Correlation of short form 36 health survey with other relevant clinical scores in patients with degenerative lumbar spinal stenosis

Siddharth Gupta; Tungish Bansal; Abhishek Kashyap; Sumit Sural; Vishal Kumar

doi:10.4103/jodp.jodp_57_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 6 | Issue : 2 | Page : 132-136

Correlation of short form 36 health survey with other relevant clinical scores in patients with degenerative lumbar spinal stenosis

Siddharth Gupta¹, Tungish Bansal², Abhishek Kashyap³, Sumit Sural³, Vishal Kumar⁴
¹ Department of Orthopaedics, ESIC Medical College and Hospital, Faridabad, Haryana, India
² Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
³ Department of Orthopaedics, Maulana Azad Medical College New Delhi, India
⁴ Department of Orthopaedics, PGIMER, Chandigarh, India

Date of Submission	10-Jul-2022
Date of Decision	20-Dec-2022
Date of Acceptance	23-Dec-2022
Date of Web Publication	3-May-2023

Correspondence Address:
Tungish Bansal
Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_57_22

Abstract

Study Design: Observational study. Objectives: To investigate the correlation of Short Form Health Survey (SF-36) score with various relevant clinical scoring systems, in patients with degenerative lumbar spinal stenosis (LSS). Materials and Methods: Eighty-two patients aged more than 40 years with clinicoradiological features suggestive of degenerative LSS were enrolled. All patients completed 10 clinical scoring questionnaires, which included SF-36, Oswestry Disability Index, Swiss Spinal Stenosis (SSS) Questionnaire, Quebec Pain Disability, Visual Analog Scale (VAS) (back pain), Modified Japanese Orthopaedic Association (mJOA), Pain Disability Index (PDI), Self-paced Walking Test (SPWT), VAS (leg pain), and Neurogenic Claudication Outcome Score. A comparison of 8 health concepts of SF-36 and health change was done with other 9 clinical scores and they were statistically analyzed and correlated. Results: The mean age was 53.02 years and included 51 females (62.2%) and 31 (37.8%) males. Out of 8 health concepts, 3 of them, pain, emotional well-being, and energy/fatigue, showed a statistically significant moderate correlation with 6 clinical scores (SSS, QPD, VAS back pain, mJOA, PDI, and SPWT) (P < 0.05, r > 0.3). The mJOA scale showed a moderate negative correlation with 4 other components also namely, role limitations due to physical health, role limitations due to emotional problems, social functioning, physical functioning as well as health change (P < 0.05, r > 0.3). Role limitations due to physical health had a moderate negative correlation with QPD scale also (P < 0.05, r > 0.3). Conclusions: Pain, emotional well-being, and energy/fatigue showed a moderate correlation with maximum number of scores and mJOA scale had a moderate negative correlation with 7 out of 8 components of SF-36 as well as Health change.

Keywords: Lumbar canal stenosis, Modified Japanese Orthopaedic Association, Neurogenic Claudication Outcome Score, Oswestry Disability Index, Short Form Health Survey-36, Visual Analog Scale

How to cite this article:
Gupta S, Bansal T, Kashyap A, Sural S, Kumar V. Correlation of short form 36 health survey with other relevant clinical scores in patients with degenerative lumbar spinal stenosis. J Orthop Dis Traumatol 2023;6:132-6

How to cite this URL:
Gupta S, Bansal T, Kashyap A, Sural S, Kumar V. Correlation of short form 36 health survey with other relevant clinical scores in patients with degenerative lumbar spinal stenosis. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jun 4];6:132-6. Available from: https://jodt.org/text.asp?2023/6/2/132/375550

Introduction

Degenerative lumbar stenosis is primarily a disease of the elderly and usually has a chronic and progressive course which directly affects the quality of life of patient. There is an increasing consensus that health-related quality of life measures are a necessary tool for assessing the outcome of spinal stenosis.^[1] Subjective self-assessment by the patient is becoming important as many of the interventions are done primarily to improve the quality of life of the patient.^[2]

Clinical score like Visual Analog Scale (VAS)^[3],[4] concentrate on the pain aspect of the disease. Other scores like Oswestry Disability Index (ODI)^[5],[6] score, Quebec pain disability (QPD)^[7] score and Pain Disability Index (PDI)^[8] quantify the disability associated with lumbar spinal stenosis (LSS). The Modified Japanese Orthopaedic Association (mJOA)^[9] score mainly looks at the neurological component and Self-paced Walking Test (SPWT)^{[10],[11],[12]} is objective measure of the claudication distance. Disease-specific scores such as Neurogenic Claudication Outcome Score (NCOS)^[13] and Swiss Spinal Stenosis (SSS)^{[11],[14],[15]} questionnaire are also being used. The traditional clinical outcome scales do not take into account the patient's experience, perception and the direct effect on quality of life. Therefore, it is not clear if they can gauge the effectiveness of health interventions in long term in term of quality of life.^[16] Moreover, there is a paucity of studies suggesting compatibility among these vast number of scales.^[1]

The Short Form Health Survey (SF-36) is one of the most frequently used questionnaires for assessing health-related quality of life in spinal disease patients.^[17],[18] It measures both physical disability and mental disability, which has been validated in various studies.^[16],[19] Being a vast generic scale, its correlation to other condition-specific scores is not well established.^{[16],[20],[21]}

Hence, we designed this study to compare the SF-36 health concepts with the traditional clinical scores for a better understanding of its use in the assessment of lumbar canal stenosis patients.

Materials and Methods

A total of 82 patients aged more than 40 years attending the outpatient department of our hospital with clinicoradiological features suggestive of degenerative LSS over a period of around 1.5 years were recruited for the study. The clearance for the study was obtained from the Institutional Ethics Committee (IEC/2020/361) and consent was obtained from all the patients.

The inclusion criteria were patients aged 40 years or more with clinical symptoms of LSS such as neurogenic intermittent claudication, leg pain and/or neurological deficit including motor weakness/numbness/bladder and bowel incontinence; magnetic resonance imaging (MRI) findings suggestive of degenerative LSS like hypertrophy of the ligamentum flavum, degenerative disc prolapse and facetal hypertrophy. The exclusion criteria included primary canal stenosis including achondroplasia, traumatic, dysplastic and isthmic causes of canal stenosis; congenital spine anomalies, prior lumbar spine surgery, polyneuropathy, osteoporosis with kyphotic deformity/vertebral collapse and proven vascular claudication.

Each of these patients was subjected to a lumbosacral spine MRI and was assessed using clinical scoring systems as described below.

Short Form Health Survey (SF-36):^{[17],[22],[23],[24]} Results were displayed in form of 8 health concepts (physical functioning, bodily pain, role limitations due to physical health problems, role limitations due to personal or emotional problems, emotional well-being, social functioning, energy/fatigue, and general health perceptions) and a separate item - Health change. These scores were calculated as per instructions^[17] in the range of 0–100 with 0 being the worst and 100 being the best health status
ODI:^[6],[25] Scores from all 10 sections were added (0-5) and a sum was recorded out of maximum 50
SSS Questionnaire:^{[11],[14],[15]} There were 18 questions divided into 3 sections. Postmanagement questions were excluded. Hence, only 2 sections (12 questions) were asked. Each score added to give a total score out of 53 (instead of 77)
Quebec Back Pain Disability Scale:^[5],[7] There were 20 questions with scores ranging from 0 to -5. These were added to give a total score out of a maximum of 100
VAS^[3],[4],[26] (Back pain and Leg pain): The VAS scale was shown to patients depicting various faces in order of severity of pain. The chosen number from 1 to 10 was recorded
mJOA:^{[9],[27],[28]} There were 4 sections. Score from each was added to give a total score from a maximum of 18
PDI:^[8],[29] This scale had 5 items each ranging from 0 to 10 in order of increasing disability. All 5 were added to give a total score from a maximum of 50. The score is recorded as a percentage out of 100
SPWT:^[10],[12] This test was administered by measuring the claudication distance traveled by the patient
NCOS:^[13],[30] There were 8 questions. Scoring of every section was recorded and added to give a total sum out of 100 with 100 being the best health status.

Data entry and statistical analysis

The collected data were transformed into variables, coded, and entered into Microsoft Excel. Data were analyzed and statistically evaluated using the SPSS-PC-22 version (IBM Armonk, New York, USA). Quantitative data were expressed in mean and standard deviation, whereas qualitative data were expressed in percentage. The Spearman's correlation coefficient was used to see the correlation between two quantitative variables. P < 0.05 was considered statistically significant. The value of r ≥ 0.7 was considered strong correlation, 0.7 > r ≥ 0.3 was considered moderate correlation, and r < 0.3 was considered weak correlation.^[31]

Results

The mean age was 53.02 ± 9.18 years. Among the selected patients, 51 (62.2%) were female and the rest 31 (37.8%) were male. A total of 33 patients (40.2%) were aged <50 years, 22 (26.8%) were between 50 and 59 years, and 27 (32.9%) of more than 60 years. A single level was involved in 25.6% of patients (21), 47.56% (39) had two-level involvement, and three or more levels were involved in 22 (26.8%) patients based on imaging. The mean, median, standard deviation, and range for all clinical scores are represented in [Table 1] and [Table 2]. The SF-36 components were correlated with other eight clinical scores and correlation coefficient and P value for significance was recorded in each case [Table 3].

Table 1: The mean, median, interquartile range, standard deviation, and range for all clinical scoring systems (excluding Short Form Health Survey-36) in lumbar spinal stenosis patients (n=82)

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Table 2: The mean, median, interquartile range, standard deviation and range for Short Form 36 Health Survey in lumbar spinal stenosis patients (n=82)

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Table 3: The correlation coefficients (r) and P value for comparison among various Short Form Health Survey-36 components and other clinical scoring systems

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Out of eight health concepts of SF-36, pain, emotional well-being, and energy/fatigue had a significant moderate negative correlation with SSS questionnaire, QPD scale, VAS, and mJOA. PDI and moderate positive correlation with Self-paced Walking Test. mJOA scale had a moderate negative correlation with 4 other components, namely, role limitation due to physical health, role limitations due to emotional problems, social functioning and physical functioning, as well as the health change. Furthermore, we found that QPD scale had a moderate negative correlation with role limitations due to physical health.

Other scores such as NCOS, ODI VAS leg pain had weak or no correlation with any of the SF-36 components. The general health component of SF-36 had weak or no correlation with any of the clinical scores.

Discussion

A wide variety of clinical scores are available that can be used to assess the status of the lumbar canal stenosis patients. These scores concentrate on different aspects of the disease and have overlapping measurement scales.^[5],[11] Some scales are pain specific like VAS^[3] and some are disability associated like ODI, QPD, and PDI.^[5],[7] There are few condition-specific scores like SSS^[11] questionnaire and NCOS.^[13] Self-paced Walking Test and mJOA^[9] score show neurological involvement. None of these scores clearly defines the health-related quality of life of the patient, which has increasing significance in modern society.^[21] SF-36 scale being the most widely used scale in spine disorders clearly defines the quality of life of the patient using eight health concepts (Physical functioning, Role limitations due to physical health, Role limitations due to emotional problems, Energy/fatigue, Emotional well-being, Social functioning, Pain and General health) for which validity is confirmed by various studies.^[16],[19]

In our study, none of the health concepts had a strong (r > 0.7) correlation with any of the clinical scores. Although, 3 of them, Pain, Emotional well-being and Energy/fatigue had moderate correlation with SSS, QPD, VAS, mJOA, PDI, and SPWT.

According to Guilfoyle et al.,^[16] VAS score had a strong correlation with bodily pain (r = −0.71, P < 0.01). Haro et al.^[2] correlated VAS with SF-36 scales both preoperatively and postoperatively. For low back pain VAS, there was no significant correlation in preoperative period; however, in postoperative, physical functioning, Role limitations, Bodily pain and General health showed significant strong correlation (r > 0.6). For lower limb VAS, Physical functioning and Role limitations due to emotional problems correlated with the lower-extremity VAS score before surgery. Physical functioning, Role limitations due to physical health, Pain and Emotional well-being significantly correlated after surgery. However, we could find a significant moderate negative correlation of VAS back pain with pain (r = −0.434), emotional well-being (r = −0.361), and energy/fatigue (r = −0.386).

According to Boden et al.,^[21] The Physical components the SF-36 showed preoperative correlations of −0.429 (P < 0.001) with ODI, and the strength of this correlation increased postoperatively. Similarly, the preoperative Mental components of the SF-36 showed moderate inverse correlations with ODI of −0.433 (P < 0.001). This correlation also increased across postoperative time. When comparing SF-36 with VAS scores, only a weak correlation appeared preoperatively. No significant correlation appeared at any postoperative time point. Ko and Chae^[32] also suggested a moderate correlation between ODI and SF-36. DeVine et al.^[20] found no strong correlation between ODI, VAS, and SF-36. The moderate correlations were between the VAS back pain change scores and the SF-36 physical composite score change scores (r = 0.67). However, in our study, ODI showed no significant correlation with any of the SF-36 components and VAS back pain showed a moderate correlation with 3 components.

Apart from this, we also found that Modified JOA scale had a moderate negative correlation with role limitations due to physical health and emotional problems, energy/fatigue, emotional well-being, social functioning, pain and physical functioning as well has single item health change. Maximum correlation was found with physical functioning (r = -0.559). Many of the disease-specific scores like ODI and NCOS showed no significant correlation with any of the SF-36 components.

Due to a paucity of studies comparing disease-specific clinical outcome scales with quality of life scales like SF-36, clinicians and researchers have to calculate a number of comprehensive scores to determine the impact of LSS. In our study, we have provided a detailed comparison of various clinical scales specific to LSS with SF-36 components. However, we understand the limitations of our study like small sample size, only preoperative assessment, and effect of comorbidities on SF-36 outcomes.

Conclusions

Pain, emotional well-being, and energy/fatigue showed a moderate correlation with maximum number of scores and mJOA scale had a moderate negative correlation with 7 out of 8 components of SF-36 as well as health change. Hence, SF-36 scale can be used to assess quality of life in LSS patients although further studies are required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Zanoli G, Jönsson B, Strömqvist B. SF-36 scores in degenerative lumbar spine disorders: Analysis of prospective data from 451 patients. Acta Orthop 2006;77:298-306.
2.	Haro H, Maekawa S, Hamada Y. Prospective analysis of clinical evaluation and self-assessment by patients after decompression surgery for degenerative lumbar canal stenosis. Spine J 2008;8:380-4.
3.	Klimek L, Bergmann KC, Biedermann T, Bousquet J, Hellings P, Jung K, et al. Visual analog scales (VAS): Measuring instruments for the documentation of symptoms and therapy monitoring in cases of allergic rhinitis in everyday health care: Position paper of the German society of Allergology (AeDA) and the German society of allergy and clinical immunology (DGAKI), ENT section, in collaboration with the working group on clinical immunology, Allergology and environmental medicine of the German society of otorhinolaryngology, head and Neck surgery (DGHNOKHC). Allergo J Int 2017;26:16-24.
4.	Reips UD, Funke F. Interval-level measurement with visual analogue scales in Internet-based research: VAS Generator. Behav Res Methods 2008;40:699-704.
5.	Fritz JM, Irrgang JJ. A comparison of a modified oswestry low back pain disability questionnaire and the Quebec back pain disability scale. Phys Ther 2001;81:776-88.
6.	Tonosu J, Takeshita K, Hara N, Matsudaira K, Kato S, Masuda K, et al. The normative score and the cut-off value of the oswestry disability index (ODI). Eur Spine J 2012;21:1596-602.
7.	Kopec JA, Esdaile JM, Abrahamowicz M, Abenhaim L, Wood-Dauphinee S, Lamping DL, et al. The Quebec back pain disability scale. Measurement properties. Spine (Phila Pa 1976) 1995;20:341-52.
8.	Chibnall JT, Tait RC. The pain disability index: Factor structure and normative data. Arch Phys Med Rehabil 1994;75:1082-6.
9.	Fukui M, Chiba K, Kawakami M, Kikuchi S, Konno S, Miyamoto M, et al. Japanese orthopaedic association cervical myelopathy evaluation questionnaire (JOACMEQ): Part 4. Establishment of equations for severity scores. Subcommittee on low back pain and cervical myelopathy, evaluation of the clinical outcome committee of the Japanese orthopaedic association. J Orthop Sci 2008;13:25-31.
10.	Lee SI, Park E, Huang A, Mortazavi B, Garst JH, Jahanforouz N, et al. Objectively quantifying walking ability in degenerative spinal disorder patients using sensor equipped smart shoes. Med Eng Phys 2016;38:442-9.
11.	Pratt RK, Fairbank JC, Virr A. The reliability of the shuttle walking test, the Swiss spinal stenosis questionnaire, the oxford spinal stenosis score, and the oswestry disability index in the assessment of patients with lumbar spinal stenosis. Spine (Phila Pa 1976) 2002;27:84-91.
12.	Rainville J, Childs LA, Peña EB, Suri P, Limke JC, Jouve C, et al. Quantification of walking ability in subjects with neurogenic claudication from lumbar spinal stenosis – A comparative study. Spine J 2012;12:101-9.
13.	Azimi P, Mohammadi HR, Montazeri A. An outcome measure of functionality in patients with lumber spinal stenosis: A validation study of the Iranian version of neurogenic claudication outcome score (NCOS). BMC Neurol 2012;12:101.
14.	Comer CM, Conaghan PG, Tennant A. Internal construct validity of the Swiss spinal stenosis questionnaire: Rasch analysis of a disease-specific outcome measure for lumbar spinal stenosis. Spine (Phila Pa 1976) 2011;36:1969-76.
15.	Tomkins CC, Battié MC, Hu R. Construct validity of the physical function scale of the Swiss spinal stenosis questionnaire for the measurement of walking capacity. Spine (Phila Pa 1976) 2007;32:1896-901.
16.	Guilfoyle MR, Seeley H, Laing RJ. The short form 36 health survey in spine disease – Validation against condition-specific measures. Br J Neurosurg 2009;23:401-5.
17.	Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-83.
18.	Bombardier C. Outcome assessments in the evaluation of treatment of spinal disorders. Introduction. Spine (Phila Pa 1976) 2000;25:3097-9.
19.	Stoll T, Kauer Y, Büchi S, Klaghofer R, Sensky T, Villiger PM. Prediction of depression in systemic lupus erythematosus patients using SF-36 mental health scores. Rheumatology (Oxford) 2001;40:695-8.
20.	DeVine J, Norvell DC, Ecker E, Fourney DR, Vaccaro A, Wang J, et al. Evaluating the correlation and responsiveness of patient-reported pain with function and quality-of-life outcomes after spine surgery. Spine (Phila Pa 1976) 2011;36:S69-74.
21.	Boden SH, Farley KX, Campbell C, Boden SD, Gottschalk MB. Rational selection of patient-reported outcomes measures in lumbar spine surgery patients. Int J Spine Surg 2020;14:347-54.
22.	Wu AW, Hays RD, Kelly S, Malitz F, Bozzette SA. Applications of the medical outcomes study health-related quality of life measures in HIV/AIDS. Qual Life Res 1997;6:531-54.
23.	Brazier J, Roberts J, Deverill M. The estimation of a preference-based measure of health from the SF-36. J Health Econ 2002;21:271-92.
24.	Franks P, Lubetkin EI, Gold MR, Tancredi DJ, Jia H. Mapping the SF-12 to the EuroQol EQ-5D index in a national US sample. Med Decis Making 2004;24:247-54.
25.	Fairbank JC, Pynsent PB. The oswestry disability index. Spine (Phila Pa 1976) 2000;25:2940-52.
26.	Kelly AM. The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain. Emerg Med J 2001;18:205-7.
27.	Yonenobu K, Abumi K, Nagata K, Taketomi E, Ueyama K. Interobserver and intraobserver reliability of the Japanese orthopaedic association scoring system for evaluation of cervical compression myelopathy. Spine (Phila Pa 1976) 2001;26:1890-4.
28.	Benzel EC, Lancon J, Kesterson L, Hadden T. Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. J Spinal Disord 1991;4:286-95.
29.	Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The pain disability index: Psychometric and validity data. Arch Phys Med Rehabil 1987;68:438-41.
30.	Suyasa IK, Adiwardhana IG, Setiawan I. A comparison of neurogenic claudication outcome score and oswestry disability index in degenerative lumbar spinal canal stenosis post decompression, posterior stabilization and fusion. Int J Orthop Sci 2018;4:409-11.
31.	Dancey CP, Reidy J. Statistics without maths for psychology. US: Pearson education; 2007.
32.	Ko S, Chae S. Correlations between the SF-36, the oswestry-disability index and Rolland-Morris disability questionnaire in patients undergoing lumbar decompression according to types of spine origin pain. Clin Spine Surg 2017;30:E804-8.