381: A Five-Domain Clinical Screen Identifies High-Risk Disability in Chronic Low Back Pain

Topic: Clinical Science
Subtopic: Pain category (ICD-11), Chronic primary musculoskeletal pain, Psychology, Assessment and Measurement of Pain/Nociception, Epidemiology

Background and Aims: In chronic low back pain (CLBP), disability is commonly approached through pain intensity alone, despite frequent co-occurrence of fear of movement and emotional distress symptoms. Aim: We examined whether a cumulative five-domain symptom-burden phenotype (pain, kinesiophobia, depression-, anxiety-, and stress-symptom domains) stratifies disability severity, and whether pain influences disability directly and indirectly via kinesiophobia and distress symptoms. We hypothesized a graded dose–response relationship between burden and disability, and a fear-mediated pathway from pain to disability.

Methods: We conducted a cross-sectional study of 756 Vietnamese adults with CLBP. Disability was assessed using the Roland–Morris Disability Questionnaire (RMDQ) and categorized into quartiles (lowest to highest disability). Pain intensity, kinesiophobia(TSK-11), and distress symptoms (DASS-21 depression/anxiety/stress subscales) were measured using validated Vietnamese instruments. Each domain was dichotomized using prespecified thresholds, summed to create a five-domain burden score (1–5 abnormal domains), and categorized as Groups A–E (A=1 domain, E=5 domains). Multinomial logistic regression estimated adjusted odds of higher disability quartiles. Path analysis with bias-corrected bootstrapping evaluated direct and mediated effects of pain on disability through kinesiophobia and distress symptoms.

Results: A steep dose–response gradient emerged: compared with Group A, odds of very severe disability (highest quartile) increased markedly with higher burden—Group B AOR=29.41, C=63.07, D=100.28, E=421.29 (all p≤.002). Monotonic increases were also observed for the third disability quartile (B 6.26, C 12.14, D 23.79, E 36.71; all p≤.002). Path analysis indicated that pain was associated with disability both directly (β≈0.54–0.55, p<.001) and indirectly via kinesiophobia (pain→kinesiophobia β≈0.40–0.42; kinesiophobia→disability β≈0.11–0.13; indirect β≈0.05, p<.001). Distress symptom domains had additional direct links with disability.

Conclusions: CLBP disability is strongly stratified by cumulative symptom burden beyond pain alone. Findings support pragmatic risk stratification using a brief five-domain screen and integrated care pathways targeting pain, fear of movement, and distress symptoms—particularly relevant for resource-limited clinical settings.

References: 1. Wu, A., et al., Global low back pain prevalence and years lived with disability from 1990 to 2017: estimates from the Global Burden of Disease Study 2017. Ann Transl Med, 2020. 8(6): p. 299.
2. Ferreira, M.L., et al., Global, regional, and national burden of low back pain, 1990&#x2013;2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology, 2023. 5(6): p. e316-e329.
3. Luan, H.D., et al., Musculoskeletal Disorders: Prevalence and Associated Factors among District Hospital Nurses in Haiphong, Vietnam. BioMed Research International, 2018. 2018(1): p. 3162564.
4. Le, T.T.T., et al., Prevalence and risk factors of work-related musculoskeletal disorders among physical therapists in Ho Chi Minh City, Vietnam. BMC Public Health, 2024. 24(1): p. 6.
5. Mescouto, K., et al., A critical review of the biopsychosocial model of low back pain care: time for a new approach? Disability and Rehabilitation, 2022. 44(13): p. 3270-3284.
6. Vlaeyen, J.W.S. and S.J. Linton, Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain, 2000. 85(3): p. 317-332.
7. Vlaeyen, J.W.S. and S.J. Linton, Fear-avoidance model of chronic musculoskeletal pain: 12 years on. Pain, 2012. 153(6): p. 1144-1147.
8. Pincus, T., et al., A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976), 2002. 27(5): p. E109-20.
9. Alhowimel, A.S., et al., Psychosocial Predictors of Pain and Disability Outcomes in People with Chronic Low Back Pain Treated Conservatively by Guideline-Based Intervention: A Systematic Review. J Multidiscip Healthc, 2021. 14: p. 3549-3559.
10. Burgess, H.J., et al., Associations between Sleep Disturbance and Chronic Pain Intensity and Function: A Test of Direct and Indirect Pathways. Clinical Journal of Pain, 2019. 35(7): p. 569-576.
11. Schiphorst Preuper, H.R., et al., Relationship between psychological factors and performance-based and self-reported disability in chronic low back pain. European Spine Journal, 2008. 17(11): p. 1448-1456.
12. Craige, E.A., et al., Effects of non-pharmacological interventions on sleep in chronic low back pain: A systematic review and meta-analysis of randomised controlled trials. Sleep Medicine Reviews, 2023. 68.
13. To, N., Validity of the Vietnamese Version of the Pittsburgh Sleep Quality Index (V-PSQI). Tạp chí Y học Dự phòng, 2017. 27: p. 50-56.
14. Woby, S.R., et al., Psychometric properties of the TSK-11: a shortened version of the Tampa Scale for Kinesiophobia. Pain, 2005. 117(1-2): p. 137-44.
15. Tran, T.D., T. Tran, and J. Fisher, Validation of the depression anxiety stress scales (DASS) 21 as a screening instrument for depression and anxiety in a rural community-based cohort of northern Vietnamese women. BMC Psychiatry, 2013. 13: p. 24.
16. Van Giang, N., et al., Validity, Sensitivity, and Responsiveness of the 11-Face Faces Pain Scale to Postoperative Pain in Adult Orthopedic Surgery Patients. Pain Manag Nurs, 2015. 16(5): p. 678-84.
17. Knol, M.J., et al., Estimating interaction on an additive scale between continuous determinants in a logistic regression model. Int J Epidemiol, 2007. 36(5): p. 1111-8.
18. Luque-Suarez, A., J. Martinez-Calderon, and D. Falla, Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. Br J Sports Med, 2019. 53(9): p. 554-559.
19. Wertli, M.M., et al., Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J, 2014. 14(11): p. 2658-78.
20. Bunzli, S., et al., Making Sense of Low Back Pain and Pain-Related Fear. J Orthop Sports Phys Ther, 2017. 47(9): p. 628-636.
21. Alsaadi, S.M., et al., Prevalence of sleep disturbance in patients with low back pain. Eur Spine J, 2011. 20(5): p. 737-43.
22. Marty, M., et al., Quality of sleep in patients with chronic low back pain: a case-control study. Eur Spine J, 2008. 17(6): p. 839-44.
23. Morelhão, P.K., et al., Bidirectional association between sleep quality and low back pain in older adults: a longitudinal observational study. Archives of Physical Medicine and Rehabilitation, 2022. 103(8): p. 1558-1564.
24. Skarpsno, E.S., T.I.L. Nilsen, and P.J. Mork, The effect of long-term poor sleep quality on risk of back-related disability and the modifying role of physical activity. Scientific reports, 2021. 11(1): p. 15386.
25. Kovacs, F.M., et al., The association between sleep quality, low back pain and disability: A prospective study in routine practice. Eur J Pain, 2018. 22(1): p. 114-126.
26. Júnior, F.B.d.S., et al., 15-item Roland-Morris disability questionnaire for general pain (RMDQ-g): Structural validity and criterion validity on Brazilian patients with chronic pain. Musculoskeletal Science and Practice, 2023. 66: p. 102823.
27. Frota, N.T., et al., 15-item Roland-Morris Disability Questionnaire (RMDQ-15): structural and criterion validity on patients with chronic low back pain. BMC Musculoskeletal Disorders, 2022. 23(1): p. 978.
28. Burbridge, C., et al., Measuring the impact of chronic low back pain on everyday functioning: content validity of the Roland Morris disability questionnaire. Journal of Patient-Reported Outcomes, 2020. 4(1): p. 70.

Presenting Author: Le Thi Cuc
Submitting Author: Thi Cuc Le

Senior Author: Le Thi Cuc

IASP 2026 Global Year theme of Neuropathic Pain: Yes

• Nguyen Thi Luong - Hanoi Medical University, Vietnam
• Pei-Shan Tsai - Taipei Medical University, Taiwan
• Siti Fadlilaha - Universitas Respati Yogyakarta, Yogyakarta, Indonesia
• Le Thi Cuc - Hanoi Medical Univesity, Vietnam