Variations in pain, disability, and psychosocial functioning among non-specific chronic low back pain patients with and without anxiety

Introduction

Low back pain (LBP) is one of the most common causes of musculoskeletal disorders, resulting in disability, reduced work hours, and rehabilitation1. Depending on its etiology, LBP can be divided into non-specific and specific forms1.
In 2015, 60.1 million people were reported to be living with LBP2. Due to rapidly changing social and economic factors, the Kingdom of Saudi Arabia has seen a considerable increase in the prevalence of LBP3. This prevalence among various professional workers in Saudi Arabia ranges from 63.8% to 89% depending on the profession, although the data varies considerably4.
In recent years, mental disorders have surpassed musculoskeletal diseases as the leading cause of early retirement due to incapacity to work5. Patients with long-term physical impairment also struggle with psychological issues like anxiety, depression, and sleep disturbance2. Some of the most prevalent conditions reported among people with chronic LBP include fear-avoidance beliefs, depression, anxiety, catastrophic thinking, and social and familial stress6.
A strong correlation has been noted between anxiety and chronic LBP7. Previous data indicates that the majority of chronic LBP patients with significant levels of anxiety, depression, and Kinesiophobia did not improve after receiving physical therapy8. Furthermore, a reciprocal and interactive relationship may exist between anxiety and lower back pain. Consequently, a growing number of studies are examining the effect of anxiety on the full range of symptoms associated with LBP: reducing anxiety has been linked to both pain alleviation and improved function9.
By understanding how anxiety relates to inter alia pain, dysfunction, and mental health issues in non-specific chronic LBP patients, it will be possible to better predict treatment outcomes and prognoses, promote patient self-management, and help choose the best course of action. However, few studies have compared psychological factors such as pain and function between patients with chronic pain anxiety and those without. Therefore, there is a role for patients with low pain in the comprehensive therapy given to them.
No studies to date have examined the effect of anxiety on the lives of patients with LBP in Saudi Arabia. Therefore, the aim of the present study is to determine whether pain, dysfunction, and psychological variables differ between LBP patients with anxiety and those without.

Materials and methods

Study design

The study is designed as a cross-sectional study. The participants were recruited through the Armed Forces Rehabilitation Center, Taif, Saudi Arabia. The study was awarded ethical approval (no. 2024-885) by the Scientific Research Ethics Committee at the Armed Forces Rehabilitation Center, Taif, Saudi Arabia. This study is reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for reporting observational studies.

Participants

The study included patients aged 18–65 years suffering from non-specific chronic LBP. Chronic LBP is defined as pain in the lower back, particularly in the lumbosacral region, lasting over 12 weeks. In addition, non-specific LBP refers to pain with no specific pathology, such as infection or neoplasm; rather, the aetiology may be mechanical10. Number of participants in the study was 60 people. These participants were classified into two groups, viz. 30 people with anxiety and 30 without, based on the result of the Generalized Anxiety Disorder – 7 Questionnaire (GAD-7).
The following inclusion criteria were applied: age between 18 and 65 years11, a verified medical diagnosis of nonspecific chronic lower back pain that has persisted for more than three months10, cooperative, and the ability to complete various questionnaires. All participants demonstrated persistent nonspecific lower back pain, as determined by an Orthopaedics specialist by a thorough examination to rule out any underlying disorders10. The following exclusion criteria were applied11: the presence of specific LBP, such as spinal stenosis, severe scoliosis or ankylosing spondylitis; lumbar disability (e.g. Lumbar Disc Herniation, Spondylolisthesis) and/or pain caused by other conditions (e.g. Kidney Stones12, Endometriosis, Pancreatitis13), other severe and/or unstable chronic diseases (Malignant Disease14), pregnancy or lactation, surgery within the preceding six months, orthopaedic or neurological conditions affecting the ability to ambulate, not being able to read or speak Arabic.
All participants provided their informed consent before participating. All were assessed by a skilled physiotherapist with experience of more than seven years, who had been blinded to the allocation of the groups. The assessment included psychological function, anxiety, pain severity, functional impairment, sleep quality, and quality of life.

Sample size calculation

The study required at least 60 participants to be included, with 30 participants for each group, showing an power of 0.800. The G-power method was used to calculate the sample size; the calculation was based on prior research that examined the pain differences experienced by individuals with lower back pain who also had anxiety (one tail; effect size, 0.65; ɑ, 0.05; power, 0.80; N2/N1, 1) according to Stubbs et al.15.

Outcome measures

Data and patient demographic information were collected using seven self-reporting instruments (Armed Forces Center for Health rehabilitation in Taif City, Saudi Arabia). Arabic versions of the instruments were used for the study. All outcome measures had been translated and modified, and all possessed sufficient psychometric qualities. The following demographic information was collected from all participants before the main instruments were administered: age, sex, height, weight, BMI, nature of pain, duration of LBP, aggravating behaviours, 24-hour pattern, and moderate-intensity physical activity per week.

Pain intensity

Pain intensity was assessed using the numeric pain rating scale (NPRS). This is an 11-point numeric pain scale, ranging from 0 to 10, on which 0 indicates “no pain” and 10 the “worst possible pain” at the time of the assessment16. The questionnaire is validated and culturally adapted into the Arabic version17.

Psychological function

The Generalized Anxiety Disorder-7 (GAD-7) Questionnaire: The GAD-7 is a 7-item self-reporting scale, based on DSM-IV criteria, used to measure the severity of generalized anxiety disorders. It has been shown to be a reliable screening tool for panic, social anxiety, and post-traumatic stress disorder18,19. The GAD-7 is an anxiety measure comprising seven items scored from zero to three points; hence, the total score ranges from 0 to 21 points, with 5, 10, and 15 points used as cut-off scores for mild, moderate, and severe anxiety symptoms respectively18. In the present study, a cutoff score of 10 points was used to classify participants into two groups: a Non-anxious group (GAD-7 < 10), consisting of Individuals with minimal to mild anxiety and an Anxious group (GAD-7 ≥ 10) comprising individuals with moderate to severe anxiety. A score of 10 or higher is widely recognized as the threshold for identifying clinically significant anxiety in research and clinical settings20. The GAD-7 exhibits excellent internal consistency (Cronbach's alpha between 0.89 and 0.92). The questionnaire is validated and culturally adapted into the Arabic version21.
The Tampa Scale for Kinesiophobia. This tool is used to quantify Kinesiophobia and examines the fear of moving caused by persistent lower back pain. It is a self-reporting questionnaire of 17 items. Each question has four response options (strongly disagree, disagree, agree, or strongly agree) with scores ranging from one to four points, respectively. The individual scores for items 4, 8, 12, and 16 were inverted to calculate the final score. The total score ranges from 17 to 68 points. Increased scores reflect an increased fear of movement, with a score of 37 representing the cutoff for a higher degree of kinesiophobia22.
The Fear-Avoidance Beliefs Questionnaire: The Fear-Avoidance Beliefs Questionnaire (FABQ) was used to screen patients according to how their current back pain was influenced by physical activity (FABQ-P) and work (FABQ-W). The 16-item self-reporting FABQ consists of two subscales with each item scored on an ordinal seven-point Likert-type scale: (1) a seven-item work subscale (FABQ-W, range 0–42), and (2) a four-item physical activity subscale (FABQ-P, range 0–24). A further five questions are used as delusive items, as proposed by Waddell et al.23. Higher total scores indicate higher levels of fear-avoidance beliefs24. The tool has demonstrated outstanding internal consistency: α = 0.82 for the FABQ total; α = 0.75 for FABQ-P; and α = 0.85 for the FABQ-W25. Physical therapists may be able to help non-specific chronic LBP patients heal by altering their perception of pain if they have a common-sense grasp of the concerns associated with pain. The Arabic version of the questionnaire has been culturally adjusted and validated26.

Disability

The Roland–Morris Disability Questionnaire: Functional deterioration due to back pain was assessed using the Roland Morris Disability Questionnaire. This questionnaire consists of 24 questions that focus on regular activities in daily living. Each affirmative answer was awarded one point. Total scores range from 0 to 24, with scores above 14 indicating severe impairment. The questionnaire is validated and culturally adapted into the Arabic version27.
Quality of life RAND-36: Quality of life was measured using the RAND 36-Item Short Form Survey version 1.0 (RAND SF-36 1.0). The instrument is a multipurpose short survey with 36 questions; it has eight subscales for assessing physical and mental health. The physical component (PCS) examines physical functioning, physical role functioning, bodily pain, and general health. The mental component (MCS) evaluated vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with higher scores indicating better health status. The tool has been validated in Arabic28.
Quality of sleep: The Pittsburgh Sleep Quality Index (PSQI) is a self-reporting questionnaire used to evaluate long-term sleep quality and sleep disorders. Buysse et al.29 report that the 19 individual questionnaire items yielded seven subscale scores between zero and three points. Higher values indicate worse sleep quality. The total PSQI score ranges from 0 to 21 points. The various versions have been found to be valid and reliable. The Arabic version of the questionnaire has been culturally adjusted and validated30.

Statistical analysis

All data was analyzed using the Statistical Package for Social Sciences (SPSS), version 27.0 (IBM Corp., Armonk, NY, USA). The Shapiro-Wilks test was used to test the normality of the data. The categorical variables were presented using frequencies and percentages. The continuous variables were found to have a non-normal distribution and were represented using the interquartile range (Q1–Q3). When the variables were classified, the chi-square test was used to compare the groups. To compare the differences in continuous variables, the Wilcoxon Mann-Whitney U test was employed. The relationship between pain severity, disability, psychological function, quality of life, sleep quality and anxiety was then investigated using Spearman's correlation. A p-value of less than 0.05 was considered a priori as statistically significant.

Results

Participant demographics

Sixty participants were enrolled after the GAD assessment and completed the entire study. Out of these, 30 participants had GAD below 10, while the other 30 had scores above 10. Table 1 presents the demographics and characteristics of all patients with non-specific chronic LBP. At baseline, the only intergroup significant differences were observed for sex and 24-hour pain pattern.
The GAD ≥ 10 group (higher anxiety) consistently showed worse outcomes with regard to pain intensity, disability, fear-avoidance beliefs, and sleep quality compared to the GAD < 10 group (lower anxiety). Strong correlations were noted between anxiety and these variables, indicating that higher anxiety levels are associated with greater impairments in these domains. No significant group differences were observed for quality of life (RAND SF-36), although it demonstrated a weak correlation with anxiety.
Any differences in pain intensity, disability or psychological function between the two groups were identified using the Mann-Whitney-Wilcoxon U-test on two separate samples (Table 2). Notable intergroup variations were found with regard to pain intensity, psychological state and impairment function for the NPRS (z = -2.42, p value=0.01), Tampa scale (z =-3.22, p-value = <0.0010), RMDQ (z = -3.58, p-value = <0.001), PSQI (z = 0.32, p-value = 0.03) and FABQ (z = -2.27, p-value = 0.02). No statistically significant difference in RAND was observed (z = -1.26, p-value = 0.19).

Discussion

This cross-sectional study examined the associations between pain, disability, psychological function and anxiety in patients with non-specific chronic LBP in Saudi Arabia. Significant differences in pain intensity (NPRS), kinesiophobia (Tampa scale), disability (RMDQ), sleep quality (PSQI), and fear-avoidance beliefs (FABQ) were found between patients with anxiety and those without. No statistically significant difference was found with regard to quality of life (RAND). Additionally, the findings showed that anxiety demonstrated a significant positive correlation, albeit moderate, with pain intensity (NPRS), kinesiophobia (Tampa scale) and disability (RMDQ).
Pain intensity is commonly used to evaluate therapeutic effectiveness and define the severity of chronic lower back pain. According to Williams and Craig31, individual experiences are influenced by a variety of inter alia genetic, psychological, cultural, and social elements. Our findings support those of Pakarinen et al.32 and Stubbs et al.15, who also report a positive link between pain and anxiety in non-specific chronic LBP patients. It is possible that multiple brain regions are able to elicit pain responses through pathologic pathways of peripheral and central sensory input, e.g. sensory, anxiety, and other emotional perceptions. As the descending pathway can regulate pain, it can either promote or inhibit nociceptive information. As such, pain may be influenced by a variety of top-down dynamic factors, such as feelings of danger, anxiety, emotion, and pain memory, which determine the outcome of pain experiences33. Due to the interplay between psychological and physiological systems, chronic pain may shift this activity to certain neural networks that process emotions, such as the prefrontal cortex34; these changes impact how pain is experienced and expressed35.
However, our findings indicate that the most severe pain score is not associated with anxiety. It is possible that anxiety may be caused by excessive internal conflict, making those with long-term frustration and low self-esteem more susceptible to feelings of being threatened. In contrast, patients with severe pain tend to concentrate on the pain itself.
Patients with non-specific chronic LBP are frequently assessed for dysfunction using the ODI and RMDQ. Reneman et al.36 and La Touche et al.37 report dysfunction to be weakly associated with mood, such as anxiety or depression, which is in line with our present findings. A long-term lack of improvement in mobility or functional activities can significantly increase the risk of developing anxiety; conversely, as anxiety is a risk factor for lower back pain recurrence, patients with LBP and anxiety are more likely to experience a relapse following successful relief of pain and dysfunction. The patients with LBP and anxiety concentrated more on self-defeating ideas and attitudes than those without anxiety, who instead focused on their health problems. The two groups clearly require different treatment approaches by clinical professionals; however, the differences between the two groups is not discussed in the present literature.
Our findings indicate a weak correlation between anxiety and TSK and FABQ-W in non-specific chronic LBP patients, which is in line with the results of a Chinese study investigating the relationship between kinesiophobia and the severity and length of clinical symptoms, discomfort, and anxiety. The findings indicate that kinesiophobia can predict the level of impairment38. Kinesiophobia may be associated with lower participation in rehabilitation exercises and daily activities as a result of negative emotions like anxiety and depression, which worsen the fear of pain and exercise. Less activity lowers aerobic capacity and muscle strength, thus further exacerbating negative emotions like irritability and frustration39.
Our data indicate that one of the most significant outcomes for patients with non-specific chronic LBP is quality of life, which is influenced by several factors, viz. mobility, followed by anxiety or depression. These results support those of Cedraschi et al.40, who report that patients with chronic musculoskeletal pain together with psychosomatic variables (depression and anxiety) reported higher levels of daily activities and more severe pain than patients with only pain. Previous studies have demonstrated that individuals with non-specific chronic LBP who suffer from psychological problems, such as mood or anxiety disorders, are more likely to experience more severe pain and impairment and dysfunctional treatment41-43. In addition to the physical features of LBP, psychological issues significantly impact the quality of life, and anxiety was found to have a negative correlation with quality of life (QoL)44.
People with chronic pain frequently experience insomnia, which is frequently assumed to be a side effect of the pain, but research shows that there is a reciprocal relationship between the two45,46. In individuals with chronic pain, the presence of sleep disturbance is closely related to central sensitization47. In healthy individuals, it has been demonstrated that nighttime sleeplessness can cause anxiety and general hyperalgesia48.
Our present findings indicate a weak positive relationship between anxiety and sleep disturbance in patients with non-specific chronic LBP, with higher degrees of sleep disturbance being associated with more severe anxiety symptoms. These findings differ from those of other similar articles; for example, a Chinese study found that mood problems may be more common as a result of circadian rhythm disruptions49. Due to the strong correlations between non-specific chronic LBP and anxiety, despair, and weariness, it is critical to evaluate sleep disruptions in these patients. Although it is widely believed that insomnia results from chronic pain, research indicates a reciprocal relationship between the two48, with a close relationship being noted between central sensitization and sleep disturbances47. It has been demonstrated that in healthy individuals, nighttime insomnia can cause anxiety and generalized hyperalgesia48.
Even though there is very little evidence linking non-specific chronic LBP symptoms to anxiety, quality of life or sleep, patients with non-specific chronic LBP nevertheless regularly suffer anxiety. Patients should be provided focused psychological intervention methods that will lessen their pain and improve their psychological health, we should collaborate and manage our care using a multidisciplinary approach. As such, to enhance the psychological well-being of the patient, multidisciplinary rehabilitation training plans should include aspects of psychotherapy, psychological counseling for individuals with anxiety disorders, and other techniques for controlling negative emotions. Also, when treating persistent non-specific chronic LBP, it is critical to identify emotional changes in the patients as soon as possible.

Clinical significance

Although anxiety is only weakly related to non-specific chronic LBP symptoms, quality of life and sleep, patients with LBP should receive psychotherapy should be an essential component of a multidisciplinary rehabilitation training strategy. Patients with anxiety should receive psychological consultations and be trained in negative emotional control strategies to improve their psychological state. When treating non-specific chronic LBP, it is important to be aware of emotional changes as soon as possible and use multidisciplinary cooperation and management approaches including focused psychological intervention measures; these will lessen pain levels and enhance psychological well-being.

Limitations

Our study does have several limitations. Firstly, due to the cross-sectional nature of the study, it is not possible to infer causality. Secondly, the predictive power of the findings are constrained by the small sample size. Therefore, a longer-term study with a larger sample size is required to confirm the influence of the tested factors on chronic pain.

Conclusion

Our findings indicate that anxiety affects psychological and functional disability, as well as the level of pain in CLBP patients. As these elements affect the effectiveness of treatment, they should be taken into consideration by clinicians, who should offer both individual and thorough evaluations.

Funding

This research received no external funding.

Conflicts of interest

The authors declare no conflict of interest.

References