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How Does Chronic Back Pain Influence Quality of Life in Koreans: A Cross-
Sectional Study

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DOI: 10.4184/asj.2014.8.3.346 · Source: PubMed

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 Asian Spine Journal
Clinical
346 Yong Soo Choi etStudy
al. Asian Spine J 2014;8(3):346-352
Asian Spine J 2014;8(3):346-352 • http://dx.doi.org/10.4184/asj.2014.8.3.346

How Does Chronic Back Pain Influence Quality of

Life in Koreans: A Cross-Sectional Study
Yong Soo Choi1, Dong Jun Kim2, Kyu Yeol Lee3, Ye Soo Park4, Kyu Jung Cho5,
Jae Hyup Lee6, Hyou Young Rhim7, Byung Joon Shin8
1
Department of Orthopedic Surgery, Kwangju Christian Hospital, Gwangju, Korea
2
Department of Orthopedic Surgery, Ewha Womans University School of Medicine, Seoul, Korea
3
Department of Orthopedic Surgery, Dong-A University College of Medicine, Busan, Korea
4
Department of Orthopaedic Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
5
Department of Orthopedic Surgery, Inha University School of Medicine, Incheon, Korea
6
Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
7
Department of Clinical Research, Janssen Korea, Seoul, Korea
8
Department of Orthopaedic Surgery, Soonchunhyang University College of Medicine, Seoul, Korea

Study Design: A cross-sectional study.

Purpose: To explore the impact of chronic low back pain (CLBP) on individuals’ quality of life; to understand current treatment prac-
tices and level of satisfaction with treatment in patients with CLBP.
Overview of Literature: Assessing subjective, patient-reported outcomes such as quality of life is essential to health care research.
Methods: Influences of the CLBP were analyzed via a questionnaire, which contained the character of CLBP, effect of pain manage-
ment, Korean version Oswestry Disability Index (K-ODI) and Korean version of 12-item Short Form Health Survey (SF-12v2).
Results: Of 3,121 subjects who responded, 67.3% had moderate to severe pain; 43.5% presented prolonged CLBP of more than
two years; and 32.4% had suffered from sleep disturbance due to pain. 22.8% of the patients were not satisfied with current pain
management. The mean K-ODI score was 37.63; and it was positively correlated with the mean pain intensity (r =0.6, p <0.001). The
SF-12v2 result was negatively correlated with mean pain intensity (PCS: r =-0.5, p <0.001; MCS: r =-0.4, p <0.001) and also negatively
correlated with the K-ODI score (PCS: r =-0.75, p <0.001; MCS: r =-0.5, p <0.001). The conformity between patients and doctors in pain
assessment was fair (к=0.2463).
Conclusions: CLBP negatively affects quality of life. Of total 22.8% of the patients were not satisfied with current pain management.
Such needs to be taken more seriously by doctors for improvement of satisfaction and quality of life in patients with CLBP.

Keywords: Chronic low back pain; Assessment; Quality of life

Introduction reasons for healthcare visits, with an episode in presum-

ably up to 75% of the population at some point [2]. Most
Low back pain (LBP) and associated disabilities constitute cases of LBP are not severe and resolves within a few
a growing public health concern, particularly in industri- days or within few weeks; but for about 6% to 10% of pa-
alized countries [1]. It is one of the three most common tients, the disease may become recurrent or chronic [3,4].

Received Jan 9, 2013; Revised May 18, 2013; Accepted May 21, 2013
Corresponding author: Byung-Joon Shin
Department of Orthopedics, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine,
59 Daesagwan-ro, Yongsan-gu, Seoul 140-743, Korea
Tel: +82-2-709-9051, Fax: +82-2-796-3682, E-mail: [email protected]
*This article was presented at the 29th Spring Congress Korean Society of Spine Surgery, 2012.

ASJ
Copyright Ⓒ 2014 by Korean Society of Spine Surgery
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/)
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Asian Spine Journal • pISSN 1976-1902 eISSN 1976-7846 • www.asianspinejournal.org
 Asian Spine Journal Relationship between chronic back pain and quality of life 347

Chronic low back pain (CLBP) is an entity developing in were recruited. The exclusion criteria were patients who
patients with LBP which persists for more than 12 weeks, had spinal fracture within six months and spinal tumor
such that recovery is slow and uncertain [4]. Chronic or other malignancy, who had undergone spinal surgery
low back pain is often poorly understood and difficult to within three months, who were taking medicine for psy-
treat and can have a significant influence on the patient’s chiatric disorder and who had possibility of exaggerated
quality of life in various areas of everyday functioning. complaints due to automobile or accident insurance.
Chronic pain is a common condition, for which patients After obtaining patient consent, patients responded to
seek care from various health care providers. It causes questionnaires on characteristics of CLBP, Korean ver-
much suffering and disability and is frequently mistreated sion of Oswestry Disability Index (K-ODI) (Suppl. 1) and
or undertreated [5]. As the importance of pain control quality of life by Korean version of Short Form 12 Health
is emphasized, the Agency for Health Care Policy and Survey V2 (SF-12v2) (Suppl. 2).
Research, a US agency, has issued recommendations for The ODI was originally developed as a self-assessment
the treatment of pain. Health care providers should view score for low back pain patients, and is based on patient’s
good pain control as a source of pride and a major re- subjective impression of his or her own state of disabil-
sponsibility in quality care [6]. ity. Though the questionnaire is rather dated, it has been
In 2007, characteristics and management patterns of validated, and its reliability and sensitivity to changes in
CLBP were investigated nationally by the Korean Soci- functional status have been documented [7,8]. It is com-
ety of Spinal Surgery. The society reported that 65% of prised of ten items, each of which is followed by six alter-
patients were satisfied with current pain management. natives [7]. Each question is scored from 0 to 5, and the
Unlike in the past, recent pain management has replaced sum of the scores is then presented as percentage. Higher
nonsteroidal anti-inflammatory drugs (NSAIDs) by more score of K-ODI means that the function has decreased.
powerful analgesics. With this change of treatment pat- The SF-12v2 is a multipurpose short-form survey with
tern, the purpose of this study is to evaluate the status of twelve questions, all selected from the SF-36 Health Sur-
CLBP management by investigating the satisfaction with vey (Ware, Kosinski, and Keller, 1996). It is consisted of
current pain management in patients with CLBP. Second- eight domains, and the values in each domain contribute
ary purpose of this study is to document pain intensity to physical and mental values (physical component score
evaluated by patients and doctors and to assess the dis- [PCS] and mental component score [MCS]), which pro-
ability and limitation of quality of life due to CLBP. vide glimpses into mental and physical functioning and
overall health-related quality of life. PCS and MCS are
Materials and Methods computed using the score of twelve questions and range
from 0 to 100, where 0 indicates the lowest level of health
Patient recruitment and data collection were performed and 100 indicates the highest level of health [9].
by 76 physicians at 62 outpatient clinical centers, of which Mean pain intensity was estimated by numeric rating
53 were general hospitals and 9 were specialized spine hos- scale (NRS), categorized into four groups: 0, pain free;
pitals in the Republic of Korea. The study was conducted 1–3, mild; 4–6, moderate; and 7–10, severe. The patient’s
from October 2011 to January 2012; and 3,345 patients satisfaction with current pain management was measured
who had visited orthopedic outpatient centers for low back using a four-point Likert scale (very satisfied, satisfied,
pain treatment were recruited. The inclusion criteria were unsatisfied, very unsatisfied), and it was categorized into
adult male or female patients of twenty-years or older, two groups (satisfaction group,very satisfied and satisfied;
with CLBP symptom duration of at least three months dissatisfaction group, unsatisfied and very unsatisfied).
and whose pain was controlled with analgesics at the time Also main causative diagnosis of CLBP and current pain
of the survey. Here we defined chronic pain patient as: a management, the degree of pain improvement, pain inten-
patient whose pain has lasted for three months or longer; sity, nature of pain and next treatment management plan
who experienced continuous pain within the last one week; were taken from doctors who managed patients with CLBP.
and/or currently taking analgesics for pain treatment. Demographic data is described with means±standard
Also the patients who were capable of understanding the deviations, median, minimum, maximum and ranges by
questionnaire and who provided written informed consent descriptive statistics. The relationship between mean pain
 348 Yong Soo Choi et al. Asian Spine J 2014;8(3):346-352

intensity and satisfaction with current pain management Table 1. Demographics of patients
was evaluated by chi-square test. The relationship between Value Number Ratio
mean pain intensity and K-ODI score was evaluated by
Sex
analysis of variance (ANOVA) test. Pearson correlation co-
Male 1,124 36
efficients were used for correlation analysis between mean
Female 1,997 64
pain intensity and other variables (SF-12v2, K-ODI). Kap-
Age
pa statistics were used to analyze conformity of mean pain
intensity evaluation between patient and doctor. Wilcoxon Mean±standard deviation (yr) 60.7±14.0 -

sum test was used for analysis of difference between pain Median 63 -
improvement evaluation between doctors and patients. Minimun–maximum 20−96 -
20−30 yr 107 3.4

Results 31−40 yr 165 5.3

41−50 yr 357 11.4
1. Demographics 51−60 yr 693 22.2
61−70 yr 867 27.8
Two hundred and twenty-four patients were excluded (62 71−80 yr 767 24.6
patients were under 19 years; 38 patients had LBP less >81 yr 165 5.3
than three months; and 169 patients did not complete Total 3,121 100
the questionnaire). Overall data of 3,121 patients could
be evaluated; and 1,997 (64.0%) were female. Mean age
was 60.7±14.0. The vast majority was between 50 years
and 70 years, over 50 years (2,492/3,121, 79.8%), and 60s
(867, 27.8%) (Table 1). The main diagnoses of patients
with CLBP were spinal stenosis (47.31%) and herniated
nucleus pulposus (23.52%) (Fig. 1).

2. Patient assessment

Nearly half of the patients (1,359, 43.5%) had prolonged

LBP for at least two years (Fig. 2). The time during the
day that the patients most frequently suffered LBP was
from 7 PM to midnight (1,027, 35.1%) (Fig. 3). 32.4% Fig. 2. Duration of chronic low back pain.

Fig. 1. Causes of chronic low back pain. HNP, herniated nucleus pulposus.
 Asian Spine Journal Relationship between chronic back pain and quality of life 349

of patients woke up from sleep at least two times due to moderate to severe pain; and for radiating pain, 49.8% of
LBP (Fig.4). The sleep disturbance was proportional to patients had moderate to severe pain. 67.1% of patients
pain intensity (Fig. 5). And 67.3% of patients presented considered that their CLBP was improved after medica-
moderate to severe pain of the mean pain intensity dur- tion; and 32.9% of patients replied that their pain was
ing the last week (Fig. 6). For LBP, 56.5% of patients had not improved (Fig. 7). The ratio of patients who received

Fig. 3. Pain evoking time-zone during the day.

Fig. 6. Mean pain intensity during the last week.

Fig. 4. Sleep disturbance in patients with chronic low back pain.

Fig. 7. Pain improvement after medication.

Fig. 5. Mean pain intensity and sleep disturbance. Fig. 8. Satisfaction of current pain management.
 350 Yong Soo Choi et al. Asian Spine J 2014;8(3):346-352

Table 2. The correlation among Pain intensity Korean version Oswestry Disability Index (K-ODI), Satisfaction Short Form 12 Health Survey V2

Item K-ODI Satisfaction PCS MCS

Pearson correlation score with pain intensity 0.61606 -0.22314 -0.45673 -0.37362
<0.001 <0.001 <0.001 <0.001
3010 2923 3010 3010
Pearson correlation score with K-ODI -0.2814 -0.67691 -0.52496
<0.001 <0.001 <0.001
2923 3010 3010
Pearson correlation score with satisfaction 0.2366 0.27047
<0.001 <0.001
2923 2923
PCS, physical component score; MCS, mental component score.

Table 3. Comparison of Korean version Oswestry Disability Index score by pain intensity

Pain intensitya) Patients Mean Standard deviation Median Min–Max

Pain free 25 11.04 9.22 10 0−28
Mild pain 995 24.76 14.31 22.22 0−86
Moderate pain 1,450b) 39.16 16.22 37.78 2−88
Severe pain 649 54.95 17.32 55.56 0−96
Total 3,119 37.63 19.3 34 0−96
a)
Analysis of variance test; F-value=505.81, p <0.001; b) Missing= 2.

Table 4. The mean Korean version Oswestry Disability Index (K-ODI) (Table 2).
score and correlation with mean pain intensity
The mean K-ODI score of all patients was 37.63. A
Item comparison of K-ODI scores of the four-group levels (di-
K-ODI vided by mean pain intensity) suggested that difference
N 3,119 was statistically significant among each group (ANOVA
Mean±standard deviation 37.63±19.3 test, p9<0.001) (Table 3). Also the correlation coefficient
Median 34 between the mean pain intensity and the mean K-ODI
Minimun–maximum 0−96
score showed highly positive correlation (Pearson cor-
relation=0.61) (Table 4). Hence, the more severe the pain,
Mean pain intensity vs. K-ODI
the higher was the disability in the low back.
Correlation coefficient 0.60873
The mean PCS was 36.25, and the mean MCS was
p -value <0.001
a)
41.77. The results of SF-12v2 were negatively correlated
Pearson’s correlation coefficient.
with mean pain intensity and K-ODI score. In addition,
there was a positive correlation between SF-12v2 and
treatment other than medication (injection therapy, patient’s satisfaction on current pain management. How-
physical therapy, therapeutic exercise) was 43.4%. Most ever, SF-12v2 did not show a significant correlation with
patients (77.2%) were satisfied with their current pain K-ODI (Table 2).
management, but 22.8% of patients were not satisfied.
The dissatisfaction percentage was higher as the pain se- 3. Doctor’s assessment
verity grew (Fig. 8). The correlation between mean pain
intensity and satisfaction with current pain management Most doctors reported that current medications were
was statistically significant. This indicated that as pain in- NSAIDs (1,724, 55.24%) and tramadol/acetaminophen
tensity increased, satisfaction level significantly decreased extended release (713 cases, 22.85%). And 61.6% of doc-
 Asian Spine Journal Relationship between chronic back pain and quality of life 351

Table 5. The conformity between patients and doctors in pain assessment

Doctors in pain assessment

Patients in pain assessment
Pain free Mild Moderate Severe Total
Pain free 6 13 5 1 25
Mild 4 600 321 60 985
Moderate 1 483 800 133 1,417
Severe 0 67 352 208 627
Total 11 1,163 1,478 402 3,054
Correlation analysis Kappa= 0.2463, p <0.001. Missing=67.

tors replied that they will maintain the current medica- pain presented moderate to severe pain [11,13]. It is im-
tion in response to a question of ‘what analgesic will portant that most CLBP patients complain of moderate
you prescribe next.’ 17.5% of doctors had administrated or severe pain.
a procedure in the past two weeks for CLBP manage- The body of evidence for chronic LBP has advanced
ment. In CLBP character assessed by doctors, 61.67% of with the development of reliable and valid patient self-
patients had LBP with radiating pain and 38.33% had reported outcome measures. However, it is often dif-
LBP without radiating pain. In pain intensity assessed by ficult to make comparisons between published studies,
doctors, 61.6% of patients had moderate to severe LBP. because different outcome measures have been utilized
The conformity between patients and doctors in pain to assess pain, function and quality of life [14]. We
assessment revealed that doctors were likely to under- sought to answer the clinical questions of how pain
estimate a patient’s pain intensity (к=0.2463) (Table 5). characteristics affected the assessment of pain intensity,
68.1% of doctors considered that the pain was improved patient’s satisfaction and quality of life. In regard to pain
after medication. The assessment of pain improvement management, most patients (77.2%) were satisfied with
between doctors and patients was similar. current pain management; and the relationship between
pain intensity and patient satisfaction was inversely re-
Discussion lated. Regarding the impact of CLBP on quality of life,
some health status surveys showed that the mean PCS
In our study, 43.5% of patients had suffered low back pain was 47.1, in people whose age was between 55 and 64
for more than two years. In a study that investigated treat- years; and the mean PCS was not below 40, in people
ment duration for work-related LBP in Korea [10], 70.7% over 65 years of age. Similarly, the mean MCS was 53.9,
of subjects were treated for LBP for more than three for those whose age was between 55 and 64 years; and
months, and 20.5% of subjects were treated for more than the mean MCS was not below 50, in people whose age
two years. In a survey of chronic pain in Europe [11], was over 65 years [9]. On the other hand, mean PCS
almost 60% of subjects had pain for more than two years. and MCS in our study were 36 and 41.5, respectively.
There is wide variance among these studies, but CLBP is As compared with health status for CLBP generally, our
often prolonged for more than two years. Alsaadi et al. results revealed lower health status than these PCS and
[12] presented that prevalence of sleep disturbance in pa- MCS. The disability and quality of life decreased when
tients with LBP was 58.7%, and that the intensity of back pain was increased; and relationship between disability
pain was weakly associated with sleep disturbance. These and quality of life was inverse. These results were similar
results were different from our results (32.4%). The dif- to other studies [11,15].
ference may be because our results did not include acute The doctors’ assessment of pain intensity was lower
LBP. than those of the patients’ assessment. But there was no
67.3% of patients presented more than moderate pain significant difference between doctors and patients evalu-
in our study. Some studies of chronic pain, not CLBP ations of the mean pain intensity. Also there was no dif-
only, reported that 80% to 100% of patients with chronic ference in assessment of pain improvement after medica-
 352 Yong Soo Choi et al. Asian Spine J 2014;8(3):346-352

tion between doctors and patients. 5. Ashburn MA, Staats PS. Management of chronic
This study was limited to patients in outpatient clinics; pain. Lancet 1999;353:1865-9.
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Conflict of Interest 9. Office of Public Health Assessment Center for Health
Data Utah Department of Health. 2001 Utah Health
No potential conflict of interest relevant to this article Status Survey report Health Status in Utah: The Med-
was reported. ical Outcomes Study SF-12 [Internet]. Salt Lake City,
UT: Office of Public Health Assessment Center for
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