Investigações sobre dor crônica na coluna e doenças crônicas não transmissíveis

Abstract

Chronic back pain (CBP) is a global public health problem. Evidence indicates the coexistence of CBP and other non-communicable chronic diseases (NCDs), leading to a condition of multimorbidity. However, the role of multimorbidity in adults with CBP remains unclear. This thesis comprises five chapters: one introductory chapter, three chapters reporting results from three studies, and a final chapter presenting overall considerations and conclusions. The studies reported in the second and third chapters are cross-sectional analyses using data from the 2019 National Health Survey (Pesquisa Nacional de Saúde). The study presented in Chapter two investigated the prevalence of NCDs among individuals with and without CBP and the association between the presence of NCDs and activity limitation among those with CBP. The NCDs assessed through self-report included hypertension, heart disease, stroke, arthritis or rheumatism, diabetes, depression, asthma, cancer, other lung diseases, and other mental disorders. Activity limitation was measured on a five-point categorical scale ranging from 0 (no limitation) to 5 (very intense limitation). Data from 18,930 adults with CBP and 68,748 adults without CBP were analyzed. Results showed higher prevalence rates of NCDs among adults with CBP compared to those without, with higher prevalences for cardiovascular diseases (40.5%), arthritis or rheumatism (19.3%), depression (19.3%), and diabetes (11.3%). Multimorbidity, defined as the presence of two or more NCDs, was reported by 62.1% of adults with CBP. Ordinal logistic regression analyses indicated worse levels of activity limitation associated with arthritis or rheumatism (OR: 2.1; 95% CI: 1.9–2.4), other lung diseases (OR: 1.8; 95% CI: 1.3–2.5), depression (OR: 1.6; 95% CI: 1.4–1.8), and cardiovascular diseases (OR: 1.5; 95% CI: 1.3–1.6). The study presented in Chapter three examined the association between NCDs and health service use and self-rated health among Brazilian adults with CBP (n = 18,930). The NCDs investigated included depression, cardiovascular diseases, diabetes, and arthritis or rheumatism. Health service use was measured by seeking care within the past 15 days and hospitalizations within the past 12 months. Self-rated health was assessed on a five-point scale ranging from 1 (very good) to 5 (very poor). Binary logistic regression models were used to analyze associations between NCDs and health service use, and ordinal logistic regression models were applied for associations with self-rated health. Results from binary logistic regression showed that depression (OR: 1.8; 95% CI: 1.6–2.1), cardiovascular diseases (OR: 1.5; 95% CI: 1.3–1.7), diabetes (OR: 1.4; 95% CI: 1.2–1.8), and arthritis or rheumatism (OR: 1.3; 95% CI: 1.1–1.5) were associated with higher health service use in the past 15 days among adults with CBP. Regarding hospitalization, depression (OR: 2.0; 95% CI: 1.5–2.7), cardiovascular disease (OR: 1.7; 95% CI: 1.4–2.0), and diabetes (OR: 1.9; 95% CI: 1.5–2.3) showed the strongest associations. The odds of reporting poorer self-rated health among participants with CBP and comorbid NCDs were 1.4 (95% CI: 1.3–1.6) for depression, 2.0 (95% CI: 1.8–2.2) for cardiovascular diseases, 2.1 (95% CI: 1.8–2.5) for diabetes, and 2.1 (95% CI: 1.9–2.4) for arthritis or rheumatism, compared to participants with CBP but without these conditions. Chapter 4 presents a secondary analysis of the randomized clinical trial Get Back to Healthy Trial conducted in Australia. Data from 337 patients with chronic low back pain (CLBP) were analyzed to describe patterns of comorbidity clusters and their association with health service use for low back pain. Data on low back pain and comorbidities were collected at baseline. Self-reported comorbidities included cardiovascular, respiratory, gastrointestinal, musculoskeletal, and neurological diseases, as well as diabetes, psychological symptoms, sleep disorders, and cancer. Information on health service use for low back pain was collected fortnightly through electronic questionnaires over a 12-month period. Health service use was measured as the mean number of consultations related to low back pain. Results indicated that 78% of participants presented at least one comorbidity in addition to CLBP, with the highest prevalence for musculoskeletal conditions (45.1%), sleep disorders (32.3%), and cardiovascular conditions (26.7%). When grouped into system morbidities, higher prevalences were found for neuromuscular (47.8%), sleep & mental health (42.4%), and cardiometabolic (41.2%) systems. Our results suggest that system morbidities tend to cluster more frequently than expected by chance, with stronger associations for the pairs: sleep & mental health and gastrointestinal (OR: 3.6; 95% CI: 2.1–6.0), neuromuscular and gastrointestinal (OR: 3.3; 95% CI: 1.9–5.5), and sleep & mental health and neuromuscular (OR: 2.9; 95% CI: 1.9–4.6). The mean number of consultations for low back pain was 4.8 in one year. No significant differences were observed between health service use and the presence of specific comorbidities, system morbidities, or the number of comorbidities. Overall, the main findings of this thesis reveal high prevalence rates of multimorbidity among adults with CBP. Specifically, among Brazilian adults, the investigated NCDs were associated with worse activity limitation, greater health service use, and poorer self-rated health. Among Australian adults with CLBP, a high prevalence of comorbidities was also observed, but no association was found between comorbidities and health service use for low back pain. Finally, this thesis provides information on the need to consider the presence of NCDs and multimorbidity during the .assessment and management of patients with CBP and reinforces the importance of investigating care strategies for this patient profile