Depressive symptoms are associated with decreased quality of life and work ability in currently working health care workers with recurrent low back pain

This is a self-archived version of an original article. This version may differ from the original in pagination and typographic details. Author(s): Title: Year: Version: Copyright: Rights: Rights url: Please cite the original version: CC BY 4.0 https://creativecommons.org/licenses/by/4.0/ Depressive symptoms are associated with decreased quality of life and work ability in currently working health care workers with recurrent low back pain © 2022 American College of Occupational and Environmental Medicine. Published version Virkkunen, Tarja; Husu, Pauliina; Tokola, Kari; Parkkari, Jari; Kankaanpää, Markku Virkkunen, T., Husu, P., Tokola, K., Parkkari, J., & Kankaanpää, M. (2022). Depressive symptoms are associated with decreased quality of life and work ability in currently working health care workers with recurrent low back pain. Journal of Occupational and Environmental Medicine, 64(9), 782-787. https://doi.org/10.1097/JOM.0000000000002586 2022 1 Depressive symptoms are associated with decreased quality of life and work ability in currently working health care workers with recurrent low back pain Virkkunen Tarja, MD1,3, Husu Pauliina, PhD2, Tokola Kari, MSc2, Parkkari Jari, MD ,PhD2,4, Kankaanpää Markku, MD, PhD1,3 1Tampere University Hospital, Department of Rehabilitation and Psychosocial Support, Tampere, Finland 2UKK Institute for Health Promotion Research, Tampere, Finland 3Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland 4Faculty of Sports Medicine, University of Jyväskylä, Jyväskylä, Finland Corresponding author: Tarja Virkkunen Department of Rehabilitation and Psychosocial Support, Tampere, Tampere University Hospital, P.O. Box 2000, FI-33521 Tampere, Finland Phone: 358331166606 email: [email protected] Funding Sources: The study was funded by The Social Insurance Institution of Finland (37/26/ 2011 and 31/26/2015; Pirkanmaa Hospital District, Tampere, Finland (9K127 and 9M099). Journal of Occupational and Environmental Medicine, Publish Ahead of Print DOI: 10.1097/JOM.0000000000002586 ACCEPTED 2 The funders had no role in the study design, collection, analysis, or interpretation of the data, writing of the report, or decision to submit the article for publication. Conflicts of Interest for all authors: None Declared. Acknowledgements: The authors wish to thank the participants of the NURSE-study at the following clinics in the city of Tampere, Finland: Rauhaniemi Hospital unit and Koukkuniemi Home for the Elderly, Kauppi Hospital, Hatanpää Hospital (surgery, infectious, medical, and general practice wards) and Park Hospital (geriatrics); Home Services; Physiotherapy Clinic and Tampere University Hospital (12 clinics with 40 wards). Ethical Considerations & Disclosure: Ethics approval and consent to participate: the Regional Ethics Committee of the Expert Responsibility area of Tampere University Hospital, Finland, (ETL code R08157) approved the study protocol. The participants recruited to the study received a written information letter clarifying the aims of the study, including the risks and benefits. The participants provided their written informed consent to participate at the first study appointment. Note: There is a significant content overlap between this manuscript and our previous unpublished version “ Associations between multisite pain, depressive symptoms and disturbed sleep with work ability and health-related quality of life in health care workers with recurrent non-specific low back pain: a cross-sectional study” on the pre-print server. ACCEPTED 3 This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ACCEPTED 4 Abstract Objective: This study investigates the association between depressive symptoms and multisite pain and health-related quality of life (HRQoL) and work ability in currently employed health care workers with recurrent low back pain (LBP). Methods: Multisite pain, depressive symptoms, quality of life, and work ability were assessed by validated questionnaires. A generalized linear model was used for statistical analysis. Results: Notably, 28% of female health care workers with LBP had at least moderate levels of depressive symptoms. Depressive symptoms were significantly associated with decreased HRQoL and work ability. Multisite pain was not significantly associated with work ability. Conclusions: Depressive symptoms are relatively common in female health care workers with LBP and treatment of these symptoms may be crucial to improve their work ability. Keywords: Depression, Pain, Nurses, Quality of Life, Work Disability ACCEPTED 5 Background Low back pain (LBP) is defined as pain of musculoskeletal origin extending from the lowest rib to the gluteal fold that may at times extend as referred pain into the thigh1, and it is a common and complex global health problem. Moreover, LBP is also a leading cause of disability and results in an enormous economic burden to society. LBP as well as depression were among the three leading causes of the disease burden in terms of years lived with disability in 20172. Most patients with LBP recover spontaneously but about 10% will go on to develop chronic LBP.3 Depression and work-related factors, such as carrying heavy loads at work, and difficult working positions were one the most frequently observed risk factors for chronic low back pain4. Estimated 85-90% of LBP cases are classified as non-specific, i.e. pain which have not a known pathoanatomical cause5. Non-specific LBP is associated with lower health-related quality of life (HRQoL), increased functional disability, and increased time off work.6 The highest prevalence of LBP has been reported among women aged between 40 and 80 years. LBP frequently causes suffering, an increased number of visits to health care centers, and increased work absenteeism.7-9 In addition, long-term musculoskeletal pain is an increasing public health problem that results in significant work absenteeism.10 The causes of the high prevalence, incidence, and recurrence of LBP are multifactorial, and LBP should therefore be understood within a biopsychosocial framework. Typically, health care workers have an increased risk for musculoskeletal disorders and the most frequently reported disorder is LBP.11 Indeed, the one-year prevalence of LBP among health care workers has been reported to be between 45% and 77%.12 In nurses, LBP can lead to impaired quality of life, work disability, and early exit from the labor market.13 Occupational risk assessment is a method for estimate health risks from exposure to various levels of a workplace hazard. ACCEPTED 6 Furthermore, understanding how much exposure to a hazard poses health risks to workers is important to appropriately eliminate, control, and reduce those risks.14 Nurses have several personal, physical, and psychosocial risk factors for musculoskeletal pain that include constrained posture, forceful movement, high emotional strain, and added pressure caused by staff shortages.15 Moreover, health care workers often have to work irregular shifts, which frequently leads to sleep disturbances.16 Work-related psychosocial factors, such as high job demand, low job control, and low social support, play an important role in the prevalence and incidence of LBP in health care workers. Organizational factors also play an important role in the occurrence of musculoskeletal disorders.17 Depressive symptoms were associated with presenteeism independently of pain intensity among health care workers with LBP.18,19 Among health care workers, musculoskeletal disorders are an important risk factor for nurses to consider changing jobs or even leaving the nursing profession.20 LBP is often concurrent with pain from other body sites.5 Multisite musculoskeletal pain has been associated with a greater negative impact on patients` physical functioning and disability, leading to an increased risk for depressive disorders. Moreover, the reporting of multisite pain appears to worsen the prognosis, as there is an increased likelihood of the problem becoming chronic. Multisite musculoskeletal pain also increases the risk for poor future work ability.21 There is a strong association between number of pain sites and sleep quality as well as psychological distress and overall health.22 The afore mentioned relationships are complex and interactive and might therefore be components of a larger, multi-symptom syndrome. The co-occurrence of musculoskeletal pain and depressive symptoms has a stronger adverse effect on physical work ability and thoughts of early retirement than either one of these alone.23 ACCEPTED 7 Psychosocial factors play an important role in the development of persistent disabling LBP and depression might have an adverse effect on the prognosis of LBP.24 Depression (major depressive disorder) is a common and serious medical illness that negatively affects how person feels, thinks and acts. Depression can lead to a variety of emotional and physical problems and can decrease ability to function at work and at home.25 Pain and depression often co-occur, share similar symptoms, may exacerbate each other.26 Patients with chronic LBP have significantly impaired psychological status and reduced HRQoL. Comorbidity of depression and chronic pain are highly prevalent in individuals suffering from physical illness.24 People with depressive symptoms or diagnosed depression may be at risk for poorer LBP recovery and may require more health care.27 Furthermore, the recent study confirmed a relationship between job demands and incident major depression, and this relationship appeared due to neither mediation by, nor interaction with LBP.28 Depression should be observed in LBP patients to reduce pain related disability.29 Work ability is defined as the physical and mental ability of workers to cope with the demands of their work.30 The interactions between the resources of a worker and the demands of the work are intensive and dynamic. Furthermore, these interactions change during aging and the life course. The balance between the human resources of workers, such as health and functional capacities, competence, values, attitudes, and motivation, and work-related factors, such as demands, arrangements and management, are therefore crucial.31 The Work Ability Index (WAI) is a valid, reliable, and commonly used instrument to assess work ability.30,32,33 The value of the WAI predicts both register-based disability pension and long-term sickness absence. The WAI consists of two questions: 1) the individual’s own evaluation of work ability compared with lifetime best work ability (WAS) and 2) the individual`s belief of future work ability (FWA) that predict both ACCEPTED 8 disability pension and long-term (>10 days) sick leave.34 The findings of a previous study suggests that the WAS could be used as a simple indicator for assessing the status and progress of work ability among women on long-term sick leave. Furthermore, the predictive value for the degree of sick leave and HRQoL was strong for the WAS.35 According to a previous study, the beliefs of workers regarding returning to work, pain intensity, and work strain are predictive of work ability among women on sick leave due to long-term LBP.36 Moreover, physical demands in the workplace might cause work disability among workers with LBP.37 In addition, individual factors, such as older age, have been associated with poor work ability.38 In the general working population, poor work ability combined with one or more chronic diseases is associated with high risk for long-term sickness absence.39 The present study investigates the associations between multisite pain and depressive symptoms and HRQoL and work ability in female health care workers with recurrent LBP. Understanding the impact of depressive symptoms and depression is important to clinical management of LBP. Patients with subacute LBP and depression will need psychological care in addition to medical or physiotherapy treatment.40,41,42 Methods Study design and participants This cross-sectional study was part of a randomized controlled trial (the NURSE-RCT, clinical trial registration NCT01465698) aimed at reducing pain, movement-control impairment, and fearavoidance beliefs in working female health care workers with recurrent LBP (n=219).43 The NURSE-RCT was conducted in the form of 3 identical consecutive sub-studies. More precise ACCEPTED 15 LBP is a leading cause of disability and results in an enormous economic burden.3 Health care work is accompanied by several individual, physical, and psychosocial risk factors, and LBP is a common problem among nurses.11 In this study, health care workers were still able to work even though they had recurrent LBP. Moreover, most (65%) of the participants had pain symptoms that had lasted for less than three months, i.e., they had no chronic pain. The reporting of multisite pain appears to worsen the prognosis and there seems to be an increased likelihood of the problem becoming chronic.22 In the current study, as many as 72% of participants reported multisite pain (musculoskeletal pain in three or more sites). Previous studies have concluded that multisite musculoskeletal pain increases the risk for poor future self-perceived work ability.21 Furthermore, the co-occurrence of musculoskeletal pain and depressive symptoms has been found to have a stronger adverse effect on physical work ability than either one of these alone.23 However, after adjustments, the findings of the present study show that although multisite pain was significantly associated with physical quality of life, it was not associated with mental quality of life or work ability. Depression might have a significant adverse effect on the prognosis of LBP.24 In our study, 28% of participants reported at least moderate depressive symptoms. According to previous studies, people who have depressive symptoms or are diagnosed with depression may be at risk for poorer LBP recovery and may require more health care.27After adjustments, the findings of this study showed that depressive symptoms were significantly associated with decreased mental quality of life and decreased work ability. Against expectations, depressive symptoms were not significantly associated with the bodily pain subscale of the RAND-36. ACCEPTED 16 People with LBP are at risk for poor HRQoL.6 The highest score of the physical components of the RAND-36 in the present study was physical functioning and the highest score of the mental components was emotional role functioning (Table 2). Higher scores represent better quality of life.45The lowest score of the physical component of the RAND-36 was bodily pain, which is lower when compared with the population data for Finnish females of the same age.45 (Table 2). The lowest score of the mental components of the RAND-36 was vitality 63, which is approximately the same as the population data for Finnish females of the same age.45 Among health care workers, musculoskeletal disorders are one important risk factor when considering changing job or even leaving the nursing profession. In addition to leading to an early exit from the labor market, LBP can also lead to work disability in nurses whose work includes lifting, carrying, and other physically demanding tasks.20 Previous studies have shown that pain intensity is predictive of self-reported work ability among women on sick leave due to long-term LBP.36 Previous studies have also shown that poor self-reported future work ability predicts longterm sickness absence, disability pension, and long-term unemployment.34 Furthermore, poor selfreported work ability combined with chronic disease is associated with high risk for long-term sickness absence.39 In this study, the majority of the participants reported their work ability to be moderate, i.e., the mean work ability score (WAS) of the participants was 7.8 (score 0-10). The work ability score (WAS) in these participants was lower than in those members of the Finnish population who were fully able to work.47 Furthermore, 12% of the participants were uncertain of their future work ability, which can be classified as poor work ability. According to these results, some of these participants might be at risk for long-term sickness absence or even at risk for permanent work disability. ACCEPTED 17 The limitations of the present study include the cross-sectional design and relatively small study sample. The strengths of the study include the unique study population in terms of non-chronic LBP (i.e., recurrent LBP) with physically strenuous work and who were still able to work. Other strengths of the study are the use of the modified Finnish version of the 9-item Patient Health Questionnaire (PHQ-9-mFIN), which was recently validated among the present study population,44 and the use of the validated questions of the quality of life (RAND-36).45 Conclusions The present study found that recurrent LBP combined with multisite musculoskeletal pain or depressive symptoms had a negative association with quality of life among currently working female health care workers. Furthermore, we found that LBP combined with depressive symptoms had a negative impact on work ability. Identifying individuals with a good or unfavorable prognosis among people with LBP is an important goal.48 Moreover, recommendations have been made for the use of screening methods in health care to identify those individuals at the early stages of LBP who are at risk for work disability. The aim is to guide them to the appropriate rehabilitation to support their work ability.49 Furthermore, the questions relating to depressive symptoms used in this study might be appropriate tools for identifying those health care workers who are at risk for work disability. In addition, assessing the functional capacity of a worker can be used to assess work ability, especially among health care workers who usually have physically and mentally strenuous work. The combination of these estimates could provide more information about a worker’s future work ability. Based on the results of the current study, it would be interesting to define the cut-off points for depressive ACCEPTED 18 symptoms and multisite pain to ascertain when they begin to significantly affect work ability. Future intervention studies should include psychological aspects alongside physical rehabilitation. ACCEPTED 19 References 1. 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TOIMIA 2015 (in Finnish) 48. Helmhout P, Staal J, Heymans M, et al: Prognostic factors for perceived recovery or functional improvement in non-specific low back pain: secondary analyses of three randomized clinical trials. Eur Spine J 2010; 19: 650-659. 49. Forsbrand MH, Grahn B, Hill JC, et al: Can the STarT Back Tool predict health-related quality of life and work ability after an acute/subacute episode with back or neck pain? A psychometric validation study in primary care. BMJ Open. 2018 ; 22;8 (12): e021748. ACCEPTED 31 Table 2. Associations between multisite pain with quality of life and work ability without adjustments _____________________________________________________________________________________ __ Multisite pain B 95% Confidence Interval Lower Upper p-value _____________________________________________________________________________________ _ Quality of life RAND-36 physical component Bodily pain -0.270 -0.373 -0.166 <0.001* Physical functioning -0.119 -0.176 -0.063 <0.001* Role functioning /physical -0.258 -0.510 -0.006 0.044* General health -0.171 -0.251 -0.091 <0.001* RAND-36 mental component Social functioning -0.107 -0.196 -0.018 0.018* Vitality -0.135 -0.250 -0.019 0.022* Mental health -0.076 -0.145 -0.006 0.034* Role functioning /emotional -0.031 -0.251 0.189 0.783 Work ability WAI short form -0.068 -0.106 -0.029 0.001* * p-value <0.05 ACCEPTED