|Year : 2021 | Volume
| Issue : 3 | Page : 215-220
A cross-sectional study for correlation of kinesiophobia with low back disability and health-related quality of life in elderly patients with chronic low back pain
Manisha Mishra, V Rajashree Naik
Department of Physiotherapy, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
|Date of Submission||28-Apr-2021|
|Date of Decision||27-Jun-2021|
|Date of Acceptance||15-Aug-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Manisha Mishra
Room Number 502, New RMO Hostel, Sion Hospital Colony, Sion, Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
Context and Aim: Evasion of activity is an elemental reaction that normally allows an injury to heal, but among patients with chronic pain, avoidance behavior is found to persist longer than it takes for the actual injury to heal. This may lead to kinesiophobia which is an irrational, weakening, and devastating fear of movement and activity stemming from the belief of fragility and susceptibility to injury. Studies have shown that older people with low back pain (LBP) demonstrate high levels of kinesiophobia with prevalence ranging up to 80%. Despite the pain and fear that they experience, advising them to avoid painful movements or activities may actually be counter-productive as it will decrease their functional independence. Hence, the aim of the present study was to assess the impact of kinesiophobia on disability and quality of life (QOL) in elderly LBP patients. Subjects and Methods: With ethical permission and informed consent from 125 elderly patients with chronic LBP fulfilling the inclusion and exclusion criteria, three scales were administered to assess kinesiophobia (Tampa Scale of Kinesiophobia), disability (Oswestry Disability Index), and QOL (WHO QoL scale). Statistical Analysis Used: Data were collected and statistically analyzed for correlation using Spearman's correlation coefficient. Results: Sixty-five percent of the study population were male of which 82% had clinically significant kinesiophobia and 45% were female of which 85% had clinically significant kinesiophobia. Kinesiophobia was found to have a moderate positive correlation with disability (r = 0.6061) and a strong negative correlation with QOL (r = −0.7598). Conclusions: Kinesiophobia has a moderate-to-severe impact on disability and QOL and should be addressed as a separate symptom and adequate intervention strategies should be incorporated so as to minimize its impact.
Keywords: Disability, elderly, kinesiophobia, low back pain, quality of life
|How to cite this article:|
Mishra M, Naik V R. A cross-sectional study for correlation of kinesiophobia with low back disability and health-related quality of life in elderly patients with chronic low back pain. Indian J Pain 2021;35:215-20
|How to cite this URL:|
Mishra M, Naik V R. A cross-sectional study for correlation of kinesiophobia with low back disability and health-related quality of life in elderly patients with chronic low back pain. Indian J Pain [serial online] 2021 [cited 2022 Jan 19];35:215-20. Available from: https://www.indianjpain.org/text.asp?2021/35/3/215/334101
| Introduction|| |
Low back pain (LBP) is pain and discomfort localized below the costal margin and above the inferior gluteal folds with or without sciatica. It can be experienced as dull aching, burning, stabbing, and sharp shooting pain, with intensity ranging from mild to severe. LBP can be classified into acute (<6 weeks), subacute (6–12 weeks) and chronic (>12 weeks) depending on the duration of its persistence and the International Association for the Study of Pain defines chronic pain as pain without apparent biological value that has persisted beyond the normal tissue healing time.
According to population-based studies, the prevalence of LBP in the elderly ranges from 36% to 70% with 13%–50% of them suffering from chronic LBP.,,, Evasion of activity is a natural reaction, which normally allows an injury to heal, but among chronic pain patients, avoidance behavior is found to persist longer than it takes for the actual injury to heal and that can lead to exaggerating beliefs and behavioral agitation which leads to fear avoidance and kinesiophobia.
Kinesiophobia, by Kori et al. (1990), was defined as an irrational, weakening, and devastating fear of movement and activity stemming from the belief of fragility and susceptibility to injury. It also includes the fear of physiological symptoms of fatigue, exhaustion, and physical and mental discomfort. The causes of kinesiophobia could be biological (morphological, genetics) or psychosocial (state of mind, susceptibility to social influence). It causes changes in cognitive as well as physical responses to pain, which, in the long term, leads to limitation in physical activity, persistence of chronic pain, decreased participation, and limitation of social and leisure activities, thus creating a negative impact on their quality of life (QOL).
Although a lot of studies have been done on kinesiophobia, no study has been done to correlate kinesiophobia with disability and QOL in elderly population which is the aim of the present study. The present study not only assesses the impact of kinesiophobia on disability and QOL but also breaks QOL into four subdomains such as physical, psychological, social, and environmental, and correlation of kinesiophobia with each subdomain is also studied to give the study a holistic nature, to observe how deeply kinesiophobia impacts the daily living and psyche of the elderly population. This will help establish kinesiophobia as an independent symptom and adequate intervention can be incorporated in treatment protocol, thus eliminating a crucial factor impeding successful outcomes.
| Subjects and Methods|| |
In this correlational study, 125 elderly patients with chronic LBP coming to the geriatric outpatient department of a tertiary care hospital in Mumbai were selected. The study was sent to the Institutional Review Board for ethics approval. After obtaining approval, the nature and need of the present study was explained to the patients and written informed consent was obtained. The inclusion criteria were elderly patients of and above the age of 60 complaining of LBP for more than 3 months. These included patients suffering from chronic mechanical LBP, Prolapsed Intervertebral Disc (PIVD), osteoporosis, senile kyphosis, degenerative joint disease, and nonspecific LBP. Patients having any other chronic musculoskeletal disorders of the lower limb such as osteoarthritis of hip or knee; major lower limb surgeries such as total knee replacement and spinal fractures; and neurological disorders such as stroke and Parkinson's disease were excluded from the study. The duration of the study was 6 months. Elderly patients who fulfilled the inclusion and exclusion criteria were then given the following scales to fill.
- Tampa Scale of Kinesiophobia (TSK)
- Oswestry LBP Disability Questionnaire (Oswestry Disability Index)
- The World Health Organization QOL-BREF (WHOQOL).
The TSK was used to assess kinesiophobia in the subject population. It is a 17-item, self-reported, subjective scale with a total score of 68 and scores above 37 indicate clinically significant kinesiophobia. The scale can be used for LBP, neck pain, fibromyalgia, cancers, etc., The scale has a 4-point Likert type scaling system (1 = strongly disagree, 2 = disagree, 3 = agree, and 4 = strongly agree).
Low back disability was assessed using Oswestry LBP Disability Questionnaire, which is a 10-item, self-reported scale, with a total score of 50 and scores above 20 signifying severely disabled. It consists of components such as sitting, standing, walking, pain intensity, lifting, and personal care. For each section, the total possible score is 5 (maximum disability) and the least possible score is 0 (minimum disability). The score is calculated as follows:
Total score/Total possible score × 100.
The WHOQOL-BREF was used to assess the QOL. It is a 26-item, self-reported scale divided into four domains (physical, psychological, social, and environmental). It consists of 5-point Likert scaling system (1 = very poor, 2 = poor, 3 = neither good nor poor, 4 = good, and 5 = very good). The total score can range within 26–150 with higher scores signifying better QOL.
| Results|| |
Demographic data such as age and gender along with the scores of the three scales were collected and documented. Data analysis was performed using SPSS software, version 23. (Prolapsed Intervertebral Disc). All the numerical data were tested for normality by using the Kolmogorov–Smirnov test. It was found to be nonnormally distributed, and hence, Spearman's rho, a nonparametric test, was used to find out the correlations between variables. All tests were performed considering 95% confidence intervals and significance at 0.05.
| Discussion|| |
Aging consists of complex physical, psychological, and social changes accumulating over time. Biological aging leads to a decrease in function and capacity of body's anatomy and physiology, with a growing risk of disease and mortality. Psychological aging refers to the changes that occur in an individual's personality and mental functioning, such as cognition, intelligence, memory, and learning ability. Social aging refers to social and cultural expectations placed on older adults and as well as their position in society.
The prevalence of musculoskeletal pain in the elderly ranges from 65% to 85% with 36%–70% of them suffering from LBP.,, In population-based studies, the 1-year prevalence of LBP in community-dwelling seniors ranged from 13% to 50% across the world.
According to [Table number 1], the average age of the geriatric population who were a part of the study was 65.5 ± 4.75. In [Table number 2], the average duration of the chronicity of the low back pain was 13.79 ± 7.51 months. As depicted by [Table number 3], 65% of the sample population were males and 45% were females.
According to [Table 4], 82% of males in the study had clinically significant kinesiophobia, i.e. scores above 37 on TSK and 85% of females had clinically significant kinesiophobia. This goes in line with the study done by DaWana et al. on the topic “Sex Differences in Pain and Pain-Related Disability among Primary Care Patients with Chronic Musculoskeletal Pain” which concluded that compared with men, women reported worse pain intensity, greater pain-related interference with function, and more disability days due to pain. They also had worse depression, anxiety, and self-efficacy.
A moderate positive correlation was observed between kinesiophobia and low back disability, as showed by [Table 5] and [Figure 1]. Painful movements, injury or re-injury, may occasionally contribute to the development of chronic pain which, when interpreted as threatening, can generate catastrophizing beliefs and abnormal coping strategies that physical activity will result in more pain, which is the basis of kinesiophobia. Kinesiophobia does not follow an all-or-none approach but is a syndrome that varies in degree. It can be acquired through two forms, direct aversive experience (pain) or social learning (observation and instruction) and its prevalence in elderly population with chronic LBP can lead to increased avoidance behavior which in the long run can cause disability, disuse, and depression. Among common everyday activities, the ones that are most affected by kinesiophobia in LBP patients are lifting, standing, sitting, traveling, and homemaking duties, thus marking disability in performing activities of daily living. Kinesiophobia leads to avoiding painful movements which if prevalent for a prolonged period can reduce the activity of back extensors and abdominal muscles, thus decreasing their strength, hence adding to the disability.
|Table 5: Correlation between kinesiophobia and low back disability in geriatric patients suffering from chronic low back pain|
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As depicted by [Figure 2] and [Table 6], a strong negative correlation was observed between kinesiophobia and physical domain of QOL, which indicates that as kinesiophobia increases, the physical QOL decreases. Primarily based on laboratory studies, age-related physiological changes occur in pain processing and pain perception. Decrease in pain threshold, decrease in pain tolerance, increased vulnerability to neuropathic pain, and decreased vulnerability to acute pain related to visceral pathology have been reported to be effects of age-related changes in the processing of pain. These changes may be due to a decrease of myelinated nerve fibers at peripheral level, loss of brain volume (mainly in the hippocampus and prefrontal cortex), and slower cognitive processing. In addition, research has also shown that older adults may be less tolerant to pain once it begins and that they experience pain for a longer time after tissue injury. This may be due to reduced plasticity and reduced functioning of the descending inhibitory pathways, resulting in maladaptive modulation of pain. To reduce pain, daily activities and functional capacity are reduced and this untreated chronic pain leads to a negative spiral leading to increase fear, avoidance behavior, disuse, disability, and further exacerbation of chronic pain. Chronic pain and kinesiophobia individually can lead to fatigue which impacts physical activity, exercise, and activities of daily living thus creating a negative impact on the physical QOL of the patients.,,
|Figure 2: Correlation between kinesiophobia and physical domain of quality of life|
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|Table 6: Correlation between kinesiophobia and physical domain of quality of life in geriatric patients suffering from chronic low back pain|
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A moderate negative correlation was observed between kinesiophobia and psychological domain of QOL, as depicted in [Table 7] and [Figure 3]. This indicates that as kinesiophobia increases the psychological QOL decreases. Fear of movement and kinesiophobia have been used synonymously in literature but to differentiate, kinesiophobia is a stronger concept with a phobic nature. Consequently, kinesiophobia leads to catastrophic cognition, anxiety, and sometimes depression and suicidal thoughts. Older adults with kinesiophobia and chronic LBP are also found to report somatic nonspecific symptoms such as irritability, insomnia, decreased energy, difficulty concentrating, and memory problems, thus affecting their psychological QOL. Two major predictors of kinesiophobia are self-efficacy which is belief in one's capacity to manage challenging situations and setbacks and self-perception which is how an individual interprets his health condition and both of them are found to be poor among older adults.
|Table 7: Correlation between kinesiophobia and psychological domain of quality of life in geriatric patients suffering from chronic low back pain|
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|Figure 3: Correlation between kinesiophobia and psychological domain of quality of life|
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As depicted by [Table 8] and [Figure 4], there was a negligible correlation between kinesiophobia and social domain of QOL. Chronic pain leads to disability and kinesiophobia and pain-related disability can be seen as an umbrella concept, which includes a variety of domains such as self-care behaviors, physical, psychological, occupational, and social functioning. Studies have shown that chronic pain, kinesiophobia, and disability lead to social isolation in the elderly but those studies were done on institutionalized elderly. The elderly population who participated in this study were noninstitutionalized community dwellers who received social support such as emotional, informational, and companionship from friends, family, and hospital staff, thus negating the impact of kinesiophobia on social QOL.
|Table 8: Correlation between kinesiophobia and social domain of quality of life in geriatric patients suffering from chronic low back pain|
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|Figure 4: Correlation between kinesiophobia and social domain of quality of life|
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As depicted by [Table 9] and [Figure 5], there was a low negative correlation between kinesiophobia and environmental domain of QOL with Spearman's correlation coefficient of − 0.4796. Environmental domain of QOL consists of transportation, access to health services, leisure activities, and access to information, healthy living conditions, safety, and financial independence (employment). All the subcomponents of the domain are independent of kinesiophobia and LBP as a health condition. Leeuw et al., in their study, hypothesized that patients are more likely to avoid the kinds of activities that they believe are related to an increased risk of pain and (re) injury rather than lessening all types of physical activity, thus making the impact on the environmental domain subjective to individual's perception of disability. The participants in the study also belonged to low-to-middle socioeconomic strata of the society and hence had less financial independence and poor living conditions thus impacting the environmental domain of QOL negatively.
|Table 9: Correlation between kinesiophobia and environmental domain of quality of life in geriatric patients suffering from chronic low back pain|
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|Figure 5: Correlation between kinesiophobia and environmental domain of quality of life|
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As depicted by [Table 10] and [Figure 6], there was a strong negative correlation between kinesiophobia and total QOL. As kinesiophobia increases, it has a strong negative impact on the physical domain, thus affecting activities of daily living. It has a moderate impact on the psychological domain as it influences mood, affect and defense mechanisms. Kinesiophobia also has a small negative impact on the environmental domain of QOL, thus impacting transportation, work life, employment, and finance. All these subcomponents of QOL are affected by kinesiophobia thus showing the strong negative correlation between the two, indicating a cumulative effect of the three domains on the total QOL.
|Table 10: Correlation between kinesiophobia and quality of life in geriatric patients suffering from chronic low back pain|
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| Conclusions|| |
Since from the present study, we can infer that kinesiophobia has a moderate-to-severe impact on low back disability and physical and psychological domains of health-related QOL (and had minimal to negligible correlation with social and environmental domain), it should be separately seen as a symptom and adequate intervention strategies should be incorporated so as to break the vicious cycle of its impact. Kinesiophobia is also known to be a barrier to rehabilitation adherence. Since it is a modifiable factor, its early detection and management may facilitate the achievement of pain relief and functional recovery. It could be achieved through the selection of functional goals, education to manage safe behaviors, and graded exposure to feared activities in the form of behavioral experiments.
This will lead to a holistic treatment program and hence better delivery of health services and lesser chances of failure of treatment.
Future scope of this study suggests that longitudinal outcome studies examining the effect of progressing age and chronicity of pain can be assessed. Furthermore, factors contributing to disability such as pain medication, work status, and depression could be included in further studies.
Due to limited scope and time, the management of kinesiophobia and its impact on rehabilitation could not be assessed in the present study and can be recommended for future studies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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