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 Table of Contents  
Year : 2018  |  Volume : 1  |  Issue : 2  |  Page : 49-54

Limitations of long-standing non-malignant pain in functioning, activity and quality of life: A gender comparison

Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden

Date of Web Publication11-Jan-2019

Correspondence Address:
Jan-Rickard Norrefalk
Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijprm.ijprm_1_18

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Background: Long-standing non-malignant pain (LSNMP) leads to limitations of function and activity as well as decreased quality of life (QoL). Aim: The aim of this study is to describe the subjective experience and to compare the gender differences of functional, activity, and QoL limitations in patients with LSNMP. Methods: Three hundred patients, 207 women and 93 men, with a median duration of pain of 49 months referred to a Pain Management Centre filled out the Functional Barometer questionnaire, adapted to the International Classification of Functioning, Disability and Health (ICF). Results: All patients reported that pain was a moderate, major or total problem. In the ICF item variables, lifting/carrying things, endurance, keeping posture, muscle strength, leisure time, sleeping and energy were indicated as major or total limitations due to pain. Women had significantly more limitations in comparison to men regarding concentration, ordinary housework stress and psychological demands, keeping posture, lifting/carrying things, gastrointestinal functions and contact with friends. Conclusion: Targeting limitations and possibilities in function, activity and QoL are of importance when tailoring an individual treatment and rehabilitation plan. Gender differences are of importance to recognize.

Keywords: Activity, function, functional barometer, pain analysis, quality of life

How to cite this article:
Norrefalk JR, Borg K. Limitations of long-standing non-malignant pain in functioning, activity and quality of life: A gender comparison. J Int Soc Phys Rehabil Med 2018;1:49-54

How to cite this URL:
Norrefalk JR, Borg K. Limitations of long-standing non-malignant pain in functioning, activity and quality of life: A gender comparison. J Int Soc Phys Rehabil Med [serial online] 2018 [cited 2019 Jul 22];1:49-54. Available from: http://www.jisprm.org/text.asp?2018/1/2/49/249849

  Introduction Top

Long-standing non-malignant pain (LSNMP) may be nociceptive, neuropathic, or a combination of both. It may originate from a variety of somatic causes, but it may also have a psychological background. Physical pain may involve musculoskeletal, vascular, and neurological systems as well as injury to organs and tissues from other disease processes and from surgical interventions. Nociceptive pain is associated with tissue damage. Neuropathic pain is, on the other hand, due to nerve injury or malfunction of the nervous system and thus may be more complex. Musculoskeletal pain is one of the most common complaints when visiting primary health care in Scandinavia. Between one-fifth and one-half of patients seeking health care experience long-term pain.[1],[2] The prevalence of persistent neuropathic pain ranges from 3% to 8% in different population-based epidemiological studies[3],[4],[5],[6] in accordance with the studies on Swedish population.[7],[8],[9],[10],[11] LSNMP leads to varying degrees of function and activity limitations as well as impact on quality of life (QoL). Furthermore, perceived LSNMP will affect an individual's life, spare time, economy, psychosocial well-being and capacity for work.[12] Long-standing pain is also a major reason for prolonged sick leave and early retirement, thereby causing high costs for the national insurance system, health care, employers and society.[13],[14],[15],[16] There is a lack of studies in which the International Classification of Functioning, Disability, and Health (ICF) coding is included and particularly, there is a lack of pain-based studies using the ICF. The Functional Barometer (FB) is a validated and quality-assured self-assessment instrument for patients suffering from pain.[17] The FB is so far the only questionnaire using ICF variables based on pain. It is of importance to detect the most common limitations of patients with LSNMP and especially the differences based on a gender perspective.

The aim of this study was to evaluate the function, activity and QoL limitations according to the ICF in patients with LSNMP seeking care in a University Hospital Pain Management Centre and to describe the gender differences.

  Method and Patient Selection Top

Out of the 346 patients referred to the Pain Management Clinic at Södersjukhuset University Hospital in Stockholm, 300 questionnaires had the quality required to be included in the study, which contains 28 questions evaluating how pain affects function, activity and QoL.[17],[18],[19],[20] Of the 28 questions, 12 cover body function and activities/participation and one additional optional item variable for the patient to assess. Twelve questions reflected QoL variables and the last four were related to pain [Table 1], [Table 2], [Table 3]. FB is based on the patient's experience of pain but is also adapted to the World Health Organization (WHO) International Classification, of patients' disability, activity, limitations and participation.[21],[22],[23],[24],[25],[26] All items are assessed by a verbal descriptive problem scale, the same as the ICF qualifier; the five categories were graded as 0–4. The categories defined as no (0), slight (1), moderate (2), major (3) and total (4) problems.[17] Based on this, all patients received an ICF code and category grade for each question. Furthermore, gender differences were evaluated.
Table 1: The occurrence of pain in different regions of the body

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Table 2: International Classification of Functioning, Disability and Health variables included in the Functional Barometer. Problems with function/activity due to pain

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Table 3: International Classification of Functioning, Disability and Health variables included in the Functional Barometer. Pain related quality of life problems

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Statistical analysis was performed using IBM SPSS Statistics version 23 (IBM, Armonk, New York, USA).

The describing statistics were performed using n, percent (%), mean, and standard deviation. For the group statistics regarding age, the t-test was used. To compare the differences between women and men, the nonparametric tests such as Mann–Whitney tests, Chi-square tests, and cross-tabulation were used. A P < 0.05 was considered statistically significant.

  Results Top

In 2015, 346 patients suffering from LSNMP were referred to the Pain Management Clinic. Of these 346 patients, 300, comprising 207 women and 93 men, aged between 18 and 88 years who completed the self-assessment FB questionnaire were enrolled in the study [Table 4]. The dropout rate was 9%. The duration of pain before referral to the Pain Management Unit and the occurrence of pain in different regions of the body are provided in [Table 4] and [Table 1], respectively.
Table 4: Demographic data of the 300 patients

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The ICF categories/variables and perceived pain are identified in the FB from the ICF score sets and are presented regarding function/activity and QoL [Table 2], [Table 3] and [Table 5]. Regarding functioning and activity [Table 2], the patients reported major or total problem due to pain in the ICF item variables; lifting/carrying things – ICF d 430 (61%), endurance – ICF b 740 (49%), keeping posture – ICF d 4153 (44%) and muscle strength – ICF b 730 (43%). No problem or slight problem due to pain was recorded for the item variables; dressing – ICF d 540 (66%), making bed – ICF d 649 (52%) and driving car – ICF d 4751 (47%).
Table 5: International Classification of Functioning, Disability and Health variables included in the Functional Barometer. Perceived pain

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For QoL [Table 3], leisure time – ICF d 920 (69%), sleeping – ICF b 134 (60%), and energy – ICF b 130 (59%) were the most affected variables due to pain. No problem or slight problem due to pain was found for the item variables; gastrointestinal function – ICF b 535 (49%), economical self-support – ICF d 870 (44%) and emotional functions – ICF b 152 (41%).

To the question, “How would you describe your pain: Just now?” – ICF b 280, 67% perceived their pain as a major or a total problem. Seventy-five percent reported their pain as a major or total problem during “last week,” and 26% reported that their pain was a major or total problem when it was at its “mildest.” When the patients perceived their pain as its “worst,” 96% reported it as a major or total problem and 100% as moderate, major or total problem [Table 5].

The open question (FB no. 13) is an additional optional item variable for the patient to assess, i.e., “Do you experience other limitations in your function/activity due to your pain?” The most common answers were sexual activity, sports and training, sitting/working in front of the computer, gardening, shopping, reading and writing.

Comparing women and men, significant differences are found as shown in [Figure 1]. Women had significantly more limitations than men due to their pain, keeping posture (P = 0.012), ordinary housework (P = 0.006), lifting/carrying things (P = 0.035), driving a car (P = 0.060), using transportation (P = 0.063), concentration (P = 0.001), stress and psychological demands (P = 0.007), gastrointestinal functions (P = 0.031) and contact with friends (P = 0.051). There were also significant differences as women experienced more pain “last week” (P = 0.021).
Figure 1: Significant differences between women and men in function/activity and quality of life caused by pain

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In the other 19 items of the FB, no significant differences were found.

  Discussion Top

The aim of this study was to evaluate the function/activity and limitations in QoL patients suffering from LSNMP and to compare the gender differences. Not surprisingly, pain itself was the major problem. When the patients perceived their pain as its “worst,” all patients reported it as moderate, major or a total problem.

Of the other item variables in the FB questionnaire, the most affected variables reported by the patients due to their pain was leisure time, lifting/carrying things, sleeping, energy, endurance, keeping posture and muscle strength.

It is obvious that the LSNMP patients in this study are suffering from secondary negative consequences due to pain. However, there are other areas which are less affected, for example, dressing, making bed and driving a car. One can speculate why these activities are less affected, such as dressing aid equipment, self-made solutions and gender aspects.

Differences in age, gender, and origin of pain have been reported in an earlier study, indicating that men more often reported physiological limitations, while women more often reported psychological limitations of functioning, activity and QoL. Women especially over 65 years of age reported statistically significant problems with “concentration,” “stress and psychological demands,” “family relation” and “contact with friends” in comparison to men and younger women.[18]

From a gender perspective, significant differences between women and men were found in this study, especially regarding cognitive and somatic functions and activities. There was no variable found that showed a significant difference where men had more difficulties than women. The significant differences between women and men highlight the difference in a gender aspect and have to be taken into account in the treatment and rehabilitation of pain patients. Thus, the result of the present study indicates that the tailored individual rehabilitation of pain patients should focus on these areas. On the other hand, no problem or slight problem due to pain was recorded for the item variables such as dressing, making bed, gastrointestinal function, driving car, economical self-support and emotional functions. These results are also important since there are functions/activities and QoL variables that pain patients may be able to perform despite pain.

One can speculate if the FB is the most sufficient instrument to assess the patient's limitations due to pain. However, the FB self-reported questionnaire is in accordance with the ICF as it provides a clear overview of the patient's limitations and meets the requirements of good construct and content validity.[17] The earlier validation study indicated strong evidence of underestimation of the patients' limitations from the professional's point of view as compared to the patient's self-assessment. The variability in the professionals' ICF demonstrated the importance of describing the patient's problems from both the patient's and the professional's perspective which were beneficial for the patient's rehabilitation.[17] In the present study, the pain rehabilitation team made an assessment and analysis of each patient's questionnaire as a part of tailoring the best possible individual rehabilitation program together with the patient. Being able to document which limitations LSNMP cause, and also what the patient is capable to perform despite and because of their pain, facilitates how to target treatment and rehabilitation individually. This will reduce patient suffering and costs. The saved costs are also expected to have a positive effect on society in general as previous research indicates.[10],[11],[12],[13]

The results from the FB in LSNMP may be performed repeatedly to follow the effect of the rehabilitation and may also be a basis for sick leave evaluation. The sick leave in Sweden is based upon function and activity limitations despite illness. The level of limitations decides if you are able to work full-time, half-time, part-time or not at all.

This study has methodological limitations with no comparison group from another pain management center. Furthermore, there are no follow-up data presented. Another limitation is that the population in the area of Södersjukhuset University Hospital has an over-representation of socioeconomic problems, immigrants and people with a low grade of education,[1],[15],[27],[28],[29],[30] which may have had an influence of the results. From a total of 346 patients, 300 patients had filled out the FB to the extent that it could be evaluated, a dropout rate of 9%. Lack of motivation, language problems, illiteracy, dyslexia, and cognitive disorders were some of the explanations for not filling out the FB to the full extent. However, we believe that the 300 patients are representative for the LSNMP patients of the Pain Management Centre of Södersjukhuset University Hospital.

Furthermore, the patients in this study were highly selected. Their pain was complex and they were referred to pain specialists at the University Hospital Pain Management Centre. They had been undergoing numerous treatments, without lasting improvement which is underlined by the fact that patients had been waiting for consultation for over 4 years.

The majority of the patients suffered from pain from more than three regions of their body. This was independent of gender. As most of the patients had different kinds of pain from different regions of their body, it was not possible to study subgroups. Pure neuropathic pain was not possible to find as it was often combined with nociceptive pain. This would have been of interest as one may anticipate differences in limitations of functioning, activity and QoL, depending on differences in type of pain.

  Conclusion Top

This study shows that patients with LSNMP report several limitations of functioning, activity, and QoL when evaluated using the FB self-assessment questionnaire with the included and corresponding ICF item variables. Furthermore, there are important differences between women and men. These results are of importance and have to be taken into account when tailoring individual treatment and rehabilitation programs.


A special thanks to Lisbet Broman at the Department of Rehabilitation, Danderyd Hospital, for statistical support and to Lovisa Pernsköld for admin support and to all the team members at the Pain Management Unit at Södersjukhuset University Hospital.

Financial support and sponsorship

The study was supported by grants from, Neuro Förbundet (Neuro Sweden).

Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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