Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : July | Volume : 15 | Issue : 7 | Page : KC01 - KC06 Full Version

Prevalence of Fatigue and its Association with Pain Intensity, Psychological Status and Sleep Quality in Patients with Neck Pain


Published: July 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/48613.15104
Mosab Aldabbas, Tarushi Tanwar, Iram Iram, Zubia Veqar

1. PhD Student, Department of Physiotherapy, Jamia Millia Islamia, New Delhi, India. 2. PhD Student, Department of Physiotherapy, Jamia Millia Islamia, New Delhi, India. 3. PhD Student, Department of Physiotherapy, Jamia Millia Islamia, New Delhi, India. 4. Associate Professor, Department of Physiotherapy, Jamia Millia Islamia, New Delhi, India.

Correspondence Address :
Zubia Veqar,
Jamia Nagar, Delhi, India.
E-mail: veqar.zubia@gmail.com

Abstract

Introduction: Neck Pain (NP) is a major public health problem. Social and economic participation of many individuals gets negatively impacted due to NP. Fatigue and pain are common complaints in patients with this condition. Both can interfere with the daily life of patients by affecting the quality of sleep which can lead to psychological issues. But, the prevalence of fatigue and its association with pain, sleep quality and psychological factors have not been examined properly in patients complaining of NP.

Aim: To examine the prevalence of fatigue and its association with pain intensity, depression, anxiety, and sleep disturbance in patients with NP.

Materials and Methods: A cross-sectional study on 296 NP patients with a mean age of 30±7.2 years (181 males and 115 females) was conducted between March 2019 till November 2019. It was conducted at the Physiotherapy Department of the University and Amarjyoti College of Physiotherapy. The Multidimensional Fatigue Inventory (MFI), Hospital Anxiety and Depression, Pittsburgh Sleep Quality Index (PSQI) and Numeric Pain Rating Scale were used to evaluate fatigue, depression and anxiety, sleep quality and pain intensity, respectively. Spearman’s rank correlation coefficient and Mann-Whitney U test were used for analysis.

Results: The point prevalence rate of severe fatigue in participants was 39.86%. Fatigue was significantly related with pain intensity, psychological factors, and sleep quality (p<0.05). We also observed a significant association between sleep quality and psychological factors in this sample (p<0.05).

Conclusion: Fatigue was a prominent factor in patients with NP and it was associated with pain intensity, depression, anxiety, and sleep disturbance. Prevalence of fatigue was higher in chronic stage of NP than in the acute sage. Identifying these factors may help in prevention and management of NP and its co-morbidities.

Keywords

Acute neck pain, Anxiety, Chronic neck pain, Depression, Fatigue symptoms, Sleep disturbances

Neck pain is a disabling musculoskeletal condition which frequently hinders the daily activities of patients (1). One-year prevalence rate for NP ranges between 4.8% to 79.5% (2). It causes significant financial burden for the individual as well as the community (3). There are different physiological and psychosocial factors involved in NP (4). Fatigue is one of these factors that could be involved in NP (5). Fatigue is a complicated phenomenon and there is hardly an exact definition (6). However, it has been defined as a subjective and internal feeling of tiredness that could or could not be related to physical activity. It can become chronic, thereby hampering daily routine activities (7).

Fatigue has as a deleterious impact on mental and physical health; it may impair or delay the recovery process and cause psychological impairments (8) as well as sleep disturbances (9). It has also been found to be closely associated with pain intensity, and that association could be aetiological in nature for chronic pain participants (10).

A few studies have demonstrated a correlation between fatigue and depression as well as sleep disturbances in Chronic Low Back Pain patients (CLBP) and fibromyalgia (11),(12),(13). For example, high prevalence of fatigue was observed in CLBP (11). Poor sleepers have reported higher fatigue and pain level in comparison to good sleepers which depict an association between fatigue and sleep disturbance in CLBP (14). A strong association between fatigue and depression has been also reported in CLBP (12). However, such associations are poorly documented in NP. There is a dearth of studies for fatigue and its association with depression, anxiety, and sleep disturbance in NP patients. A more thorough research of the complexities of fatigue, psychological factors, and sleep disturbances is essential for the development of targeted interventions for treatment of NP.

As far as we know, no previous research has appropriately investigated the prevalence of subjective fatigue in acute and chronic stage of NP which is also an important concern in patient management. A thorough knowledge of the associations between all these factors would be useful in understanding and explaining how these factors interrelate and lead to high costs and sufferings.

Therefore, the objectives of the present study was two-fold: To study the prevalence of fatigue in acute and chronic stage of NP and secondly, to understand the relationship between fatigue, pain intensity, psychological factors, and sleep disturbances in NP patients. In this study, It has been hypothesised that NP participants will have a high prevalence of fatigue and that the fatigue would have a significant association with pain intensity, quality of sleep and psychological factors.

Material and Methods

A cross-sectional survey of NP patients was conducted at the Centre for Physiotherapy and Rehabilitation Science, Jamia Millia Islamia and Amarjyoti College of Physiotherapy in New Delhi, India over a period of 10 months (March to December 2019) in New Delhi, India. The study received ethical approval from the Ethics Committee of the University (19/2/210/JMI/IEC/2019) prior to its commencement and was performed in accordance with the Helsinki Declaration (1964). The study was also registered under the clinical trials registry (CTRI/2019/09/021028).

Sample size calculation: A sample of 296 participants (181 males and 115 females) with NP was arrived at using free open-source epidemiological statistics toolset (OpenEPI) by using the data of prevalence of fatigue in low back pain patients (11). The number of participants were determined within a design effect of 1.0, and a confidence interval limit of 95%, and an anticipated frequency of 26%.

A total of 402 participants with NP were screened and finally 296 were recruited after applying inclusion and exclusion criteria.

Inclusion criteria: Participants in acute (<3 months) and chronic (>3 months) stage of pain (15); participants aged 18 years and older; no spine surgery in the preceding year; preserved communication; and working knowledge of English, were included in this study.

Exclusion criteria: Cancer; acute or chronic medical conditions; and any medication or disease that precluded informed consent, were excluded from the study.

Study Procedure

The principal investigators diligently screened and assessed the participants for eligibility. All the patients were explained about the procedure in detail and they were informed about their right to withdraw at any time during the study. They gave their written informed consent before enrollment for the study. Socio-demographic data was collected from NP participants which included questions about age, height, weight, body mass index, gender, marital status, level of education, income, and employment status (retired, employed, applicant). Questions related to lifestyle (physical activity status, smoking, alcohol consumption, coffee, and tea) were also asked. Each participant was required to complete MFI, Hospital Anxiety and Depression Scale (HADS), PSQI, and Numeric Pain Rating Scale.

Outcome Measures

Fatigue: Fatigue was assessed by MFI. It is a self-reporting tool aimed to ascertain subjective fatigue (16). It contains 20 items, purporting to assess five fatigue subscales: general fatigue, physical fatigue, mental fatigue, reduced activity, and reduced motivation. Each subscale contains five points. Each subscale has a score range between 4 and 20 and the total score range is between 20 and 100. A higher score indicates a higher level of fatigue. A score of ≥13 in general fatigue domain or ≥10 in reduced activity domain have been identified as an indicator of severe fatigue (17). In the present research, the score of general fatigue subscale was preferred and used to indicate severe fatigue as previously recommended (16). The MFI is a psychometrically suitable questionnaire to assess fatigue, with high internal consistency and validity (16).

Psychological factors: Depression and anxiety were examined by HADS. It is a valid self-rating scale that rates the level of depression and anxiety (18). HADS consists of 14 items, seven of which refer to anxiety and the other seven to depression. Each question has four possible answers, corresponding to scores between 0 and 3. Therefore, the score for classification of depression and anxiety ranges from zero to 21 points: 0-7 indicating no depression and anxiety symptoms, 8-10 indicating mild symptoms, score range between 11-14 indicating moderate depression and anxiety, and finally, a score of ≥15 reflecting severe depression and anxiety symptoms (19). HADS has performed consistently well in evaluating the severity of depression and anxiety symptoms in psychiatric and somatic primary care patients and the general population (20).

Sleep quality: The PSQI was administered to assess quality of sleep in NP patients. It is a self-reporting questionnaire that asks participants to describe their sleep quality in the one-month (21). The PSQI has been widely and extensively used among different populations for clinical and research purposes. The PSQI contains 19 questions, distributed into seven components that accumulatively form a global score of PSQI. These seven components relate to: sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleeping medications and daytime dysfunction. Each component has a score range from 0-3. And the total score is made up from the sum of the scores obtained from the seven components giving a cumulated score range between 0-21; the higher the score, greater is the sleep disturbance. A score of more than five depicts a poor quality of sleep (21).

Pain intensity: Pain intensity was evaluated by using 11-point Numerical Pain Rating Scale (NPRS). The NPRS asks participants to rate their pain from 0-10, wherein 0 means “no pain” and 10 means the “worst possible pain”. The NPRS is easy to administer and has been widely used in research and in different musculoskeletal conditions. It has a good validity, and previous research demonstrates a positive and significant association of NPRS with other measures of pain intensity (22).

Physical activity: The level of physical activity was screened by asking “In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate. This may include activities such as brisk walking or cycling for recreation but should not include activities that could be part of your job”. The question has a valid open-response ranging from zero to seven days in the past week (23). This question has shown moderately validity and demonstrated strong repeatability, suggesting that this single item has the potential for screening participants for a range of physical activity interventions (23).

Statistical Analysis

Initially, the distribution of data was checked by Kolmogorov-Smirnov test as the data was not normally distributed. The data was entered into a database and analysed using the SPSS-version 21. The associations between fatigue, pain, sleep, and psychological factors were measured using Spearman’s correlation coefficient, at an alpha level of less than 0.05. Mann-whitney U test was used for comparisons of fatigue prevalence, depression, anxiety, and sleep disturbance between (acute-chronic) NP participants, and between male and female participants.

Results

Prevalence of fatigue in NP Patients

Among the recruited participants, 167 patients had chronic (duration >3 months) and 129 had acute (duration <3 months) pain. A 41.7% of the participants were married, 94% had completed at least graduation level, and 43.7% were employed. The average age of participants was 29.85±11.1 years and the average present pain intensity was 4.84±1.7. Demographic and clinical characteristics of NP patients are represented in (Table/Fig 1).

Overall, 118 participants (39.86%) presented MFI general fatigue of >13 and therefore, 115 (38.85%) participants were classified as severely fatigued (Table/Fig 2). When the data was divided into two groups (acute stage and chronic stage), we observed that participants in acute and chronic stage of NP differ considerably in regard to the level of fatigue. A higher prevalence of fatigue (49.1%) was documented among chronic NP patients as compared to 27.1% prevalence point of fatigue in acute NP patients (p<0.05). No significant gender difference was noted in fatigue severity p>0.05 (Table/Fig 2).

Psychological factors, sleep disturbance and physical activity status in NP patients

More than half of the participants reported sleep disturbances, and anxiety symptoms, and almost half of the participants reported depressive symptoms. The results did not reveal a gender difference in depression, anxiety and sleep disturbance p>0.05, but significant differences were observed between chronic and acute stage of NP in which chronic NP patients reported more depressive and anxiety symptoms as well as sleep disturbances p<0.05 (Table/Fig 3), (Table/Fig 4). An analysis of the association between psychological factors and sleep quality shows a significant association between these factors. Only 14% of the sample were physically active, and 86% did not meet the minimum recommended level of physical activity that is 150 minutes of moderate-intensity aerobic physical activity throughout the week (24).

Correlations of Pain Intensity, Anxiety and Depression and Sleep with Fatigue

The Global score and all MFI domains except mental fatigue are significantly correlated with pain intensity (p<0.005). A significant correlation was also found between the Global fatigue score and its domains with psychological factors (p<0.005). Also, all fatigue domains and Global MFI score were significantly associated with quality of sleep (p<0.005). In addition, a significant association of psychological factors with sleep quality was observed (p<0.005) (Table/Fig 5).

Discussion

The study was designed to examine the prevalence of fatigue in acute and chronic stage of NP and to assess if there exists any correlation of fatigue with depression, anxiety, and sleep disturbances. Up to the best of our knowledge, no prior studies have examined the prevalence of subjective fatigue among acute and chronic NP patients. The current study reveals that fatigue is a notable problem in NP. The fatigue prevalence in this sample was high (39.86%), which is higher than chronic fatigue syndrome observed in the general population which is 9.9% and 0.9% (25). A previous study with a smaller sample of chronic NP patients (N=33) documented that, fatigue is a significant complaint in chronic NP patients (5). The study was the first study that used fatigue inventory to clearly document fatigue in chronic NP and CLBP patients. The results and discussion of this study mainly relied upon the data gathered from CLBP patients (N=175) rather than the chronic NP patients (N=33). Moreover, the said study recruited only chronic pain participants (5). A high prevalence rate of fatigue has also been observed among CLBP patients which were 26% and 70% (11),(12), respectively.

In the present study, the data was divided based on gender (male or female), and the stage of NP (acute or chronic). It was found out that there were no differences in fatigue based on gender; however, there was a significant difference in fatigue between acute and chronic stage of NP. Fatigue is a prominent complaint among both acute and chronic stage of NP, but participants in the chronic stage reported significantly higher fatigue level compared to those in the acute stage of NP. There is a broad body of literature (17 high quality articles) evaluated by Fishbain DA et al., 2003, which points to a significant relationship of fatigue level with pain intensity across various clinical conditions (10). A previous study conducted on rheumatic arthritis patients also reported a significant association between fatigue and pain (26). A recent study similarly reported strong and significant association of pain severity with fatigue level amongst CLBP patients (27). The present results, therefore, support previous studies on the association of pain with fatigue.

The aetiopathogenesis of fatigue symptoms is not well-known. However, the structures that are related to pain physiology can explain the fatigue-pain association. Involvement of structural lesions that impair the normal process of activations in pathways linked the higher cortical centre and basal ganglia, thalamus, limbic system (28). These similarities may explain the close association between fatigue and pain found in the relevant literature. Previous findings have shown that improvement in fatigue level could be secondary to reduction in pain intensity (29). And this association could be aetiological in nature, as previous literature suggests that fatigue reduction is mediated by pain reduction, night pain, and sleep interference (9),(10).

One of the most remarkable findings to emerge from the present results is the significant association of fatigue domains with depression, anxiety, and sleep disturbance in this population. The association between fatigue with depression and anxiety seems to be important, as both symptoms perpetuate fatigue (30). It has been demonstrated that higher depression scores are linked with an aggravation of fatigue (31). It is also essential to consider that fatigue is one of the diagnostic criteria for depression (32). Fewer studies in the literature have examined the relationship between fatigue symptoms and anxiety. The evidence could appear to indicate that anxiety is linked with poor fatigue prognosis (33), so delineating the exact nature of the association may be complicated and requires further research.

Proposing the association between fatigue and sleep disturbance would appear intuitive, as it is logical that fatigue leads to sleep disturbance or vice versa. However, the nature of their relationship is not well-documented. However, previous studies have noticed that there is a relationship between the magnitude of fatigue observed and corresponding disturbances (34). The most persuasive evidence concerning the association between fatigue and sleep disturbance emerges from the experimental study, which demonstrated an increased level of fatigue with experimentally created sleep deprivation (35),(36). It is essential to consider that there seems to be a complex interrelationship association between fatigue and sleep (35). It’s also important to consider that none of the studies in the literature were found to exactly determine whether sleep disturbance has a direct impact on fatigue, or this association could be mediated through the increased level of pain that was found after poor sleep (37).

These finding highlights that, little is known about the existence of fatigue and its association with depression, anxiety, and sleep disturbance in patients with NP. These results have a significant value for understanding the determinants of NP and for improving and managing the signs and symptoms associated with it. Our results are in accordance with results reported by Fishbain DA et al., 2004 that observed an association between depression and fatigue in CLBP patients and chronic NP patients (5). The study reported that depression is a significant predictor of fatigue in CLBP and chronic NP patients. Furthermore, depression was strongly associated with fatigue in CLBP patients (12).

There is scarcity of research on the association between fatigue and sleep in NP patients. The present findings demonstrate a significant association between fatigue and sleep. Interesting, results obtained by Moxham EG, 1999, have shown that sleep disturbance mediates the association between fatigue and pain in fibromyalgia patients (38). Similar findings have also been observed in fibromyalgia patients in which fatigue was significantly associated with sleep disturbance (13). A recent study conducted by Saravanan A et al., 2019, reported that CLBP co-exists with fatigue, sleep disturbance, and depression (27).

The present study findings regarding the psychological factors and sleep quality in NP patients are also important. The results show that symptoms of anxiety, depression and sleep disturbance are prominent and significantly correlated in NP patients. Presence of depression was reported as significant predictor for sleep disturbance in chronic pain participants (39). Prior findings have revealed a significant association between depression and sleep disturbance in CLBP (40). The present findings also show that symptoms of anxiety, depression and sleep disturbance, are more prominent in chronic stage of NP than acute stage.

The results of the index study may provide a crucial data on the pathogenesis of acute and chronic NP. Generally, it is believed that the exact cause of NP is not known, although there is consensus that the most likely causes of NP are multi-factorial in nature. Many patients with NP who suffer with chronic pain also state that in the early history of their illness, the symptoms were simply acute, and then later evolved into a long-term condition. In the last few decades, efforts have been made to identify patients with acute pain who are at high risk to develop chronic pain. This process of identification has significant theoretical and clinical importance. Previous research has recognised the role of psychosocial factors such as depression and anxiety in the pathophysiology of acute and chronic pain and in the transition from acute to chronic pain conditions (41). The present results supplement the existing literature about the transition from acute to chronic stage of NP. The results show that fatigue, depression, anxiety, and sleep disturbances are more prominent in chronic stage of NP than acute stage, thus implying that the above-mentioned factors might have a role in the aetiology of acute NP as well as in the transition from acute to chronic stage of NP. Therefore, management of these factors is probably essential in preventing or controlling the symptoms of NP. The present study results establish a link between fatigue, depression, anxiety, and sleep disturbance thus prompting us to suggest treating these symptoms as early as they are diagnosed.

This study highlights the role of fatigue, depression, anxiety, and sleep disturbance in NP. Appropriate intervention for these factors may help in decreasing pain associated co-morbidities in NP. Our findings suggest that fatigue management, reduction of depression and anxiety symptoms, and restoration of healthy sleep might be beneficial to NP patients to reduce their pain or to reduce his/her vulnerability to develop more severe stages of pain. The higher incidence of fatigue in chronic NP can also be used as a predictor for the development of chronicity. Consequently, improving these co-morbidities could reduce vulnerability to NP, and allow therapeutic interventions to be used more effectively.

Limitation(s)

The present study did not include objective methods for assessing fatigue and other variables. Because of the large sample size, it was difficult to take care of all the confounders such as age, stress, fear, and pain catastrophising. Future research may address these limitations, using a different methodology that allows substantiating this association.

Conclusion

The current study found a relatively high prevalence of fatigue in NP patients. Pain intensity, anxiety, depression, and sleep were significantly associated with fatigue. Further research is required to determine the factors that might be associated with fatigue in NP patients. It seems that the relationships among these variables suggest that an indirect pathway exists between them, but further research is required to extensively investigate this issue. Fatigue, sleep disturbance, and psychological factors in NP are quite unexplored and poorly understood. Future research needs to further substantiate this association and to examine the prognostic capacities of these factors. Further interventional and cross-sectional studies are required to investigate when and how these factors develop and how they interrelate and impact the pain intensity. Moreover, further research explaining the effect of different treatment approaches on these factors are needed.

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DOI and Others

10.7860/JCDR/2021/48613.15104

Date of Submission: Jan 20, 2021
Date of Peer Review: Apr 07, 2021
Date of Acceptance: Apr 30, 2021
Date of Publishing: Jul 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

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