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Which came first: pain or disability?

Posted Mar 16 2009 3:55pm

ResearchBlogging.org

‘It’s my back, the pain - I can’t do anything because I’m so sore…’
The cry of the weekend gardener! I’m one of them - I spent a good part of my Sunday out in the garden, lugging really heavy (20 litre) bags of compost about, bending, weeding, carrying - and by the end of Sunday I was walking very, very slowly… with a lot of groaning!
People with chronic pain often say it’s the pain that stops them doing things - but in this interesting study by researchers from Maastrich University, the intriguing issue of whether a high level of pain-related disability is associated with a low activity level or whether changes in the level of activity over time provoke pain and are then themselves disabling is explored.

42 people with chronic low back pain were recruited and asked to carry a digital diary for seven days over which time they were asked at random periods to record their activity level and responses to several well-known pain questionnaires including the Tampa Kinesiophobia Scale, Quebec Back Pain Disability Scale and likert-type scales about pain intensity and ‘level of effort’.

Correlations and multiple regression analyses were carried out on the data, arriving at some interesting findings.

Results indicated that fluctuations in the activity level seemed more associated with the level of disability as compared to the mean activity level over time in patients with CLBP. The intensity of activity fluctuations over time was positively associated with a patient’s perceived level of disability, whereas his/her mean activity level did not have any significant disabling influence. This means that for most of the participants, their activity levels varied from day to day, with high activity levels interspersed with low activity level days. The authors suggest that ‘for patients with chronic pain this could represent an activity pattern characterised by interfering involuntary rest stops due to pain. The high level of fluctuations could be a representation of the sawtooth pattern in their activities. Patients go on with their activities till the activity is finished and afterwards they have to take rest to recover.’

This pattern is a familiar one for most of us - we work very hard physically one day, then perhaps take a day or two to ‘recover’ from it. In chronic pain patients, however, it seems exaggerated - taking longer to recover from days that are busier, and leading to a gradual decline in activity level as they develop awareness that if they ‘push’ themselves on ‘good days’, they hurt - so on ‘good’ days they moderate their activity level, do less, but continue to need recovery days afterwards.

Interestingly in this study, no association could be determined between pain intensity and the mean activity level or the fluctuations in activity, despite this finding in previous studies by other authors.

Most of the research into activity and low back pain has been to help people who are chronic ‘avoiders’ up-regulate their activity level. The problem is that not all people with back pain are ‘avoiders’ - in fact, there are a substantial group of people who demonstrate exactly the pattern that was observed in this study: the boom and bust pattern. The authors suggest ‘patients who have a disabling fluctuating pattern in their activities, [may] benefit more from learning strategies to fine tune their activities during the day instead of increasing their activity level.’

They add that there is currently no scientific data to support this view at present - so as usual, room for more research!

There are several limitations to this study - mainly the level of self report it relied upon, some limitations arising from using digital diaries, and the lack of a theory base to explain this type of behaviour. It seems from this study at least, ‘fluctuations in the activity level instead of the mean activity level over time could explain the level of disability.’

Once again, we are left to ponder that not all people with chronic disability arising from pain are the same - some become deactivated, while others over-do. And some, like this group, boom and bust and may need to have a different approach for their ongoing management.
HUIJNEN, I., VERBUNT, J., ROELOFS, J., GOOSSENS, M., & PETERS, M. (2009). The disabling role of fluctuations in physical activity in patients with chronic low back pain European Journal of Pain DOI: 10.1016/j.ejpain.2008.12.008

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