Strategies for Coping with Chronic Lower Back Pain in Patients with Long Physiotherapy Wait Time

Background

The increasing prevalence of back pain diagnosis among people of different ages, working in highly industrialized/developed countries, highlights the need for new treatment methods [1–5]. High-efficacy treatment has become a challenge to both the health care system and individuals suffering from back pain, e.g. patients need to be less reliant on self-coping and be more proactive in seeking out professional help and support with regard to their treatment and pain management. However, some aspects of the process of diagnosis and effective treatment still remain unexplained. Hence, tailoring the protocols of examination and therapeutic programmes, where multidisciplinary diagnosis and multidimensional structure of the pain are taken into consideration becomes increasingly important [6,7]. In reality, a cursory attitude to the bio-psychological approach to chronic pain treatment may result in patients’ disappointment with treatment outcomes [8–12].

Coping with pain is an important element in pain perception and responses. Therefore, it plays an important role in the healing process [13,14]. Lazarus and Folkman [15,16] developed a concept that fits well in the discussion on the problem of coping with chronic pain. According to them, coping means making cognitive and behavioral efforts to control the external and internal demands which a person considers as aggravating or exceeding his/her resources. The behavioral efforts refer to the measures taken to reduce pain, and the cognitive ones are those aimed at reinterpreting pain or finding a distraction [17]. Prior research has demonstrated poor treatment outcomes for patients who used passive coping strategies [18–20]. Passive coping with pain, catastrophizing, avoidance, depression and anxiety are important predictors of problems with adapting to chronic pain and the consequential further psychosocial problems [11,19–21]. Moreover, the passive coping strategy is accompanied by low self-efficacy, higher pain intensity and disability [20].

Age is considered one of the risk factors for low back pain (LBP) as its prevalence increases with age [4,5]. For young adults, pain is often associated with a sense of disability, lowered performance (loss of productivity), unemployment, and a serious limitation affecting the process of self-realization [22,23]. On the other hand, the elderly suffering from pain are exposed to functional limitations, economic difficulties and social isolation [11,24].

Scientific research has evaluated strategies that representatives of different populations use to cope with pain for different medical conditions [7,14,17,18,20,25–39]. There are, however, gaps in research assessing the need of psychosocial factors included in the rehabilitation process that focus on somatic disorders. The bio-psychosocial model in the case of LBP has not yet been extensively analyzed [10]. The scientific publications emphasized the need to create new healthcare models for patients suffering from pain that would cover self-management of pain [4,40,41]. The present study attempted to adopt a different perspective on the development of research focusing on tailoring rehabilitation protocols and modifying therapeutic programmes for LBP rehabilitation.

The authors of the following survey have assumed that patients with chronic back pain need strategies to manage their pain and its impact, because coping is not restricted to one dimension of human functioning (cognitive, affective, behavioral, physiological) [14]. It may have significant outcomes in the process of physiotherapy and its long-term efficacy.

The aim of this study was to evaluate self-management and pain coping strategies in patients with CLBP awaiting rehabilitation just before commencing their treatment programme. The authors took into account the basic assessment that could be provided by a physiotherapist before therapy. Especially in situations when patients must longer (even more than 2 months) wait for the ordered rehabilitation, struggling themselves in this time with pain [42]. The general assessment of mental health seems to be sufficient for rehabilitation needs. The following hypotheses were analyzed:

Material and Methods

The study involved 88 patients: 52 women and 36 men, experiencing CLBP (related to degenerative diseases), attending physical therapy in two rehabilitation centers in Warsaw. The diagnosis of lumbar spine degeneration was made by a specialist orthopaedic surgeon based on clinical examination, confirmed by X-ray imaging and MRI. The height of the respondents averaged 166±11.30 cm, weight 79±14.33 kg, and BMI 28.58±3.36. The range of pain intensity (VAS scale 0–10) before the treatments in each group is presented in Table 1. The duration of back pain ranged from 4 months to 23 years, mean 11.32±6.81 years. Mean waiting time for ordered rehabilitation in primary health care was 6.82±5.46 weeks. The most frequently recommended forms of treatment included individual or group exercises, interference currents, laser therapy, cryotherapy and massage. The respondents completed the study questionnaire and interview form before physiotherapy services. The patients did not use professional psychological counselling before.

The inclusion criteria for the study were as follows: chronic LBP lasting more than 3 months, degenerative changes of lumbar spine, no other acute conditions, referral to physiotherapy from physician, consent to participate in the study. The criteria for exclusion from the study were: difficulties in contact with the patient, identified deeper mental disorders, other significant pain, and age below 20 years.

According to the hypothesis, the results were analyzed for three age groups: young adults (21–40 years old), middle-aged (41–60 years old) and the elderly (61 years of age and older). The age groups were determined according to the human development periods (Table 2).

The management of the rehabilitation centers also gave their written consent to conduct the research and were informed about the purpose of the study, respecting the principles of anonymity and the fact that at any time they could terminate their participation without indicating the cause. The tested subjects were qualified for participation in the study based on the date of application for rehabilitation treatments. The permission to conduct the research was granted by the Ethics Committee at the Physiotherapy Faculty of the Jozef Pilsudski University of Physical Education in Warsaw (SKE no.01-5/2014). The participants provided their written informed consent to participate in this study. The ethics committees approved this consent procedure.

This study utilized the Coping Strategies Questionnaire (CSQ) by Rosenstiel and Keefe (1983), adapted to Polish by Juczyński [28], which was filled out by the subjects immediately prior to a series of physiotherapy treatments. This enabled evaluating the strategies used to cope with pain. In addition, it also made it possible to predict if the patient adapted to chronic pain. The tool consists of 42 statements describing different ways of coping with pain, related to 7 pain coping strategies (each strategy consists of 6 statements).

The authors of the questionnaire proposed six cognitive strategies: (1) distraction, (2) re-evaluation of the sensation of pain, (3) catastrophizing, (4) ignoring the sensations, (5) praying/hoping, and (6) declaring the pain manageable, as well as one behavioral strategy (7) defined as increased behavioral activity. Those strategies comprise three factors: (1) cognitive coping, (2) distraction and taking substitutive steps, (3) catastrophizing and searching for hope.

Apart from assessing the 42 statements above, the respondents answered two questions concerning assessment of their own self-control and ability to ease the pain. The scales were as follows: Likert scale of 0–6 for the 42 statements, where 0 means ‘I never do that’ and 6 means ‘I always do that’. Hence, for each strategy, the final scores ranged from 0–36 points. The higher the score, the more important the strategy was to the patient. Two extra questions regarding control and alleviation of pain were separately graded by the respondent on a scale 0–6, where 0 means ‘I do not control the pain’ (in first question) and ‘I cannot alleviate it’ (in second question), and 6 means ‘I completely control the pain’ and ‘I can reduce it completely’ respectively. The higher the score, the more convinced the patient was about his/her ability to cope with pain. Cronbach’s alpha for the entire tool was 0.80, and particular strategies exceeded this value. The exceptions were two strategies: distraction, 0.64, and increased behavioral activity, 0.63.

Regarding statistical analysis, due to the fact that the distributions of variables were not normal, as shown by the Shapiro-Wilk test, the statistical analysis was performed based on non-parametric tests and Spearman’s pairwise correlations. The Kruskal-Wallis test was applied to compare the differences between the age groups. The level of significance was set at p≤0.05.

Results

GENDER DEPENDENT CHOICE OF STRATEGIES FOR COPING WITH CHRONIC PAIN:

Men and women tended to choose different strategies to cope with pain. Women were more likely to use distraction techniques than men (p=0.045) and exhibited greater behavioral activity (p=0.027). They were also ignoring the sensation of pain (p=0.045) less frequently. For the remaining strategies, no differences were noted (Table 4).

Regarding opinions on pain control and the ability to reduce it (two additional questions), even though no gender related differences were found, the authors analyzed the relationship between these opinions and the strategies used to cope with pain in the same group of women and men (with the use of Spearman’s pairwise correlations). Among women, the opinions on pain control skills correlated positively with declarations of coping (rho=0.352, p=0.01), and negatively with catastrophizing (rho=–0.276, p=0.048), while the sense of effective reduction of pain was associated positively with declarations of coping (rho=0.352, p=0.01), and negatively with catastrophizing (rho=–0.340, p=0.014).

In the group of men, pain control was positively correlated with praying/hoping (rho=0.484, p=0.003) and ignoring pain (rho=0.417, p=0.003). The opinions on the reduction of pain correlated with re-evaluation of the experience of pain (rho=0.581, p=0.0001), increased behavioral activity (rho=0.712, p=0.0001), and distraction (rho=0.510, p=0.001).

AGE RELATED CHOICE OF STRATEGIES FOR COPING WITH PAIN:

To compare the differences between the groups of patients based on age, the Kruskal-Wallis test was applied. People over 60, compared to younger people, more often resorted to the strategy of declaration of coping with pain (χ2=8.693). Although the rest of the results were not statistically significant, it was worth analyzing some of them with regard to their clinical significance and their value to medical practice and to the functioning of individuals in a social context. Particularly noteworthy were: catastrophizing, which – as indicated by the average scores in the Kruskal-Wallis test – was most often used by young people and less often by the middle-aged and the elderly (respectively: 11.98; 8.59; 8.96), ignoring pain was most frequently chosen by the elderly (respectively: 13.25; 14.78; 15.46), and increased behavioral activity was also most commonly used by the elderly (respectively: 14.64; 17.06; 18.64). The above data is presented in Table 5.

Another analysis consisted of a comparison of self-assessment of pain control skills and the ability of reducing pain, depending on the age group. There were no significant differences found in this respect, nevertheless, some correlations were found within each group. In all groups, positive correlations were found between the sense of controlling the pain and the ability to reduce it, and the declarations of coping. Among the middle-aged and older people, there was a relationship between the sense of pain control and the ability to reduce the suffering. Among young people, no such correlation was observed. However, in this group, unlike in the other groups, negative correlations between pain control and catastrophizing were noted. The statistically significant correlations are presented in Table 6.

Discussion

STRENGTHS AND LIMITATIONS:

Regarding limitations, the authors acknowledge that there were some factors that restrict the present research (small group of patients, one strategy evaluating tool, too few reliable pain measurements). This was a preliminary study and not all analyses were included because of the size of the present study and this will be reflected in the next research.

The value of the study was to focus on a more accurate psycho-social assessment of the patient in physical therapy with regard to coping strategies, especially when they have to wait longer than their prescribed rehabilitation treatments.

In order to obtain successful treatment outcomes, the development of modern, up-to-date methods of rehabilitation, and emphasis placed on the relevant upgraded, modified research protocols are of great importance. All the above are believed to facilitate better assessment of a patient who enters the prescribed rehabilitation program. Learning about, among others, the current ways of coping with pain may help a therapist identify the patient’s needs in this regard. In consequence, the activation of the needs and finding support should facilitate more effective and active ways of coping with symptoms, even after the completion of a rehabilitation program.

We postulate that the assessment of self-management of pain (coping, controlling) should be consciously, intentionally, and consistently taken into account in the chronic pain rehabilitation process. Striving for more efficient and effective primary health care, as well as updating and tailoring diagnostic and therapeutic protocols, should keep up with the changing needs and challenges of the health of people of all ages.