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Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 10  |  Issue : 3  |  Page : 574-579  

Correlation of quality of life scores to clinical outcome of lumbar epidural steroids in chronic low back pain


1 Department of Anaesthesia, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India
2 Department of Radiology, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India
3 Department of Anaesthesia, SGRDIMS&R, Amritsar, Punjab, India
4 Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
5 Department of Community Medicine, BPS Government Medical College, Khanpur Kalan, Sonepat, Haryana, India

Date of Web Publication27-Sep-2016

Correspondence Address:
Saru Singh
405/12, Krishna Colony, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0259-1162.183563

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   Abstract 


Context and Aim: The assessment of severity of low back pain includes subjective questionnaires to quantify the impact on routine life. The objective of current study was to correlate various quality of life (QOL) scores to the clinical outcome measured as improvement in Visual Analog Score (VAS) after interventional treatment.
Subjects and Methods: Fifty-one consecutive chronic low backache patients were assessed for pain intensity using VAS, revised Oswestry Disability Index (ODI), Quebec's, Roland–Morris disability questionnaire (RMDQ), and depression score at presentation. All subjects received interventional therapy complemented with physiotherapy; changes in scores were evaluated at 2 weekly intervals till 12 weeks.
Type of Study: Prospective, observational, cohort study.
Results: All scores depicted highly significant statistical improvement over baseline scores (P < 0.001). The Pearson correlation of VAS with rest of the scores showed that all variables correlate well with VAS at various time periods till 3 months. However, the best outcome predictor for VAS in QOL scores was Oswestry score as well as depression score which had an additive predictive effect. Among the QOL scores best intercorrelation was found with ODI and RMDQ scores at baseline as well as at all treatment follow-ups.
Interpretation and Conclusion: ODI and depression score closely parallel trends of reduction in VAS indicating that these scores may be the best outcome predictor after interventional treatment of pain. Among QOL scores ODI and RMDQ evaluated in the current study record comparable degree of physical incapacity; the exception is Quebec's score.

Keywords: Depression score, low back pain, lumbar epidural steroid injection, Quebec back pain disability scale, revised Oswestry Disability Index, Roland–Morris disability questionnaire, Visual Analog Score


How to cite this article:
Singh S, Singh K, Gupta R, Kaur N, Bansal P, Singh S. Correlation of quality of life scores to clinical outcome of lumbar epidural steroids in chronic low back pain. Anesth Essays Res 2016;10:574-9

How to cite this URL:
Singh S, Singh K, Gupta R, Kaur N, Bansal P, Singh S. Correlation of quality of life scores to clinical outcome of lumbar epidural steroids in chronic low back pain. Anesth Essays Res [serial online] 2016 [cited 2020 Jul 6];10:574-9. Available from: http://www.aeronline.org/text.asp?2016/10/3/574/183563




   Introduction Top


Low back pain is the leading cause of disability in the general population; the increasing prevalence may be attributable to the changing lifestyles, poor postures, diet, and physical activity. Patients of chronic low back pain experience a major setback in the daily routine, social, and occupational activities. This is further worsened by the consolidated effect of physical incapacity and depression. This further accentuates the patient's perception of pain, thus setting up a vicious cycle.

Assessment of intensity of pain involves both subjective and objective evaluations, but it is important to evaluate the impact of pain on patient's day to day activities, in another words quality of life (QOL). Visual Analog Score (VAS) in chronic pain has been researched and now considered a validated tool to measure the condition-specific disability in a 2000 systemic review of research.[1] Further, the effect of pain on QOL has also been evaluated using disease specific questionnaire which provides a distinct advantage of focusing on the range of activities affected in this symptom complex.[2],[3],[4] Out of these scores modified Oswestry disability questionnaires, SF-36, and Quebec's scale have been recommended for evaluating the effect of physical therapy.[5]

A variety of versions and translations of different scores are being used at various pain clinics to quantify improvement in physical disability after lumbar epidural steroid injections (LESIs). This depends on the clinician and patient's preferences.[3],[6],[7] However, there is no recent study to directly compare the intensity of disability due to chronic back pain and therapeutic response of LESI measured using these scores.

The present study aims to compare four QOL questionnaires in terms of severity of disability measured in preprocedure scores, quantification of improvement after LESI, correlation of these scores with VAS and intercorrelation among the QOL scores to evaluate whether these scores measure similar grades of disability during treatment. We hypothesized that all scores used in our study do not correlate with VAS or with each other.


   Subjects and Methods Top


A prospective observational study was planned at a single urban pain management center after attaining approval from hospital ethics committee over a period of 1 year. Fifty-one consecutive patients between 18 and 70 years with low back ache (LBA) of more than 3 months attending pain clinic were enrolled for this longitudinal qualitative study. Patients with cauda equina syndrome, coagulation disorder, allergy to drugs used and concurrent use of systemic steroid medications, opioid habituation, psychiatric disorders, altered mentation, and pregnancy were excluded from the study.

After screening through the selection criteria written informed consent was obtained. One patient did not undergo intervention due to technical difficulties and was thus excluded from the trial. Two patients got diagnosed as chronic depression during the study, hence, excluded. Another four patients were lost during follow-up. Thus, a data of 44 patients entered the statistical analysis [Figure 1].
Figure 1: Consort Diagram

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Pain intensity was scaled using VAS from 0 to 100. The physical disability was assessed using revised Oswestry Disability Index (ODI), Quebec's, and Roland–Morris disability questionnaire (RMDQ) for QOL and mental health using depression score with the help of a nonmedico translator (VK) blinded to the study. As provided in the questionnaires, scores of ODI was be graded as minimal (0–20%), moderate (21–40%), severe (41–60%), crippled (61–80%), and bedridden (81–100%). The Quebec's score was be graded as no (0–20), borderline (21–40), mild (41–60), moderate (61–80), and severe (81–100). Depression score was graded as minimal, 0–4; borderline, 5–11; mild, 12–21; moderate, 22–31; and severe, 32–51. The Roland–Morris is not provided with any grading.[8]

After a thorough assessment of pain, the case was managed with a multimodal approach using interventional pain management complemented with pharmacotherapy, physiotherapy, psychotherapy. Patients were followed up at 2, 4, 6, 8, 10, and 12 weeks after the therapy and the outcome assessed using VAS, revised ODI, Quebec's, RMDQ, and depression scores.

Outcome and statistical analysis

The baseline scores were condensed as mean ± standard deviation. The baseline scores were compared among each other by plotting the values as 0–100, where 0 depicted least value and 100 denoted best possible health status reflected by each score.

Taking an α error of 0.05, including 43 subjects for this study provided a power of 80% in detecting a change in variables over time. For our trial, a total of 44 patients entered the assessment. The primary outcome was evaluated as correlation among all measurement tools using Pearson analysis applied at all time intervals. The secondary outcome was assessed using comparison in severity of disability recorded with each questionnaire at baseline. Tertiary outcome was focused on evaluating the statistical improvement over baseline scores using repeated anova test at all follow-up intervals showing trend in the scores.


   Results Top


The patients followed in our study were predominately males (26:18), of mean age 42.38 ± 13.72 years; 71.90 ± 8.86 kg weight; and 166.13 ± 7.03 cm height with chief complaints of LBA with or without radiation. The baseline scores (secondary outcome) show that mean values of Quebec's disability scale were lowest as compared to the rest of the scores [Figure 2]a. In addition, grades of disability provided by the scales (except Roland–Morris) were also calculated and compared for each patient [Figure 2]b. Most of the patients were rated as moderately disabled by revised ODI and moderately depressed according to the depression score whereas the Quebec's scale counted most of the patient as having no disability.
Figure 2: (a) Baseline scores, (b) grading of baseline scores

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The VAS shows improvement in mean scores at all follow ups starting from 2 weeks post procedure till 3 months follow up. By applying repeated anova test, all the quality of life score including the oswestery diability score, roland morris, quebec disability as well as depression score also show highly significant improvement (tertiary outcome) till 3 months follow up (P< o.oo1) [Table 1].
Table 1: Comparisons of improvement in pain (visual analogue score) and quality of life scores

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The Pearson correlation of VAS with QOL and depression score (primary outcome) studied at all follow-ups till 3 months showed that all variables correlate well with VAS at various time. This correlation appeared to be strengthening with time, which implies that correlation is moderate at severe pain intensity and strong when the pain scores are low [Table 2]. The best outcome predictor for VAS was seen to be ODI at preprocedure and at all follow-ups till 6 weeks (P < 0.001), with depression score having predictive effect from 6 weeks to 3 months [Table 2]. Rests of the variables were excluded at respective time. These correlation coefficients also increased with time, which may indicate that at lower disabilities, scores correlated better.
Table 2: Correlation of visual analogue score with quality of life scores and depression scores

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The scatter plot showing correlation among QOL scores demonstrated a strong positive correlation between RM and Oswestry with the correlation coefficients in the range of 0.76–0.94 [Figure 3].
Figure 3: The correlation between quality of life scores

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   Discussion Top


Chronic pain levies a deep impact on the overall health status of individuals suffering from it. As the intensity of pain aggravates, the physical disability increases and this sets up a worsening cycle of depression which further aggravates the patient's perception of pain. A growing awareness of managing this multifaceted problem led to the proposal of various scores to evaluate the degrees and dimensions of the physical and psychological impact. The prime objective of our study is to outline the most suitable score to be used for routine LBA assessment and treatment which would effectively express the quantum of improvement after LESI.

The commonly used scores include Oswestry and Roland–Morris scale in addition to the VAS. Apart from these, two more scores are chosen in the current study which has been specific for low back pain being used in our setup routinely. However, it has not been possible to include other disease-specific scores in our study because that would make the evaluation far too exhaustive for the patient.

The scores at the baseline revealed the mean values and grades of Quebec's disability scale low as compared to the rest of the scores. The formula involved to calculate Quebec's disability amounts to zero when the questionnaire sums up to 20 or less indicating minimal difficulty to perform the tasks. This might be the presumed reason of Quebec's score apparently underestimating the disability which may have been counted in moderate to severe disability by other scales.

The improvement in physical and mental handicap has been uniformly demonstrated by all the scores till 12 weeks follow-up. In a randomized prospective studies for evaluation of outcome after LESI using Oswestry disability questionnaire (ODQ) and Roland–Morris scale, highly significant improvement has been reported till half to one yearly follow ups.[9],[10],[11] Another retrospective evaluation of up to 9 years follow-up demonstrated functional improvement of up to 2 points or more on Roland–Morris score equivocated to 50% improvement in VAS.[12]

Various versions and translations of ODQ are available, and a review on normal and back pain patients shows it to be valid and vigorous tool; on the other hand, its sensitivity in terms of change has not found to be clear.[1] In our patients, we have used the revised ODI, which avoids the detailing of disability related to the sexual activity since most of the patients in our set up avoid such questions.[13],[14] Further, previous studies evaluating VAS and ODQ recorded in patients of chronic LBA have demonstrated moderate correlation between them (r = 0.62).[15] In our evaluation, lower correlation has been seen at baseline evaluation (r = 0.477); and a stronger correlation with VAS (r = 0.785) at 3 months follow-up. This outlines the fact that at severe pain intensity, patients enter a vicious cycle of worsening mental health, physical inactivity, and comorbidities; which amounts to a disability level unexplainable by pain intensity alone.

In addition to ODI, depression score clearly outlined the pattern of change in pain intensity following interventional therapy. The extent of psycological impact of pain was graded using general questions with respect to how frequently the patient experiences a particular negative emotion or thought. Majority of the patients seemed more eager to respond to the psychological evaluations rather than the physical ones.

The intercorrelation among the scales surfaced that Roland–Morris score and ODQ demonstrated strong correlation which intensified further with increasing relief of symptoms. Commensurate to this, Leclaire et al. compared two populations of patients with low back pain of different levels of severity and revealed moderate correlation 0.66–0.72 (P < 0.0001) concluding that both functional disability scales accurately discriminated between patients with low back pain of different severity.[16] Further, a research involving these tools revealed RMDQ may be more suited to milder disability whereas ODI may prove better in persistently disabled patients.[17],[18] Roland–Morris scale provides the benefit of being concise, easy to respond and may also be preferred in routine assessments. Furthermore, the questionnaire itself includes a sector a psychological assessment which is not offered by the other two QOL scores. Apart from this, the questions have been based on the activities that are of the daily routine. However, there is no grading of the extent of difficulty involved in carrying out those activities.

Apart from this, during the study, the authors also appreciated that Oswestry and Quebec's disability scale work well for detailing of extent to disability related to pain due to the grading of subjective symptoms. Over and above, ODI has distinct benefit of the provision of calculating scores even when all the questions are not answered.

The limitations of our study included the use of only a single score for depression in psychological evaluation. Moreover, most of the patients required the help of a translator which may have resulted in observer bias. Furthermore, the evaluation of socioeconomic status could have been included in demographic profile; pattern of baseline physical status may be contributing factor in patients where QOL scores do not improve.


   Conclusion Top


  • All the QOL scores correlated well with VAS however revised Oswestry proved to be the best outcome predictor in terms of pain relief, followed next by depression score
  • Among the QOL scales, revised Oswestry and Roland–Morris questionnaires addressed similar grades of disability in the periprocedural scores
  • All the scores measured the disability due to pain at first evaluation; Quebec's scale underestimated the severity of disability with respect to other scales.


Acknowledgment

The authors would like to thank the computer operator Mrs. Varinder Kaur (VK) for rendering her support in translating the questionnaires and data acquisition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Fairbank JC, Pynsent PB. The Oswestry Disability Index. Spine (Phila Pa 1976) 2000;25:2940-52.  Back to cited text no. 1
    
2.
Suarez-Almazor ME, Kendall C, Johnson JA, Skeith K, Vincent D. Use of health status measures in patients with low back pain in clinical settings. Comparison of specific, generic and preference-based instruments. Rheumatology (Oxford) 2000;39:783-90.  Back to cited text no. 2
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Rados I, Sakic Zdravcevic K, Hrgovic Z. painDETECT questionnaire and lumbar epidural steroid injection for chronic radiculopathy. Eur Neurol 2013;69:27-32.  Back to cited text no. 3
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4.
Kopec JA, Esdaile JM, Abrahamowicz M, Abenhaim L, Wood-Dauphinee S, Lamping DL, et al. The Quebec Back Pain Disability Scale. Measurement properties. Spine (Phila Pa 1976) 1995;20:341-52.  Back to cited text no. 4
    
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Davidson M, Keating JL. A comparison of five low back disability questionnaires: Reliability and responsiveness. Phys Ther 2002;82:8-24.  Back to cited text no. 5
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Vincent JI, Macdermid JC, Grewal R, Sekar VP, Balachandran D. Translation of Oswestry Disability Index into Tamil with cross cultural adaptation and evaluation of reliability and validity(§). Open Orthop J 2014;8:11-9.  Back to cited text no. 6
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Mousavi SJ, Parnianpour M, Mehdian H, Montazeri A, Mobini B. The Oswestry Disability Index, the Roland-Morris Disability Questionnaire, and the Quebec Back Pain Disability Scale: Translation and validation studies of the Iranian versions. Spine (Phila Pa 1976) 2006;31:E454-9.  Back to cited text no. 7
    
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Deardorff WW. Depression and Chronic Back Pain. Spine-health. Available from: http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain. [Last accessed on 2016 May 09].  Back to cited text no. 8
    
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Ghai B, Vadaje KS, Wig J, Dhillon MS. Lateral parasagittal versus midline interlaminar lumbar epidural steroid injection for management of low back pain with lumbosacral radicular pain: A double-blind, randomized study. Anesth Analg 2013;117:219-27.  Back to cited text no. 9
    
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Amr YM. Effect of addition of epidural ketamine to steroid in lumbar radiculitis: One-year follow-up. Pain Physician 2011;14:475-81.  Back to cited text no. 10
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Bawa CK, Gupta R, Mahajan L, Singh S. A placebo controlled trial to evaluate effectivity of pain relief using ketamine with epidural steroids for chronic low back pain. Int J Sci Res 2016;5:546-8.  Back to cited text no. 11
    
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Barre L, Lutz GE, Southern D, Cooper G. Fluoroscopically guided caudal epidural steroid injections for lumbar spinal stenosis: A restrospective evaluation of long term efficacy. Pain Physician 2004;7:187-93.  Back to cited text no. 12
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13.
Hudson-Cook N, Tornes-Nicholson K. The Revised Oswestry Low Back Pain Disability Questionnaire. Anglo-European College of Chiropractic; Thesis. Bournemouth, England; 1988.  Back to cited text no. 13
    
14.
Aithala JP. Difficulties in using Oswestry Disability Index in Indian patients and validity and reliability of translator-assisted Oswestry Disability Index. J Orthop Surg Res 2015;10:90.  Back to cited text no. 14
    
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Grönblad M, Hupli M, Wennerstrand P, Järvinen E, Lukinmaa A, Kouri JP, et al. Intercorrelation and test-retest reliability of the Pain Disability Index (PDI) and the Oswestry Disability Questionnaire (ODQ) and their correlation with pain intensity in low back pain patients. Clin J Pain 1993;9:189-95.  Back to cited text no. 15
    
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Leclaire R, Blier F, Fortin L, Proulx R. A cross-sectional study comparing the Oswestry and Roland-Morris Functional Disability scales in two populations of patients with low back pain of different levels of severity. Spine (Phila Pa 1976) 1997;22:68-71.  Back to cited text no. 16
    
17.
Roland M, Fairbank J. The Roland-Morris Disability Questionnaire and the Oswestry Disability Questionnaire. Spine (Phila Pa 1976) 2000;25:3115-24.  Back to cited text no. 17
    
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Roland M, Morris R. A study of the natural history of low-back pain. Part II: Development of guidelines for trials of treatment in primary care. Spine (Phila Pa 1976) 1983;8:145-50.  Back to cited text no. 18
    


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