF-36 and impact scores of patients with back pain ( $n=$ 70)

Domains of SF-36	Original score		Impact score
Mean (SD)	Total		Total		Male		Female		$P$ (male vs. female)
PF	50.9	(25.9)	$-$ 30.3	(24.2)	$-$ 31.4	(24.9)	$-$ 29.3	(23.9)	0.73
RP	37.4	(45.1)	$-$ 32.2	(47.6)	$-$ 40.6	(45.8)	$-$ 25.2	(48.5)	0.18
BP	54.2	(24.0)	$-$ 8.8	(24.7)	$-$ 12.4	(24.5)	$-$ 5.8	(24.7)	0.27
GH	52.6	(18.7)	$-$ 30.3	(18.6)	$-$ 32.2	(15.7)	$-$ 28.7	(20.9)	0.44
VT	56.1	(18.6)	$-$ 15.7	(19.5)	$-$ 21.3	(15.1)	$-$ 10.9	(21.6)	0.02
SF	66.1	(22.2)	$-$ 8.6	(23.0)	$-$ 11.1	(21.0)	$-$ 6.5	(24.6)	0.40
RE	50.7	(47.0)	$-$ 27.5	(46.5)	$-$ 33.8	(46.5)	$-$ 22.0	(46.5)	0.30
MH	63.0	(17.7)	2.9	(19.9)	$-$ 2.7	(19.4)	7.6	(19.4)	0.03
	Impact score
	Masculinity		Femininity		Androgyny		Undifferentiated		$p$
PF	$-$ 20.9	(25.5)	$-$ 28.4	(26.7)	$-$ 31.5	(25.1)	$-$ 36.0	(20.7)	0.36
RP ${}^{*}$	$-$ 8.2	(48.8)	$-$ 25.6	(48.9)	$-$ 30.1	(48.2)	$-$ 54.5	(37.8)	0.03
BP	$-$ 3.9	(21.5)	$-$ 4.1	(33.0)	$-$ 7.1	(22.8)	$-$ 16.5	(21.8)	0.35
GH	$-$ 30.0	(14.0)	$-$ 30.4	(23.1)	$-$ 23.0	(20.0)	$-$ 36.9	(15.2)	0.12
VT ${}^{*\#}$	$-$ 9.5	(10.5)	$-$ 18.5	(20.6)	$-$ 3.6	(20.5)	$-$ 28.8	(13.7)	$<$ 0.001
SF ${}^{*}$	3.2	(15.4)	$-$ 12.7	(29.2)	$-$ 4.5	(17.9)	$-$ 17.2	(24.5)	0.045
RE ${}^{*\#}$	$-$ 6.4	(43.8)	$-$ 19.0	(45.7)	$-$ 17.2	(47.6)	$-$ 54.6	(37.0)	0.007
MH ${}^{*\#}$	11.0	(20.8)	0.6	(12.4)	9.7	(19.4)	$-$ 7.0	(20.2)	0.01

SF-36: Short form-36. PF: physical functioning; RP: role limitations due to physical health problems; BP: bodily pain; GH: general health; VT: vitality; SF: social functioning; RE: role limitations due to emotional problems; MH: mental health. ${}^{*}$ : $p<$ 0.05 after post hoc analysis for masculinity and undifferentiated. ${}^{\#}$ : $p<$ 0.05 after post hoc analysis for androgyny and undifferentiated.

3.2 Disability

The mean percentage of disability was 32.6 ${\pm}$ 20.5%, and the mean logit score was $-$ 0.89 $\pm$ 1.33 logits, indicating less disability in our cases than in the norms of patients with low back pain (Table 2). The disability level of females ( $-$ 0.56 logits) was more severe than that of males ( $-$ 1.29 logits; $p<$ 0.05). For gender, there were no significant differences in disability among the 4 types in either percentage of disability or logit score.

3.3 HRQOL

Table 3 presents the 8 domains of HRQOL and the impact scores between sexes and among the four gender role orientations. The scores of the 8 domains ranged from 37.4 to 66.1. The RP score was only 37.4, which was the lowest score in any domain. None of the domain scores of HRQOL differed significantly between sexes. Compared with those of age- and sex-matched norms, 7 of the 8 domains of HRQOL were lower in patients with low back pain (impact scores for the 7 domains: $-$ 8.6 to $-$ 32.2). The impact scores for 2 of the 8 domains (VT and MH) differed significantly between females and males, while 5 of the 8 domains (RP, VT, SF, RE, MH) differed significantly among the four gender role orientations ( $p<$ 0.05). The impacts on VT and MH were greater in males than in females. Patients with undifferentiated gender characteristics had the largest negative impact scores for all domains of HRQOL, while those with masculinity gender characteristics had the least negative impacts in most of the domains of HRQOL.

4. Discussion

Recognition of sex and gender differences is increasing in healthcare, but the effects on disability and HRQOL remain unclear. We investigated the effects of sex and gender role orientation on disability and HRQOL in patients with low back pain. The results showed that although the participants had mild to moderate disability, their HRQOL was lower than that of healthy norms in many domains. The disability differed significantly in males and females, but not in the different gender role orientations; on the other hand, the HRQOL of the patients differed significantly among the four gender role orientations. Females suffered from more disability, and people with more positive masculine characteristics had the best HRQOL.

Females had more disability than males did, while no significant difference was found for the different gender types. We calculated the percentages of disability and used logit scores to demonstrate the levels of disability of patients with low back pain, and the results showed that females had more disability than males. More negative logit values indicate less disability; males, with a mean score of $-$ 1.29 logits, had less disability than did females ( $-$ 0.56 logits). Females may more easily fear physical activity; in a study by Stenberg et al., respondents expressed fears that activity could “make the damage worse” [30]. Thus, it is essential to give advice on what activities to do and how to do them, and also to focus on how patients perceive the message that they must stay active. Since they may feel anxiety during painful movements, physical therapists should analyze the problems, design training programs and/or teach patients how to modify the activities to avoid pain. Of the item difficulties of the 10 items of the ODI, lifting items is the most common difficult activity [24]. Females may have less muscle strength than males for this activity. Therefore, safe lifting strategies should be taught and safe movements encouraged. A study by Docking et al. suggested that clinicians should be aware of not only the short-term implications of disabling back pain but also the longer-term effects; females experienced a 40% increase in the risk of mortality associated with disabling back pain [31].

Most of the domains of HRQOL differed significantly among the four gender role orientations. A more negative impact score indicated worse quality of life. The impact score is an easy and fair way to represent the condition of HRQOL compared to healthy norms. We were surprised that females did not have higher impact scores than males did; on the other hand, females had better HRQOL with lower impact scores on the VT and MH domains (Table 3). Considering the findings of sex differences in both disability and HRQOL, a person with a high level of disability may not necessarily have poor HRQOL.

The more important finding was that gender characteristics affected many domains of HRQOL. Patients with more masculine characteristics had the lowest impacts in RP, SF, RE and MH, and patients with undifferentiated characteristics always had the largest impacts in all domains of HRQOL (Table 3). A series of gender and well-being studies in a Spanish population were conducted by Matud et al., who found that high scores on masculine/instrumental traits were an important predictor of high life satisfaction in both men and women [32]. In both genders, masculinity was associated with greater psychological well-being, such as self-acceptance, autonomy, environmental mastery, purpose in life, and personal growth [33]. Although good masculinity/instrumental and femininity/expressive traits were both associated with men’s psychological well being, the relationship was stronger for masculinity than for femininity [13]. In a study on coronary syndrome in both sexes, feminine traits were associated with higher rates of recurrent acute coronary syndrome; however, female sex was not associated with the outcomes of post acute coronary syndrome. Possible reasons could be the increased anxiety associated with feminine traits [34], which may induce excessive activation of the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system, and poor health behaviors [35].

All items on the BSRI are positively valued personality aspects, and the information on gender role orientation could have implications for treatment. The beneficial masculine characteristics include independence and self-confidence. An effective strategy may be to promote positive masculine characteristics in the rehabilitation process for patients with traumatic brain injury [36]. We also suggest that therapists could encourage some positive masculine characteristics to improve HRQOL in patients with low back pain. In a rheumatoid arthritis study, researchers suggested that both women and men could benefit from coping with their health problems in a self-focused and instrumental fashion [20]. Individuals with an agentic orientation are likely to be successful in caring for themselves without sacrificing their relationships. Patients could be encouraged to appreciate the importance of caring for both themselves and others. In a study of men’s adjustment to spinal cord injury, those who adhered to primacy of work demonstrated lower rates of depression, while those who adhered to self-reliance demonstrated higher depression scores [37]. The centrality of work in defining masculinity may have prompted efforts to return to work or to retain one’s work-related identity, which in turn promoted lower rates of depression. Ahlsen et al. suggested that health care professionals could listen carefully to the patients’ own stories and should be sensitive to the significance of gender when trying to understand these people’s health problems so as to improve the quality of health care for men and women living with chronic pain [38]. The information may be used in communication, and the timing and the wording of the messaging included in the implementation of the intervention should be tailored differently to match sex and gender identity characteristics [7]. Therapists could provide useful advice to help patients to achieve treatment goals in a step-by-step manner, which would increase self-confidence and decrease dependence while promoting HRQOL.

The males in this study did not necessarily have masculine gender identities; in fact, a large portion (33.3%) had undifferentiated identities. Likewise, females did not necessarily have feminine identities; a large portion (33.3%) of the females were found to have androgynous identities. This may be the reason why females experienced smaller impacts in the VT and MH domains of HRQOL than the males did. In many countries, the social status of females is elevated and the government pursues sexual equality in many public areas, such as in education, work and elections. Therefore, the percentage of females with masculine characteristics may be increasing.

The limitations of this study should be noted. First, the sample was a small number of patients with back pain from a single center. We provided the norms (disability of back pain and HRQOL of an age- and sex-matched group) to precisely reveal the conditions of our sample. Multicenter studies with larger sample sizes are needed to improve the generalizability. In addition, differences in how gender orientation affects HRQOL in African-American, Hispanic, and White youths have been reported [39]. Therefore, the proportions of gender orientations and their impacts on the HRQOL of patients with back pain may vary in different ethnic groups.

5. Conclusion

Disability and poor HRQOL in both the physical and mental domains were found in patients with back pain. Females had more disability but not worse HRQOL than males did. Most of the domains of HRQOL differed significantly among the four gender role orientations. Good masculine characteristics may facilitate better HRQOL in patients with back pain.

Footnotes

Acknowledgments

This work was supported by the National Science Council (grant number NSC 101-2629-B-037-002) and the Kaohsiung Medical University (KMU-M103015).

Conflict of interest

None of the authors have any conflict of interest to report.

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A cross-sectional study of disability and quality of life in patients with low back pain: Focus on sex and gender

Abstract

BACKGROUND:

OBJECTIVES:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1. Background

2. Methods

2.1 Subjects

2.2 Procedures

2.3 Instruments

2.3.1 Disability

2.3.2 HRQOL

2.3.3 Gender identity

2.4 Data management and statistical analyses

Table 1 Demographic data and clinical characteristics of patients with back pain

3.1 Study population

Table 3 Original scores of the SF-36 and impact scores of patients with back pain ( n = 70)

3.3 HRQOL

4. Discussion

5. Conclusion

Footnotes

Acknowledgments

Conflict of interest

References

Table 1
Demographic data and clinical characteristics of patients with back pain

Table 3
Original scores of the SF-36 and impact scores of patients with back pain ( $n=$ 70)