Pain Experience in Individuals With Chronic Low Back Pain

Self-management will be assessed with the Health Education Impact Questionnaire (heiQ) that measures the ability of a patient to self-manage their condition and features 40 questions that spread across 8 distinct domains (Health Directed Behavior: 4 items; Positive and Active Engagement in Life: 5 items; Self-Monitoring and Insight: 6 items; Constructive Attitudes and Approaches: 5 items; Skill and Technique Acquisition: 4 items; Social Integration and Support: 5 items Health Service Navigation: 5 items; and Emotional Wellbeing: 6 items). Each item is rated with a 4-level scale (Strongly agree to Strongly disagree) and a number (1-4) is allocated that leads to the calculation of a mean. No single value can be produced for heiQ. Rather, each domain must be used individually. The higher the value the best the self-management ability in all domains apart from Emotional Wellbeing where a high value represents a low self-management ability.

Pain will be assessed with the Numerical Rating Scale (NRS) where patients will be asked to rate their current pain on a scale from 0 to 10 with 0 indicating no pain and 10 the worst pain imaginable.

Disability will be assessed with the Roland-Morris Disability Questionnaire (RMDQ) where patients are asked to tick a box if they agree with 24 statements regarding their ability to perform certain activities (dressing, housework, walking). If the don't agree with the statement (able to perform thoe activities) they need to leave the tick-box blank or unchecked. Every agreement (tick) counts as a point and an absolute value is formed (min: 0, max: 24). The higher the value the higher the disability level.

Quality of Life will be assessed with the EQ-5D-5L questionnaire. EQ-5D-5L has two components: health state description and evaluation. In the description part, health status is measured in terms of 5 dimensions (5D); mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. The respondents self-rate their level of severity for each dimension using a five-level (5L) scale (no problem to extremely severe). Each dimension can be used for analysis as a categorical variable or combined with the others as a 5-digit value according to responses (example 11231). On a single dimension, a categorical value of 1 signifies no problem and a value of 5 extremely severe problem. Similarly, a combined value of 11111 shows excellent quality of life whereas a value of 55555 shows a severely affected quality of life.

Self-efficacy will be assessed with the Pain Self-efficacy Questionnaire (PSEQ) where patients are asked to indicate their levels of confidence with a 0-6 scale (0 indicates not at all confident and 6 extremely confident)on an array of 10 questions. A sum of all responses is calculated (60 being the maximum) for analysis. The higher the value the higher the levels of self-efficacy.

Fatigue will be assessed with the Fatigue Severity Scale (FSS) where patients are asked to indicate their levels of agreement with a 0-7 scale (0 indicates strong disagreement and 7 strong agreement) at 9 questions. A sum of all responses is calculated (63 being the maximum) for analysis. The higher the value the higher the level of fatigue.

Also, patients are asked to rate their global fatigue on a 0-10 scale with 0 being worst and 10 being normal fatigue. This sub-scale will be used on its own for analysis.

Anxiety will be assessed with the Anxiety part of the Hospital Anxiety and Depression Scale (HADS) where patients are asked to indicate their levels of emotion frequency with a 4-level scale (0-3: 0 indicates never and 3 all the time) at 7 questions. A sum of all responses is calculated (21 being the maximum) for analysis. The higher the value the higher the levels of anxiety.

Depression will be assessed with the Depression part of the Hospital Anxiety and Depression Scale (HADS) where patients are asked to indicate their levels of emotion frequency with a 4-level scale (0-3: 0 indicates all the time and 3 never) at 7 questions. A sum of all responses is calculated (21 being the maximum) for analysis. The higher the value the higher the levels of depression.

Catastrophization will be assessed with the Pain Catastrophizing Scale (PCS) where patients are asked to indicate their levels of belief frequency with a 5-level scale (0-4: 0 indicates not at all and 3 all the time) at 13 questions. A sum of all responses is calculated (52 being the maximum) for analysis. The higher the value the higher the levels of catastrophizing.

Kinesiophobia will be assessed with the Tampa Scale for Kinesiophobia (TSK) where patients are asked to indicate their levels of agreement with a 4-level scale (1-4: 1 indicates not at all and 3 all the time) at 17 questions. A sum of all responses is calculated (68 being the maximum) for analysis. The higher the value the higher the levels of kinesiophobia.

Neuropathic pain will be assessed with the Pain-DETECT questionnaire (PD-Q) where patients are firstly asked to describe the course of their pain by choosing one of 3 different pictures. A value has been allocated to each picture (-1, 0, +1 and +1). Secondly they are asked to indicate (yes or no) whether their pain radiates to a different part of their body. Yes is marked with +2 whereas No with 0. Thirdly, patients are asked to indicate their symptom intensity with a 6-level scale (0-5: 0 indicates never and 5 very strongly) at 7 questions. A sum of all responses is calculated and a final value is formed with the addition of the values from step one and two (38 being the maximum) for analysis. The higher the value the higher the levels of neuropathic pain.

Widespread pain will be assessed with the the use of a blank body manikin where patients are asked to draw the areas of pain on the manikin. Unbeknownst to patients, the manikin is divided into 46 body areas. A categorical variable is entered (1 for pain on the area, 0 for no pain) according to the pain distribution of the patients. No single value can be produced for analysis. Areas distant to the primary area of pain (Lower Back), like the chest or the forearm, will be used as independent variables in a multivariate regression model.

Fibromyalgia severity will be assessed with the Fibromyalgia Severity Scale (FMSS) where patients are firstly asked to tick a box on a body manikin if they feel pain on that area. Each tick is marked with 1 point. Then, patients are asked to indicate their symptom severity with a 4-level scale (0-3: 0 = no problem and 3 = severe) at 3 questions about tiredness, sleep and forgetfulness. A sum of all responses is calculated and is added to the total manikin value. Lastly, patients are asked to indicate whether they experienced headaches, depression and abdominal pain amongst 37 other symptoms. If they did, a point for each symptom is added on their overall mark (min: 0, max: 31). The higher the overall value the higher the severity of fibromyalgia.

Health care utilisation will be measured with the unvalidated Health Care Utilisation Questionnaire for Low Back Pain (HCUQ-LBP) where patients will be asked to indicate the type and amount of health care utilisation (visits to hospital, visits/calls to general practitioners (GPs) and practice nurses, use of social care, physiotherapists, chiropractors, psychologists, osteopaths and occupational therapists) in the last 3 months. Every health care use will be marked with a point and a total value will be produced for analysis (min: 0, max: any). The higher the value the higher the health care utilisation.

Medication type utilisation will be determined when patients will be asked to record on a specially designed sheet the type of received medication in the last three months. Separate categories will be formed according to medication type (e.g. anti-inflammatory non-steroidal drugs, steroids, opioids, non-opioids) and a categorical variable will be stored (1 for yes, 0 for no) on these categories. No single value can be produced for analysis for this sub-questionnaire. Categories of medication types will be used as categorical independent variables in a multivariate regression model.

The prognosis of Low Back Pain will be determined with the Keele Stratification and Screening Tool for Low Back Pain (STarT-Back) where patients are asked to agree or disagree with 8 sentences (tick appropriately) and on a 9th question indicate how bothersome their back pain is on a 5-level scale (not at all to extremely). Every agreement is marked with 1 point as well as if patients rate their back pain as very much or extremely bothersome. A sum of all responses is calculated (9 being the maximum) for interpretation and analysis. The higher the value the higher the risk of unfavourable prognosis.