KURDISTAN REGION OF IRAQ MINISTRY OF HIGHER EDUCATION & SCIENTIFIC RESEARCH UNIVERSITY OF SULAIMANI COLLEG OF NURSING
ASSESSMENT OF QUALITY OF LIFE AND DISABILITY AMONG PATIENTS WITH CHRONIC LOW BACK PAIN IN SULAIMANI CITY
ATHESIS SUBMITTED TO THE COUNCIL OF THE COLLEGE OF NURSING / UNIVERSITY OF SULAIMANI IN PARTIAL FULFILLMENT OF THE REQUIREMENT THE DEGREE OF MASTER OF SCIENCE IN NURSING
BY YOUSIF YAHYA HASSAN B.Sc. NURSING (2011)
UNDER SUPERVISION OF Assist.Prof.Dr. MUHAMMAD RASHID AMEN Ph.D in Adult Nursing
2017 APRIL
2717 GULAN
ﺑﺴﻢ اﻟﻠﻪ اﻟﺮَّﺣْﻤَﻦِ اﻟﺮَّﺣِﯿﻢِ
وَﻣَﺎ ﺑِﮑُﻢْ ﻣِﻦْ ﻧِﻌْﻤَﺔٍ ﻓَﻤِﻦَ اﻟﻠﱠﻪِ ﺛُﻢﱠ إِذَا ﻣَﺴﱠﮑُﻢُ اﻟﻀﱡﺮﱡ ﻓَﺈِﻟَﯿْﻪِ ﺗَﺠْﺄَرُونَ ﺻﺪق اﻟﻠﻪ اﻟﻌﻈﯿﻢ ﺳﻮرةاﻟﻨﺤﻞ اﻻﯾﺔ][٥٣
Dedication To my Parents & Family To my dearest wife, Tavga To my lovely daughter, Tlova To whom taught me
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Acknowledgment Before all, great thanks to God "Allah", the most gracious compassionate, and merciful. I would like to express my sincere thanks to Assist.Prof.Dr. Atiya K. Mohammed, Dean of the College of Nursing / University of Sulaimani for her cooperation. I’m deeply grateful to Assist.Prof.Dr.Muhammad Rashid Amen academic advisor for his support, guidance, and encouragement throughout my study, whose help, advice and supervision were invaluable. I would like to present my appreciation to all experts who have enriched the study by their scientific advice. Great thanks to the director and medical staff of Rheumatology and Physical Rehabilitation Center in Sulaimani City for their precious assistance. I warmly thank all the patients who took part in this study and allowed me to widen my knowledge and improve my work. I would like to thank all staff in the College of Nursing for their support and help especially the staff at post graduate department and library. Finally, I would like to thank my friends and all those who assisted me to deliver this thesis.
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Abstract Background: Chronic low back pain is a very common health problem among the population and a major cause of disability that affects physical performance and wellbeing. It is associated with significant reductions in quality of life, which can negatively impact overall functions of the body. Aim: The aim of the study is to assess quality of life and functional disability among patients with chronic low back pain in Sulaimani city. Methods: One hundred sixty-five patients aged 18 years old or more who clinically diagnosed as having chronic low back pain participated in this study. The study carried out in the period of 15 th November 2016 to 15 th April 2017 at Rheumatology and Physical Rehabilitation center in Sulamani city. A non-probability convenience sampling technique was applied in the present study. The study used World Health Organization Quality of Life-Brief for assessing quality of life and Oswestry Disability Index for assessing functional disability.During the interviews the questionnaire was filled out by the resacher, descriptive and inferential statistics was used for data analysis Results: General results indicate that the patients with chronic low back pain had the low quality of life mean score compared to standers range value and less than 60 which is considered cut-off point in all domains with some variations; physical (40.8±12.1),environment (48.3±10.8), psychological (51.9 ±14.4) and social (57.2±15.1). The average percentage of disability was (28.1±12.6), the proportion of minimal disability was (37.6%) and moderate disability was (44.8%).Patients' quality of life and functional disability affected by their own age, body mass index and physical exercises, (p ˂ 0.05). Conclusions: The researcher concluded that the quality of life of low back pain patients was poor; the physical domain was amongst the most affected domain. Functional disability level was mild to moderate. Obese and non- physically active patients had the poorest quality of life, and high functional disabilities. Recommendation: Depending on study findings, we recommend particular focuses to improve, quality of life and functional abilities for the patients with low back pain.
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List of Contents No.
Contents
Pages
Acknowledgment
I
Abstract
II
List of Contents
III-IV
List of Tables
V
List of Figures
VI
List of Abbreviations List of Appendices Chapter One: Introduction
VII- VIII III 1-6
1.1
Introduction
1-3
1.2
Importance of the study
3-4
1.3
The statement of the problem
1.4
The objectives of the study
4-5
1.5
Definitions of terms
5-6
Chapter Two: Review of Literatures 2.1
4
7-37
Low back pain
7
2.1.1
Historical background
7
2.1.2
Pain
8
2.1.3
Structures of the low Back
9
2.1.4
Classification of low back pain
10
2.1.5
Epidemiology of low back pain
10
2.1.6
Causes of low back pain
11
2.1.7
Risk factors of low back pain
14
2.1.8
Clinical features of low back pain
17
2.1.9
Diagnosis of low back pain
18
2.1.10 Management of low back pain
19
2.1.11 Nursing management of low back pain
23
2.1.12 Prognosis of low back pain
25
2.2
Quality of life
25
2.2.1
Quality of life: An overview
25-26
2.2.2
Quality of life domains
27-28
IV
No.
Contents
Pages
2.2.3
QoL assessment tools
28
2.2.4
Impact of chronic low back pain on QoL
29
Disability
30
2.3.1
Overview and definitions
30
2.3.2
Disability assessment tools
31
2.3.3
Impact chronic low back pain on functional disability
32
2.3
2.4
Previous studies
34-37
Chapter Three:Methodology
38-46
3.1
Design of the study
38
3.2
Administrative arrangements
38
3.3
Setting of the study
38
3.4
Sample of the study
39
3.5
Study instrument
39
3.6
Validity of the questionnaire
43
3.7
Pilot study
44
3.8
Reliability of the questionnaire
44
3.9
Data collection methods
45
3.10
Statistical analysis
45
3.11
Limitation of the study
46
Chapter Four: Results &Discussion
47-74
Chapter Five: Conclusion & Recommendations
75 -76
5.1
Conclusions
75
5.2
Recommendations
76 References List of appendices
77-93
V
List of Tables Tables Table (1): Distribution of the study sample according sociodemographic characteristics
Pages 48-49
Table (2 ): Distribution of the study sample according to body mass index and duration of the disease
50
Table (3 ): Distribution of the study sample according to their some lifestyle factors
51
Table (4 ): Distribution of quality of life domains', general QoL,
53
general health scores and functional disability Table (5 ): Correlation among participants' quality of life domains' and disability
58
Table (6): Distribution of difference mean scores of quality of life domains' and disability according to the patient's age
60
Table (7): Distribution of difference mean scores of quality of life domains' and disability according to the patient's gender
62
Table (8): Distribution of difference mean scores of quality of life domains' and disability according to patient's marital status
63
Table (9): Distribution of difference mean scores of quality of life domains' and disability according to patient's education
64
Table (10): Distributions of difference mean scores of quality of life domains' and disability according to patient occupation.
66
Table (11): Distribution of difference mean scores of quality of life domains' and disability according to patient's financial status
67
Table (12): Distributions of difference mean scores of quality of life domains' and disability according to patients body mass index
68
Table (13): Distributions of difference mean scores of quality of life domains' and disability according to patient's lifestyle factors
70
Table (14): Distribution of difference means scores of quality of life domains' and disability according to patient's duration of disease
73
VI
List of Figures No.
Figures
Pages
2.1
Low back vertebrae and discs
9
4.1
Distribution of the sample according functional disability level
54
VII
List of Abbreviations ACP
American College of Physicians
ADLs
Activity of Daily living
ALBP
Acut Low Back Pain
AMA
American Medical Association
BC
Before Christ
BMI
Body mass index
C/S
Comparative significant
CLBP
Chronic low back pain
CT
Computed Tomography
F
Frequency
HRQOL
Health-related quality of life
ICIDH
International Classification of Impairments Disabilities and Handicaps
IV
Intravenous
LBP
Low Back Pain
MRI
Magnetic Resonance Imaging
NLBP
Non-Specific Low Back Pain
NSAIDs
Non-Steroidal Anti Inflammatory Drugs
ODI
Oswestry Disability Index
QoL
Quality of Life
r
Correlation
RMDQ
Roland Morris Disability Questionnaire
SD
Standard Deviation
VIII
SF
Short Form
Sig.
Significant
SPSS
Statistical Package Social Sciences
TENS
Transcutaneous Electric Nerve Stimulation
UAE
United Arab Emirates
UK
United Kingdom
USA
United States America
VAS
Visual Analogue Scale
WHO
World Health Organization
WHOQoL
World Health Organization Quality of Life
IX
List of Appendices Subject
Appendices
Ethical committee approval
A
Official letter from from the College of Nursing / University of
B
Sulaimani to the Rheumatology and Physical Rehabilitation Center Questionnaire in Kurdish language
C
Questionnaire in English language
D
List of Experts
E
CHAPTER ONE INTRODUCTION
Chapter One
Introduction
1
CHAPTER ONE INTRODUCTION
1.1 Introduction: Low back pain (LBP) is one of the most common symptoms experienced by most of the people throughout the world. It is referred to pain or stiffness in muscle localized below the costal margin and above the inferior gluteal folds, with or without leg pain, and is defined as chronic when it persists for 3 months or more (Bindra et al., 2013). Between 2-7% of patients with acute low back pain (ALBP) develop chronic low back pain (Hoy et al., 2014). Low back pain and lumbosacral radicular pain have a large number of causes. They are intervertebral disc degeneration, disc herniation, and osteoarthritis of facet joints, fractures of pars interarticularis, spondylolisthesis, injury to ligaments, paravertebral and gluteal muscle trigger points and injury or inflammation of sacroiliac joints. In addition, back pain can arise as a result of primary and metastatic malignant conditions of the spine, osteoporotic vertebral fractures, inflammatory disorders of the spine, genitourinary, gastrointestinal and gynecological causes and these causes should not be missed in the diagnosis (Lionel, 2014). Although there are a large number of causes for low back pain, in the majority of cases of CLBP the etiology is unknown (Strong et al., 2013). According to majority of studies bad posture, lack of physical exercise, presence of low back pain related genes, low levels of education and poor nutrition had a significant association with low back pain. Also, certain physical activities such as lifting heavy weights have been rcognized as a risk for low back pain (Lionel, 2014).
Chapter One
Introduction
2
The studies have done all over the world show that the prevalence of CLBP is increasing. This increase in chronic low back pain prevalence is a concern for worry because it is a condition responsible for substantial social impact and an important source of demand for health services (Lionel, 2014). The quality of life plays a considerable role in individual and social health. Low back pain is the most common musculoskeletal disorders and causes negative impact on various aspects of life. Quality of life is an important consequence of public health that is a dynamic and multi-dimensional concept which relates to physical, psychological and social aspects and environmental of life and has different interpretations of the philosophical and political aspects of health (Panahi et al., 2016). Furthermore, the World Health Organization (WHO) defined quality of life as the "individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns" (WHO, 1995).This is a broad and multidimensional concept that incorporates information about physical health, psychological state, social relationships, and relationship with the environment in which people live (Bruvik et al., 2012). Within the context of the health sciences, QoL encompasses the subjective wellbeing and functioning in the physical, psychological and social domains. QoL informs about the aspects of health care that "actually get to the patient". Therefore, QoL can be considered as a highly important endpoint within health services research (Koller et al., 2009). Disability caused by LBP affects approximately one-quarter of adults in any one year and is the most common cause of physical disability in the working age population. People report that most if not all aspects of their lives are significantly affected by chronic low pain (Maughan and Lewis, 2010).
Chapter One
Introduction
3
Low back pain is a major cause of disability in developed and developing countries and is estimated to be the most prevalent type of pain. It may be one of the major symptoms of some diseases and causes deterioration of the patients’ daily activities and quality of life. Therefore, it is essential for clinicians to evaluate the LBP in patients accurately (Duruöz et al., 2013).
1.2 Importance of the study: It is well known that LBP is a common condition that causes many individuals suffering and a large burden on medical service and society.Assessment and documentation of the patient’s functional status and quality of life have become an essential part of understanding the impact of the LBP on the patient’s life. QoL measures have become a vital and often required part of health outcomes appraisal. For populations with chronic disease, measurement of QoL provides a meaningful way to determine the impact of health care when cure is not possible (Monazea et al., 2012). In this context, the assessment of the quality of life and any functional disability brings about permits further knowledge on chronic low back pain patients. Hence, measuring these variables can contribute to direct treatment, through the monitoring of conditions and the assessment of care outcomes (Stefane et al, 2013). This study is significant in a several way. The results include many implications for both health care professionals and for society as a whole. The clear understanding of the experience of living with chronic low back pain will be beneficial to health care providers, nurses in particular, who care for patients living with this condition. Nurses in practice will benefit from this study as they are on the front lines, encountering patients with low back pain in their work probably on a near-daily basis, the nurses advocating for appropriate treatment to improve patients’ lives and satisfaction with their health care.
Chapter One
Introduction
4
Patients also benefited from the present study by gaining knowledge about his/her condition and gain some information about their lifestyle which is responsible for their mobility, personal care, usual activities, and mental status. Nurses in research have the responsibility to discover and disseminate knowledge. Understanding how patients experience health care conditions, learning what is important to them as they live with medical conditions and treatments, and discerning the effects their health care encounters have on them will contribute greatly to a health care system that is both holistic and human. To our knowledge, the similar study has not conducted in Sulaimani city or Kurdistan region and Iraq, so the present study will be a resource for nurses and other health care professionals to analysis and finds out the efficiency of the treatment, and evaluate that the therapy is working or not.
1.3 The statement of the problem: Assessment of Quality of Life and Disability among Patients with Chronic Low Back Pain in Sulaimani City
1.4 Objectives of the study: 1.4.1 General objective of the study: To assess quality of life and functional disability among patients with low back pain attending Rheumatology and Physical Rehabilitation Center in Sulaimani City. 1.4.2 Specific objectives of the study: 1. To identify the socio-demographic characteristics of patients with chronic low back pain, which include: age, gender, marital status, occupation, level of education, residency and economic status. 2. To identify lifestyle and biomedical factors of patients with chronic low back pain, which include: smoking, alcohol intake, exercises, use analgesic drugs, body mass index, and duration of disease.
Chapter One
Introduction
5
3. Find out correlation among participants' QoL domains and functional disability levels. 4. Find out differences between patients QoL domains and functional disability levels with some variables, which include: patients' age, gender, marital status, level of education, occupation, economic status, body mass index, smoking, alcohol intake, exercise and use analgesic drugs.
1.5 Definitions of terms: 1.5.1 Assessment Theoretical definition: A systemic collection of data about individual health status, concerns mainly with current problems and needs that hinder the achievement of optimal health and well-being (Boyd, 2008). Operational definition: A systemic data collection from patients with chronic low back pain who attended Rheumatology and Physical Rehabilitation Center during data collection period and according to inclusions criteria of the study 1.5.2 Quality of life Theoretical definition: Quality of life as the individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns (WHO, 1995). Operational definition: It is the level of well-being and satisfaction of patient's life in the context of four domains Physical, Psychological, social and environmental measured by WHOQoL-BREF.
Chapter One
Introduction
6
1.5.3 Disability Theoretical definition: Disability is a defined as a physical impairment that has a substantial and longterm adverse effect on his or her ability to carry out normal day-to-day activities (Smedley et al., 2013). Operational definition: Disability is considered as the physical limitation or capcity in the ability to carry out basic functional activities among patients with chronic low back pain who attending and Rheumatology Physical Rehabilitation Center in Sulaimani City. 1.5.4 Low back pain Theoretical definition: Low back pain is defined as pain and discomfort localized below the costal margin to the inferior gluteal folds with or without sciatica (Chou, 2011). Operational definition: Pain in the low back (lumbar region), with no pathological reason, the pain lasted for more than 3 months, which is considered chronic among patients who attending Rheumatology Physical Rehabilitation Center in Sulaimani City.
CHAPTER TWO LITERATURE REVIEW
Chapter Two
Literature Review 7
CHAPTER TWO LITERATURE REVIEW
2.1 Low Back Pain: 2.1.1 Historical background: Low back pain has been a problem for mankind throughout history.The oldest surviving text on the subject was written on papyrus about 1500 BC. It is a series of 48 cases, the last of which was an acute back strain (Waddell, 2004). As we travel forward through history, many of the practices of western medicine can be traced to the Corpus Hipppocraticus (circa 400 BC), the collated writings of the Greek Library at Cos and Cnidus. It was there that Galen of Pergamon and his disciples dominated the writings for the next 1200 years terms such as sciatica pain and LBP were first mentioned by Hippocrates’ teachings for most of the early century of the first millennium. Arabian influence then permeated into the medical landscape with the writing of The Canons of Medicine by Avicenna (981-1037) physicians of the time recommended that surgery could not be performed on the back and most recommendations centered around watchful waiting (Gakuu, 2015). By 1800, physicians were beginning to look for a cause of back pain and suggested that it was "rheumatic phlegm". In the nineteenth century, two key ideas laid foundations for our model approach to back pain; that it came from the spine and that it was due to trauma. In 1828 it was suggested for the first time that the vertebral column and the nervous system could be the source of back pain, which should be treated with rest. World War II saw an increase in LBP and, instead of being diagnosed as "fibrositis" or a "rheumatic condition" it was more likely to be attributed to "strain" (Waddell, 2004).
Chapter Two
Literature Review 8
However, unlikely that a specific cause for low back pain can be during the 20th century the popularity of such proposed causes decreased. Harvey Williams Cushing an American neurosurgeon in Monusov boosted the acceptance of surgical treatments for low back pain in the early 20th century. In the 1920s and 1930s, new theories of the cause arose, with physicians proposing a combination of nervous system and psychological disorders such as nerve weakness (neurasthenia) and female hysteria. Muscular rheumatism (now called fibromyalgia) was also cited with increasing frequency. The introduction of technologies such as X-rays provided physicians with new diagnostic tools. This helped in revealing the intervertebral disc as a source of back pain in some cases. In 1938, orthopedic surgeon Joseph S. Barr in Lutz et al reported on cases of disc-related sciatica improved or cured with back surgery. As a result of this work, in the 1940s, the vertebral disc model of low back pain took over, dominating the literature through the 1980s, adding further by the rise of new imaging technologies such as CT and start of the 20th century was that low back pain is MRI (Mafuyai et al., 2013).
2.1.2 Pain: Pain is one of the body's most important adaptive and protective mechanisms and all definitions suggest it is a complex phenomenon and cannot be characterized as only a response to injury. A widely accepted definition of pain is that drafted by International Association for the Study of Pain (IASP) and accepted by Amerian Pain Society and the World Health Organization:"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Waddell define pain as '' asymptom, not a clinical sign, diagnosis or disease." A clear understanding of the complexitities of the pain experience specifically one that encompasses an individual's emotions, cognition, motivation, prior history, and even issues of secondary gain is needed to mange pain and to futher understand the pain processes (McCance and Huether, 2015).
Chapter Two
Literature Review 9
2.1.3 Structures of the low back: The low back (lumbosacral area) is between the bottom of the rib cage and top of the legs and comprises of the following structures: 1. Five irregular bones (the lumbar vertebrae) with inter-vertebral discs between each bone and spinous processes at the back of the vertebral bones that from the attachment points for all the muscles. 2. The inter-vertebral discs, with a strong fibrous external layer and a gel-like pulp in the center. These allow the spine to be flexible and act as shock absorbers. 3. The spinal cord and nerves, which run through the center of the vertebral column and are protected by the bony structures of the spine. The nerves transmit messages to and from the brain. 4. Strong ligaments, which attach to adjacent vertebral bones, giving support and stability. 5. Various muscles, surrounding the spine, which moves (mobilize) and helps to stabilize the spine (transversus abdominus, multifidus, internal and external obliques, rectus abdominus, erector spinae and other stabilizers of the pelvis which will also affect posture) (Lawrence and Barnett, 2013).
Figure 2.1 Low back vertebrae and discs (Lawrence and Barnett, 2013)
Chapter Two
Literature Review 10
2.1.4 Classification of low back pain: Based on duration, low back pain can be acute which persist for <4 weeks, subacute between 4-12 weeks, chronic when >12 weeks. LBP is typically classified as specific and non-specific. Specific LBP is caused by specific pathophysiological mechanism whereas non-specific LBP is defined as symptoms due to anon-specific cause, i.e. LBP of unknown origin (Desai and Bisen, 2017).
2.1.5 Epidemiology of low back pain: Low back pain is one of the most common symptom experienced by most of the people throughout the world. It is estimated that 70 to 80% of the world’s population has been suffered at least one episode of LBP in their lifetime (Barua and Sultana, 2015). As part of the Global Burden of Disease Study 2010, Expert Group showed that low back pain is among the top ten high burden diseases and injuries, with an average number of disability-adjusted life years (DALYs) higher than HIV, road injuries, tuberculosis, lung cancer, chronic obstructive pulmonary disease and preterm birth complications (Awaji,2016). Prevalence of low back pain varied depending on definitions and study populations and also differs from countries to countries. The point prevalence, or the percentage of people experiencing low back pain at a given moment in time, was reported between 21.5% and 57%. One year prevalence was reported between 37.8% and 61.3%. The six month prevalence was reported between 40.8% and 42.6%, and the lifetime prevalence was reported between 61.6 % and 70% (Abebe et al., 2015). Balagué et al (2012) reporting a lifetime prevalence as high as 84% in the United States of America adult populations. Consequently, one study in Canada estimated that 84% of adults have had LBP during their lifetime.
Average
prevalence was 59% in UK, 70% in Denmark, and 75% in Finland (Biglarian et al., 2012).
Chapter Two
Literature Review 11
Furthermore, Bener et al (2014) the prevalence rate in general populations in Arab countries are reported to be 56.5% in Qatar, 64.6% in the United Arab Emirates (UAE), 51.0 % in Tunisia.A systematic review of the global prevalence of LBP conducted by Hoy et al (2010) using 165 studies from 54 countries revealed that LBP is most prevalent among females and persons aged 40–80 years.
2.1.6 Causes of low back pain: A. Mechanical causes: The mechanical causes of low back pain are given bellow: 1. Sprain and strain Lumbosacral strain/sprain is the most common cause of low back pain. It is defined as a stretch injury to the large muscles of the low back and/or the ligaments and tendons, leading to microscopic tears and inflammation in these soft tissues. It manifests as pain in the low back and upper buttocks. Low back muscle spasm can also occur, and patients will often feel stiffness of the low back. Lumbosacral strain/sprain typically occurs because of overuse, improper use of muscles, such as lifting heavy object improperly, twisting the back in an unusual manner, or trauma (Patel et al., 2014). 2. Degenerative disc disease Low back pain due to degenerative disc disease is believed to be a result of the loss of normal structure and function of the intervertebral disc. In a degenerating disc, over time, the collagen structure of the annulus fibrosus weakens and the proteoglycan content decreases. These physiologic changes lead to a decrease in the water content of, and nutritional supply to the disc, making it more susceptible to mechanical stresses. This progress to altered spinal biomechanics, which, combined with release of neural mediators and neurovascular ingrowth into the disk, generate LBP (Anderson, 2013).
Chapter Two
Literature Review 12
3. Herniated disc A herniated disc refers to localized displacement of the nucleus pulposus through a tear in the annulus fibrosus beyond the limits of the intervertebral disc space. The tear in the annulus fibrosus may result in the release of inflammatory mediators which may cause severe pain even without nerve root compression. Most common level for lumbar disc herniation occurs between L4–5 and L5–S1 (Patel et al., 2014). 4. Spinal stenosis Lumbar spinal stenosis is defined as any type of narrowing of the spinal canal, nerve root canals, or intervertebral foramen. This narrowing can be caused by soft tissue, bone, or a combination of both. The resultant nerve root compression leads to nerve root ischemia and clinical syndrome associated with variable degrees of low back, buttock and leg pain (Devlin, 2012). 5. Spondylolisthesis Spondylolisthesis is a recognized cause of back pain. It is characterized by a slipping forward of one vertebra on another, most commonly at L4/L5 (Ballinger, 2012), if the degree of slippage is significant and impinges on the central canal or intervertebral foramina, it can cause radicular pain and neurologic deficits (Bartleson and Deen, 2009). 6. Vertebral compression fracture Compression fractures are fractures of the vertebrae, most commonly due to osteoporosis, but they can also occur with trauma or tumors. Severe pain in the area of the fracture is the most common manifestation. Pain may be due to the compression fracture itself or associated paraspinal muscle spasm (Weiss et al., 2010).
Chapter Two
Literature Review 13
B. Non-Mechanical causes: The non mechanical causes of low back pain are described below: 1. Neoplasm Tumors within the spine or spinal canal are a rare but a serious cause of low back pain. Only 1% all cases of low back pain are attributable to malignant neoplasm, and greater than 80% of these patients are over 50 years old of age. The principal cancers which metastasize to bone are lung, prostate, breast, thyroid, and kidney. Other malignancies affecting the spine or spinal canal are malignant myeloma, lymphoma, leukemia, primary bone tumors, and primary cord or dural tumors.Patients with spinal malignancies often present with complaints of low back pain lasting greater 6 weeks, pain which is worse at night, and recent weight loss (Aghababian, 2010). 2. Infection Vertebral osteomyelitis is one of the etiologies of back pain that can cause significant neurological compromise if misdiagnosed or left untreated. It is defined as an infection of the bone of the spine. It can be caused by hematogenous spread from any source in the body by direct inoculation arising from the injection, trauma, or spinal surgery, or by contiguous spread from adjacent soft tissue infection (Roos, 2012). Discitis is characterized by inflammation of intervertebral disc spaces and vertebral body endplates, primarily involving the lumbar spine. Inflammation is thought to result from low-grade bacterial or viral infection of the disc space, although trauma may also play a role (Florin et al., 2011). C. Referred visceral pain Disease in organs that share segmental innervation with the spine can cause pain to be referred to the spine. In general, pelvic diseases refer pain to the sacral area, lower abdominal diseases to the lumbar area, and upper abdominal diseases to the lower thoracic spine area. Local signs of disease such as tenderness to palpation, paravertebral muscle spasm, and increased pain on spinal motion are absent.
Chapter Two
Literature Review 14
Vascular, gastrointestinal, urogenital, or retroperitoneal pathology may on occasion cause LBP. A partial list of causes includes an expanding aortic aneurysm, pyelonephritis, ureteral obstruction due to renal stones, chronic prostatitis, endometriosis, ovarian cysts, inflammatory bowel disorders, colonic neoplasms, and retroperitoneal hemorrhage (Firestein et al., 2017).
2.1.7 Risk factors of low back pain: Low back pain can be due to a number of factors include individual characteristics, working conditions, lifestyle and social, economic, cultural and ethnic factors. These risk factors may be non-modifiable, such as age and gender, or modifiable such as obesity, smoking status, depression and physical activity (Stewart Williams et al., 2015). A. Non- modifiable risk factors: 1. Age Age is one of the most common factors in the development of low back pain, with most studies finding the highest incidence in the third decade of life and overall prevalence increasing until age 60 to 65 years. However, there is recent evidence that prevalence continues to increase with age with more severe forms of back pain. Other studies show that back pain in the adolescent population has become increasingly common (Patrick et al., 2016). 2. Gender The overall prevalence of low back pain is higher in women than in men. A systematic review of the global prevalence of LBP conducted by Hoy et al (2010) using 165 studies from 54 countries revealed that LBP is most prevalent among females. In a study covering seventeen countries across six continents with a total sample size of over 85, 000 adults, females were reported to have a higher prevalence of back pain (Fillingim et al., 2009).
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Literature Review 15
While it is apparent that gender may have an effect on pain, and specifically LBP, the mechanisms there are not well understood. There are multiple components which may be responsible for this effect including biological factors such as hormonal influences, psychosocial factors such as gender role expectations, or a combination of both factors (Leboeuf-Yde et al. 2011). B.Modifiable risk factors: 1. Obesity Overweight and obesity are risk factors for both lumbar radicular pain and sciatica, and a direct relationship exists between body mass index and low back pathology and pain in men and women. A meta-analysis of 28 studies found overweight and obesity was associated with lumbar radicular pain, increased the risk of hospitalization for sciatica, and increased the risk of lumbar disk herniation surgery. These associations were similar for men and women (Shiri et al., 2014). Clarification of whether or not LBP precedes obesity was addressed by an 11year longitudinal study of 25,450 individuals. Among those without LBP at baseline, a significant positive association was found between BMI ≥30 and risk of LBP in men and women, and risk of chronic LBP recurrence in women, but not men. In contrast, LBP at baseline had little effect on later changes in BMI (Heuch et al., 2013). 2. Smoking The associations between smoking and low back pain vary across studies. Balagué et al. (2012) identified LBP as a weak risk factor for LBP, while Shiri et al (2010) assessed the association between smoking and low back pain with Metaanalysis and concluded that both current and former smokers have a higher prevalence and incidence of low back pain than never smokers. The most widely accepted explanation for the association between smoking and low back pain is disc degeneration via malnutrition of spinal disc cells by carboxyhemoglobin-induced anoxia or vascular disease. Smoking introduces a variety of
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toxic substances (e.g., carbon monoxide) that may damage the interior lining of blood vessels, thus decreasing their capacity to carry oxygen, leading to tissue starvation, degeneration, and death. There is also some evidence that nicotine may accelerate intervertebral disc degeneration by instigating cell damage in both the nucleus pulposus and anulus fibrosus, and/or influencing the metabolism of the intervertebral disc Indeed, nicotine has been shown to induce serum proteolytic enzyme activity( Ditre et al., 2011). 3. Psychosocial factors Psychosocial factors appear to play a substantial role in the frequency of low back pain. Persons with negative affectivity, low levels of social support in the workplace, low level of job control, high psychological demands and work dissatisfaction, as well as stress, anxiety, depression are more prone to low back pain (Duthey, 2013). Consequently, the high prevalence of depression (78.75%) was found in patients with CLBP of any origin and there was the strong relation between pain severity and depression (Anap et al., 2013). 4. Lack of physical activity Physical activity (PA) to increase aerobic capacity and muscular strength, especially of the lumbar extensor muscles, is important for patients with chornic low back pain in assisting them to complete activities of daily living. However, different exercises have been found to result in varying levels of effectiveness in reducing low back pain (Gordon and Bloxham, 2016). Nilsen et al (2011) reported that even individuals who performed as little as one hour of physical activity per week had a reduced risk of developing chronic LBP. Sports activities such as swimming and soccer were associated with decreased prevalence of low back pain. According to studies done in Sri Lanka reported that taking part in exercises such as walking and running 20 minutes/day more than three times a week had a significant protective effect on low back pain (Lionel, 2014).
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2.1.8 Clinical features of low back pain: LeMone et al (2015) stated that the clinical features of low back pain are as follow: A. Alteration in gait and flexion: 1. Walking in a stiff, flexed state. 2. Inability to bend at waist. 3. Limp, which may indicate impairment of the sciatic nerve. B. Neurological involvement: 1. When tested for light and deep touch with a pin and cotton ball, may feel sensations in both limbs but experience a stronger sensation in the unaffected side. 2. Loss of both bowel and bladder control due to the involvement of the sacral nerve. C. Pain: 1. Pain in the affected leg when walking on heel or toes. 2. Continuous, knife-like localized pain in muscles close to the affected disc.
3. Pain that radiate down posterior of leg. 4. Sharp burning pain in the posterior thigh or calf. 5. Pain in middle of buttock. 6. Tenderness when muscle close to the affected disc is palpated. 7. Sever pain with straight leg raising maneuver. 2.1.9 Diagnosis of low back pain: A.History and physical examination: Assess history of present illness, including onset, duration, severity, radiation, exacerbating and alleviating factors, functional disability, and associated symptoms (e.g., night pain, morning stiffness, numbness, weakness, and bowel/bladder dysfunction).
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Evaluate range of motion, sensation, strength, straight-leg raise test, reflexes, and neurovascular status. Evaluate for “red flags” that may indicate serious condition: 1. Red flags suggestion fracture: trauma, strenuous lifting in older or osteoporotic patients. 2. Red flags suggesting tumor or infection: age (>50 or<20 years), history of cancer,
presence
of
constitutional
symptoms,
IV
drug
use,
immunosuppression, worsening pain at night. 3. Red flags suggesting cauda equina syndrome: saddle anesthesia, recent onset of incontinence, severe or progressive neurological deficit in the leg (Kahan, et al., 2009). B. Diagnostic imaging and testing: The Clinical Guidelines Committee of the American College of Physicians (ACP) concluded that diagnostic imaging is indicated for patients with low back pain only if they have severe progressive neurologic deficits or signs or symptoms that suggest a serious or specific underlying condition. In other patients, evidence indicates that routine imaging is not associated with clinically meaningful benefits but can lead to harms. They concluded that more testing does not equate to better care and that implementing a selective approach to low back imaging, as suggested by the ACP and American Pain Society guideline on low back pain, would provide better care to patients, improve outcomes, and reduce costs (Chou,2011). Standing plain radiographs of the lumbar spine are the initial imaging modality of choice.Though not likely to reveal the exact pathologic cause of a patient’s symptoms, these images will rule out troubling disorder such as fracture, tumor, or infection. With these diagnoses largely excluded with plain radiographs, most patients with low back pain do not require further imaging. MRI should be used in patients with neurologic complaints or in those for whom the clinician has a high level of suspicion for an occult fracture, tumor, or early infection (Patrick et al., 2016).
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Other imaging modalities that are used in patients with back pain include computed tomography, myelography, and bone scans. The computed tomography (CT scans) useful in identifying underlying problems, such as obscure soft tissue lesions adjacent to the vertebral column and problems of vertebral disks. And the myelography permits visualization of segments of the spinal cord that may have herniated or may be compressed and bone scan may disclose infections, tumors, and bone marrow abnormalities (Smeltzer et al., 2010). Laboratory tests can help confirm suspicion of spinal infection or tumor. With spine infection, laboratory testing is low in specificity, and diagnostic confirmation requires MRI and frequently biopsy (Casazza, 2012).
2.1.10 Management of low back pain: A. Pharmacological treatment: Medications are commonly used for the management of low back pain. Acetaminophen (paracetamol), non-steroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, antidepressants, and pain medication are some of the more commonly prescribed medications for low back pain (Pinheiro-Franco et al., 2016). In the acute period, paracetamol is one of the first line options for the treatment of low back pain. A big advantage of this medication is its high safety profile with a low risk of serious side effects. Besides paracetamol non-steroidal antiinflammatory drugs (NSAID) are also recommended as initial treatment for either acute or chronic low back pain. However, as all NSAIDs can cause gastrointestinal bleeding and renal adverse effects, their use should be limited to the lowest dose possible and as short as possible (Uhl, 2010). Muscle relaxants include benzodiazepines, non-benzodiazepines and antispasticity agents. A Cochrane review concluded that muscle relaxants were effective for alleviating symptoms in chronic LBP, but that drowsiness, dizziness and other adverse effects were frequent. The risk of long-term dependence is also a
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concern. While muscle relaxants are recommended in the acute setting, their use is not recommended for the management of chronic LBP (Morlion, 2013). Opioid medications are also used for low back pain. There is moderate evidence for short-term benefit. There is a lack of evidence for long-term use in chronic low back pain. The most common side effects of these medications include dizziness, drowsiness, nausea, constipation, rash, and at high doses respiratory suppression (Pinheiro-Franco et al., 2016). Futhermore,antidepressants may be effective for treating chronic pain associated with symptoms of depression, but they have a risk of side effects. Although the antiseizure drugs gabapentin and carbamazepine are sometimes used for chronic low back pain and may relieve sciatic pain, there is insufficient evidence to support their use (Miller, 2012). B.Non-pharmacological treatment: Another treatment category available for patients with low back pain is nonpharmacologic therapies; there is significant clinician variability in recommending these treatments, alone or in adjunct with medications. Physical therapy is a broad term that includes the following: exercise therapy, transcutaneous electrical nerve stimulation (TENS), massage, traction, lumbar support, and heat/cold treatments (Borczuk et al., 2013). 1. Exercise therapy Multiple studies have found that exercise results in positive outcomes in the treatment of chronic low back pain, including pain relief, improvement in function and slightly reduced sick-leave.The most effective exercise for low back pain includes an individualized treatment learned and performed under the supervision of a therapist that includes stretching and strengthening. The purpose of exercises for the treatment of low back pain is to strengthen and increase endurance of muscles that support the spine and improve flexibility in areas that have stiffness (Ojoga and Marinescu, 2013).
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2. Transcutaneous electric nerve stimulation (TENS) Transcutaneous electric nerve stimulation provides pulses of electrical stimulation through surface electrodes. For acute back pain, there is no proven benefit. Two small studies produced inconclusive results, with a trend toward improvement with TENS. In chronic back pain, there is conflicting evidence regarding its ability to help relieve pain. One study showed a slight advantage at one week for TENS but no difference at three months and beyond. Other studies showed no benefit for TENS at any time (Arya, 2014). 3. Traction Traction has been classically used for patients with radicualr symptoms to help resolve neurologic deficits and reduce pain. Studies addressing the efficacy of traction have been largely inconclusive. A recent systematic review found that traction provided no benefit in the short or long term for patients with low back pain with or without sciatica (Buttaro et al., 2016). 4. Heat / cold therapy Other interventions include local application of heat and cold. Cold can be applied to the low back with towels, gel packs, ice packs, and ice massage. Heat methods include water bottles and baths, soft packs, saunas, steam, wraps, and electric pads. There are few high-quality randomized controlled trials supporting superficial cold or heat therapy for the treatment of acute or subacute low back pain. A Cochrane review cited moderate evidence supporting superficial heat therapy as reducing pain and disability in patients with acute and subacute low back pain, with the addition of exercise further reducing pain and improved function. The effects of superficial heat seem strongest for the first week following injury (Petering and Webb, 2011).
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5. Massage Massage, is defined as manipulation of muscle and fascia using one's hands or a mechanical device, is widely used adjunctive treatment in patients with back pain. Systematic reviews of massage therapy have concluded that massage is effective for subacute and chronic low back pain. Although limited in number and mixed in quality, clinical trials have shown massage is more effective than exercise, acupuncture, and self-care education in improving symptoms and function in patients with nonspecific low back pain. Several trials have suggested that addition of massage to exercise improves out come in patients with low back pain compared with exercise alone (Steinmetz and Benzel, 2016). C.Surgical treatment: The broad range of operative techniques is used to treat low back pain, including spinal decompression, discectomy, foraminotomies, disc prosthesis (artificial disc replacement), minimally invasive and microsurgeries, and various approaches for spinal fusion with or without instrumentation.The general indications for commonly performed lumbar spine operations include spinal decompression for radicular symptoms including lumbar spinal stenosis as well as spinal fusion or disc prosthesis for discogenic LBP without nerve root involvement (Hooten and Cohen, 2015). Spinal decompression surgery involves complete or partial removal of lumbar spine structures causing neural impingement, such as large disc herniations and spinal
stenosis.
This
includes
open
discectomy,
microdiscectomy,
and
laminectomy. Fusion surgery joins adjacent vertebrae in an unstable vertebral motion segment to alleviate pain in advanced spinal degeneration. Disc arthroplasty treats degenerative changes confined to one vertebral motion segment by disk removal with artificial disk replacement (Morlion, 2013). Evidence supports laminectomy for disabling leg pain due to spinal stenosis and open discectomy or microdiscectomy for radiculopathic pain associated with
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lumbar disk herniation. Post surgery symptom relief seldom persists longer than two years. Better outcomes with radiculopathy and lumbar disk herniation are associated with patient age younger than 40 years of age and symptom duration less than three months (Bostelmann and Steiger, 2014). Fusion surgery has a weak recommendation for non-radicular chronic LBP associated with degenerative disk disease, with greatest benefit in patients with moderately severe pain or disability, one or more years of conservative management without improvement, and absence of psychiatric or medical comorbidities (Chou et al., 2009).
2.1.12 Nursing management of low back pain: Cheever and Hinkle (2014) specify nursing assessment and nursing interventions for low back pain as follow:
Nursing assessment: 1. Encourage patient to describe the discomfort (location, severity, duration, characteristics, radiation, and weakness in the legs). 2. Obtain history of pain origin and previous pain control; assess environmental variables, work situations, and family relationships. 3. Observe patient's posture, position change, and gait. 4. Assess spinal curves, height of the iliac crests, leg length discrepancy, and shoulder symmetry. 5. Palpate paraspinal muscles and note spasm and tenderness; spasms may resolve when the patient is in the prone position. 6. Note discomfort and limitations in movement when patient bends forward and laterally; access the impact of these limitations on performing ADLs. 7. Evaluate nerve involvement by assessing deep tendon reflexes, sensations, and muscle strength; back and leg pain on straight -leg raising (with the patients in the supine position, the patient's leg is lifted upward with the knee extended) suggests nerve root involvement.
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8. Assess patient's response to analgesic agents; evaluate and note patient's response to various pain management modalities.
Nursing interventions: 1. With severe pain, discourage extended periods of inactivity on bed rest. 2. Advise patients to rest on a medium to firm, non-sagging mattress. 3. Help patients to increase lumbar flexion by elevating the head and thorax 30 degrees using pillows or foam wedge and slightly flexing the knees supported on a pillow; avoid prone position. Alternatively, the patient can assume a lateral position with knee and hips flexed with a pillow between the knee and legs and pillow supporting the head. 4. The nurse instructs the patients to get out of bed by rolling to one side and placing the legs down while pushing the torso up, keeping the back straight. 5. As the patient achieves comfort, help patient gradually resumes activities and initiate an exercise program; begin with low-stress aerobic exercises.Begin conditioning exercise in coordination with physical therapist; each 30 minute daily exercise period should begin and end with relaxation. 6. Encourage patient to adhere to the prescribed exercise program; alternating activities may facilitate adherence to the regimen. 7. Encourage patient to improve posture and good body mechanics and to avoid excessive lumbar strain, twisting, or discomfort (e.g., avoid activities such as horseback riding and weight lifting). 8. Educate patient regarding how to stand,sit, lie,and lift properly:
Shift weight frequently when standing and rest one foot on a low stool; wear low heels.
Sit with knee and hips flexed and knees level with hips or higher.keep feet flat on the floor.Avoid sitting on stools or chairs that do not provide firm back support.
Sleep on side with knee and hips flexed or supine with knees flexed and supported; avoid sleeping prone.
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9. Lift objects using thigh muscles, not back.place feet hip-width apart for a wide base of support, bend the knees, tighten the abdominal muscles, and lift the object close to the body with a smooth motion.Avoid twisting and jarring motions. 10.Assist patient to resume former role-related responsibilities. 11.Refer patient to psychotherapy or counseling, if needed. 12.If patient is obese, assist with weight reduction through diet modification; note achievement, and provide encouragement and positive reinforcement to facilitate adherence.
2.1.12 Prognosis of low back pain: The prognosis for people with acute back pain associated with red flags depends on the underlying cause of the pain. Up to 90% of people experience an episode of back pain without other health concerns, and their symptoms will go away on their own within a month. For about half, back pain may return. About 80% of people with sciatica will eventually recover, with or without surgery. The recovery period is much longer than for uncomplicated, acute back pain. One can improve one’s chances of early recovery by staying active and avoiding more than two days of relative bed rest (Arya, 2014).
2.2 Quality of Life: 2.2.1 Quality of life: An overview: In 1948 the World Health Organization defined health as being not only the absence of disease and infirmity but also the presence of physical, mental and social well-being.Since that time quality of life issues have been increasingly recognized as important parameters in determining health status. A single definition of quality of life is difficult to find,without a clear definition multiple interpretations of what quality of life is have evolved.This has lead to the development of a number of different measures which assesses varying aspects of quality of life (Mamula et al.,2013).
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In connection with this, the world Health Organization (WHO) defines quality of life as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns. It is a broad ranging concept affected in a complex way by the person's physical health, psychological state, personal beliefs, social relationships and their relationship to salient features of their environment (WHO, 1995). Quality of life can be defined as an overall sense of well-being, including aspects of happiness and satisfaction with life as a whole, which is measurable through mental well being, physical functioning and overall health status (Butt et al., 2012). Fothermore, Moons et al (2006) stated that the quality of life often seems to be an umbrella term, covering a variety of concepts, such as functioning, health status, perceptions, life conditions, behaviour, happiness, lifestyle, symptoms, etc. Divergent approaches have been adapted to QoL studies over the last decades, and the official definitions used in these studies are still not consistent. For instance, different measurements of QoL have been published, however, there is still no scientific consensus regarding official instruments for these measurements. As the result, various methods are used for the assessment of QoL.In addition, there is a disagreement among scientists about two basic concepts of QoL, subjectivity and multidimensionality.Subjectivity is related to the fact that QoL can only be understood from an individual perspective.Multidimensionality comes from traditional psychometric assessment of health condition and requires the evaluation of different dimensions of individual health while measuring QoL. The biggest obstacle in the interpretation of QoL measuring is lack of a “gold standard” or a unit of measurement that would allow comparison of QoL among different populations, regions, and over different periods (Sljivo et al., 2016). Caqueo- Urizar et al (2009) stated that the QoL concept comprises different dimensions: Individuals physical and emotional health, psychological and social
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wellbeing fulfillment of personal expectations and goal, economic assurance, and finally functional capacity to develop daily routines normally. Although QoL and HRQoL are often used interchangeably to refer to the same concept, there are differences between the two. QoL is a broad concept covering all aspects of human life, whereas HRQoL focuses on the effects of illness and specifically on the impact of treatment on QoL. HRQoL is a reflection of the way that individuals perceive and react to their health status and the nonmedical aspects of their lives, which include health-related factors, such as physical, functional, emotional, and mental well-being as well as nonhealth-related elements, such as job, family, friends, and other situations in life. Regarding health outcomes, most indicators reflect a disease model, but HRQoL provides a comprehensive evaluation encompassing all the important aspects of QoL related to health (Lin et al., 2013).
2.2.2 Quality of life domains: 1. Physical domain The physical domain includes pain and discomfort, energy and fatigue, sleep and rest. This domain explores understand physical sensations experienced by a person and, the extent to which these sensations are distressing and interfere with life. It is acknowledge that people respond to pain differently, and differing tolerance and acceptance of pain is likely to affect its impact on QoL (WHO, 2001). 2. Psychological domain The psychological domain includes how much a person experience positive feelings of the good things in life, explores persons view of his/her thinking and ability to make decision, how people feel about themselves, persons satisfaction with the way he/she looks, and how much a person experiences negative emotions such as sadness and anxiety (WHO, 2001).
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3. Social domain The social relationships domain assesses an individual's perceptions on personal relationships, social support, social inclusion and sexual activity (Peter et al., 2014).People value their relationships with self and with others. Humans need to feel a sense of belongcing and acceptance; they need to love and be loved both sexually and non-sexually. In the absence of such belonging, individuals become susceptible to loneliness, anxiety, and depression. When an individual is no longer able to physically, emotionally, or sexually relate to self and others, quality of life is often negatively affected (WHOQoL-HIV, 2003a). 4. Environment domain The environment domain refers to physical safety and security, home environment, financial resources, health and social care (accessibility and quality), opportunities for acquiring new information and skills, participation in and opportunities for recreation/leisure activities, physical environment (pollution, noise, traffic, climate), and transport (Bakiono et al., 2015).
2.2.3 QoL assessment tools: At the current time, there are in excess of 1000 instruments, designed specifically for the measurement of quality life. Some of these are generic, for use in the general population and can be applied to a number of conditions.Others are disease specific, pertaining to a particular pathology (Theofilou, 2013). One of these instruments is the World Health Organization quality of life- BREF (WHOQoL-BREF) questionnaire which captures many subjective aspects of QoL, This questionnaire is one of the best known instruments that has been developed for cross-cultural comparisons of QoL and is available in many languages.The WHOQoL BREF covers four different domains of quality of life, which include: physical, psychological, social and environment domain (Gholami et al., 2013). The Medical Outcomes Short Form–36 questionnaire (SF-36) is a generic HRQoL instrument that has been a commonly used frequently used generic HRQoL assessment.This multi-purpose, short-form health survey is comprised of
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36 questions which provide an eight-scale profile of functional health and wellbeing scores (physical function, role function, bodily pain, general health, vitality, social functioning, emotional well-being and mental health) as well as composite physical and mental health summary measures(Theofilou, 2013). Another generic instrument, the European Quality of Life Questionnaire, has also been widely used in evaluative QoL studies (Mustur et al., 2009).
2.2.4 Impact of chronic low back pain on QoL Chronic LBP can negatively impact patient QoL as a result of pain, impaired mobility, decreased social activity, and changes in mood. Hence, QoL measurements in people with chronic disease are useful for assessing general disease impact (Kim et al., 2015). There are a number of studies that attempt to understand low back pain in terms of quality of life and the impact of back pain on the living of people. The results of regional study which conducted by Panahi et al (2016) found that the participants who suffering from low back pain had lower quality of life compared with the students without low back pain. Furthermore, Darzi et al (2014) assessed two hundred and fifty six low back pain patients and healthy people.The researcher found that the scores of these four domains and general quality of life and general health of QoL-BREF were lower in low back pain patients.They concluded that patients with low back pain have low QoL when compare to healthy persons. Also, Stefane et al (2013) reported that poor QoL among low back patients and the most affected QoL domain found in this study was the physical with in accordance other studies. They stated that the physical QoL domain comprises questions related to pain, discomfort, energy, fatigue, sleep and rest, revealing the extent to which these factors are negatively influenced in chronic low back pain patients.
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2.3 Disability: 2.3.1 Overview and definitions: Disability and (disabled) are words commonly used. Like other concepts they are contested. (Dis) is associated with a lack of something, in this case (ability), which means capacity. Thus, disability is concerned with lacking capacity in some way. The World Health Organization (WHO) indicates that: More than one billion people in the world live with some form of disability, of who nearly 200 million experience considerable difficulties in functioning (Kennedy, 2013). The number of people with disability is growing due to a number of factors including the aging population and the global increase in chronic health conditions associated with disability. People with disabilities have poorer health compared to the general population, depending on the type of disability and the setting they live in, they may be more vulnerable to secondary complications or co-morbidities, and they may be at higher risk due to poor diet and reduced physical activity (WHO, 2011) Disability is restricted activity. The standard definition is by the World Health Organization (WHO 1980): Any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being. To that we might add: compared to a healthy person of the same age and sex. The American Medical Association Guides (AMA 2000) gives a similar definition. Disability is an alteration of an individual’s capacity to meet personal, social or occupational demands because of impairment (Waddell, 2004). The more recent definition of WHO defines disability as an umbrella term, covering impairments, activity limitations, and participation restrictions. WHO states that impairment is a problem in body function or structure; an activity limitation is a difficulty encountered by an individual in executing a task or action; while a participation restriction is a problem experienced by an individual in involvement in life situations. According to WHO, disability is thus not just a
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health problem. It is a complex phenomenon, reflecting the interaction between features of a person's body and features of the society in which he or she lives (Abeyratne, 2015).
2.3.2 Disability assessment tools: Two of the most commonly used self-report questionnaires to assess back pain are the Oswestry Disability Index (ODI) and the Roland Morris Disability Questionnaire (Payares et al., 2011). Both the ODI and the RDQ measure activity limitations and participation restrictions associated with LBP. Therefore, they are both clinically meaningful outcomes instruments that help the clinician understand the full impact of injury on patient status and progress (Vela et al., 2011). The Oswestry Disability Index (ODI) is one of the most widely used disease specific self administered questionnaires for back pain. The questionnaire assesses the pain problem and the resulting functional disability. The ODI can precisely estimate the level of dysfunction, and the item difficulty of the ODI matches the person ability (Lu et al., 2013) Multiple studies have shown that the ODI is more reliable and responsive than other low back instruments.The ODI is a performance and capacity based outcomes instrument consisting of ten questions assessing pain intensity and limitations in various activities (Vela et al., 2011). The Roland Morris Disability Questionnaire (RDQ) is widely used to assess physical disability associated with back pain and has been shown to be valid, reliable, and responsive to treatment. The RDQ is scored on a scale of 0 to 24. Each item has dichotomous yes/no-type answer, and the total score is the sum of all answers, with higher scores indicating greater physical disability. The RDQ is suggested for use in patients with mild to moderate low back injuries (Tetsunaga et al., 2016).
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2.3.3 Impact chronic low back pain on functional disability: Persons with low back pain often report impaired ability to perform daily activities. The impact of pain on a patient’s daily functioning can be expressed as a patient’s level of disability or a reduction in physical functioning. It is often assumed that patients who feel more disabled and thus report more daily life restrictions due to LBP will be those who are less physically active (Lin et al., 2011). According to the International Classification of Impairments, Disabilities and Handicaps (ICIDH) disability has been defined as ‘‘any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being” (Verbunt et al.,2009). Any existing disability seriously affects the functional ability and working status of the young and adult population. Studies have shown that low back pain limits the ability of disabled individuals to perform the activities of daily living, reduces health-related quality of life and causes important health care expense. While in patients with acute low back pain disability improves within one month, in patients with chronic pain it is ongoing and therefore hard to manage. In patients with acute low back pain, disability is mainly associated with the pain itself, whereas in patients with chronic low back pain, psychological factors rather than biomedical or biomechanical factors have a substantial impact on the disability (Klemenc-Keti, 2011). Many researchers have explored the relationship between low back pain and functional limitations during work and other activities of daily life. This relationship has been a prominent issue in the research of low back pain and has significant implications for the practice of rehabilitation. Physiological, psychological, social, economic, psychological and social factors can interact and interact to influence functional deficits associated with back pain (McGorry et al., 2011).
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Some authors consider pain intensity as the main factor, and others affirm that psychosocial factors are the most disabling. Evidence exists that psychosocial factors can be more important than physiological aspects in the development of chronic pain and disability (Salvetti et al., 2012). Several behaviours and/or belief systems have been hypothesised to mediate the relationship between LBP and functional limitation, most notably including pain catastrophising, fear avoidant beliefs (McGorry et al., 2011). According to the fear-avoidance model of chronic pain, these patients may have catastrophic thoughts about their pain resulting in fear of pain, which is characterized by escape and avoidance behavior. Eventually, avoidance leads to disability, depression, and disuse, which fuel the pain experience resulting in a vicious cycle. Individuals who do not catastrophize about their pain will not become fearful and will expose themselves to daily activities leading to recovery (Huijnen et al., 2009). On the subject of disability, it is possible to say how much an individual can be able to function more and how much pain and difficulty he might face while doing his/her daily tasks such as walking around, lifting things up, sitting down, doing his/her personal work, standing up, sleeping, doing the sexual activity, and traveling.The more tasks a disabled individual is up to do, the higher low back pain can be sensed. Therefore, inability to perform daily activity can cause low back pain and also can be resulted from back pain (Panahi et al., 2016). The goal of patients with LBP is the restoration of function and a return to the workplace as quickly and safely as possible. General recommendations to prevent long-term disability for patients with LBP are early activation and restoration of function. Especially, the evaluation of functional ability with LBP patients is essential for confirming treatment effects and predicting prognosis (Kim et al., 2014).
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2.4 Previous studies: The followings are some previous studies carried out and related to the quality of life and disability in low back pain: 1. To find out prevalence of low back pain and its relation to quality of life and disability among women in rural area in India Ahdhi et al (2016) conducted a cross-sectional study among 250 women in age group of 30-65 years residing in field practice area of a Tertiary Care Medical Institution, PuducherryIndia.Severity of the pain was assessed using Numerical Pain Scale. Modified Oswestry Low Back Pain Disability Questionnaire was used to measure the disability level and WHOQoL-BREF scale to assess the QoL among women with low back pain.They found that the majority of women (60.9%) with low back pain experienced moderate disability. Almost 72% of women with low back pain perceived their QoL as good and overall mean QoL score was (88.41± 12.9).The low back pain was influenced by the demographic variables that include age, marital status, illiteracy, total family income. Disability was influenced by age, education, and occupation, whereas QoL was influenced by education of the women with low back pain.The researcher was concluded that moderate disability was more among those with low back pain, overall QoL was good. Disability intervention measures may help in reducing the impact of low back pain and improving the QoL among women with low back pain. 2. To assess quality of life, level of disability and quality of sleep in patients with chronic low back pain (Romanenko, 2016) conducted case control study on 103 patients with chronic low back pain and 30 healthy persons.EuroQoL-5D questionnaire, Oswestry disability questionnaire and Center of somnology quality of life questionnaire were applied by researcher in order to study peculiarities of quality of life, level of disability and quality of sleep. The finding of the study revealed, in the group of patients with LBP the quality of life was significantly lower (5 (4; 6) points out of 10 possible) than in the control group (9 (8; 10) points). The average level of disability according to Oswestry questionnaire in the
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group of patients corresponded to 30.50 ± 13.55 %. The researcher concluded that the patients with LBP showed a reduction in the level of quality of life, as well as the degree of restriction of function according to Oswestry disability questionnaire. All patients have had sleep problems of various severities. 3. Al-disoky (2015) studied the prevalence of low back Pain and its effect on quality of Life among patients in Egypt. The study was conducted in abu-khalefa family center, Ismailia Governorate on 259 of attendees aged (18-65)years, data were collected through a semi structured questionnaire containing three parts: first part containing socio-demographic information, second part about characteristics of LBP and thrid part investigating the effect of LBP on QoL through Oswestry disability questionnaire. The study reveals that the (61 %) of patients with LBP had minimal disability, (24%) had moderate disability, (12%) had severe disability, (2%) were bed-bound or exaggerate their symptoms and (1%) were crippled. There was statistically significant relationship between degree of disability and each of age, gender, marital status, residence and income. 4. To compare QoL between low back pain patients and healthy people, (Darzi et al., 2014) conducted descriptive analytic study on 256 low back pain patients and healthy people in Iran, using WHOQoL-BREF which is a generic and overall instrument. The participants filled out the questionnaires personally and the scores of different domains in two groups were compared. WHOQoL-BREF has four domains of physical health, psychological health, social relations and environment health. The researcher found that the scores of these four domains and general quality of life and general health of WHOQoL-BREF were lower in low back pain patients. These differences were statistically significant in physical health and environmental health. The researchers concluded that patients with low back pain have low QoL when compare to healthy persons. 5. Demirtas (2013) studied the effects of low back pain on quality of life and functional disability in nurses with low back pain. A total of 122 nurses completed
Chapter Two
Literature Review 36
a demographic questionnaire. HRQoL was assessed by the Medical Outcomes Study 36-Item Short Form Health Survey questionnaire (SF-36). It was used Visual Analogue Scale (VAS) and the Oswestry Low Back Pain Disability Questionnaire to assess the self-perceived pain and functional disability. The researcher found that the nurses who had more pain intensity had significantly worse scores of functional disability (p<0.001) and general health (p<0.05), physical function (p<0.001), role physical (p<0.001), social function (p<0.05), bodily pain (p<0.001) domains of SF-36 compared to nurses who had less pain intensity. The findings of this study suggest that HRQoL is more seriously affected and becomes worse with the increment of LBP intensity, also low back pain causes functional disability in nurses.Therefore, comprehensive interventions aimed at minimizing the risk of LBP and improving HRQoL and functional status among nurses are needed. 6. To assess perceive pain, disability and quality of life in individuals with chronic low back pain. Stefane et al (2013) conducted a cross-sectional study on 97 patients with chronic low back pain. An 11-point numerical scale was used to measure pain intensity, the Roland-Morris questionnaire for disability and the WHOQoL-BREF to measure quality of life. The researchers found that the mean disability score was 14.4 (60%); mean pain intensity score at the moment of the interview 5.4; and mean general quality of life score 48.1 points. The physical quality of life domain was the most impaired, with a score of 44.1 points. According to result of the study researchers concluded that the perceived pain intensity was considered high, the disability level found was considered severe and the physical quality of life domain appeared as the most impaired and strongly associated with the disability level. 7. To identify the prevalence of disability and factors associated with disability outcome in CLBP adults, (Salvetti, 2012) conducted a descriptive study on 177 patients with CLBP. Respondents were answered questions from: Demographic Identification Form, Oswestry Disability Index, Chronic Pain Self-efficacy Scale,
Chapter Two
Literature Review 37
Tampa Scale Kinesiophobia, Beck Depression Inventory, and the Revised Piper Fatigue Scale. The prevalence of disability among the respondents was 65%, and disability was moderate to severe in 80.7% of them. The multiple regression models identified three factors as independently associated with disability: work situation, low self-efficacy and depression.They concluded that the factors identified to be associated with disability are modifiable. 8. Horng (2005) conducted his study “Predicting health-related quality of life in patients with low back pain.” Data were collected from 232 patients with low back pain who were consecutively recruited from several clinics of physical medicine and rehabilitation. Every patient received physical examination and completed a set of questionnaire, including the Taiwan version of the Questionnaire of the World Health Organization on quality of life (WHOQoL-BREF), Modified Roland and Morris Disability Questionnaire, and visual analogue scale for pain intensity and for HRQoL. These patients were observed with a mail questionnaire 8 weeks later. The results of WHOQoL-BREF were also compared to those obtained from another 213 healthy volunteers who were accompanied persons with patients, volunteer workers in hospitals, and hospital employees. Results showed that there were significant correlations of HRQoL with pain intensity, disability scale, and disability days. Among the results of physical examination, lumbosacral radiculopathy was the only factor with moderate correlation with HRQoL. The significant predictors for HRQoL included physical domain, psychological domain, pain intensity, and family income. Among all the 232 study patients, 100 of them responded to the follow-up questionnaire. Changes in environmental domain, disability days, educational level, receiving herb drugs, and physiotherapy were the significant predictors for the changes of HRQoL.The HRQoL of patients with low back pain depended on functional status and psychological factors more than simple physical impairment. Future intervention may need to put more emphasis on improving functional status and psychological stress for these patients.
CHAPTER THREE METHODOLOGY
Chapter Three
Methodology 38
CHAPTER THREE METHODOLOGY
3.1 Design of the study: A quantitative design descriptive study was used to assess the quality of life and disability among patients with low back pain. The study was carried out during the period of 15th November 2016 to 15th April 2017.
3.2 Administrative arrangement: The protocol of the study was accepted by the council of the College of Nursing and approved by the ethical committee in the College of Nursing-University of Sulaimani (Appendix A). Accordingly an official letter from the College of Nursing/ University of Sulaimani to the Rheumatology and Physical Rehabilitation center in Sulaimani city (Appendix B), to obtain facilitation and cooperation during data collection of this study.
3.3 Setting of the study: The present study was conducted at Rheumatology and Physical Rehabilitation Center in Sulaimani City, which is largest and the only rehabilitation center that provide outpatient service for the rheumatologic patients in Sulaimani city. This center consists of two parts (administrative and medical); the administrative part includes director room, administration room and registration room. The medical part consists of physician (consultant rheumatologist) room, X- ray room, pharmacy room, nursing room and physiotherapy hall. The medical staff that working in the center consist of (5) rheumatologist and (45) nurse.
Chapter Three
Methodology 39
The physiotherapy hall is the main part in this center which provide services to the patients that ordered by the physician such as TENS, Galvanic, Faradic, Ultra Sound Therapy, Infrared, Micro wave, Short wave and Traction. Every day about one hundred patients visit this center for various reasons such as diagnosis, medicaltreatment and physiotherapy. The patients first time diagnosed by physicians and establish a line for treatment that includes medications, investigations, admission to the hospital, and refer to physiotherapy if need.
3.4 The sample of the study: Anon-probability, convenience sample size of (165) outpatients diagnosed with CLBP were slected from Rheumatology and Physical Rehabilitation Center. The sample was selected according to certain inclusions and exclusions criteria. The inclusion criteria: 1. Patients with non-specific chronic lower back pain. 2. Patients being 18 years old and more of both genders. 3. Duration of low back pain more than three months 4. Patients who willing to participate in the study. The exclusion criteria: 1. Other chronic diseases or physically disabled conditions. 2. Pregnant women. 3. Patients who were not interested to participated in the study.
3.5 The study instrument: The questionnaire was constructive by the researcher to measure the variables underlying the present study, mainly to assess QoL and functional disability in patients with lower back pain. The constructive questionnaire was based on the following resources:
Chapter Three
Methodology 40
1. The extensive review of the literature and previous related studies. 2. The standardized World Health Organization Quality of Life-BREF (WHO QoL-BREF).Washington version (USA, 2005). 3. The standardized Oswestry Disability Index (ODI). The initial English draft of the questionnaire (Appendix C) was translated into the Kurdish language; the forward-backward procedure was applied to translate English to Kurdish, and then translated into the English language by two bilingual experts in the department of English language in Sulaimani University (Appendix D).Then a provisional version of the Kurdish questionnaire was subjected to test for validity and reliability. The study questionnaire consists of four parts, which distributed as following: Part one: patients' socio-demographic data form, which include: age, gender, marital status, level of education, occupation, residential area, and economics status. Part two: patients' lifestyle and biomedical factors, which include: body mass index, cigarette smoking, drink alcohol, exercise, duration of disease and analgesic use. Part three: WHOQoL-BREF inventory form: The WHOQoL-BREF consists of 26 items; the first two questions evaluate the self-perceived quality of life (general QoL) and satisfaction with health (general health). The remaining 24 questions represent each of the 24 facets of which the original instrument is composed (WHOQoL-100), divided into four domains: physical, psychological, social relationships and environment. In contrast to the WHOQoL-100, in which each of the 24 facets is evaluated using four questions, in the WHOQoL-BREF only one question is used: that which has the highest correlation with the total score, calculated by the mean of all the facets (Silva et al., 2014).
Chapter Three
Methodology 41
The quality of life scores in the WHOQoL-BREF domains ranges between zero and 100. The higher the score in each domain, the better the quality of life will be. The WHOQoL-BREF contains five Likert-style response scales: "very poor to very good"(evaluation scale),"very dissatisfied to very satisfied" (evaluation
scale),
"none
to
extremely"(intensity
scale),"none
to
complete"(capacity scale) and"never to always" (frequency scale). Each domain is made up of questions for which the scores vary between one and five. The mean score in each domain indicates the individual’s perception of their satisfaction with each aspect of their life, relating it to the quality of life. The higher the score, the better this is perceived to be. The QoL items are rated on five-point Likert scale in positively framed direction (1-5) except items (No. 3, 4 and 26) scaled in negatively from direction (5-1). The higher mean scores indicate better QoL. A list of (26) items assessing the patient's QoL in four domains and two general questions as followings: a) Individual's overall perception of quality of life (one item) include: question number, 1 b) Individual's overall perception of health (one item) include: question number, 2 c) Physical domain (seven items) includes: questions number, 3, 4, 10, 15, 16, 17 and 18 d) Psychological domain (six items) includes: questions number, 5, 6, 7, 11, 19, and 26. e) Social domain (three items) includes questions number, 20, 21 and 22. f) Environment (eight items) includes: questions number, 8, 9, 12, 13, 14, 23, 24 and 25. Silva et al (2014) considered that the QoL ≥ 60 cut-off point as moderately sensitive for recognising individuals with good/satisfactory QoL. On the other hand, the sensitivity of the test with the QoL < 60 cut-off point was optimum, as was the negative predictive value for screening older adults whose QoL was poor/ unsatisfactory.
Chapter Three
Methodology 42
Part Four: Oswestry Disability Index (ODI) The Oswestry Disability Index (ODI) is one of the most widely used diseasespecific self-administered questionnaires for back pain. The questionnaire assesses the pain problem and the resulting functional disability. Previous study results showed that the ODI is a unidimensional questionnaire with high reliability (Smeets et al., 2011).The ODI can precisely estimate the level of dysfunction, and the item difficulty of the ODI matches the person ability. For clinical application, using logits scores could precisely represent the disability level, and using the item difficulty could help clinicians design progressive programs for patients with back pain. The ODI is the most common outcome measures in patients with low back pain. It has been extensively tested, showed good psychometric properties, and applicable in a wide variety of settings. A number of the different questionnaires exist to assess function, but WHO recommends ODI as an outcome measure for LBP. The ODI consists of 10 items that measure the degree to which back or leg trouble has affected the ability to manage activities of everyday life (Lu et al., 2013). The 10 items ask about the following: it covers 1 item on pain and 9 items on the level of disability of personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling.Each item is scored on a 6-point scale, with 0 representing no limitation, and 5 representing the maximal limitation. The range of the ODI raw score (the sum of the scores from the 10 items) is from (0 to 50). Score Interpretation: The total ODI score ranges from 0 (no disability) to 100 (maximum disability), the levels of disabilities according to (Fairbank et al., 1980; Fairbank & Pynsent, 2000; Davidson & Keating, 2002) are listed as following: 1. 0%-20% Minimal disability: This group can cope with most living activities. Usually, no treatment is indicated, apart from advice on lifting, sitting posture,
Chapter Three
Methodology 43
physical fitness, and diet. In this group, some patients have particular difficulty with sitting, and this may be important if their occupation is sedentary, e.g., a typist or truck driver. 2. 21%-40% Moderate disability: This group experiences more pain and problems with sitting, lifting, and standing. Travel and social life are more difficult and they may well be off work. Personal care, sexual activity, and sleeping are not grossly affected, and the back condition can usually be managed by conservative means. 3. 41%-60% severe disability: Pain remains the main problem in this group of patients, but travel, personal care, social life, sexual activity, and sleep are also affected. These patients require detailed investigation. 4. 61%-80% Crippled: Back pain impinges on all aspects of these patients’ livesboth at home and at work and positive intervention is required. 5. 81%-100%: These patients may be bed bound or exaggerating their symptoms. Careful evaluation is recommended.
3.6 Validity of the questionnaire: The validity of the questionnaire is a determination of the extent to which the instrument actually reflects the abstract concept being examined. A measurement instrument is valid if it measures what it says it does (Blair and Tylor, 2008). The face validity of the present study questionnaire was established through a panel of (12) experts of different specialities including (Nursing, Medicine, Surgery, Orthopedic, Rheumatology). These experts were asked to investigate the questionnaire for content clarity, relevancy and adequacy in order to achieve the present study objectives. The vast majority of experts indicated minor changes should be done to few descriptive characteristics. The questionnaire was appropriately considered valid after taking into consideration their valuable suggestions.
Chapter Three
Methodology 44
3.7 Pilot study: A pilot study was conducted on a purposive sample of ten outpatients with chronic low back pain at Rheumatology and Physical Rehabilitation center in Sulaimani city. It was carried out from 7th and 8th January 2016 until the 21st and 22nd January 2016. The sample of the pilot study was excluded from the present study sample. The purpose of the pilot study was: 1. To enhance the reliability of the questionnaire. 2. To determine the clarification items of the questionnaire for the respondents. 3. To determine the average time required for data collection. The result of pilot study showed that the items of the questionnaire were clear and understood, the time need for interviewing each patient took about (45-60) minutes.
3.8 Reliability of the questionnaire: Reliability is concerned with how consistently the measurement instrument measures the concept of interest. In other words, a measurement instrument is reliable if the same results are obtained every time the same items are measured (Blair and Tylor, 2008). To measure the reliability of the questionnaire of this study, a test- retest statistical method was used; A (10) patients who recruited in pilot study interviewed again after (14-15) days, the researcher re-administrated the same process of gathering data to find out the correlation between tests and re-test. A Parson's coefficient correlation test (r-test) was used and the result (r=0.91) and it is significant p>0.01 level. The questionnaire had an adequate level of consistency and equivalence measurability.
Chapter Three
Methodology 45
3.9 Data collection methods: The initial step of data collection was (the patients already diagnosed with low back pain) identifying patients according to criteria of the sample selection. Before interviewing the subjects, an introduction was given and the purpose of the research was explained personally by the researcher to the subjects and to achieve verbal informed consent. The data were collected through the utilization of the questionnaire and means of structured interview technique with low back pain patients, by using Kurdish version of the questionnaire, researcher-administered forms were used. The interview was conducted in physiotherapy hall. The socio-demographic data, data regarding lifestyle and biomedical factors, assessment quality of life, and functional disability of patients was completed by the researcher based on their responses.The data collection process has been performed from 3rd March 2016 until 18th July 2016.
3.10 Statistical analysis: The data was analyzed with Statistical Package for the Social Sciences (SPSS) version (22.0). Different statistical tests were used in order to achieve the objectives of the study as following: Descriptive statistics: Descriptive statistics were used, starting with exploratory data analysis, such as participants' socio-demographic characteristics, lifestyle and biomedical factors. Also, the primary outcome of the study was showed in (frequency, percentage, mean, standard deviation, minimum, maximum and range). Inferential statistics: The inferential statistical method was used to establish the correlation among the variables of interest such as quality of life domains and disability for this reason Pearson's correlation coefficient was applied. Also, to determine the significant differences in patients' QoL domains and disability score in different socio-
Chapter Three
Methodology 46
demographic, lifestyle and biomedical factors, F-test and t-test were used. Factor analysis (F-test) was used for multiple variables more than two categories such as (age, marital status, level of education, occupation, financial status ,body mass index and duration of disease) and independent t-test for simple variable only two categories like (gender, smoking, alcohol intake, exercises and use analgesic drug) was used. Corelation scores: Zhang et al (2015) stated that the degrees of correlations through Pearson's correlation coefficient as follow: 0-0.2
Very weak or no correlation
0.2- 0.4
Weak correlation
0.4-0.6
Moderate correlation
0.6-0.8
Strong correlation
0.8-1.0
Very strong correlation
Body Mass Index: Razak et al (2007) classified the body mass index for adults as follow: A BMI below (18.5) is considered underweight. A BMI of (18.5 to 24.9) is considered healthy (Normal). A BMI of (25 to 29.9) is considered overweight. A BMI of (30 or higher) is considered obese.
3.11 Limitation of the study: 1. The lack of a control group for comparison was another limitation of the present study. 2. Patients with other chronic disease or permenant disabiled condition excluded that lead to limitation of sample size.
CHAPTER FOUR RESULTS & DISCUSSION
Chapter Four
Results & Discussion 47
CHAPTER FOUR RESULTS & DISCUSSION
One hundred sixty-five patients with chronic low back pain participated in the present study. In this chapter the data was analyzed, interpreted, and supported by previous studies according to the objectives of the study and organized as follow: First: Description and interpretation of socio-demographic characteristics of participants of the study and comparing with the previous study in this field. Second: Description and interpretation of participants' lifestyle and biomedical factors, and comparing results with the previous study in this field. Third: Statistical analysis of participants' quality of life and functional disability. Interpretation of data has been done according to results of study and in comparing to the previous study in the field of chronic low back pain Fourth: Statistical analysis regarding correlation among quality of life domains' and disability level and comparing results with the previous study in this field. Fifth: Statistical analysis of participant's QoL domains and disability level in relation to some variables including:A- The socio-demographical characteristics. B- Lifestyle and biomedical factors.
Chapter Four
Results & Discussion 48
Table (1): Distribution of the study sample according to the socio-demographic characteristics Age Group / Years
Frequency
Percentage
20 – 29
24
14.5
30 – 39
28
17.0
40 – 49
43
26.1
50 – 59
42
25.5
60 – 69
22
13.3
≥ 70
6
3.6
Total
165
100
Mean ± S.D
46.5 ± 13.6
Gender
F
%
Male
65
39.4
Female
100
60.6
Total
165
100
Marital Status
F
%
Single
22
13.4
Married
135
81.8
8
4.8
165
100
Education
F
%
Illiterate
51
30.9
Primary
52
31.5
Secondary
37
22.4
Institute or University
25
15.2
Total
165
100
Widow/widower Total
Chapter Four
Results & Discussion 49
Continue table (1) Occupation
F
%
Governmental Employed
38
23.0
Self Employed
32
19.5
House Wife
74
44.8
Retired
21
12.7
Total
165
100
F
%
Urban
147
89.1
Sub urban
11
6.7
Rural
7
4.2
Total
165
100
Economic Status
F
%
Insufficient
73
44.2
Barely Sufficient
76
46.1
Sufficient
16
9.7
Total
165
100
Residency
Table (1) shows that the majority percentage of the sample (26.1%) and (25.5%) were distrubted between two age groups (40-49)and (50-59) years old respectivly.The hieghiest percentage (60.6%) of the study sample were female.As expected the majority (81.8%) of the sample was married and percentage of single was (13.4%). Participants education level was another item showed in the table (1), illiterate and primary school graduate had a similar percentage (30.9%) and (31.5%) respectively. Regarding participants' occupation, the housewife has higher percentage (44.8%) government employees (23.0%), and then self-employed (19.5%). The majority (89.1%) of the sample were from an urban area. Also the
Chapter Four
Results & Discussion 50
table shows participants' economic status, and it reveals that (46.1%) of the sample were barely sufficient, (44.2%) had insufficient, while (9.7%) were sufficient The results of the present study come with the findings of Nesto (2014) study who stated that most of the patients with low back pain were female, married,their ages were between 45 to 54 years old with the mean age (47.7± 13.2) years, they were from an urban area, and mostly had lower educational level. Also, this finding is in agreement with Khan et al (2014) who reported that seventy percent of the participants with low back pain were female, peak prevalence occurring in those aged 45 to 59 years old with the mean age of (45.8 ±10.8) years, more than two third of patients were married and housewives.Furthermore, our finding agree with (Bener et al., 2014) study, they found that the prevalence of LBP may be slightly greater in those from a lower socioeconomic class. Also, this result comes along with the finding a regional study in which reported that the people with low income had the higher prevalence of LBP (Biglarian et al., 2012). Table (2): Distribution of the sample according to body mass index and duration of the disease Body Mass Index
Frequency
Percentage
Normal
45
27.3
Overweight
84
50.9
Obese
36
21.8
Total
165
100
Mean ± S.D
27.3 ± 3.4
Duration of Disease
F
%
˂ 1 Year
58
35.2
1 – 3 Years
62
37.6
˃ 3 Years
45
27.2
Total
165
100
Chapter Four
Results & Discussion 51
Table (2) indicates that (50.9%) of the participants were overweight, (21.8%) were obese and (27.3%) of the participants had normal body mass index, average body mass index was (27.3 ±3.4). Regarding duration of the disease, (37.6%) of them had it from one to three years, (35.2%) of participants had it for less than one year, and the duration of condition was more than three years for (27.2%) of participants. The results of the present study agree with the results of the previous study done by Salvetti et al (2012) which found that most patients with CLBP were overweight or obesity and the mean score of body mass index were (27.2±5.4). Similar findings were also reported by a metaanalysis including 33 studies showed that obesity was associated with increased prevalence of low back pain in the past 12 months (Shiri et al., 2010). Table (3): Distribution of the sample according to their some lifestyle factors Smoking
Frequency
Percentage
Yes
21
12.7
No
144
87.3
Total
165
100
Alcohol Intake
F
%
Yes
18
10.9
No
147
89.1
Total
165
100
Exercises
F
%
Yes
46
27.9
No
119
72.1
Total
165
100
F
%
Yes
131
79.4
No
34
20.6
Total
165
100
Use Analgesic Drugs
Chapter Four
Results & Discussion 52
Table (3) indicates that the majority (87.3%) of the participants were nonsmoker, (89.1%) of them did not drink alcohol. As for physical exercise (72.1%) of the participants did not exercise, using of analgesics was other items presented in above tables, majority of participants (79.4%) were used analgesics. There are many studies similar to our findings (Rafeemanesh et al., 2017; Mirsalimi, 2016) who found in their studies there is no relationship between LBP and smoking. These results of our study go with the findings of Johnson and Edward (2016) who conducted a study among workers in a health facility in south Nigeria that found only (2%) of respondents reported history of smoking and (10%) respondents reported alcohol intake. Also, this result is consistent with previous study of Ogunbode et al (2013) done amongst adult patients in Nigeria they found that (14.6%) of patients consumed alcohol, and (2.5%) of respondents smoked tobacco. Gotfryd et al (2015) reported in their study (31%) of paricipants participated in physical excercise. However, Abebe et al (2015) stated that the participating in any physical exercise reduces the prevalence of low back pain compared to not participating in any physical exercise. Furthermore, according to study done in Sri Lanka taking part in exercises such as walking and running 20 minutes/day more than three times a week had a significant protective effect on low back pain (Lione, 2014; Karunanayake et al., 2013). Using analgesic is very common in Kurdish society, especially in muscuskeletal pain such as back, neck, knee and ect.,using conservative treatment is low when compare to pharmacological treatment due to low knowledge regarding health.
Chapter Four
Results & Discussion 53
Table (4): Distribution of quality of life domains', general QoL, general health scores and functional disability QoL Domains
Mean
SD
Minimum
Maximum
Range
Physical Domain
40.8
12.1
6
81
75
Psychological Domain
51.9
14.4
13
88
75
Social Domain
57.2
15.1
25
94
69
Environment Domain
48.3
10.8
25
75
50
General QoL
53.7
16.3
20
100
80
General Health
51.9
18.1
20
100
80
Mean
SD
Minimum
Maximum
Range
28.1
12.6
10
62
52
ODI Functional Disability
SD: Standard deviation, QoL: Quality of life Table (4) shows that the lowest mean score was belong to physical domain and it was (40.8±12.1), followed by environmental domain, (48.3±10.8). The third domain was psychological with a mean score of (51.9 ±14.4) and the highest score was for social relations (57.2±15.1). The mean score of general QoL and general health were (53.7±16.3), (51.9±18.1) respectively. Furthermore, the mean of functional disability score was (28.1±12.6).
Chapter Four
Results & Discussion 54
Regarding level of disability according to ODI as prsented in figure (4.1) nearly of half (44.8%) of participants had moderate disability, minimal disability were (37.6%), while severe disability proportion were (16.4%), and (1.2%) of participants were crippled.
Figure 4.1: Distribution of the sample according functional disability level
Chapter Four
Results & Discussion 55
Non-specific lower back pain (NLBP) is rarely fatal but greatly affects the functional status and QoL of patients. The general results indicate that patients with lower back pain had statistically lower QoL mean score compared to standers range values in all domains with some variations. The scores of QoL found by present study was lower than normal value which reported by (Silva et al., 2014), the study results indicated a critical value 60 as the optimal cut-off point for assessing perceived quality of life and satisfaction with health and they considered 60 as a minimal value for good QoL domains, overall QoL and general health. Despite QoL mean scores' for all domains was less than 60 and below the standard range, the effect of lower back pain was varied on different domains. As expected physical aspect was most affected domain by lower back pain, this reduced in a physical domain may be due to the pain that limits most of the physical functions and physical activities and caused deteriorations in physical QoL, or could have resulted because the physical domain comprises questions related to pain and discomfort, revealing the extent to which these factors are negatively influenced in chronic low back pain patients (Stefane et al., 2013). The present study found different level of disability, the proportion of minimal disability was more than one-third. This group can cope with most living activities. Usually, no treatment is indicated. Panahi et al(2016) stated that mild disability does not require specific treatment, doing appropriate exercise and correct vertebra position while doing daily activities as well as modification of physical condition are strongly recommendation. Around half had the moderate disability, this group experiences more pain and problems with sitting, lifting and standing. Personal care, sexual activity, and sleeping are not grossly affected, and the back condition can usually be managed by conservative means. The overall percentage of disability was between (20%- 40%) which considered as the moderate disability. While the proportion of severe disability was lower than one-six, pain remains the
Chapter Four
Results & Discussion 56
main problem in this group of patients, but travel, personal care, social life, sexual activity, and sleep are also affected. Present study finding indicated that chronic low back pain could be the cause of greater disability and lower quality of life. This finding is in agreement with Darzi et al (2014) who found that the scores of the four domains, general quality of life and general health of WHOQoL-BREF were lower in low back pain patients when compared to healthy people. These differences were statistically significant in physical and environmental health. Furthermore, the finding of the Romanenko (2016) study revealed, in the group of patients with LBP the quality of life was significantly lower (5 points out of 10 possible) than in the control group (9 points out of 10). While the average level of disability according to ODI in the group of patients was (30.50 ± 13.55 %), which is similar to our finding. The low physical QoL domain in the current study is similar to the result reported by Stefane et al (2013) who found that the physical domain most affected and the average score of the physical domain was (44.1±21.0). Hence, recent regional study Panahi et al (2016) reported that the quality of life for participants with lower back pain is lower in all aspects than participants without back pain. Also it consistent with results of Demirtas (2013) who studied lower back pain in the nurses and reported that the nurses who had low back pain had significantly worse scores of functional disability (p<0.001) and general health (p<0.05), physical function (p<0.001), social relation (p<0.05), domains of QoL compared to nurses who had no pain. The findings of this study suggested that QoL is more seriously affected and becomes worse with the increment of LBP intensity. LBP also causes functional disability in nurses. Regarding functional disability,the present study finding agrees with previously reported by (Klemenc- Ketis,2011; Payares et al., 2011; Maughan and Lewis, 2010) the mean scores of ODI as (29.2±18, 29±20, 30±15) respectively.Whereas, the level of functional disability Payares et al (2011) in Colombia agree with of
Chapter Four
Results & Discussion 57
present study results who found that (45.9%) of participants had the moderate disability, (32.4%) of participants had minimal, (20.7%) of participants had severe and only (0.9%) of participants had crippled disability. Furthermore, this finding was agreement with AL-Disoky et al (2015) who reported that (61%) of patients with CLBP had the minimal disability, (24%) of patient the moderate disability, (12%) had the severe disability, and (1%) crippled disability. In another study conducted by Okokon et al (2016), the researchers stated that all subjects reported some form of disability, more than half reported moderate levels of disability. There was the similarity in a study undertaken in Slovenia, approximately 50% of the chronic low back pain sample presents moderate to severe disability (Klemenc- Ketis, 2011). The result is different from the study conducted by Gupta and Nandini (2015) in India among non-working rural housewives, who found that 8% rural housewives had minimal disability, 22.3% had moderate disability, 51.5% had severe disability, and 16.6% rural housewives were crippled.The rationale for this difference, may be related to different sample, we studied general population, while the assess housewife disability level, which expects to be greater than general population due to duty and responsibility of housewife holding, other reason may be the majority of present study sample were from urban area while their sample was from rural area.
Chapter Four
Results & Discussion 58
Table (5): Correlation among participants' quality of life domains' and disability Quality of life Domains
Variables
Psychological
Social
Environment
r (p-value)
r (p-value)
r (p-value)
Disability r (p-value)
Physical
Psychological
0.44 (0.001)
0.40 (0.001)
0.42 (0.001)
-0.28 (0.001)
0.31 (0.001)
0.41 (0.001)
-0.27 (0.001)
0.34 (0.001)
-0.26 (0.001)
Social
Environment
-0.23 (0.003)
As present in above table, there is a positive correlation among all quality of life domains, physical domain correlated to psychological, social and environment domains.The psychological domain also correlated to social and environment domains, and social and environment domains were correlated to each other. The highest r-score was (0.44) which reflected correlation between physical and psychological domains and lowest r-score was (0.31) which was correlation between psychological and environment domains. Different quality of life domain was correlated together; any deterioration of one domain causes worseness in other domains. For example, the changes in physical domain cause the change in psychological, social and environmental and viceversa and it will be the same for other domains. Positive change in one domain causes the positive response in other domains and negative change in one domain causes the negative response in other domains.
Chapter Four
Results & Discussion 59
Regarding the correlation between disability and QoL domains', there was negative correlation between disability and all QoL domains', the correlation was various, the correlation between disability and the physical domain was stronger than other domains (-0.28), and it was weakest in the environment (-0.23). Despite the difference in r-score the correlation was significant statistically among QoL domains' and disability. Our finding reveals that any reduce in one domain of quality of life cause poorness in others three domains and lead to more functional disability. Consequently, increase functional disability lead to reduce in all QoLs' domains and the P-value less than 0.01 Darzinaghibi et al (2012) come with result of present study and demonstrated that significant correlation between all aspects of QoL and functional disability. Correlation between functional disability and all aspects of QoL was negative. It means that higher impairment in physical function can lead to lower QoL and viceversa. Also, this result was in line with previous studies conducted by (Ahdhi et al., 2016; Okokon et al, 2016) who demonstrated negative correlation between the level of disability and QoL domains. Furthermore, Klemenc-Ketis (2011) study has shown that disability and quality of life as self-reported by patients with CLBP correlate with each other and this study showed that the QoL of LBP patients worsen with increasing severity of disability. This inverse relationship has been reported in other studies conducted by (Ogunlana et al., 2012), who stated that the subjects with poor QoL were also more likely to have severe disability (0.006) among such patients.
Chapter Four
Results & Discussion 60
Table (6): Distribution of difference mean scores of quality of life domains' and disability according to patients age groups Quality of life Domains
Age Group
Disability Physical
Psychological
Social
Environment
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
20 – 29
42.8±10.2
51.8±14.2
54.1±11.5
48.5±9.9
21.6±8
30 – 39
41.5±9.4
56.2±13.3
61.6±15.3
55.4±8.6
24.7±10.4
40 – 49
40.3±13.3
52.9±15.7
55.9±15.5
44.9±11.6
29±13.2
50 – 59
37.5±10.9
46.6±15.2
58.4±16.7
45.5±10.2
29.6±12.9
60 – 69
45.2±14.9
55.6±11.4
56.5±13.6)
49.3±9.8
30.2±11.8
≥ 70
39.7±16
50±6.6
52.±18.5
54.3±9.5
43.7±17.1
F(pvalue)
1.4(0.23)
2.1(0.07)
0.9(0.46)
4.7(0.001)
4.2(0.001)
C/S
Not Sig.
Not Sig.
Not Sig.
Highly Sig. Highly Sig.
(Years)
F: F-test, SD: Standard deviation, C/S: Comparative significant, Sig: Significant Table (6) shows mean scores for different QoL domains and disability, as for physical and psychological domains age group (50-59) years old had lowest mean scores, (37.5±10.9) and (46.6±15.2) respectively, and in social domain, age group 70 years old or more had lowest mean scores (52±18.5) but the difference is not significant statistically. Regarding environmental domain the participants aged (40-49) years old has lowest mean scores (44.9±11.6) among different age groups and the difference was significant statistically. Disability is another item presented in above table and it is clear that the disability mean scores increase with increase age, from (21.6±8) to (43.7±17.1) for (20-29) to (70 or more) years old respectively, the difference significant statistically.
Chapter Four
Results & Discussion 61
There was a slight difference in QoL levels; physical, psychological and social, among different age groups, while the difference was not statistically significant, which means that there is no relationship between mentioned QoL domains and age. Furthermore, lower back pain had the negative effect on the environmental domain in relation to age and it was poorest in (40 to 59) years old. Generally, it seems that QoL scores are low among patients (40-59) years old in all four domains, while this reduced in the score is significant in the environmental domain only, the p-value is less than (0.05). It may be resulted from that this age group still working and have the advanced age. In the current study, there was a significant correlation between degree of disability and multiple patient related factors. The first factor was age as the degree of disability increases with increasing age with more disability in patients aged more than 70 years old. According to our finding old adult experience more disability than the young or middle adult, in other word increasing age lead to more functional disability due to the physiological change in all systems are responsible for performing physical activity and activity of daily living, such as muscle weakness, poor equilibrium. The results of our study go with the findings of Al-disoky et al (2015) they found that the degree of disability increases with increasing age. Also our results, are consistent with the study conducted in India by Ahdhi et al (2016), they found that there was a significant difference between the mean score of disability and age.
Chapter Four
Results & Discussion 62
Table (7): Distributions of difference mean scores of quality of life domains' and disability according to patient's gender.
Quality of life Domains Gender
Environment Disability
Physical
Psychological
Social
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD Mean ±SD
Female
41.7±11.6
50.5±14.2
57.6±15.6
48.6±10.7
27.6±12.4
Male
39.5±12.9
57.6±15.6
56.5±14.4
47.8±11.1
28.7±12.9
t(p-value)
1.2(0.25)
1.6(0.11)
0.5(0.65)
0.5(0.63)
0.6(0.57)
C/S
Not Sig.
Not Sig.
Not Sign.
Not Sign.
Not Sign.
Table (7) indicated that the QoL scores for physical, social relation and environment domains in the female (41.7±11.6), (57.6±15.6) and (48.6±10.7) were greater than in the male (39.5±12.9), (56.6±14.4) and (47.8±11.1), while the scores for the psychological and disability were vice-versa. Despite the existence of this variety in QoL and disability scores, the difference was not significant statistically. The results showed that the quality of life for the male was lower than female in all domains except psychological domain but there was no significant difference between the quality of life and gender. The results are consistent with study of Ono et al (2011) who found that men tend to experience a greater decrease in quality of life than women. Furthermore, Ogunlana et al (2012) stated that female LBP patients are in fact likely to have a better health-related quality of life than male LBP patients. The recent study conducted by Ghassemi et al (2016) who confirmed our result and stated that there is no significant difference between both sexes regarding quality of life domains.
Chapter Four
Results & Discussion 63
In the present study, there was no significant difference between the functional disability and gender. In other words, gender has no effect on disability level among patients with low back pain. Our finding is confirmed by Al-disoky et al (2015) study, who reported there was no significant relationship between the degree of disability and gender. Table (8): Distributions of difference mean scores of quality of life domains' and disability according to patient marital status. Quality of life Domains Marital
Physical
Psychological
Social
Environment
Disability
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Married
41.5±12.6
51.9 ±14.3
56.8±15.7
48.7±10.1
28.2±12.6
Single
37 ± 10.1
51.6±15.6
61.1±12.3
48.4±10.1
22.6±9.7
Widowed
39.2±5.8
53±14.4
50±6.4
41±3.2
40±12.2
F(p-value)
1.4(0.25)
0.03(0.97)
2.04(0.13)
1.95(0.15)
6(0.003)
C/S
Not Sig.
Not Sig.
Not Sig.
Not Sig
Sig.
Status
Regarding participant's marital status, despite single person had (37±10.1) lower score in the physical domain, widowed in social relation and environmental domains (50±6.4) and (41±3.2) respectively, the differences were not significant statistically. Regarding disability, widowed had a greater mean score (40±12.2), which means greater disability than other and unmarried had the lower mean score (22.6±9.7). As presented in above table, physical and psychological were poor among unmarried participants, while married had low social relation and environmental
Chapter Four
Results & Discussion 64
QoL, despite these differences, there was no significant difference between marital status and QoL domains. This finding was in line with the outcome of Hammed and Agbonlahor (2016) study showed that marital status correlated poorly and inversely with all domains of QoL insignificant relationship was found between marital status and domains of QoL. The researchers concluded that marital status cannot determine or predict QoL among LBP patients, and it might not be necessary to take them into consideration during rehabilitation of these individuals. Disability increased among widowed patients with a significant correlation between marital status and degree of disability (p˂ 0.05), this may be due to increase psychosocial stressors and progress in age.The results of the present study in agreement with previous study Al-disoky et al (2015) who reported similar results and mentioned that the disability increase among married low back pain patients. Furthermore, Okokon et al (2016) found the percentage of severity of disability among married as (39.7%) while it was less among unmarried participants (35.9%). Table (9): Distributions of difference mean scores of quality of life domains' and disability according to patient education. Quality of life Domains Education
Physical Psychological
Social
Environment Disability
Mean ±SD
Mean ±SD
Mean± SD
Mean ±SD
Illiterate
40.0±13.9
50.7 ±14.2
58.8 ±14.9
48.5±10.9
30.1±14.2
Primary school
37.4 ±10.4
50.9±14.5
56.7±13.7
45.1±10.2
28.3±12.2
Secondary school 42.0 ±10.2
52.2 ±14.4
54.7 ±19.0
49.6 ±10.3
24.8 ±12.3
Institute or University
47.4±11.9
56.3 ±14.1
58.5±11.7
51.0 ±12.3
26.3±9.0
F(p-value)
4.2(0.007)
0.97(0.41)
0.62(0.6)
1.5(0.21)
1.93(0.13)
Sig.
Not Sig.
Not Sig.
Not Sig.
Not Sig.
C/S
Chapter Four
Results & Discussion 65
Table (9) shows that the illiterate and primary school graduted had lower physical QoL scores (40±13.9) and (37.4±10.4) respectively, than better educated secondary school (42±10.2) and instituted and university graduated (47.4±11.9), the differences were significant statistically. Institutes and university graduated seems to have the higher score in the psychological and environmental domain also, while the differences were not significant statistically. Disability score (30.1±14.2) was higher in illiterate but not significant statistically. The finding of the present study confirmed that participants' level of education did not interfere with lower back pain patients QoL and level of functional disability except physical domain. Low educated participant, both illiterate and primary school graduated had poorer QoL than better educated. Regarding the effect of lower back pain on physical QoL Ogunlana et al (2012) found that the low back pain has the greater effect on physical domain than other domains. The mean score of no educated was (41.3±4.0) and the p-value was 0.024, they found the significant relationship between the level of education and physical domain in patients with low back pain. As results showed that the higher mean score disability was found in illiterate but no significant statistically. This finding is in agreement with Klemenc- Ketis (2011) who reported that patients with primary education in comparison with others reported greater disability. Furthermore, this result comes along with the finding of the study Al-disoky et al (2015), who found that there is no significant association between disability and education.
Chapter Four
Results & Discussion 66
Table (10): Distributions of difference mean scores of quality of life domains' and disability according to patient occupation. Quality of life Domains Occupation
Psychological
Social
Mean ±SD
Mean ±SD
Mean± SD
43.4±12.5
52.8±14.1
60.0±16.4
49.8±9
26.0±11.2
Self Employee
40.8±11.8
56.0±15.9
56.2±15.8
48.2±13.1
28.3±12.4
House wife
41.0±11.2
49.8±14.2
56.7±15.2
48.3±10.4
27.8±13.4
Retired
35.1±13.8
51.5±13
55.4±11.3
45.8±11.5
32.3±12.2
F(p-value)
2.2(0.09)
1.5(0.2)
0.61(0.6)
0.62(0.6)
1.1(0.3)
Not Sig
Not Sig.
Not Sig.
Not Sig.
Not Sig.
Governmental Employed
C/S
Environment
Disability
Physical
Mean ±SD Mean ±SD
As presented in table (10) retired patients has low scores in physical (35.1±13.8), social (55.4±11.3) and environmental domain (45.8±11.5) and higher disability score (32.3±12.2) than other occupations. In psychological domain housewife has lower score (49.8±14.2). The retired tend to has poor QoL in most domains with the higher disability than other, while the differences were not significant statistically. This slight reduced in QoL domains and experience more disability may be related to advance age in retired people, as explained bfore by increasing age reduce QoL and lead to more disability. Another factor may be related to retired patients not participated in physical exercise our result indicated that greater disability in patients not participated in physical exercise.
Chapter Four
Results & Discussion 67
The result of present study goes with the findings of Okokon et al (2016) who report similar score for all QoLs' domain and levels of disability in different occupations, they reported that there is no significant difference in QoL and disability among patients with low back pain regarding occupation and p-value were (0.98) and (0.33) respectively. Klemenc- Ketis (2011) stated that employment status have no effect on quality of life or level of disability among patients with lower back pain. Furthermore, Al-disoky et al (2015) confirmed our result and reported that there is no significant association between level of disability and occupation. Table (11): Distribution of difference mean scores of quality of life domains' and disability according to patient economic status Quality of life Domains Economic
Physical
Psychological
Social
Environment
Disability
Mean ±SD
Mean ±SD
Status Mean ±SD Insufficient
Mean ±SD Mean ±SD
39.1±11.7
48.4±14.8
55.5±14.1
46.8±9.4
32.8±12.6
43.3±11.7
54.2±13.7
58.5±15.3
48.7±12.0
24.1±9.8
Sufficient
36.5±13.9
57.1±13.2
58.1±18.6
53.5±9.5
25.0±17.5
F(p-value)
3.5(0.03)
4.2(0.01)
0.8(0.4)
2.6(0.07)
10.4(0.000)
Sig.
Sig.
Not Sig.
Not Sig.
Highly Sig.
Barely Sufficient
C/S
Table (11) shows that the participants who had sufficient had the lower score in physical domain (36.5±13.9). The lower scores for psychological (48.4±14.8), social (55.5±14.1), environmental (46.8±9.4) domains and higher score for disability (32.8±12.6) were belonging to participants who had insufficient
Chapter Four
Results & Discussion 68
economic status.These differences were significant statistically in physical, psychological domains and functional disability. According to results of present study, economic status plays an important role in determining QoL of low back patients.The rich person had poorer physical QoL and had better psychological QoL than poor persons.Our result consistent with other studies conducted in Hong Kong and found that the significant relationship between income and QoL (Ko et al., 2006). While Horng et al (2005) found that patients with a higher family income had a better health related quality of life. A significant relationship between economic status and degree of disability was found with more disability in patients with insufficient income. This may due to that the poor individual had less access to health service and management.On the other hand, poor person involves in more difficult work that leads to more disability. The results of the present study go with the findings of Stefane et al (2013) who reported that the significant relationship between income and disability with more disability in patients with insufficient income Table (12): Distribution of differences means scores of quality of life domains' and disability according to patient body mass index. Quality of life Domains BMI
Physical
Psychological
Mean ±SD
Mean ±SD
Normal
45.69±12.6
Overweight Obese
Social
Environment
Disability
Mean ±SD
Mean ±SD
Mean ±SD
57.1±14.0
60.4±15.5
49.2±10.1
21.1±8.1
41.1±10.0
52.8±11.9
57.1±13.9
49.7±10.6
29.8±13.0
30.5±12.1
39.1±16.0
51.3±17.2
41.2±11.1
35.8±12.7
F(p-value)
15.6(0.001)
16.2(0.001)
3.1(0.04)
6.1(0.003) 14.2(0.001)
C/S
Highly Sig.
Highly Sig.
Sig.
Highly Sig.
Highly Sig.
Chapter Four
Results & Discussion 69
Table (12) shows that the obese patients had lower score for all quality of life domains, physical (30.5±12.1), psychological (39.1±16.0), social relation (51.3±16.7), and environmental (41.2±11.1).These differences were significant statistically for all domains and p-value was less than 0.05. As for disability there was significant elevation on disability score (35.8±12.7) when compared to normal body mass index (21.1±8.1) or even overweight patients (29.8±13.0). Obesity has previously been demonstrated to be a risk factor for back pain. The results of the present study confirmed that obesity reduces QoL and increase the occurrence of disability in low back pain. The findings of the present study are consistent with results of Okokon et al (2016) they found a significant association between QoL and overweight/obesity and stated that obese and overweight patients were more likely to have poor QoL compared to their normal weight counterparts. Furthermore, Rahimi et al (2015) reported that the obese and overweight subjects more likely to have poor QoL compared to their normal weight counterparts (p=0.003). Uluğ et al (2016) conducted a study to evaluate the characteristics quality of life in patients with low back and neck pain. Pain duration was longer, body weight was greater and physical domains of quality of life scales were worse in the low back pain. They reported that obesity is among the lifestyle factors that cause low back pain. They also showed that the severity of pain and disability in patients with low back pain increased as the BMI increased
Chapter Four
Results & Discussion 70
Table (13): Distribution of differences mean scores of quality of life domains' and disability according to patient's lifestyle factors. Quality of life Domains Smoking
Environment Disability
Physical
Psychological
Social
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Yes
34.9±7.1
47.6±11.6
54.2±11.2
44.3±9.3
31.9±13.3
No
41.8±12.5
52.9±14.8
57.8±15.7
49.1±10.9
27.4±12.4
t(p-value)
-2.5(0.009)
-1.5(0.14)
-1.1(0.29)
-2.0(0.04)
1.64(0.10)
Sig.
Not Sig.
Not Sig.
Sig.
Not Sig.
Alcohol Intake Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Yes
36.0±6.1
47.2±10.9
53.4±11.5
45.1±9.3
32.3±14.1
No
41.5±12.6
52.7±14.8
57.6±15.5
48.6±10.0
27.4±12.3
t(p-value)
-2.0(0.04)
-1.7(0.09)
-1.5(0.14)
-1.5(0.14)
1.7(0.09)
Sig.
Not Sig.
Not Sig.
Not Sig.
Not Sig.
Exercises
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Yes
47.4±12.5
58.8±13.3
60.7±14.8
51.8±10.2
23.2±8.5
No
37.7±10.8
48.9±13.9
55.5±15.1
46.9±10.6
30.8±13.3
t(p-value)
-5.1(0.000)
-4.3(0.000)
-2.1 (0.04)
-2.8(0.006)
-4.2(0.000)
C/S
Highly Sig.
Highly Sig.
Sig.
Sig.
Highly Sig.
Analgesics
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Mean ±SD
Yes
42.2±11.5
56.4±13.9
56.9±14.5
50.8±10.7
26.4±10.9
No
40.3±12.3
50.2±14.3
57.3±15.4
48.3±10.8
28.7±13.2
t(p-value)
0.9(0.37)
2.5(0.012)
0.13 (0.90)
1.7(0.06)
1.1(0.29)
C/S
Not Sig.
Sig.
Not Sig.
Not Sig.
Not Sig.
C/S
C/S
Chapter Four
Results & Discussion 71
Table (13) presents patient's lifestyle factors such as smoking, drinking alcohol, performing physical exercises and using analgesics. Non-Smoker had higher score for all QoL domains, but differences were significant statistically in physical (41.8±12.5) and environmental (49.1±10.9) domains only. Non-Alcohol drinker had high QoL score for all domains when compare to alcohol drinker, while the difference was significant in physical domain (41.5±12.6) only. As for disability scores, there was different in scores, smoker and alcohol drinker had higher scores but the different was not significant statistically, p-value more than 0.05. Regarding exercise, participants who performed physical exercises had higher scores in all QoL domains, physical (47.4±12.5) psychological (58.8±13.3), social relation (60.7±14.8) and environmental (51.8±10.2) and the percentage of physical function impairment was lower among non exercised patients.The differences were significant statically in all QoL domains and disability levels, p-value less than 0.005. Last items that covered by above table was using analgesic by participants and shows the participants who used analgesic had higher scores in physical(42.2±11.5),
psychological
(56.4±13.9)
and
environmental
domain
(50.8±10.7), while the difference was significant in the psychological domain only. As for disability score there was no significant difference between participants who used analgesics (26.4±10.9) or did not use them (28.7±12.3). Previously reported that the sedentary lifestyle, obesity, tobacco smoking and drug dependence would be the modifiable risk factor for low back pain and can interfere with low back patients' and impair QoL and physical functions. Present study results indicate that ciggrate smoking and drinking alcohol reduce physical quality of life significantly, while they had no effect on others QoL domains and physical functions. There was a significant relationship between quality of life and lifestyle factors in Panahi et al (2016) they found a significant relationship between physical quality of life and smoking so that QoL scores in terms of physical among smokers
Chapter Four
Results & Discussion 72
were lower than non-smokers. This finding is consistent with results of other studies (Ballinger and Fallow field, 2009; Nejat, 2008) where the quality of life was reported better among nonsmokers rather than smokers (Castro et al., 2010). The result of the Rahimi et al (2015) study indicated a significant association between the QoL and smoking. Regarding disability, Okokon et al (2016) reported there was no significant relation between smoking and functional disability among patients with low back pain. Donovan et al (2005) stated that frequent heavy drinking or episodic heavy drinking (e.g., five or more drinks per occasion) patterns were associated with reduced QoL. Alcoholics had lower levels of QoL compared with general population norms. As mentioned before there was not a significan association between drinking alchol and disability but greater disability was found in drinker alcohol compared to non-drinker. According to the results of this study, a significant relationship was found between quality of life and physical activity. The person who is active physically (performed physical exercise), had better QOL in terms of physical, psychological, social relation and environmental. This result is consistent with the results of studies conducted by Panahi et al (2016) the researcher stated that physical exercise improves QoL in patients with low back pain. Furthermore, Okokon et al (2016) found sedentary lifestyle lead to be significantly associated with poor QoL (p<0.05) in patients with low back pain. Finally, According to the result of Rahimi et al (2015) study, there was a significant association between QoL and exercise. The researcher showed that exercise capacity significantly associated with all subscales of QoL. This study concluded that exercises reduced pain and improved the physical and psychological domain as well as social relationship domains of the quality of life of patients with non-specific chronic low back pain (Akodu et al 2016).
Chapter Four
Results & Discussion 73
Persons with non-specific low back pain (NLBP) often report impaired ability to perform daily activities. The impact of low back pain on a patient’s daily functioning can be expressed as a patient’s level of disability or a reduction in physical functioning. The finding of the current study indicated that the patients with a sedentary lifestyle had the higher level of disability when compared to active patients. It is often assumed that patients who feel more disabled and thus report more daily life restrictions due to LBP will be those who are less physically active (lin et al., 2011). Lin and colleagues (2011) found a moderate correlation between physical activity and disability for persons with CLBP, which indicates that persons with chronic LBP and high levels of disability are also likely to have low levels of physical activity. The more recent study found exercises and physical activity lead to reduced functional disability in patients with chronic low back pain (Kapetanovic et al., 2016). This result consistent with previous studies of Klemenc- Ketis (2011) who found that Patient's not participated in physical activity at all had the lower quality of life and greater disability. Table (14): Distribution of difference mean scores of quality of life domains' and disability according to patient duration of disease Quality of life Domains Duration of Disease
Physical
Psychological
Social
Mean ± SD
Mean ± SD
Mean ± SD
Mean ± SD
Less than 1 years
41.6±11.9
53.8±13.7
59.8±14.3
51.0±9.8
24.1±10.5
1-3 years
41.9±10.8
50.1±15.6
58.3±15.6
46.4±11.1
28.9±11.4
More than 3 years
38.3±13.8
50.8±13.8
52.3±14.7
47.4±11.1
31.9±15.2
F(p-value)
1.3(0.2)
0.7(0.4)
3.4(0.03)
3.1(0.4)
5.3(0.005)
Not Sig.
Not Sig.
Sig.
Not Sig.
Sig.
C/S
Environment Disability
Chapter Four
Results & Discussion 74
Table (14) indicates patients that had low back pain for more than 3 years had reduced QoL score in two domains physical (38.3±13.8), social (52.3±14.7) and had higher disability scores (31.9±15.2). The differences were significant in social domain and disability (p ˂ 0.05).Our finding reveals that the longer duration of low back pain reduces social relation QoL and lead to more disability. As presented in above table duration of low back pain had no effect on patients QoL except social domain. This finding is in line with Rafeemanesh et al (2017) result, reported multiple linear regression models did not detect an influence of duration of low back pain on the patients' quality of life, except social relation. Furthermore, Yazdi-Ravandi et al (2013) data revealed that pain duration could not anticipate the QoL among patients with low back pain. This is consistent with the study conducted in Egypt by Al-disoky et al (2015) who found there was a significant relationship between the degree of disability and duration of low back pain. In contrary, other study founds that duration of pain had no effect on disability (Klemenc- Ketis, 2011).
CHAPTER FIVE CONCLUSIONS & RECOMMENDATIONS
Chapter Five
Conclusions &Recommendations 75
CHAPTER FIVE CONCLUSIONS &RECOMMENDATIONS
5.1 Conclusions: Based on the results of the study, the researcher concludes that: 1. The analysis of descriptive characteristics in the study sample showed the predominance of the participant was middle adult, female, married, low education, housewife, from an urban, low-income population and overweight or obese. 2. Despite QoL mean scores' for all domains was less than 60 and below the standard range, the effect of lower back pain was varied on different domains, physical aspect was most affected domain by lower back pain 3. The present study found the different level of disability, the proportion of minimal disability was more than one-third. Around half had the moderate disability. While the proportion of severe disability was lower than one-six. 4. The finding revealed reversal correlation between functional disability and each of QoL domains and positive correlation was observed among QoL domains. 5. The physical domain was low in participants who were low educated, sufficient financially, obese, smoker, alcohol drinker, and not exercising. The psychological domain was low in poor, obese, not exercising and participants who did not use analgesics. A social relation was low among obese and not exercising patients. Finally, the environmental domain was poor in middle adult, obese, smoker, and not exercising participants. 6. Participants advanced age, widowed, insufficient financially, obese or overweight, and not exercising, experienced more disabilities in their physical functions. While participants education, smoking, drinking alcohol and using analgesics are not related to participants disability. 7. Participants' gender and occupations are neither related to QoL domains nor the functional disability.
Chapter Five
Conclusions &Recommendations 76
5.2 Recommendations: 1. Physical domain was amongst the most affected domain of the QoL by chronic low back pain, thus offering a direction towards a more targeted treatment should give priority for most affect domain. 2. The fact functional disabilities were amongst the most prevalent characteristics of the low back patient that could provide recommendations on what the treatments should focus on. 3. Healthcare professional should pay more attention to more risky groups for reduced QoL and functional disability such as elderly, widowed, obese or overweight and not exercising patients with low back pain. 4. As obesity and sedentary lifestyle are risk factors for LBP incidence and reduced of QoL and functional ability. LBP management and clinical research should focus on preventing or reduce obesity and encourage people to engage in physical exercise and activity.
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Appendix (D) “QUESTIONNAIRE” “Assessment of Quality of Life and Disability among Patients with Chronic Low Back Pain in Sulaimani City” Form No.
Part One: Sociodemographic data of the patient: 1. Age
years
2. Gender: Male Female 3. Marital status Single Married Widowed/er 4. Level of education Illitrate primary school Secondary school Institute or University 5. Occupation Governmental employee Self employee House wife Retired 6. Residential area Urban Sub urban Rural
7. Finiacial stutus Sufficient Barely sufficient Insufficicent
Part Two: lifestyle and biomedical factors of the patients kg
8. Wieght
Hight
cm
9. Do you smoke cigarettes? Yes
No
10.Do you drink alcohol? Yes
No
11. Do you do exercise? Yes
No
12. Duration of lower back pain 13. Do you use analgesic? Yes
No
months
Part Three: The World Health Organization Quality of Life Breif (WHOQOL-BREF) Very poor
1.
How would you rate your quality of life?
1
Poor
2
Neither poor nor good 3
Good
Very good
4
5
satisfied
Very satisfied
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied Satisfied
1
2
3
4
5
Not at all
A little
A moderate amount
Very much
Anextreme amount
To what extent do you feel that physical pain prevents you from doing what you need to do?
1
2
3
4
5
How much do you need any medical treatment to function in your daily life?
1
2
3
4
5
5.
How much do you enjoy life?
1
2
3
4
5
6.
To what extent do you feel your life to be meaningful?
1
2
3
4
5
Not at all
A little
A moderate amount
Very much
Extremely
2.
3.
4.
How satisfied are you with your health?
7.
How well are you able to concentrate?
1
2
3
4
5
8.
How safe do you feel in your daily life?
1
2
3
4
5
9.
How healthy is your physical environment?
1
2
3
4
5
10
11
12
13
14
15
Not at all
A little
Moderately
Mostly
Completely
Do you have enough energy for everyday life?
1
2
3
4
5
Are you able to accept your bodily appearance?
1
2
3
4
5
Have you enough money to meet your needs?
1
2
3
4
5
How available to you is the information that you need in your dayto-day life?
1
2
3
4
5
To what extent do you have the opportunity for leisure activities?
1
2
3
4
5
Very poor
Poor
Neither poor nor good
Good
Very good
1
2
3
4
5
Very dissatisfied
dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
How well are you able to get around?
16
How satisfied are you with your sleep?
1
2
3
4
5
17
How satisfied are you with your ability to perform your daily living activities?
1
2
3
4
5
How satisfied are you with your capacity for work?
1
2
3
4
5
How satisfied are you with yourself?
1
2
3
4
5
18
19
Very dissatisfied
Dissatisfied
Neither satisfied nor dissatisfied
Satisfied
Very satisfied
How satisfied are you with your personal relationships?
1
2
3
4
5
21
How satisfied are you with your sex life?
1
2
3
4
5
22
How satisfied are you with the support you get from your friends?
1
2
3
4
5
How satisfied are you with the conditions of your living place?
1
2
3
4
5
How satisfied are you with your access to health services?
1
2
3
4
5
How satisfied are you with your transport?
1
2
3
4
5
Never
Seldom
Quite often
Very often
Always
1
2
3
4
5
20
23
24
25 .
26
How often do you have negative feelings such as blue mood, despair, anxiety, depression?
Equations for computing domain scores
Raw score
Transformed scores 4-20
Domain 1
6-Q3) + (6-Q4) + Q10 + Q15 + Q16 + Q17 + Q18 + + + + + +
0-100
a. =
b:
c:
Domain 2
Q5 + Q6 + Q7 + Q11 + Q19 + (6-Q26) + + + + +
a. =
b:
c:
Domain 3
Q20 + Q21 + Q22
a. =
b:
c:
a. =
b:
c:
+ Domain 4
+
Q8 + Q9 + Q12 + Q13 + Q14 + Q23 + Q24 + Q25 +
+
+
+
+
+
+
Part Four: Oswestry Low Back Pain Disability Questionnaire Section 1: Pain Intensity □ □ □ □ □ □
I can tolerate the pain I have without having to use pain killers. [0 points] The pain is bad but I manage without taking pain killers. [1 point] Pain killers give complete relief from pain. [2 points] Pain killers give moderate relief from pain. [3 points] Pain killers give very little relief from pain. [4 points] Pain killers have no effect on the pain and I do not use them. [5 points]
Section 2: Personal Care □ □ □ □ □ □
I can look after myself normally without causing extra pain. [0 points] I can look after myself normally but it causes extra pain. [1 point] It is painful to look after myself and I am slow and careful. [2 points] I need some help but manage most of my personal care. [3 points] I need help every day in most aspects of self care. [4 points] I do not get dressed wash with difficulty and stay in bed. [5 points]
Section 3: Lifting □ I can lift heavy weights without extra pain. [0 points] □ I can lift heavy weights but it gives extra pain. [1 point] □ Pain prevents me from lifting heavy weights off the floor but I can manage if they are conveniently positioned for example on a table.[2 points] □ Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned. [3 points] □ I can lift only very light weights. [4 points] □ I cannot lift or carry anything at all. [5 points]
Section 4: Walking □ □ □ □ □ □
Pain does not prevent me walking any distance. [0 points] Pain prevents me walking more than 1 mile. [1 point] Pain prevents me walking more than 0.5 miles. [2 points] Pain prevents me walking more than 0.25 miles. [3 points] I can only walk using a stick or crutches. [4 points] I am in bed most of the time and have to crawl to the toilet. [5 points]
Section 5: Sitting □ □ □ □ □ □
I can sit in any chair as long as I like. [0 points] I can only sit in my favorite chair as long as I like. [1 point] Pain prevents me sitting more than 1 hour. [2 points] Pain prevents me from sitting more than 0.5 hours. [3 points] Pain prevents me from sitting more than 10 minutes. [4 points] Pain prevents me from sitting at all. [5 points]
Section 6: Standing □ □ □ □ □ □
I can stand as long as I want without extra pain. [0 points] I can stand as long as I want but it gives me extra pain. [1 point] Pain prevents me from standing for more than 1 hour. [2 points] Pain prevents me from standing for more than 30 minutes. [3 points] Pain prevents me from standing for more than 10 minutes. [4 points] Pain prevents me from standing at all. [5 points]
Section 7: Sleeping □ □ □ □ □ □
Pain does not prevent me from sleeping well. [0 points] I can sleep well only by using tablets. [1 point] Even when I take tablets I have less than 6 hours sleep. [2 points] Even when I take tablets I have less than 4 hours sleep. [3 points] Even when I take tablets I have less than 2 hours of sleep. [4 points] Pain prevents me from sleeping at all. [5 points]
Section 8: Sex Life □ □ □ □ □ □
My sex life is normal and causes no extra pain. [0 points] My sex life is normal but causes some extra pain. [1 point] My sex life is nearly normal but is very painful. [2 points] My sex life is severely restricted by pain. [3 points] My sex life is nearly absent because of pain. [4 points] Pain prevents any sex life at all. [5 points]
Section 9: Social Life □ My social life is normal and gives me no extra pain. [0 points] □ My social life is normal but increases the degree of pain. [1 point] □ Pain has no significant effect on my social life apart from limiting energetic interests such a dancing. [2 points] □ Pain has restricted my social life and I do not go out as often. [3 points] □ Pain has restricted my social life to my home. [4 points] □ I have no social life because of pain. [5 points]
Section 10: Traveling □ □ □ □ □ □
I can travel anywhere without extra pain. [0 points] I can travel anywhere but it gives me extra pain. [1 point] Pain is bad but I manage journeys over 2 hours. [2 points] Pain restricts me to journeys of less than 1 hour. [3 points] Pain restricts me to short necessary journeys less than 30 minutes. [4 points] Pain prevents me from traveling except to the doctor or hospital. [5 points]
Appendix (E) List of the Experts No.
Scientific Degree
Work place
Dr. Salwa Shakir Alkurwi
Professor Psychiatric Nursing
College of Nursing University of Sulaiman
2.
Dr .Saadia Ahmed Khuder
Professor Adult Nursing
3.
Dr. Mohammed O. Mohammed
Professor
4.
Dr. Taha Ahmed karboli
Professor
1.
Name of the expert
Collage of Nursing Hawler Medical University College of Medicine University of Sulaimani College of Medicine University of Sulaimani
Dr. Raof Rahim Mirza
Assistant Professor Rheumatologist
College of Medicine University of Sulaimani
Dr. Atiya Karim Mohammed
Assistant Professor
College of Nursing University of Sulaimani
7.
Dr. Radhwan Hussein
Assistant Professor community Nursing
8.
Dr. Aso Ali Bakr
Orthopedic surgeon
Dr. Ariwan Mohammed Salih
Lecturer Orthopedic surgeon
College of Medicine University of Sulaimani
Lecturer
College of Medicine University of Sulaimani
Lecturer Pediatric Nursing
College of Nursing University of Sulaimani
5.
6.
9.
College of Nursing University of Mosul Shar teaching hospital
10.
Dr. Bakhtyar Fayaq
11.
Dr. Bahar Nasradin Majeed
12.
Dr. Hadil Abdullah
Lecturer
College of Nursing University of Sulaimani
13.
Dr.Shelan Ali Hama Sur
Lecturer
College of languge University of sulaimani
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