Relationship between depressive symptoms and acute low back pain at first medical consultation, three and six weeks of primary care

Sociodemographic differences in low back pain: which subgroups of workers are most vulnerable?

BACKGROUND

Low back pain (LBP) is a common health problem in workers that contributes to work disability and reduces quality of life. However, studies examining vulnerable groups in relation to sociodemographic differences in LBP remain scarce. Therefore, the current study investigates which sociodemographic groups of workers are most affected by LBP.

METHODS

Data from the 2018 BIBB/BAuA employment survey were used (N = 16252). Age, education, occupational group, income, working hours, atypical working time, relationship status, and having children were used as sociodemographic predictors. Gender-stratified logistic regression analyses and intersectional classification tree analyses were conducted.

RESULTS

A higher prevalence of LBP was observed for women compared to men. Significant differences in LBP emerged for age, working hours, atypical working time, occupational group and education, with some gender differences in the importance of predictors: Age was a significant predictor mostly in men as compared to women, atypical working hours had a slightly greater effect in women, whereas differences in LBP according to the occupational group were more pronounced for men. Vulnerable groups were found to be women who work in occupations other than professionals or managers, work atypical hours and have an intermediate or low educational level as well as men who work as skilled agricultural workers, craft workers, machine operators, or elementary occupations and are between 35 and 64 years old.

CONCLUSIONS

Thus, workers with certain occupations and lower levels of education, middle-aged men and women with unfavourable working time characteristics are most affected by low back pain. These groups should be focused on to potentially increase healthy working life and prevent work disability.

Association Between Depressive Symptoms or Depression and Health Outcomes for Low Back Pain: a Systematic Review and Meta-analysis

BACKGROUND

Study results vary on whether depressive symptoms are associated with worse prognosis for low back pain (LBP). We assessed the association between depressive symptoms or depression and health outcomes in persons with LBP.

METHODS

We searched MEDLINE, Embase, CINAHL, and PsycINFO from inception to June 2020. Eligible studies were cohort and case-control studies assessing the association between depressive symptoms (questionnaires) or depression (diagnoses) and health outcomes in persons aged ≥16 years with LBP in the absence of major pathology. Reviewers independently screened articles, extracted data, and assessed risk of bias using the Quality in Prognosis Studies tool. We classified exploratory versus confirmatory studies based on phases of prognostic factor investigation. We conducted random-effects meta-analyses and descriptive synthesis where appropriate.

RESULTS

Of 13,221 citations screened, we included 62 studies (63,326 participants; 61 exploratory studies, 1 confirmatory study). For acute LBP, depressive symptoms were associated with self-reported disability (descriptive synthesis: 6 studies), worse recovery (descriptive synthesis: 5 studies), and slower traffic injury-related claim closure (1 study), but not pain or work-related outcomes. Depressive symptoms were associated with greater primary healthcare utilization for acute LBP (1 confirmatory study). For chronic LBP, depressive symptoms were associated with higher pain intensity (descriptive synthesis: 9 studies; meta-analysis: 3 studies, 2902 participants, β=0.11, 95% confidence interval (CI) 0.05-0.17), disability (descriptive synthesis: 6 studies; meta-analysis: 5 studies, 3549 participants, β=0.16, 95% CI 0.04-0.29), and worse recovery (descriptive synthesis: 2 studies; meta-analysis: 2 studies, 13,263 participants, relative risk (RR)=0.91, 95% CI 0.88-0.95), but not incident chronic widespread pain (1 study).

DISCUSSION

Depressive symptoms may be associated with self-reported disability and worse recovery in persons with acute and chronic LBP, and greater primary healthcare utilization for acute LBP. Our review provides high-quality prognostic factor information for LBP. Healthcare delivery that addresses depressive symptoms may improve disability and recovery in persons with LBP. Confirmatory studies are needed to assess the association between depressive symptoms and health outcomes in persons with LBP.

PROTOCOL REGISTRATION

PROSPERO database (CRD42019130047).

Cerebral mechanism of opposing needling for managing acute pain after unilateral total knee arthroplasty: study protocol for a randomized, sham-controlled clinical trial

Background

Opposing needling is a unique method used in acupuncture therapy to relieve pain, acting on the side contralateral to the pain. Although opposing needling has been used to treat pain in various diseases, it is not clear how opposing needling affects the activity of the central nervous system to relieve acute pain. We herein present the protocol for a randomized sham-controlled clinical trial aiming to explore the cerebral mechanism of opposing needling for managing acute pain after unilateral total knee arthroplasty (TKA).

Methods

This is a randomized sham-controlled single-blind clinical trial. Patients will be allocated randomly to two parallel groups (A: opposing electroacupuncture group; B: sham opposing electroacupuncture group). The Yinlingquan (SP9), Yanglingquan (GB34), Futu (ST32), and Zusanli (ST36) acupoints will be used as the opposing needling sites in both groups. In group A, the healthy lower limbs will receive electroacupuncture, while in group B, the healthy lower limbs will receive sham electroacupuncture. At 72 h after unilateral TKA, patients in both groups will begin treatment once per day for 3 days. Functional magnetic resonance imaging will be performed on all patients before the intervention, after unilateral TKA, and at the end of the intervention to detect changes in brain activity. Changes in pressure pain thresholds will be used as the main outcome for the improvement of knee joint pain. Secondary outcome indicators will include the visual analogue scale (including pain during rest and activity) and a 4-m walking test. Surface electromyography, additional analgesia use, the self-rating anxiety scale, and the self-rating depression scale will be used as additional outcome indices.

Discussion

The results will reveal the influence of opposing needling on cerebral activity in patients with acute pain after unilateral TKA and the possible relationship between cerebral activity changes and improvement of clinical variables, which may indicate the central mechanism of opposing needling in managing acute pain after unilateral TKA.

Trial registration

Study on the brain central mechanism of opposing needling analgesia after total kneearthroplasty based on multimodal MRI ChiCTR2100042429. Registered on January 21, 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06066-6.

How does individualised physiotherapy work for people with low back pain? A Bayesian Network analysis using randomised controlled trial data

PURPOSE

Individualised physiotherapy is an effective treatment for low back pain. We sought to determine how this treatment works by using randomised controlled trial data to develop a Bayesian Network model.

METHODS

300 randomised controlled trial participants (153 male, 147 female, mean age 44.1) with low back pain (of duration 6-26 weeks) received either individualised physiotherapy or advice. Variables with potential to explain how individualised physiotherapy works were included in a multivariate Bayesian Network model. Modelling incorporated the intervention period (0-10 weeks after study commencement-"early" changes) and the follow-up period (10-52 weeks after study commencement-"late" changes). Sequences of variables in the Bayesian Network showed the most common direct and indirect recovery pathways followed by participants with low back pain receiving individualised physiotherapy versus advice.

RESULTS

Individualised physiotherapy directly reduced early disability in people with low back pain. Individualised physiotherapy exerted indirect effects on pain intensity, recovery expectations, sleep, fear, anxiety, and depression via its ability to facilitate early improvement in disability. Early improvement in disability, led to an early reduction in depression both directly and via more complex pathways involving fear, recovery expectations, anxiety, and pain intensity. Individualised physiotherapy had its greatest influence on early change variables (during the intervention period).

CONCLUSION

Individualised physiotherapy for low back pain appears to work predominately by facilitating an early reduction in disability, which in turn leads to improvements in other biopsychosocial outcomes. The current study cannot rule out that unmeasured mechanisms (such as tissue healing or reduced inflammation) may mediate the relationship between individualised physiotherapy treatment and improvement in disability. Further data-driven analyses involving a broad range of plausible biopsychosocial variables are recommended to fully understand how treatments work for people with low back pain.

TRIALS REGISTRATION

ACTRN12609000834257.

Psychosocial morbidity profile in a community based sample of low back pain patients

Low back pain (LBP) is a major health concern and is closely associated with psychosocial morbidity and diminished Health-related quality of life (HRQoL). This is minimally investigated in community-based samples of developing nations like India. This study is aimed to specifically investigate the exposure-outcome associations between LBP and burden of disability (Modified Oswestry questionnaire (MODQ)), psychological morbidities (Depression, Anxiety and Stress Scale (DASS-21)), and HRQoL (Short Form -12 version 2 (SF12V2). A Cross-sectional study using a community-based sample of LBP positive population was conducted. The range of treatment options sought was also collected. Chi-square tests and independent t-test were used to analyze the data. Of 1531 recruited participants, 871(57%) were identified as LBP positive of whom 60% were females. Mean (SD) of age and pain intensity of LBP patients was 33 (11) years and numeric rating scale4.2 (2.6) respectively. Two-third reported minimal/moderate disability. Mean (SD) scores of depression 11.87 (4.05), anxiety (8.32), stress 13.7 (5.98), physical and mental summary scores of SF-12v2 were 47.9 (7.4) and 42.2 (10.4). A multitude of remedial options was sought for the ailment. LBP causes significant disability and psychological morbidity among affected population. This may adversely affect their HRQoL and subsequently productivity. Acupuncture was a preferred treatment sought by Indian LBP patients.

AAAPT Diagnostic Criteria for Acute Low Back Pain with and Without Lower Extremity Pain

OBJECTIVE

Low back pain is one of the most common reasons for which people visit their doctor. Between 12% and 15% of the US population seek care for spine pain each year, with associated costs exceeding $200 billion. Up to 80% of adults will experience acute low back pain at some point in their lives. This staggering prevalence supports the need for increased research to support tailored clinical care of low back pain. This work proposes a multidimensional conceptual taxonomy.

METHODS

A multidisciplinary task force of the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) with clinical and research expertise performed a focused review and analysis, applying the AAAPT five-dimensional framework to acute low back pain.

RESULTS

Application of the AAAPT framework yielded the following: 1) Core Criteria: location, timing, and severity of acute low back pain were defined; 2) Common Features: character and expected trajectories were established in relevant subgroups, and common pain assessment tools were identified; 3) Modulating Factors: biological, psychological, and social factors that modulate interindividual variability were delineated; 4) Impact/Functional Consequences: domains of impact were outlined and defined; 5) Neurobiological Mechanisms: putative mechanisms were specified including nerve injury, inflammation, peripheral and central sensitization, and affective and social processing of acute low back pain.

CONCLUSIONS

The goal of applying the AAAPT taxonomy to acute low back pain is to improve its assessment through a defined evidence and consensus-driven structure. The criteria proposed will enable more rigorous meta-analyses and promote more generalizable studies of interindividual variation in acute low back pain and its potential underlying mechanisms.

The Impact of Social Isolation on Pain Interference: A Longitudinal Study

Background

Evidence suggests social interactions play an important role in pain perception.

Purpose

The aim of this study was to determine whether social isolation (SI) in people with persistent pain determines pain interference (PI) and physical function over time.

Methods

Patients seeking care at a tertiary pain management referral center were administered the Patient Reported Outcome Measurement Information System (PROMIS^®) SI, PI, physical function, depression, and average pain intensity item banks at their initial consultation and subsequent visits as part of their routine clinical care. We used a post hoc simulation of an experiment using propensity score matching (n = 4,950) and carried out a cross-lagged longitudinal analysis (n = 312) of retrospective observational data.

Results

Cross-lagged longitudinal analysis showed that SI predicted PI at the next time point, above and beyond the effects of pain intensity and covariates, but not vice versa.

Conclusions

These data support the importance of SI as a factor in pain-related appraisal and coping and demonstrate that a comprehensive assessment of the individuals’ social context can provide a better understanding of the differential trajectories for a person living with pain. Our study provides evidence that the impact of pain is reduced in individuals who perceive a greater sense of inclusion from and engagement with others. This study enhances the understanding of how social factors affect pain and have implications for how the effectiveness of therapeutic interventions may be improved. Therapeutic interventions aimed at increasing social connection hold merit in reducing the impact of pain on engagement with activities.

Longitudinal Associations between Anatomical Regions of Pain and Work Conditions: A Study from The SwePain Cohort

We investigated the time-based associations between workload (physical and mechanical), psychosocial work stressors (demands, control, and support), and the number of anatomical regions with pain (ARP). This population-based study with a two-year follow-up included 11,386 responders (5125 men, 6261 women; mean age: 48.8 years; SD: 18.5) living in south-eastern Sweden. Predictive associations were assessed through generalised linear models, and changes over time were examined using a generalised estimating equation. The results of both models were reported as parameter estimates (B) with 95% confidence interval (CIs). Mean changes in the number of ARP, workload, and psychosocial work stressors were stable over time. High mechanical workload and job demands were likely associated with the number of ARP at the two-year follow-up. In the reverse prospective model, we found that the number of ARP was also associated with high physical and mechanical workload and low job control and support. In the two time-based models of changes, we found a reciprocal association between number of ARP and mechanical workload. Our results add epidemiological evidence to the associations between work conditions and the extent of pain on the body. Components of work conditions, including job demands and mechanical strain, must be considered when organisations and health policy makers plan and employ ergonomic evaluations to minimise workplace hazards in the general population.

Investigating the prevalence of anxiety and depression in people living with patellofemoral pain in the UK: the Dep-Pf Study

Background and aims Patellofemoral pain (PFP) is a common knee condition causing pain around or behind the kneecap which is exacerbated by certain activities. Traditionally it has been viewed as a self-limiting condition. Recent research proves this is not the case and the evidence for poor long-term outcomes is growing. Whilst the evidence base for PFP treatment and the understanding of its aetiology is improving, it remains a complex and difficult to treat condition. In many physical conditions, it has been shown that anxiety and depression negatively affect both their management and duration. It is unclear how prevalent anxiety and depression are in PFP. This study aimed to identify the prevalence of anxiety and depression in people living with PFP in the UK. Methods In order to investigate this, a cross-sectional online survey was undertaken. Four hundred participants with self-reported symptoms of PFP were recruited through a tailored social media campaign, using modified snowball sampling. Eligibility criteria were (i) aged between 18 and 44, (ii) self-reported symptoms of PFP (using accepted criteria) (iii) resident in the UK. Exclusion criteria were previous history of patella dislocation or previous surgery to affected knee. The survey recorded demographic information, previous treatment for both PFP and anxiety and depression, the Hospital Anxiety and Depression Scale and the Anterior Knee Pain Scale. Ethical approval was gained from a University of Plymouth Ethics Committee. Results Half (49.5%; n=198) of respondents were classified as experiencing anxiety and 20.8% (n=83) as experiencing depression. The levels of anxiety and depression identified in this study are higher than those found in the general population (5.9-7.8% and 3.3-7.8%, respectively). This mirrors results which have been reported in other studies into PFP in different settings and with other musculoskeletal conditions, such as osteoarthritis and contracted shoulder. Conclusions Anxiety and depression are more common in people living with PFP than in the general population. These findings support the need for greater research into the effects of psychological factors, such as anxiety and depression, in PFP. A key area of future research will be to determine whether these psychological factors affect treatment outcomes in people living with PFP. Implications This is the first study to investigate the prevalence of anxiety and depression in people living with patellofemoral pain in the UK. This study shows that anxiety and depression are very common in people living with patellofemoral pain. The need for further work into the effects of psychological factors in patellofemoral pain is indicated.

The pain, depression, disability pathway in those with low back pain: a moderation analysis of health locus of control

Low back pain (LBP) is common, impacts on the individual and society, and is a major health concern. Psychological consequences of LBP, such as depression, are significant barriers to recovery, but mechanisms for the development of depression are less well understood. One potential mechanism is the individual’s health locus of control (HLoC), that is, perception of the level of control an individual has over their health. The objective of this study is to investigate the moderation effect of HLoC on the pain–depression–disability pathway in those with LBP. The design is a nested cross-sectional analysis of two existing cohorts of patients (n=637) who had previously consulted their primary care physician about LBP. Measures were taken of HLoC, pain intensity and interference, depression, disability, and bothersomeness. Structural Equation Modeling analysis was applied to two path models that examined the pain to depression to disability pathway moderated by the HLoC constructs of Internality and Externality, respectively. Critical ratio (CR) difference tests were applied to the coefficients using pairwise comparisons. The results show that both models had an acceptable model fit and pathways were significant. CR tests indicated a significant moderation effect, with stronger pathway coefficients for depression for those who report low Internality (β 0.48), compared to those with high Internality (β 0.28). No moderation effects were found within the Externality model. HLoC Internality significantly moderates the pain–depression pathway in those with LBP, meaning that those who have a low perception of control report greater levels of depression. HLoC may signify depression among people with LBP, and could potentially be a target for intervention.

Relationship of depression in participants with nonspecific acute or subacute low back pain and no-pain by age distribution

BACKGROUND AND PURPOSE

Nonspecific low back pain (LBP) is the most prevalent musculoskeletal condition in various age ranges and is associated with depression. The aim of this study was to determine the Beck Depression Inventory (BDI) scores in participants with nonspecific LBP and no-pain by age distribution.

METHODS

A case-control study was carried out following the Strengthening the Reporting of Observational Studies in Epidemiology criteria. A sample of 332 participants, divided into the following age categories: 19-24 (n=11), 25-39 (n=66), 40-64 (n=90), 65-79 (n=124), and ≥80 (n=41) years was recruited from domiciliary visits and an outpatient clinic. The BDI scores were self-reported in participants with nonspecific acute or subacute (≤3 months) LBP (n=166) and no-pain (n=166).

RESULTS

The BDI scores, mean ± standard deviation, showed statistically significant differences (p<0.001) between participants with nonspecific acute or subacute LBP (9.590±6.370) and no-pain (5.825±5.113). Significantly higher BDI scores were obtained from participants with nonspecific acute and subacute LBP in those aged 40-64 years (p<0.001; 9.140±6.074 vs 4.700±3.777) and 65-79 years (p<0.001; 10.672±6.126 vs 6.210±5.052). Differences were not significant in younger patients aged 19-24 (p=0.494; 5.000±2.646 vs 8.250±7.498), 25-39 (p=0.138; 5.440±5.245 vs 3.634±4.397), and in those aged ≥80 years (p=0.094; 13.625±6.1331 vs 10.440±5.591).

CONCLUSION

Participants with nonspecific acute and subacute LBP present higher BDI depression scores, influenced by age distribution. Specifically, patients in the age range from 40 to 80 years with LBP could require more psychological care in addition to any medical or physical therapy. Nevertheless, physical factors, different outcomes, and larger sample size should be considered in future studies.

The Impact of Body Mass Index on Fluoroscopy Time During Lumbar Epidural Steroid Injection; A Multicenter Cohort Study

Objective

This study aimed to assess the relationship between BMI and fluoroscopy time during lumbar epidural steroid injections (LESIs) performed for lumbosacral radicular pain.

Design

Multicenter retrospective cohort study.

Setting

Three academic, outpatient pain treatment centers.

Subjects

Patients who underwent fluoroscopically guided LESI.

Methods

Mean and standard deviation (SD) fluoroscopy time were compared between patients with normal (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), and obese (≥30.0 kg/m2) BMI. Statistical significance was set at P=0.01 due to multiple comparisons.

Results

A total of 2,930 procedure encounters were included, consisting of 598 interlaminar LESIs and 2,332 transforaminal LESIs. Fluoroscopy time was significantly longer in the obese patients compared to normal and overweight patients during interlaminar LESI (P < 0.01). Fluoroscopy time was significantly longer with each increasing BMI category in during transforaminal LESI (P < 0.01). These relationships remained when a trainee was involved (P < 0.01; P<0.01), during repeat injections (P < 0.01; P < 0.01), and during bilateral transforaminal LESIs (P < 0.01). While longer fluoroscopy times were required in high BMI categories during L5-S1 transforaminal LESI (P < 0.01), there was no relationship between fluoroscopy time and BMI during L4-L5 and S1 transforaminal LESI (P = 0.02; P = 0.13). Fluoroscopy time during interlaminar LESI compared to transforaminal LESI was significantly lower within all BMI categories (all P<0.01).

Conclusions

The findings of this study indicate that fluoroscopy time is increased during interlaminar LESIs and during L5-S1 transforaminal LESIs in patients who are obese. These relationships are not affected by injection number, performance of bilateral injections, or trainee involvement. Further study is needed to determine if this increase in fluoroscopy time is indicative of a clinically significant associated increase in radiation dose.

Symptoms of depression as a prognostic factor for low back pain: a systematic review

BACKGROUND CONTEXT

It has been proposed that depression plays an important role in the course of low back pain; however, there is considerable uncertainty on its predictive value.

PURPOSE

This systematic review aims to investigate the effect of depression on the course of acute and subacute low back pain.

STUDY DESIGN

This is a systematic review.

METHODS

We searched the following databases using optimized search strategies: AMED, CINAHL, EMBASE, Health & Society Database, LILACS, MEDLINE, PsycINFO, Scopus, and Web of Science. We only included prospective studies that investigated a cohort of participants with acute or subacute non-specific low back pain (pain of less than 12 weeks' duration). The prognostic factor of interest was depression or symptoms of depression assessed at baseline. The outcomes of interest included pain intensity, chronicity (non-recovery from low back pain), disability, return to work, health-related quality of life, and overall patient satisfaction. Two independent reviewers selected the studies, extracted the data, and assessed the methodological quality of the studies that were included.

FUNDING

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no conflicts of interest-associated biases.

RESULTS

Seventeen articles reporting 13 cohort studies were included in this review. There was considerable variability between studies in terms of the method of assessment of depression and low back pain, statistical methods, and follow-up length, which precluded the quantitative synthesis of the results. Definition of outcomes varied across studies, but overall they could be divided into work-related outcome measures, followed by disability, pain, self-perceived recovery, and mixed outcomes. Eleven out of 17 articles (or 8 out of 13 cohorts) reported that symptoms of depression at baseline are related to worse low back pain outcomes (measured in various ways) at follow-up, and the effect sizes (odds ratio [OR]) ranged from 1.04 to 2.47. Only two studies that did not find a statistically significant association reported quantitative results: OR=1.03, 95% confidence interval (CI) 0.98-1.08; and OR=1.02, 95% CI 0.99-1.06. All included studies, regardless of statistical significance, showed an effect in the direction of harm.

CONCLUSIONS

Although a definitive answer on the effect of depression on the course of low back pain is not available, the findings of this systematic review suggest that depression might have an adverse effect on the prognosis of low back pain. Future large studies that enroll an inception cohort and that employ a standardized method for assessing depression and low back pain are needed.