Jan 30, 2019 - B) Psychological evaluation: MMPI Questionnaire was used to .... of the patient, the idea of ad. MMPI test was given to the patient. The tes.
Available online at http://www.journalijdr.com
ISSN: 2230-9926
International Journal of Development Research Vol. 09, Issue, 01, pp.25072-25076, January, 2019
ORIGINAL RESEARCH ARTICLEORIGINAL RESEARCH ARTICLE
OPEN ACCESS
CHRONIC LOW BACK PAIN& PSYCHOLOGICAL COMORBIDITY 1Osama
E. El Dib, 2Saber abd El Azeem, 3Manal S. Awadh and 4Mahmoud Rizk 1Department
Neurology, Menofiya University, Egypt Zagazeg University, Egypt 3Physical Medicine & Rehabilitation, Ain Shams University, Egypt 4Internal Medicine Department, Benha University, Egypt 2Psychiatry,
ARTICLE INFO
ABSTRACT
Article History:
Aim: Low back pain is a common disease, and it is observed at least once in 70-85% of the population during their lifetime.Chronic low back pain (CLBP) significantly limits the physical capabilities of a large number of patients.This study will evaluate the relationship between mental disorders, depression, hypochondriasis and anxiety, and the functional status of chronic low back patients. Subjects and methods: The study was carried out on a sample of 200 agreed to participate in this cross-sectional study. The patients were divided into two group of 100 patients each:1. Chronic low back pain with obvious organic lesion proven radiologically. 2. Chronic low back pain in which no organic cause was found either clinically or radiologically, which was termed as ‘functional’. The following procedures were done for every patient: A) Medical evaluation: 1. Neurological evaluation. 2. Systemic examination especially gynecological examination in all female patients and 3. Radiological examination which included a) Plain x-ray of lumbosacral spine with necessary views. b)Magnetic Resonence Imaginglumbosacral spine. B) Psychological evaluation: MMPI Questionnaire was used to identify depression, Anxiety and hypochondriasis were assessed. Results: The study sample consisted of 53% males and 47% females in organic group while 30% males and 70% females in functional group. In Organic group thereis significant correlation between age and LBP. Absence of radiation in 9% in Organic group while 60% in functional group. Parathesia present in 85% of organic group, while functional group 20%. Severe pain in 70% in organic group, while 25% in functional group, Depresion (15%) was observed in organic group, 35% in functional group in LBP patients, depression scores for the functional group are strikingly higher than for the organic group.Anxity were (14%) in organic group, 20% in functional group, hysteria scores for the functional group are decidedly higher than for the organic group. and Hypochondriasis disorders (9.5%) in organic group, 15% in functional group, hypochondriasis scores for the functional group are definitely higher than for the organic group. Conclusion: Depression, anxiety, and hypochondriasis are conditions with high prevalence among chronic low back pain patients. So it must not be conditions overlooked when attempting to manage pain. Therefore treating a patient’s mental dysfunctions might have efficacious results in improving the functional status of patients. If treatment of depression and anxiety can improve functional status doctors might be able to better serve their patients without placing patients on addictive pain management regimens.
Received 18th October, 2018 Received in revised form 21st November, 2018 Accepted 06th December, 2018 Published online 30th January, 2019
Key Words: Back Pain Depression Hypochondriasis Parathesias.
Copyright © 2019, Osama E. El Dib et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Citation: Osama E. El Dib, Saber abd El Azeem, Manal S. Awadh and Mahmoud Rizk. 2019. “Chronic low back pain& psychological comorbidity”, International Journal of Development Research, 09, (01), 25072-25076.
INTRODUCTION Low back pain is a common disease, and it is observed at least once in 70-85% of the population during their lifetime. Chronic low back pain (LBP) significantly limits the physical capabilities of a large number of patients (Hiyama, 2016). *Corresponding author: Osama E. El Dib Department Neurology, Menofiya University, Egypt
The severity of the pain can range from interfering with work and recreational activities to inhibiting daily actions (Finan, 2013). LBP is ranked first as a cause of disability and inability to work, and is expected to affect most adults at some point during their lifetime (Bener, 2004). Eight in every ten adults experience LBP at some point in their lifetime. LBP is a complex condition produced by multiple factors. There is evidence that psychosocial difficulties and psychological factors might be associated with LBP (Bener, 2013). Despite
25073
Osama E. El Dib et al. Chronic low back pain& psychological comorbidity
the recognition that excessive pain complaints are associated with psychological problems, the exact relationship between pain behavior and psychological factors continues to be unclear. It was reported that LBP can have a substantial negative impact on quality of life and that psychological distress is common in patients with LBP (Bener, 2006). The hypothesis is that subjects exhibiting excessive pain complaints would be more depressed than those who do not exhibit excessive levels of pain complaints. Several psychiatric disorders commonly accompany chronic low back pain (Ramond-Roquin, 2015 and Breslau, 2003). ). In clinic samples, rates of current major depression can range from 30 to 54% Significantly higher than the rate of 5–8% 8% found in the general population (Kessler, 2003). International data from the World Health Organization (WHO) collaborative study on psychological problems in primary care. Sartorious et al and Von Korff M et al showed that 32% of patients with somatoform atoform pain disorder also met criteria for a depressive disorder (Sartorious, 1996 and Von Korff, 1996). There are two major goals of patients receiving treatment; managing the pain and improving their functional capabilities. The majority of the research focuses on managing the pain with the understanding that improving pain levels will allow for a higher degree of function. It has been shown that the most important variable in successful treatment of chronic LBP is the reduction of subjective feelings of disability in patients.[11] How are depression and anxiety associated with functional status of chronic low back pain patients? This study will evaluate the relationship between mental disorders, depression, anxiety hypochodriasisand the functional status statu of chronic low back patients.
general types – a) Specific somatic complaints and b) Denial of any emotional or inter-personal personal difficulty.
PATIENTS & METHODS
F-test in one-way way analysis of variance is used to assess whether the expected values of a quantitative variable within several pre-defined defined groups differ from each other.
This is study, including patients aged 15–60 15 years who attended outpatient Neurology, Internal Medicine and Physical medicine clinic. Data collection took place from patients with chronic low back pain for more than six months. No response to adequate and supervised conservative treatment. The patients were divided into two group of 100 patients each:1. Chronic low back pain with obvious organic lesion proven radiologically. 2. Chronic low back pain in which no organic cause was found und either clinically or radiologically, which was termed as ‘functional’. The following procedures were done for every patient: A) Medical evaluation:1. Neurological evaluation. 2. Systemic examination especially gynecological examination in all female patients tients and 3. Radiological examination which included a) Plain x-ray ray of lumbosacral (LS) spine with necessary views. b) MRI LS spine.B) spine. Psychological evaluation: The original (MMPI) test was studied and analyzed. It consisted of a 550 item questionnaire, that t are answered in ‘true’, cannot say or false categories. Clinical scales in the assessment test (MMPI): (MMPI) Scale 1: Hypochondriasis (Hs) This scale consisted of 20 times concerned with complaints about vague and non specifically bodily function. Hypochondriasis driasis means an abnormal concern over bodily health. High scores on this scale are usually seen in pessimistic, cynical and defeatist personalities. Scale 2; Depression (D) This scale consisted of twenty items, measuring the degree of depth of symptomatic depression, poor morale and lack of hope in the future. Scale: 3: Hysteria (Hy) This scale comprised of twenty items, related to two
Procedure: After ter thorough clinical and radiological examination of the patient, the idea of administration of the MMPI test was given to the patient. The test was administered in a congenial atmosphere, choosing a quiet room and in a language understood by the patient. Patients were instructed to answer the questions honestly and the way they feel at the time of examination, in three options – ‘yes’ ‘no’ or ‘can’t say’. Full secrecy was guaranteed to the patients. The answers were analyzed according to the original MMPI (Bener, 2013). Statistics The SPSS 16 (SPSS Inc., Chicago, IL, USA) was used for data analysis. SS is the sum of squares of the differences from the mean. SS = Σ (x - m(x))² DF (the number of degrees of freedom) is the number of values in the final calculation of a statistic that are free to vary. That is the value you should be mostly concerned with to know if there is significant differences or not. M-estimators are a broad class of estimators, which are obtained as the minima of sums of functions of the data.
or
The "explained variance", or "between
RESULTS Table 1. The number and percentage of demographic data in the studied groups as regard sex
Male Female Total
N % N % N %
Functional 30 30 70 70 100 100
Organic 53 53 47 47 100 100
Total 83 41.5 117 58.5 200 100
Table 2. The mean values of demographic data in the studied groups as regard age Age 20-40 40-60
Functional 70 30
Organic 35 65
Total 105 95
25074
International Journal of Development Research, Vol. 09, Issue, 01, pp. 25072-25076, January, 2019
There is a definite correlation between age and cause of chronic low back pain. Most of the patients with functional back pain were in 20 to 40 year age group. Table 3. The correlation between the work pattern and back pain
It means that males and females in general do not differ among themselves with respect to their score. The main effect "B" (organic Vs functional) is however statistically significant indicating that hysteria scores for the functional group are decidedly higher than for the organic group. Table 9. Analysis of variance of hypochodriasis
Functional Male 10 5 15
Sedentary Moderate Severe
Organic Male 20 3 30
Female 40 10 20
Female 20 7 20
There is high number of moderate exerter females showing functional low back pain. A significant amongst the work patternsas far as functional pain is concerned, was found in the present study sample. Table 4. Presence of radiating pain Functional 11 20 60 9
Both LL Only Rt or Lt Absence Occasional
Organic 26 40 9 25
Table 5. Presence of parathesias in lower limbs Functional 20 80
Present Absent
Organic 84 16
Table 6. Pain scale scores
Mild (Grade I,II) Severe (Grade III,IV)
N % N %
Functional 75 75 25 25
Organic 30 30 70 70
Grade I: Mild pain that does not require medication. GradeII: Pain require medication and gets satisfactory relief. Grade III: Pain require medication but no relief. Grade IV: Severe pain. Grade I and II: Mild pain. Grade III and IV: Severe pain
HS HY D
Functional Male 7.94 8.72 10.61
Female 9.55 7.87 11.42
Organic Male 4.48 4.65 5.32
Female 4,82 5.13 5.92
Hysteria and depression for the functional group(irrespective of the sex) are significantly higher than those for the groupof low back pain patients with organic cause (Hy= Hysteria, Hs= Hypochodriasis, D= Deprssion) Table 8. Analysis of variance of hysteria SS DF A 0.0604 1 B 72.085 1 AXB 1.399 1 Within Cell 95/98 A = the main effect sex– B= the main effect
SS 5.243 93.52 1.825
DF 1 1 1 95/98
M 4.695 95.53 1.824 68.64
F 0.529 13.42 0.13
It means that males and females in general do not differ among themselves with respect to their score on hypochondriasis scale. The main effect "B"(organic Vs functional) is however statistically significant indicating that hypochondriasis scores for the functional group are definitely higher than for the organic group. Table 10. Analysis of variance of depression
A B AXB Within Cell
SS 214 82.65 0.032
DF 1 1 1 95/98
M 215 83.21 0.032 10.67
F 0231 6.488 2.594
It means that males and females in general do not differ among themselves with respect to their score. The main effect "B" "(organic Vs functional) is however statistically highly significant indicating that depression scores for the functional group are strikingly higher than for the organic group. After analyzing MMPI scores of all the 3 relevant scales for low back pain; hysteria, hypochondriasis and depression, it can be concluded that: 1- The MMPI scores of choronic low back pain patient in functional group are significantly higher than those in organic group , on all the three scales, especially on the dimension of depression. 2- The MMPI scores on the three scales, do not vary significantly with the sex of patients, 3The intersection between the function Vs organic and sex of the patient has not come out to be significant, on the three scales.
DISCUSSION
Table 7. Analysis of MMPI scores AVG Score
A B AXB Within Cell
M F 0.0623 0.036 72.086 5.42 1.562 0.13 12.67 Organic Vs functional
LBP is widely regarded as a biopsychosocial problem (Waddell, 2004). The physical and psychological stressors are known to increase LBP risk (Mattila, 2008). In this study, the occurrence of LBP increased between 20 to 40 years and more in female in functional group, which is consistent with a study by Kostova and Koleva (Kostova, 2001). It was found that LBP symptoms were consistently more common among the studied women (53.9%) compared to men (46.1%). Other studies also reported a similar finding that women were more likely to present with LBP than men (Dempsey, 1997). The higher stress levels among women due to the combination of work-related stressand stress related to responsibilities for the family might be the reason for the higher incidence of LBP among women. In the present study there are a significant association between the psychological distress and LBP,The depression represent 15% in organic group, 35% in Functional group, and anxiety disorders 14% in organic group, 20% in Functional group. This results were higher compared to their healthy counterparts. In contrast, Dickens et al showed that
25075
Osama E. El Dib et al. Chronic low back pain& psychological comorbidity
patients with and without excessive pain behavior had similar levels of anxiety and depression, especially in women (Dickens, 2002). A significant association between psychological distress and increasing risk of LBP were observed in studied subjects with LBP (Bener, 2013; Schneider, 2005 and Manchikanti, 2002). The association between depression and medically unexplained pain has been investigated extensively. Depression has been shown to be positively associated with somatisation and somatoform disorders, in which medically unexplained pain may arise (AlShammari, 1994; Delisa, 2005; Palmer, 2000; Cassidy, 1998). Numerous hypotheses have arisen to explain the mechanisms by which depression might play a role in the aetiology of otherwise unexplained pain (Al-Shammari, 1994 and Palmer, 2000). Generalised anxiety disorder is the other comorbidity which has been shown to be significantly different among cases (14% in organic, 20% in functional group) in our study. Manchikantiet al showed that generalised anxiety disorder was present in 40% cases compared to 14% controls (Manchikanti, 2002). Whereas, other studies reported 15% and 20% of chronic pain patients had the same psychiatric disorder (Waddell, 2004 and Kostova, 2001). Another study showed that 18% of patients with current musculoskeletal pain had comorbid anxiety disorder which was similar to the present study (Dempsey, 1997). The analysis of other studies indicated that those with LBP scored significantly higher on depression than those without (Bene, 2004 and Bener et al., 2006). Among the types of psychological distress, somatization was more prevalent in LBP patients, followed by depression and then anxiety (Kostova, 2001). In another study, anxiety presented with the highest prevalence, followed by somatization and then depression (Manchikanti, 2003). The study findings describe the psychological issues among LBP patients and show that psychological factors are associated with LBP. Iranian LBP patients have an increased occurrence of coexistent psychological distress (Mirzamani-Bafghi, 2003), as has been shown in the current LBP patient population. In an Australian study, depression was associated with LBP (Henschke, 2008). The psychological factors associated with LBP show that distress may aggravate the pain (Burton, 2004). On the contrary, in a study focused on the impact of anxiety or somatization on the occurrence of LBP, no association was found with anxiety; however, somatization was found to be predictive of disability (Burton, 2004). The most common somatic symptom was “headaches” (41.1%) and most of the depressed patients were “feeling down, depressed, or hopeless” (49.2%). Nearly half of the LBP patients with anxiety symptoms (41.8%) were “feeling nervous and anxious or on edge.” LBP poses a significantly greater psychological strain on the patient and is one of the most challenging problems faced by health care consumers as well as health care providers. LBP patients manifest concurrent psychiatric illness, most commonly depression and somatization. The current study provides epidemiological evidence for the higher frequency and severity of depression, and anxiety symptoms in patients with LBP compared to patients without LBP. The current findings on LBP and its associated psychosocial factors urge health care practitioners to consider and identify psychological obstacles to recovery. Understanding the importance of the psychosocial pathway in the development of LBP lies not only in the advancement of knowledge in the phenomenon, but also in designing preventive interventions.
Conclusion The study findings revealed that LBP is a common problem in the general population. The data indicated that a significant association was observed between psychological distress and the prevalence of LBP. Depression was more prevalent in LBP, followed by anxiety then hypochondriasis. So it must not be conditions overlooked when attempting to manage pain. Therefore treating a patient’s mental dysfunctions might have efficacious results in improving the functional status of patients. If treatment of depression and anxiety can improve functional status doctors might be able to better serve their patients without placing patients on addictive pain management regimens.
REFERENCES Al-Shammari SA, Khoja TA, Kremli M, Al-Balla SR. Low back pain and obesity in primary health care, Riyadh Saudi Arabia. Saudi Med J. 1994;15:223–226. Bener A, Al-Kazaz M, Ftouni D, Al-Harthy M, Dafeeah EE. Diagnostic overlap of depressive, anxiety, stress, and somatoform disorders in primary care. Asia Pac Psychiatry. Epub July 23, 2012. Bener A, El-Rufaie OF, Kamran S, Georgievski AB, Farooq A, Rysavy M. Disability, depression and somatization in low back pain population. Int J Rheum Dis. 2006;9(3):257– 263. Bener A, El-Rufaie OF, Siyam A, Abuzeid MSO, Toth F, Lovasz G. Epidemiology of low back pain in the United Arab Emirates. Int J Rheum Dis. 2004;7(3):189–195. Bener A, Verjee M, Dafeeah A, Falah , et al. Psychological factors: anxiety, depression, and somatization symptoms in low back pain patients Journal of Pain Research 2013:6 95–101 Breslau N, Lipton RB, Stewart WF, Schultz LR, Welch KM () Comorbidity of migraine and depression: investigating potential etiology and prognosis. Neurology., 2003; 60: 1308-1312. Burton AK, McClune TD, Clarke RD, Main CJ. Long-term follow-up of patients with low back pain attending for manipulative care: outcomes and predictors. Man Ther. 2004;9(1):30–35. Cassidy JD, Caroll LJ, Cote P. The Saskatchewan health and back pain survey. The prevalence of low back pain and related disability in Saskatchewan adults. Spine (Phila Pa 1976). 1998;23(17):1860–1866. Delisa JA, editor. Physical Medicine and Rehabilitation, Principles, and Practice, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005:156–167. Dempsey PG, Burdorf A, Webster BS. The influence of personal variables on work-related low-back disorders and implications for future research. J Occup Environ Med. 1997; 39(8):748–759. Dempsey PG, Burdorf A, Webster BS. The influence of personal variables on work-related low-back disorders and implications for future research. J Occup Environ Med. 1997;39(8):748–759. Dickens C, Jayson M, Creed F. Psychological correlates of pain behavior in patients with chronic low back pain. Psychosomatics. 2002;43(1): 42–48.
25076
International Journal of Development Research, Vol. 09, Issue, 01, pp. 25072-25076, January, 2019
Finan PH, Smith MT. The comorbidity of insomnia, chronic pain, and depression: dopamine as a putative mechanism. Sleep Med Rev. 2013; 17(3):173–83. Henschke N, Maher CG, Refshauge KM. Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ. 2008;337:a171. Hildebrandt, J. Prediction of success from a Multidisciplinary Treatment Program for Chronic Low Back Pain. Spine 1 May 1997 Hiyama A, Watanabe M, Katoh H, Sato M, Sakai D, Mochida J. Effect of depression and neuropathic pain using questionnaires on quality of life in patients with low back pain; cross-sectional retrospective study. Eur Spine J. 2016;25:2750–60. Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, Rush AJ, Walters EE, Wang PS. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCS-R). J Am Med Assoc 2003;289:3095–105. Kostova V, Koleva M. Back disorders (low back pain, cervicobrachial and lumbosacral radicular syndromes) and some related risk factors. J Neurol Sci. 2001; 192(1–2):17– 25. Kostova V, Koleva M. Back disorders (low back pain, cervicobrachial and lumbosacral radicular syndromes) and some related risk factors. J Neurol Sci. 2001; 192(1–2):17– 25. Manchikanti L, Singh V, Saini B. Epidemiology of low back pain. In: Manchikanti L, Slipman CW, Fellow SB, editors. International Pain Management: Low Back Pain –
Diagnosis and Treatment. Paducah, KY: ASIPP Publishing; 2002:3–20. Mattila VM, Saarni L, Parkkari J, Koivusilta L, Rimpela A. Predictors of low back pain hospitalization – a prospective follow-up of 57,408 adolescents. Pain. 2008;139:209–217. Mirzamani-Bafghi SM, Sadidi A, Sahrai J. Psychological aspects of low back pain. Arch Iran Med. 2003;6(2):91–94. Palmer KT, Walsh K, Bendall H, Cooper C, Coggon D. Back Pain in Britain: comparison of two prevalence surveys at an interval of 10 years. BMJ. 2000; 320(7249):1577–1578. Ramond-Roquin A, Pecquenard F, Schers H, et al. Psychosocial, musculoskeletal and somatoform comorbidity in patients with chronic low back pain: original results from the dutch transition project. FamPract 2015;32:297–304. Sartorious N, Usten TB, Lecrubier Y, Wittchen HU. 1979. Depression comorbid with anxiety: results from the WHO study of psychological disorders in primary health care. Br J Psychiatry,. 168:38–43. Schneider S, Schmitt H, Zolter S, Schittenwolf M. Workplace stress, lifestyle and social factors as correlates of back pain: a representative study of the German working population. Int Arch Occup Environ Health. 2005;78(4):253–269. Von Korff M, Simon G. The relationship between pain and depression. Br J Psychiatry, 1996;168(Suppl. 3):101–8. Waddell G. The Back Pain Revolution, 2nd ed. London: Churchhill Livingstone; 2004.
*******
