Relationship between depression, catastrophizing and pain strength with the functional disability of patients with chronic low back pain before and after therapeutic exercises

Uvod: Kronična križobolja je vrlo prevalentno stanje koje je povezano s brojnim psihosociološkim promjenama i primjer je bolesti koja zahtjeva biopsihosocijalni pristup. Stoga, da bi se ostvario optimalan rezultat liječenja potrebno je identificirati koji su to čimbenici i u kojoj mjeri važni za nastanak, razvoj i tijek bolesti. Psihološko-psihijatrijski čimbenici kao što su depresija i katastrofiziranje boli, te intenzitet boli mogu značajno utjecati na onesposobljenost bolesnika s kroničnom križoboljom. Poznato je da terapijske vježbe koje su temelj liječenja, odnosno prevencije pogoršanja stanja u bolesnika s kroničnom križoboljom imaju somatske, ali i psihološke učinke. Međutim, nije poznata veličina tog učinka, odnosno koliko mogu utjecati na taj međuodnos. Stoga je cilj ovoga rada evaluirati odnos depresije, katastrofiziranja boli i intenziteta boli prema onesposobljenosti i ukupnoj kvaliteti života povezanoj sa zdravljem (engl. skr. HR-QoL), te koliki je u tome učinak terapijskih vježbi u bolesnika s kroničnom križoboljom. Prva hipoteza istraživanja je da razina depresije, katastrofiziranje boli i bol prije i nakon provedenih terapijskih vježbi imaju značajan utjecaj na funkcionalnu onesposobljenost u bolesnika s kroničnom nespecifičnom križoboljom. Druga hipoteza istraživanja je da razina depresije, katastrofiziranje boli i bol prije i nakon provedenih terapijskih vježbi značajno utječu na kvalitetu života povezanu sa zdravljem (HR-QoL) u bolesnika s kroničnom nespecifičnom križoboljom. Metode: U istraživanju je sudjelovalo 129 konsekutivnih bolesnika s kroničnom križoboljom, koji su se dobrovoljno odazvali na interni oglas za sudjelovanje u istraživanju u Domu zdravlja Zagrebačke županije – Ispostava Samobor. Od toga je bilo 96 (74,42%) žena i 33 (25,58%) muškarca prosječne životne dobi 49,30±5,47 god. (raspon od 40 do 60 godina). Uvjet za uključenje u istraživanje bila je samoprocijenjena bol minimalno 4 prema vizualnoj analognoj skali 0 - 10, te minimalno 5 bodova u onesposobljenosti mjereno Roland - Morrisovim upitnikom. Svi bolesnici su provodili iste terapijske vježbe 2 do 3 puta tjedno kroz razdoblje od četiri tjedna. Parametri istraživanja su uključivali: samoprocjenu intenziteta boli u pokretu i mirovanju (mjereno na VAS), katastrofiziranja boli (mjereno PCS), depresiju (mjereno BDI-II), funkcionalnu onesposobljenost (mjereno RMDQ) i opću kvalitetu života povezanu sa zdravljem (HR-QoL) (mjereno SF-36). Evaluacija je je provedena inicijalno (prije početka vježbanja), nakon provedenih terapijskih vježbi te dva mjeseca od završetka intervencije. Rezultati: Statistički značajna povezanost nađena je inicijalno između depresije, stupnja katastrofiziranja boli i intenziteta boli u odnosu na fizičko onesposobljenje i kvalitetu života povezanu sa zdravljem (p < 0,05). Potvrđena je prva hipoteza da razina depresije, katastrofiziranja boli i intenzitet boli prije i nakon provedenih terapijskih vježbi ima značajan utjecaj na funkcionalnu onesposobljenost u bolesnika s kroničnom križoboljom. Što se tiče učinka terapijskih vježbi neposredno nakon terapijskih vježbi ni jedno od inicijalnih stanja više nije utjecalo na učinke terapijskog programa na funkcionalnu onesposobljenost (p ≥ 0,05), kao i 2 mjeseca nakon terapijskih vježbi (p ≥ 0,05). Druga hipoteza koja se odnosi na to da razina depresije, katastrofiziranja boli i intenziteta boli prije i nakon provedenih terapijskih vježbi ima značajan utjecaj na HR-QoL u bolesnika s kroničnom križoboljom potvrđena je u dijelu koji se odnosi na statistički značajnu povezanost između razine: depresije, katastrofiziranja boli i boli u pokretu prije terapijskih vježbi, a nije potvrđena u dijelu koji se odnosi na inicijalnu povezanost boli u mirovanju i HR-QoL. Gledano na učinke terapijskog programa neposredno nakon terapijskih vježbi ni jedno od inicijalnih stanja više ne utječe na učinke terapijskog programa na HR-QoL (p ≥ 0,05), kao i 2 mjeseca nakon terapijskih vježbi (p ≥ 0,05). Katastrofiziranje boli, depresija, bol, funkcionalna onesposobljenost i kvaliteta života povezana sa zdravljem znatno su se poboljšali nakon provedenih terapijskih vježbi, a učinci terapijskog programa vježbanja još su se poboljšali nakon 2 mjeseca od prestanka intervencije. Dob ne utječe na učinke terapijskog programa vježbanja na bol, katastrofiziranje boli, depresiju, funkcionalnu onesposobljenost i kvalitetu života povezanu sa zdravljem. Žene imaju veća poboljšanja kvalitete života povezane sa zdravljem uslijed terapijskog programa vježbanja u odnosu na muškarce. Zaključak: Fizioterapijske vježbe djelovale su pozitivno u smislu smanjenja razine depresije, katastrofiziranja boli, boli u mirovanju, boli u pokretu i onesposobljenja, a poboljšale su kvalitetu života temeljenu na zdravlju. Inicijalna depresija, katastrofiziranje boli i intenzitet boli nisu povezani s učincima terapijskih vježbi neposredno nakon njihova provođenja te dva mjeseca po završetku vježbanja. Purpose: Chronic low back pain is a prevailing state related to numerous psychosociological changes and is the example of a disease which demands a biopsychosociological approach. Therefore, to achieve optimal results in treatment it is necessary to identify which factors and in what extent they are important for the appearance, development and course of the disease. Psychological-psychiatric factors like depression, pain catastrophizing and pain intensity can significantly affect the disability of a patient with chronic low back pain. It is well known that therapeutic exercises which are the basic treatment for curing as well as preventing of worsening the state in patients with chronic back pain, have somatic but also psychological effects. But the intensity of their impact and how much they can affect that interaction is not known. Therefore the aim of this study was to evaluate the relation between depression, pain catastrophizing and pain intensity in relation to disability and overall health related life quality (HR-QoL) and what in this is the impact of therapeutic exercises in patients with chronic low back pain. The first study hypothesis is that the depression level, pain catastrophizing and the pain before and after the performed exercises have a significant impact on functional disability in patients with chronic nonspecific low back pain. The second study hypothesis is that the depression level, pain catastrophizing and the pain before and after the performed therapeutic exercises have a significant effect on health related life quality (HR-QoL) in patients with chronic nonspecific back pain. Methods: 129 consecutive patients with chronic low back pain participated in the study. The patients voluntarily answered an internal notice for participation in the study at the Samobor division of the Zagreb County Health Centre. There were 96 (74.42%) women and 33 (25.58%) men average age 49.30±5.47 (40 - 60 years span). The condition for participation in the study was self assessed pain, minimum 4 on the visual analog scale 0 - 10, and minimum 5 points in disability measured by Roland-Morris questionnaire. All patients performed the same therapeutic exercises 2 - 3 times a week through a four week period. The study parameters included self assessment of the pain intensity in movement and stillness (measured on VAS), pain catastrophizing (measured on PCS), depression (measured by BDI-II), functional disability (measured RMDQ) and general health related life quality (HR-QoL) (measured SF-36). The evaluation was carried out initially (before the start of exercises), after the performed therapeutic exercises and two months after the end of intervention. Results: Statistically significant: connection between depression, pain catastrophizing level and pain intensity was initially found in relation to physical disability and pain related life quality (p < 0.05). The first hypothesis that the depression level, pain catastrophizing and pain intensity before and after performed therapeutic exercises have a significant impact on functional disability in patients with chronic low back pain has been confirmed. As for the impact of therapeutic exercises immediately after therapeutic exercises, neither of the initial states had any further influence on the effects of therapeutic programme on functional disability (p ≥ 0.05), as well as two months after therapeutic exercises (p ≥ 0.05). The other hypothesis which refers to the fact that the depression level, pain catastrophizing and pain intensity before and after performed therapeutic exercises has a significant influence on HR-QoL in patients with chronic low back pain has been confirmed in the part which refers to the statistically significant connection between depression level, pain catastrophizing and movement pain before therapeutic exercises, but is not confirmed in the part which refers to the initial connection between pain at rest and HR-QoL. Looking at therapeutic programme effects immediately after therapeutic exercises, neither of the initial states have any further impact on the therapeutic programme effects on HR-QoL (p ≥ 0.05) as well as two months after therapeutic exercises (p ≥ 0.05). Discussion and conclusions: Most patients initially report mild to moderate pain intensity, minimal to moderate depression, a lower than established value for the significance of pain catastrophizing, disability ranging from minimal to moderate, and mean values of health-related quality of life components are significantly lower on average for overall physical health than for mean values of mental health. A positive interconnection was found between depression and catastrophizing pain, pain and functional disability because higher values also indicated greater disability. The results speak of depression as an important factor in the lives of patients with low back pain – having the higher value of depression there is the lower degree of health-related perception of quality of life. The interrelationship of the examined components was also confirmed, with the exception of the association between resting pain and catastrophizing pain and resting pain and HR-Qol. Intervention with the performed exercises had positive effects. Pain catastrophizing, depression, pain, functional disability and health related life quality have significantly improved after performed therapeutic exercises and the effects of the therapeutic exercise programme have improved even more two months after the end of the intervention. The age had no impact on the effects of the therapeutic exercise programme on pain, pain catastrophizing, depression, functional disability and HR-QoL. Women have a greater improvement of health related life quality as a result of the therapeutic exercise programme in relation to men. Physiotherapeutic exercises had a beneficial effect on lowering the depression level, pain catastrophizing, pain at rest and movement and disability as well as improved the HR-QoL. Initial depression, pain catastrophizing and pain intensity are not connected to therapeutic exercise effects immediately after they were performed as well as two months after the end of exercises.