IMPACT OF KINESIOPHOBIA ON QUALITY OF LIFE IN SUBJECTS WITH LOW BACK PAIN: A CROSS-SECTIONAL STUDY

Background: Studies has demonstrated the development of Kinesiophobia in Low Back Pain (LBP) and identified as one of the risk factor for chronicity in LBP. In addition to deconditioning effect, Kinesiophobia also install functional disability and does that affect quality of life? Literatures had exposed the association of Kinesiophobia in chronic and acute low back pain separately but paucity in estimating their quality of life thus this study aims to explore the impact of Kinesiophobia on the quality of life in LBP.

time in life [1]. LBP is defined as pain in the area on the posterior aspect of the body from the lower margin of the twelfth ribs to the lower gluteal folds with or without pain referred into Low Back Pain (LBP) is one of the most common complaints of all the musculoskeletal disorders that most people experience at some point of one or both lower limbs. It is the most second common reason for visits to physicians [2]. Prevalence and incidence of LBP is increasing steadily in all industrialised countries and in Indian population it has been found to range from 6.2% to 92% that increase with age leading to activity limitation, absenteeism from work and enormous socioeconomic burden [3,4]. Symptoms of LBP may be experienced as dull aching to burning, stabbing and sharp shooting, localised to vague presentation with intensity of pain ranging from mild to severe. According to fear avoidance model it has been postulated that in acute stage of pain, fear of movement or ''Kinesiophobia'' is adopted which leads to the systematic avoidance of physical activity thus in long term result in physical deconditioning. Vlaeyen et al in 1995 [5] describes Kinesiophobia with cognitive behavioural perspective that persons who catastrophically misinterpret innocuous pain are likely to become fearful of pain that results in at least avoidance behaviours, avoidance of movement particularly physical activity, increased bodily awareness and pain hypervigilance that might exacerbate the painful experience [5][6][7]. Enormous literature has demonstrated development of Kinesiophobia among LBP patients. In 1990 Kori et al defined Kinesiophobia as an "unreasonable and irrational fear of pain and painful re-injury upon physical movement" [11]. It is regarded as a salient predictor of pain disability in chronic pain population and has been identified as one of the risk factors for chronicity in LBP. Kinesiophobia can be assessed psychometrically by using Tampa Scale of Kinesiophobia (TSK) and/or Fear-Avoidance Beliefs Questionnaire (FABQ) [7][8][9][10][11]. Both instruments yielded high values for internal consistency, reproducibility and shows good construct validity. However, TSK was shown to be more responsive than the FABQ in all internal and external responsiveness analyses also in identifying fear avoidance changes over time [10]. TSK consist of 17 components which measures degree of Kinesiophobia subjectively. Originally this scale was constructed to differentiate between non-excessive fear and phobia among chronic musculoskeletal pain [8,12]. Avoidance behaviour in Kinesiophobia is not only restricting in deconditioning effect on musculoskeletal system but also installing functional disability, absenteeism from work, limitation for social and leisure activities which in turn exhibit the development of generalised withdrawal and a depressive syndrome that likely to affect the quality of life. Global burden of disease 2010 study reported, LBP causes more global disability and ranked sixth in terms of overall burden [13] [16,17]. Similarly Short Form Health Survey (SF-36), developed by Ware and Sherbourne in 1992, Questionnaire helps in measuring the areas and amount of quality of life that affected, it consists of eight scaled scores, which are the weighted sums of the questions in their section [18]. Its reliable and valid measure for clinical and general populations with an estimated interclass correlation coefficient of 0.85 [18,19]. A wealthy of literature which had exposed association of Kinesiophobia in chronic and acute low back pain separately but lacking in estimating their quality of life. Hence this study aims to explore the impact of Kinesiophobia on the quality of life in patients with low back pain with the objectives to find out the occurrence of Kinesiophobia in acute, sub-acute and chronic LBP patients and its association between pain, functional disability and Quality of Life.

MATERIALS AND METHODS
This is a cross sectional study, carried out between January 2016 to June 2016 after obtaining institutional ethical committee approval. One hundred and twenty study participants were recruited by convenient sampling method from Mumbai and Navi Mumbai. Clinically subjects who were diagnosed as Low back pain of both sexes aged between 18 -60 years were included in the study. Based on duration of the pain they were grouped into acute (up to 6weeks), subacute (6weeks-12 weeks) and chronic (more than 12 weeks). Subjects with neurological diseases (CVA, Cerebral palsy, Parkinson's disease), any type of recent fractures, chronic cancer pain, LBP with non-musculoskeletal causes as well as subjects who are recuperating in post-operative process of any nature were carefully excluded. A self-made questionnaire was developed to record basic demographic details of the study participants. The purpose of the study was explained in the language they understand and informed consent was obtained for those who fulfilled inclusion and exclusion criteria. Tempa scale of Kinesiophobia (TSK) was used to measure fear of movement/ Kinesiophobia [8]. It consists of 17 questions and each addressing intensity of pain and symptoms. The responses were measured in 4 point Likert scale where "totally disagree" is equivalent to one point, two for "partially disagree", "partially agree" and "totally agree" shares three and four points respectively. To obtain the final score it is necessary to invert scores of questions 4, 8, 12 and 16. The possibility score in the scale may range from minimum of 17 to utmost 68 points, being that the higher the score indicates (Ã37) higher the level of Kinesiophobia. [5,20]. The level of pain intensity among the participants was rated in Numerical Pain Rating scale (NPRS). It is an 11 point scale that demonstrate good psychometric properties. Participants were asked to indicate the intensity of current, best, and worst pain levels over the past 24 hours on a scale of 0 (no pain) to 10 (worst pain imaginable). Average of three pain level was considered where score of zero indicates no pain, 1-3 mild pain, 4-6 moderate pain and 7-10 as severe pain. [21,22]. Functional disability in LBP was assessed by Modified Oswestry Disability Questionnaire. The responses were measured from zero to five points for all ten activities described in the scale, the possible highest score being 50, scores which are weighted by the sums of all the question and the percentage was obtained. Scores between 0-20% denote as minimal disability, 21-40% indicate moderate disability, 41-60% for severe disability, 61-80% suggest that the subject is crippled whereas scores between 81% to 100% meant either the subject is bed-bound or exaggerating his symptoms [16,17].  Figure.1. Distribution pattern of Kinesiophobia with respect to pain duration of LBP shown in Figure 2. However, among the subjects with high degree of Kinesiophobia, majority were seen in chronic LBP which accounted for 49% followed by sub-acute 27% and acute 24%. The mean score of pain intensity, TSK, SF36 and MODQ with respect to duration of LBP in shown in Table 1   67% of subjects with Kinesiophobia demonstrated sever pain intensity whereas in subjects without Kinesiophobia, majority of 64% of them showed moderate intensity of pain and illustrated in Figure.3. It has been observed as the pain intensity increases in LBP the development of Kinesiophobia also increased and its association exhibited as weak positive linear corre-lation (r=0.256, p=0.032), shown in Figure 4.   (41.03±14.68) was found to be more than in subjects without Kinesiophobia (25.52±11.24). Frequency of functional disability is shown in Figure 5. Correlation between Kinesiophobia and Oswestry disability shows moderate positive correlation (r = 0.495, p=0.000), shown in Figure 6. To measure the impact of Kinesiophobia on Quality of Life, mean score of SF-36 was compared between subjects with and without Kinesiophobia. It was found that the mean score of QOL in subjects with Kinesiophobia was lesser than those without, that includes 41.28±7.19 and 52.58±8.57 respectively. However, Correlation between Kinesiophobia and QOL shows moderate negative correlation (r = -0.420, p=0.000) that can be seen in Figure 7.

DISCUSSION
This study explored the impact of Kinesiophobia on quality of life in subjects with low back pain and also explored its association with pain intensity as well as functional disability. There is high degree of Kinesiophobia found and its prevalence among female was found to be more.
Though the reason is unclear perhaps it could be owing to decreased bone mass, reduced muscle strength, sensitivity to pain and repeated exposure to ADL such as lifting, bending as compared to their male counterpart thus increasing risk. Atalay et al (2001) stated as age increases there is a higher prevalence of Kinesiophobia, similarly subjects who exhibited high degree of Kinesiophobia, in this study, were in the age group of 50-60 years [24]. Despite prevalence of Kinesiophobia was evident in acute and sub-acute phase of LBP, majority of 49% were of in chronic phase and it was observed that as the duration of the LBP increases the prevalence rate of the Kinesiophobia also increased. This agrees with population based cohort study that carried out by H. Susan J. Picavet et al in 2002 [25]. The prevalence of Kinesiophobia was found to be more in chronic cases because in the acute pain situation, avoidance of daily activities that increase pain is a spontaneous and adaptive reaction of the individual as described by Wall (1979) which usually allows the healing process to occur. Bortz et al in 1984 explained that in chronic pain patients, however, avoidance behaviour appears to persist beyond the expected healing time, and may subsequently lead to 'disuse' syndrome. The disuse syndrome is a detrimental condition, associated with physical deconditioning, in which performance of physical activities leads more easily to pain and physical discomfort which in turn makes avoidance more likely [26]. Nevertheless the prevalence rate of Kinesiophobia was higher among the chronic LBP but their mean score of intensity of pain was found lesser as when compared to sub-acute and acute LBP. Participants of sub-acute LBP had demonstrated greatest affection not only in pain intensity but also in TSK as well as in Modified MODQ. This observed difference amongst sub-acute LBP, need to explore in a large scale to understand its relationship and is out of scope for the discussion here. Is it a cognitive-behaviour influenced in development of higher rate of Kinesiop-hobia among chronic LBP? Explains cog nitive-behavioural model, Vlaeyen et al in 1995 [5], which represents the mechanism how fear of movement/ (re)injury possibly contributes to the maintenance of chronic pain disability in CLBP, starting with the injury occurring during the acute phase. The painful experiences, which are intensified during movement, will elicit catastrophizing cognitions in some individuals and more adaptive cognitions in others [5]. However weak positive linear association between pain intensity and Kinesiophobia (r=0.256) was ascertained and this result is in parallel with the results found in the literature.
As the intensity of pain increases the perception of the Kinesiophobia also increases, allowing restricted pattern of movement, and lead into development of functional disability.  [29]. It is now widely recognized that pain has both sensory and cognitive dimensions. Fear of pain and pain avoidance behaviour are two important factors that should be integrated in the clinical assessment of low back pain. Aspects of cognitive treatment focussing on these attitudes and beliefs should be incorporated in the behavioural treatment of Low back pain. Thus, LBP patients in particular require an approach that address both physical (Biological) and psychosocial dimensions of their problem. This modern approach is termed as Biopsychosocial (BSP) approach. Rather than focussing on structural causes and cures, this new paradigm emphasize the goal of maintaining and restoring function [30]. Affection of cognitive behaviour in the occurrence of Kinesiophobia demands of multidisciplinary approach in the inceptive phase of LBP to decrease functional disability and enhancing QOL. Limitation of this study includes relationship in the development of Kinesiophobia in subacute LBP was overlooked and mental component in QOL was not analysed with statistical application. In the future, study can also explore the benefit of biopsychological approach in acute LBP in improving QOL.
In this study the prevalence rate of Kinesiophobia was reported as highest among chronic LBP subjects. It has been observed that there is a direct relationship between pain and the development of Kinesiophobia in LBP which in turn increase in the development of functional disability thus marking decreased QOL among these populations.