Evaluation of patients with low back pain due to facet joint arthrosis: The relationship between pain beliefs and pain,function,and quality of life

Abstract

OBJECTIVE:

The study aimed to determine the clinical and functional status of patients with chronic low back pain (CLBP) due to facet joint arthrosis (FJA) and to examine the relationship, if any, between pain beliefs and clinical and functional status.

METHODS:

This descriptive, cross-sectional study involved patients who had been diagnosed with CLBP due to mild to moderate FJA. The participants were evaluated using the Numeric Pain Rating Scale (NPRS rest and activity), the Oswestry Disability Index (ODI), the Short-Form Quality of Life Index 12 version 2 (SF-12v2; PCS and MCS) and the Pain Beliefs Questionnaire (PBQ). Statistical analyses were performed using SPSS.

RESULTS:

This study involved 58 patients (28 females and 30 males) with a mean age of 52.12±4.64 years. The reported pain intensity was 1.93±1.52 at rest and 5.10±1.10 during activity, while the ODI was 24.59±6.61. The MCS was higher than the PCS, with mean scores of 43.52±5.86 and 38.97±5.01, respectively. The participants had higher scores for organic pain beliefs (3.81±0.51) than for psychological pain beliefs (3.35±0.69). A weak positive correlation was found between psychological pain beliefs and functional status (r = 0.336; p = 0.010).

CONCLUSIONS:

Patients with CLBP due to FJA experienced mild pain at rest, moderate pain during activity, and moderate functional disability. Participants with stronger psychological pain beliefs exhibited a higher level of functional disability. Addressing pain beliefs may help to improve functional outcomes.

Keywords

Low back pain function cross-sectional study facet joint

1 Introduction

Chronic low back pain (CLBP) results in negative effects on daily living, work, social or recreational activities and Quality of Life (QoL) [1]. Lumbar facet arthropathy (LFA) accounts for 15% –40% of CLBP prevalence [2], with facet joint arthrosis (FJA) being the most common form of LFA. FJA is a degenerative process that typically starts in the third decade of life and progresses to clinical signs, pain, and functional disability over an average of 15 years [3]. The prevalence of FJA in young adults is estimated to be between 10% and 15%. However, as age increases, FJA prevalence also tends to increase [4].

Patients with CLBP due to FJA experience a complex biopsychosocial condition. Therefore, the approach to treatment and recovery should include not only physical components but also psychosocial components [5 –7]. Among the psychosocial factors, pain beliefs, which encompass an individual’s subjective beliefs, perceptions, and attitudes about their pain experience, play a significant role in chronic pain management [6 , 9]. For example, negative pain beliefs, such as the belief that treatment will cause harm or that pain will persist regardless of adherence, can result in noncompliance and hinder treatment progress. Conversely, positive pain beliefs, such as a sense of control over pain, optimism about recovery, and confidence in the effectiveness of treatment, are associated with better outcomes, including reduced pain intensity, improved functional abilities, and enhanced quality of life [5 –8]. These beliefs can influence various aspects of pain management. Therefore, it is crucial to conduct a multidimensional assessment that considers the impact of pain beliefs on treatment outcomes [9, 10].

This study aimed to determine the clinical and functional status of patients with CLBP due to FJA and to investigate the relationship between pain beliefs and clinical and functional status.

2 Materials and methods

This study was conducted in cooperation with the Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Istanbul University-Cerrahpaşa and the Department of Neurosurgery at Istanbul Okan University Hospital (both in Istanbul, Turkey) between May and November 2021. It was conducted in accordance with the Declaration of Helsinki under the ethical approval of the Medical Faculty Clinical Research Ethics Committee at Istanbul University-Cerrahpaşa, with decision number E-59491012-604.01.02-194611.

2.1 Participants

The sample size was calculated using G*power 3.1.9.2, which required 52 patients and a size effect of 0.7, 80% power, and an error probability of 0.05. Fifty-eight participants were included in the study, based on the probability that 10% of the patients could be excluded.

Patients who presented with CLBP at the Department of Neurosurgery and reported experiencing FJA-related symptoms were screened for this condition. In cases where a patient’s medical history and physical examination indicated the possibility of FJA, the neurosurgeon (OK) thoroughly reviewed the radiological findings to confirm the diagnosis. Patients who were diagnosed with FJA underwent grading using the Pathria classification [11]. The classification system involved three levels: level 1 (mild), which indicated joint space narrowing; level 2 (moderate), which indicated additional sclerosis or joint hypertrophy; and level 3 (severe), which indicated the presence of additional osteophytes. Patients with mild and moderate FJA were provided with detailed information about the study’s purpose. The potential participants provided written consent by signing an informed consent form. They were also advised not to use any prescribed medication until their evaluation sessions. Subsequently, the potential participants were referred to a physiotherapist (BO) to schedule their evaluation sessions at their earliest convenient time.

The inclusion criteria were as follows: being between the ages of 40 and 65, having a diagnosis of level 1 or 2 FJA according to the Pathria classification [11], and experiencing CLBP primarily due to FJA for at least 12 weeks.

The exclusion criteria were as follows: having undergone conservative treatment or surgery in the lumbar region within the last six months and having CLBP-related conditions, such as symptomatic disc pathology, spinal stenosis, fibromyalgia, chronic pain syndrome, or spondylolisthesis. Additionally, individuals who experienced claudication, numbness, or weakness in the legs; referred pain from a non-spinal source; abdominal or pelvic pain; red or orange flags associated with low back pain (including infection, fracture, cancer, severe osteoporosis, depression, anxiety, cauda equina syndrome, or motor weakness); or seronegative rheumatological diseases (inflammatory conditions) were also excluded. Patients with symptoms that could confound the assessment of CLBP primarily caused by FJA, such as pain exacerbated or induced by trunk flexion and characterized by disc pathology, were excluded from the study.

2.2 Evaluations

After referral, all potential participants were offered an online appointment via phone call. Afterward, they were evaluated for the criteria during an evaluation session before enrolling in the study.

The evaluation methods used in the study were chosen based on the categories of body function, activity, and participation in the Comprehensive ICF Core Set for Low Back Pain [12, 13]. A patient form was created to obtain the demographic and clinical features of the participants. Age, gender, height, weight, body mass index (BMI), educational status, pain side, drug use, chronic disease, and other musculoskeletal pain were recorded. Pain intensity at rest and during activity, functional status, QoL, and pain beliefs were measured using the Numeric Pain Rating Scale (NPRS), the Oswestry Disability Index (ODI), the Short-Form Quality of Life Index 12 version 2 (SF-12v2), and the Pain Beliefs Questionnaire (PBQ), respectively. An experienced physiotherapist (BO) conducted the evaluations once, one-on-one, and in real time using the tele-assessment method (Google Meets). Prior to the appointment day, communication channel links, and passwords were sent to the potential participants. The evaluations took approximately 40–45 min. Questions or items were shared one at a time with the patient via a screen. No comments were made about the questions or items. The participants responded to all the items and answered all the questions. The answers/responses were recorded in an Excel file on a different screen.

The NPRS, a Likert scale used to measure pain intensity, consists of a horizontal line with 11 matching options. On the scale, 0 reflects no pain, and 10 reflects unbearable pain [14]. Additionally, 1, 2, or 3 is interpreted as mild pain; 4, 5, 6, or 7 as moderate pain; and 8, 9, or 10 as high-intensity pain. A two-unit change or difference in the scale is considered clinically significant [15]. The participants were asked to choose an option from 0 to 10 on the horizontal line to indicate the maximum pain they experienced at rest and during activity, and their answers were recorded.

The ODI, a patient-reported outcome measure, was used to evaluate disability and functionality in the lumbar region. It comprises a questionnaire with 10 questions [16, 17]. Each question has six options, ranging from 0 to 5. The highest score is 50. The scale is interpreted by converting it to a percentage score. A score of 0–20 is interpreted as mild functional disability, 21–40 as moderate functional disability, 41–60 as severe functional disability, 61–80 as crippled, and above 80 as bed dependent. The participants were asked to answer each question with the option most suitable for them, and the answers were recorded.

The SF-12v2, a QoL measure, consists of 12 items and assesses different dimensions of health and well-being. These dimensions include physical functionality (two items), physical role (two items), body pain (one item), general health (one item), vitality (one item), social functionality (one item), emotional role (two items), and mental health (two items) [18, 19]. The second updated version produces two scores: the physical component score (PCS) and the mental component score (MCS) [20]. US norms (a mean of 50 and a standard deviation of 10) are used to obtain interculturally comparable and interpretable scores with the second edition. The higher the score, the better the health-related QoL [21].

Pain beliefs were assessed using the PBQ, which comprises 12 items, wherein 8 items focus on organic belief scores and 4 items focus on psychological belief scores. The most appropriate 6-point Likert option between “never” (1) and “always” (6) was selected for each item [22, 23]. The score for each subtest was calculated by dividing the sum of the scores by the number of items belonging to the subtest. The organic subscale mainly reflects the organic aspects of pain with items such as “pain is a result of damage to the tissues of the body” or “experiencing pain is a sign that something is wrong with the body.” The psychological beliefs scale mainly reflects the effects of psychological factors on pain using items such as “being anxious makes the pain worse” or “thinking about pain makes it worse.” There is no cutoff point for scores, and the scores can only range from 1 to 6 points, with an increase in the sub score indicating high/strong pain beliefs and a decrease indicating low/weak pain beliefs about that score.

2.3 Statistical analysis

Statistical analysis was performed with IBM SPSS 20.0 on Windows 10.0 software. The normality of the parameter distribution was assessed using the Shapiro–Wilk test, with skewness being between +1.0 and –1.0 [24]. P < 0.05 was considered significant. The descriptive data were expressed as mean (M), standard deviation (SD), frequency (%), and the number of participants (n). Pearson’s correlation was used to evaluate the relationship between pain beliefs and clinical and functional outcomes.

3 Results

Seventy-six potential participants were referred for this study, and fifty-eight of them met the inclusion criteria. There were 28 females (48.3%; 52.61±4.86 years) and 30 males (51.7%; 51.67±4.75) with an overall mean age of 52.12±4.64 (range: 43–61). Table 1 lists the demographic and clinical features of the participants. Regarding BMI classification, most females (53.6%) were normal, whereas most males (66.7%) were overweight. Drug users (4.71±1.00; n = 21) and nonusers (5.32±1.10; n = 37) exhibited a significant difference in pain intensity during activity (p = 0.042), but they exhibited no difference in disability. There was no difference between the level of education and pain intensity (p = 0.577). Twenty-four patients (41.4%) reported experiencing musculoskeletal pain other than low back pain, whereas twenty-eight patients (48.3%) had at least one chronic disease.

Table 1
Demographic and clinical features

M±SD

(range)

n = 58

Age, years 52.12±4.64

(43–61)

Height, meter 1.67±0.07

(1.57–1.84)

Weight, kg 73.33±9.58

(55–93)

BMI, kg/m² 26.07±3.16

(20.18 –34.16)

BMI group

Normal 24 (41.4%)

Overweight 29 (50%)

Obese 5 (8.6 %)

Educational status

Primary 5 (8.6%)

High school 28 (48.3%)

Graduate+ 25 (43.1%)

Pain side

Right 8 (13.8%)

Left 16 (27.6%)

Not determined 19 (32.8%)

both side 15 (25.9%)

Presence of other pain

Yes/No 24 (41.4%)/34 (58.6%)

Drug use

Not using 21 (36.2%)

Once a day 10 (17.2%)

Twice a day 7 (12.1%)

Three on a day 3 (5.2%)

When pain elevates 17 (29.3%)

Presence of chronic disease

Yes/No 28 (48.3%)/30 (57.7%)

Disc pathology 12 (40%)

Hipertension 4 (6.9%)

Visseral diseases 2 (3.4%)

Other 9 (15.5%)

	M±SD
Age, years	52.12±4.64
	(43–61)
Height, meter	1.67±0.07
	(1.57–1.84)
Weight, kg	73.33±9.58
	(55–93)
BMI, kg/m²	26.07±3.16
	(20.18 –34.16)
BMI group
Normal	24 (41.4%)
Overweight	29 (50%)
Obese	5 (8.6 %)
Educational status
Primary	5 (8.6%)
High school	28 (48.3%)
Graduate+	25 (43.1%)
Pain side
Right	8 (13.8%)
Left	16 (27.6%)
Not determined	19 (32.8%)
both side	15 (25.9%)
Presence of other pain
Yes/No	24 (41.4%)/34 (58.6%)
Drug use
Not using	21 (36.2%)
Once a day	10 (17.2%)
Twice a day	7 (12.1%)
Three on a day	3 (5.2%)
When pain elevates	17 (29.3%)
Presence of chronic disease
Yes/No	28 (48.3%)/30 (57.7%)
Disc pathology	12 (40%)
Hipertension	4 (6.9%)
Visseral diseases	2 (3.4%)
Other	9 (15.5%)

M: Mean; SD: Standart Deviation; kg: kilogram; BMI: Body Mass Index; kg/m²: kilogram/meter square.

The results showed that the pain intensity at rest was 1.93±1.52 on the NPRS, indicating mild pain (NPRS < 3). However, the pain intensity during activity was moderate, with a mean score of 5.10±1.10 on the NPRS. Similarly, functional disability was found to be moderate (3 < NPRS < 8), with a mean score of 24.59±6.61 on the ODI (20 < ODI < 40). Table 2 presents the patients’ clinical and functional outcomes.

Table 2

Clinical and functional outcomes

Outcome	M±SD
(range)	n = 58
NPRS rest	1.93±1.52
(0–10)
NPRS activity	5.10±1.10
(0–10)
ODI	24.59±6.61
(0–100)
SF-12v2
PCS	38.97±5.01
(0–50)
MCS	43.52±5.86
(0–50)
PBQ
OPB	3.81±0.51
(1 –6)
PPB	3.35±0.69
(1 –6)

M: Mean; SD: Standart Deviation; NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; SF-12v2: The Short Form Quality of Life Index 12 version 2; PCS: Physical Component Score; MCS: Mental Component Score; PBQ: Pain Beliefs Questionairre; OPB: Organic Pain Beliefs; PPB: Psychological Pain Beliefs.

The participants’ MCS was higher than their PCS, with mean scores of 43.52±5.86 and 38.97±5.01, respectively. The mean scores for psychological pain beliefs and organic pain beliefs were 3.35±0.69 and 3.81±0.51, respectively.

There was a weak negative correlation between organic pain beliefs and pain intensity during activity (r = –0.312; p = 0.018). Similarly, a weak negative correlation was observed between psychological pain beliefs and pain intensity at rest (r = –0.340; p = 0.009). Furthermore, a weak positive correlation was observed between psychological pain beliefs and functional status (r = 0.336; p = 0.010). This indicates that as psychological pain beliefs increase, the level of functional disability also increases, or vice versa (Table 3).

Table 3

Relationship between pain beliefs and clinical and functional outcomes

	n = 58
	r
PBQ	OPB	PPB
NPRS rest	–0.237	–0.340
NPRS activity	–0.312	–0.142
ODI	0.133	0.336
SF-12v2
PCS	–0.043	–0.079
MCS	0.018	0.088

NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; SF-12v2: The Short Form Quality of Life Index 12 version 2; PCS: Physical Component Score; MCS: Mental Component Score; PBQ: Pain Beliefs Questionairre; OPB: Organic Pain Beliefs; PPB: Psychological Pain Beliefs; r: Pearson Correlation Coefficiant. Bold results are significant (p < 0,05).

4 Discussion

This study presents the clinical and functional status of patients with CLBP due to FJA. According to the study findings, patients with CLBP due to FJA experienced mild pain at rest, moderate pain during activity, and moderate functional disability, which resulted in a moderate level of impairment in daily functioning. The mental well-being of the patients was better than their physical health. Furthermore, the participants attributed their pain to physical factors (organic pain beliefs) rather than psychological factors (psychological pain beliefs). Our findings suggest that patients with stronger psychological pain beliefs tend to have a higher level of functional disability.

Although pain intensity and functional disability increase with age in FJA patients, quality-of-life scores have been observed to increase as age increases. However, the effects of low back pain symptoms on daily life decrease as chronic sensorimotor disorders occur with age [25]. Conversely, studies on a population with FJA have shown that the mean age of FJA patients is lower. Specifically, the mean age was 63.4±0.0 years in 2013 [26], 55.1±9.4 years in 2017 [27], and 51.3±9.6 years in 2021 [28]. In our study, the mean age was 52.12±4.64 years. Therefore, assessment outcomes, treatment goals, and targeted strategies for pain management should be reviewed and adapted accordingly.

Depalma et al. [29] reported that, in addition to aging, an increase in BMI is associated with low back pain and that age and a BMI of 30 or above are particularly associated with low back pain originating from the facet joint [29]. Herschkovich et al. [30] conducted an epidemiological study on 829,791 patients with low back pain; they suggested that the average BMI increase has accelerated in societies and that one of the negative consequences of this increase is an increase in low back pain prevalence [30]. Their findings have also revealed a positive relationship between pain and pain-related symptoms in height, weight, and BMI subgroups. According to BMI classification, 50% of the patients in our study were overweight, and 8.6% were obese. Considering public health and low back pain risk, BMI should be assessed, and approaches should contain a target to keep BMI within normal ranges.

Ferrari et al. [31] stated that functional disability is much common among Italian female patients and drug users [31]. They also reported that low educational level negatively affects perceived pain and functionality. In our study, gender had no impact on the outcomes. The mean pain intensity during activity was 4.71±1.00 in nondrug users (n = 21) and 5.32±1.10 in drug users (n = 37). This difference was significant between the users and nonusers (p = 0.042). Additionally, 43.1% of the patients in our study were graduates. There was no difference in pain intensity according to educational level. Nonetheless, it is difficult to conclude that education does not affect pain and pain-related outcomes. To better understand the clinical status of patients with low back pain, detailed analyses should be performed according to stratified subgroups of patients’ demographic and clinical information, such as age, BMI, educational level, and drug use.

A previous study concluded that women experience more pain sensitization and chronic pain than men because of their lower pain threshold and tolerance [32]. Another study [33] showed that females experience deep muscle pain under less pressure and report experiencing more severe pain than males do in response to a similar painful stimulus. The sense of pain intensity is a physical output. However, the experience is altered by the interpretation of many complex inputs, such as emotional, cognitive, and environmental factors, at the cerebral level [34]. Therefore, it is essential to determine to what extent the individual’s clinical and functional status, pain beliefs, and QoL are affected in order to manage chronic pain [35].

The identification of a patient’s cognitive and behavioral patterns plays an important role in CLBP management. Cognitive behaviors regarding pain are crucial for resolving complex pain perception and coping mechanisms [23]. Patients who believe that pain has an organic origin feel more helpless, expect recovery with medication, and believe there is nothing they can do about their pain [36]. A study that used cognitive approaches to reduce organic pain beliefs [37] revealed that the functional status of patients with low back pain improved with a reduction in organic belief scores. The researchers argued that eliminating false and negative pain beliefs or replacing them with positive ones may contribute to the success of chronic pain management. Furthermore, Alaca et al. (2020) discovered a negative relationship between organic pain beliefs and functionality [8]. In our study, pain beliefs were similar regardless of the level of functionality. Additionally, although the mean psychological pain beliefs score (3.35±0.69) was lower than the mean organic pain beliefs score (3.81±0.51), the gap between the two subtests was narrower than that of another study (Organic Pain Beliefs = 4.53±1.12 and Psychological Pain Beliefs = 2.18±0.60 [8]). According to our findings, which align with previous findings [8 , 37], patients are much likely to use drugs to cope with the organic cause of their pain. They are unaware of what they can do to improve their functionality and QoL. Moreover, our results indicate that when the psychological pain belief score decreases, the severity of the disability increases. In this sense, low organic pain beliefs and high psychological pain beliefs can contribute to patients’ pain management and functionality. These findings emphasize the potential impact of psychological factors on an individual’s ability to engage in daily activities. Therefore, we suggest that addressing pain beliefs may aid in improving functional outcomes and modulating pain experiences.

This study was conducted on patients with CLBP due to FJA, and it revealed the clinical and functional current status of the patients as well as the relationship between pain beliefs and outcomes in middle-aged patient groups. Future studies are required to reveal differences among groups with different levels of pain beliefs and to compare the results with results from other age groups. This study has several limitations, including the determination of clinical and functional status based on patient-reported outcomes and the assumption that patients comprehended the questions and statements on the scales. No causal inferences were made in this cross-sectional study. This limitation may be attributed to various factors, such as coping mechanisms, psychological resilience, or the influence of other contextual factors that were not directly assessed in this study. Further exploration of emotional, cognitive, and environmental contributors could provide valuable insights into the complex relationship between pain beliefs, pain, function, and QoL.

In conclusion, it is beneficial to identify false pain beliefs to better understand chronic pain population characteristics and motivate patients to replace their false pain beliefs with positive beliefs and attitudes. By identifying these factors, healthcare providers can better understand the impact of pain beliefs on patient outcomes and develop additional targeted interventions to improve patient care from a biopsychosocial viewpoint.

Footnotes

Acknowledgments

All authors thank to Istanbul Okan University Hospital for referring patients.

Author contributions

All authors contributed to conception and design of the study, acquisition, analysis and interpretation of data, writing, supervision and final approval of the version to be submitted.

Conflict of interest

The authors have no conflict of interest to report.

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