Problems and Functional Disabilities Among Patients with Cervical Disc and Relationship with Low Back Pain

Background: cervical disc disorder is associated with many problems and functional disabilities which affect quality of life for patients. Neck pain is as common as low back pain which are considered from associated problems with cervical disc. Aim: This study was conducted to assess problems and functional disabilities among patients with cervical disc and relationship with low back pain. Design and Setting: A descriptive exploratory correlational study design was used and data were collected from Physical Medicine and Rehabilitation Department and it's affiliated out patient clinic of Tanta Main University Hospital. Sample: Purposive sampling of (90) patients from previous mentioned setting during follow-up period. Tools: Three tools were used for data collection: Tool (I); Sociodemographic and Medical data of the patients, Tool (II); Neck Disability Index scale to examine the degree of disability resulted from cervical disc and its effect on daily activities. Tool (III); RolandMorris Low Back Pain and Disability Questionnaire to assess pain-related disability resulting from low back pain. Results: As a result of this study, the majority (66.7%) of the patients had complete level of neck disability and (82.2%) of them had high level of disability due to low back pain. Moreover the majority of the patients (67.6%) had high level of disability due to low back pain associated with complete neck disability due to cervical disc. Significant positive correlation was noted between total score of neck disability index and total score of rolandmorrislow back pain and disability.Conclusion and Recommendation: These results indicate that majority of the patients had complete level of neck disability and high level of disability due to low back pain. Significant positive correlation was noted between total score of neck disability index and total score of roland-morrislow back pain and disability. Further research must be done in many settings to evaluate whether disability prevention or interventions can improve functional disabilities.

reported having low back pain also reported having neck pain due to cervical disc that are supported its relationship (Green etal., 2001).
Low back pain affects about 60% to 80% of the adult population. Many studies documented that the causes of low back pain often are very difficult to determine, for up to 85% of patients, no specific cause can be found (Hart etal., 1995;Deyo & Tsui-Wu 1987;Barr & Harrast 2007). Low back pain is major health problems that are caused by variety of pathologies such as degenerative disc disease as cervical disc, annular tears, and loss of disc height or collapse which can result in abnormal motion of the segment and biomechanical instability causing pain (Pengel etal., 2003;Frelinghuysen etal., 2005). Low back pain is known to be associated with degeneration of the spinal motion segment. Degeneration is thought to initiate in the intervertebral disc with subsequent degeneration that are occurring in the facet joints (Katz 2006;Pereira etal., 2017). Although cervical disc degeneration occurs frequently with aging, and may be asymptomatic in most cases but in certain instances it can cause severe LBP (Edgar 2017;Balagué etal., 2012).
The first line of the management for cervical disc disease is evaluation of patients that are carried out with assessment of neurological symptoms (complaints) and signs (examination of neurological deficits) (Epstein & Hollingsworth 2017). Physical therapy is a major treatment option for cervical disc in addition to medication to control pain. The therapist can use cervical traction to restore mobility through exercises and manipulation of the muscles to reduce pain, stiffness and correct postures to help for improving complaints especially low back pain (Kim 2019). If pain, numbness, tingling or weakness persists beyond six to eight weeks, surgery may be indicated (Gilbert 2019). It is very important that cervical disc patients take precautions regarding passive manipulation of the cervical spine because such forceful movement on the cervical spine can increase arm pain, numbness, weakness, with potentially catastrophic results (Gilbert 2019;Nadri & Ramandi 2016;Yan etal., 2016).
Cervical neck pain and low back pain together could cause abstinence in competition and substantially affect patient's functional status which impede their quality of life (Farahbakhsh etal., 2018), and lead to physical impairments and psychosocial disturbance which are including pain, impairments in the cervical range of motion, low self-efficacy, depression, sickness-related absences were associated with neck disability and low back pain (Saavedra-Hernandez etal., 2012). Evaluating these functional disabilities that are associated with cervical disc and low back pain is a pressing demand in nursing management of patients with vertebral disorders or vertebral disfunctions in order to best manage injuries and prevent further disabilities (Farahbakhsh etal., 2018). Therefore the aim of this study was to assess problems and functional disabilities among patients with cervical disc and relationship with low back pain.

Significance of the study
Cervical disc disorders cause severe neck pain which are leading to weakness or numbness from shoulders down to arms and descending to cause back pain (Brannen 2018). Patient may experience low back pain due to several factors which is increased over time. Cervical disc and low back pain may be interferes with physical functional capacity, quality of life and leads to limitations of daily activities among patients which increased need for understanding long-term outcome in patients after cervical disc and its' association with low back pain in order to optimize the clinical interventions and enhance the epidemiological research in the future and permit for these patients to life without surgery.

Aim of the study
The study was conducted to assess problems and functional disabilities among patients with cervical disc and relationship with low back pain.

Research questions
To fulfill the aim of the study the following research questions were formulated -what are the problem and functional disabilities experienced by patients with cervical disk? -what are the problems experienced by patients during low back pain? -What is the relationship between cervical disk and low back pain?

Subjects
Purposive sampling of (90) patients who are visiting the previous mentioned setting during follow-up period. The sample size was estimated by using Epi Info Software Statistical package created by World Health Organization and Center for Disease Control and Prevention, Atlanta, Georgia, USA version 2002 according to the following parameters; Total target population size= 400 patients, confidence level= 99.9%, expected frequency= 50%, accepted error= 5% and confidence coefficient =95%. The acceptable sample size was 90 patients.
Inclusion criteria for the patients -Both gender.
-All patients were preoperative in the acute and chronic stage.
-Educated patients and able to drive.
Exclusion criteria for the patients -Patients with decompensated liver cirrhosis, rheumatoid arthritis and osteoporosis.

Tools of data collections
Three tools were used to collect data for this study. These tools aimed to assess problems and functional disabilities among patients with cervical disc and relationship with low back pain. Tool (I): Sociodemographic and Medical data of the patients:-It was comprised of two parts:-Part (1): Socio-demographic characteristics of patients: which includes; patient' code, age, gender, marital status, occupation, educational level, place of residency, smoking. Part (B): Patients' clinical data:-: It was developed by the researchers to assess patients' clinical data regarding; presence of neck pain, low back pain, headache, neck stiffness, numbness, upper limb weakness, burning sensation, stabbing sensation, disturbance of the balance, limping when walking, diabetes and hypertension. Scoring system: clinical data scored as the following; if the problem present scored (1) and if the problem absent scored (0).

Tool (II): Neck Disability Index scale (NDI):
Neck Disability Index scale was developed by Vernon & Mior (1991). It was modified by the researchers according to literature reveiew (Macdermid etal., 2009;Stratford eta., 2009;Young 2010;Lucas hoving 2003). Neck Disability Index was designed to assess limitations of the cervical spine function during everyday activities. The NDI is comprised of 10 questions regarding: pain intensity, personal care, lifting, sleeping, driving, recreation, headache, concentration, reading and work, each item is expressed by 6 different assertions scored from 0-5, with 0 indicating no disability, 1 indicating mild disability, 2 indicating moderate disability, 3 indicating fairly severe disability, 4 indicating very disability and 5 indicating highest disability. Total scoring; ranged between 0-50. The following guide used for interpretation of patients score: 0-4= no disability, 5-14=mild disability, 15-24= moderate disability, 25-34= severe disability and 35 or over= complete disability.

Tool (III): Roland-Morris Low Back Pain and Disability Questionnaire (RMQ):
Roland-Morris Low Back Pain and Disability Questionnaire was developed by (Roland & Morris (1983;Stratford etal., 1996;Baker eta., 1989;Grotle etal., 2004;Lauridsen etal. 2006;Roland & Fairbank 2000). The RMQ is comprised of 24-item patient-reported outcome measure that inquires about pain-related disability resulting from low back pain. The Roland-Morris Questionnaire (RMQ) is a self-administered disability measure in which greater levels of disability are reflected by higher numbers on a 24-point scale. The RMQ has been shown to yield reliable measurements, which are valid for inferring the level of disability, and to be sensitive to change over time for groups of patients with low back pain. Scoring system; Items are scored 0 if left blank or 1 if endorsed, for a total RMQ score ranging from 0 to 24 where zero (indicating no dis-ability) and 24 (indicating severe disability).

Ethical consideration
An official permission was obtained from the Head of the Physical Medicine and Rehabilitation Department and its affiliated Out patient Clinic of Tanta Main University Hospital. Informed consent was taken from every patient after clarifying the procedures and the purpose to participate in the study. They were informed about confidentiality of data collection, their right to refuse participation and to withdraw at any time without any consequences. A code number was used instead of name.

Methods of data collection
1-Tools of the study were developed by the researchers after reviewing relevant literature and used to collect data except tool (II) Neck Disability Index scale was developed by Vernon & Mior (1991) and tool (III) Roland-Morris Low Back Pain and Disability Questionnaire was developed by Roland and Morris (1983).
2-The tools were tested for its content validity by a jury of five experts in the area of Medical Surgical Nursing and Physical Medicine and Rehabilitation, Their opinions were elicited regarding tools format and consistency, it was calculated and found to be = (98%). The reliability for the study tools was calculated by Cronbach's alpha test; it was 0.887 for tool (1) part B and 0.910 for tool (II) and 0.87 for tool (III). 3-A pilot study was carried out to test the study tools. It was conducted on 10% of the total sample size to test the feasibility and applicability of the tools, evaluate the research plan and to determine any obstacles that may encountered during the period of data collection, accordingly, needed modification was done. The pilot patients were excluded from the study sample. 4-All Tools of data collection were translated into Arabic language because the study subjects had different levels of education. 5-This study was conducted at the beginning of November 2018 to February 2019. 6-Procedure of data collection:--Patients were invited to participate in the research study at the morning shift while they were waiting physiotherapy session in the Physical Medicine and Rehabilitation Department and it's affiliated out patient clinic of Tanta Main University Hospital during follow up period. The researchers were contacted with each patient who arrived to clarify importance of the research and take consent.
-The data were collected from the patients in the special room, started by using tool (I): part (A) and (B) to collect baseline data and Tool II and Tool III to assess the degree of disability resulted from cervical disc pain and painrelated disability resulting from low back pain.
-Sheet was distributed on the attending patients, each of them was asked to complete assessment sheets and return them to the researchers in the same visiting.
-Instructions were provided to the patients about how the questions should be answered. Each question answered and a mark was allocated for each suitable answer. The researchers were available for any explanations and checking each questionnaire after the completion, to be sure that there were no missed items.
-The researchers were collected the questionnaire sheets personally at the end of time. Each participant was taking approximately 30 minutes to complete all sheets.

Methods of data analysis
All data were collected, coded, tabulated and subjected to statistical analysis. Statistical analysis is performed by statistical Package SPSS in general (version 20), also Microsoft office Excel is used for data handling and presentation. Descriptive statistics including frequency distribution, means and standard deviation, suitable statistical analysis was utilized: probability of errors was p<05.  Table (1) showed the distribution of studied patients' relevant to their socio-demographic characteristics. As regards age, the table revealed that nearly half of the patients (43.3%) were in the age group (41-≤ 50) with and more than half of them (62.2%) were male. Regarding marital status, the table revealed that about (61.1%) of patients were married. As for occupation the majority of them (42.2%) were employers. Also the majority of them (46.7 and 43.3%) were secondary and university educated respectively. Majority of patients (53.3%) were from city and (52.2%) were smokers. Showed the distribution of the studied patients according to their levels of low back pain related disability. The table showed that the majority of the patients (go up stairs more slowly than usual, avoid heavy jobs around the house, avoid heavy jobs around the house, only stand up for short periods, have to hold on to something to get out of an easy chair, change position frequently to be comfortable, walk more slowly, appetite is not very good, find it difficult to get out of a chair, lie down to rest more often, and more irritable and bad tempered with people than usual as following; (85.6 , 85.6 ,84.4, 84.4 , 83.3 ,83.3 ,81.1 , 80, 78.9,and 78.9 %) respectively. Part B ; Showed the total levels of low back pain and disability among studied patients . The table showed that majority (82.2%) of the patients had high level of disability due to low back pain, whereas (17.8%) of the patients had had low level of disability due to low back pain with highly significant value at P < 0.05. showed the relationship between patients' total level of neck disability and total level of low back pain related disability. The table revealed that the majority of the patients (67.6%) had high level of disability due to low back pain associated with complete neck disability due to cervical disc with not significant difference.  : showed the relationship between socio-demographic characteristics of the studied patients and their level of low back pain and disability. The table showed that there was significant relationship between age and level of low back pain and disability at P <0.05. whereas there was no significant relationship between sex, marital status, occupation, educational level, place of residency and level of low back pain and disability.   Table (8): showed the correlation between total score of neck disability and total score of low back pain and disability and socio-demographic characteristics of the studied patients. The table showed that there was a significant correlation between age and gender, marital status, smoking, total score of neck disability index scale and total score of back pain and disability where p= P < 0.05 and < 0.01. While there was a high significant positive correlation between total score of neck disability and total score of low back pain and disability where p= P < 0.05 and < 0.01.

Discussion
Cervical disc often results in neck pain for affected patients as a result of direct impingement of nerve roots and associated inflammatory processes (Carette & Fehlings 2005). Disc provides stability and allowing a relatively wide range of motion in all directions in the neck and low back. When a disc starts to lose its strength and pliability, however, it can cause a range of painful and potentially debilitating symptoms (Stephen & Falatyn 2018). This study aimed to assess problems and functional disabilities among patients with cervical disc and relationship with low back pain.
Concerning to socio-demographic data of the patients, the study results revealed that the majority of patients were in the age group (41-≤ 50) years / old and more than half of them were male. For about marital status, the findings revealed that majority of patients were married and nearly half of them were employers, also the majority of them were secondary and university educated in addition to nearly half of them were from city and smokers. These results were in the same line with Bremerich etal., (2008;Clair & Edmondston 2009) who mentioned that in their study about neck pain, the mean age for the study was relatively young (39 years) in comparison with other validity studies, where the mean age of patients ranged from 38 to 65 years and majority of the sample were female Also this result was supported by Karl and Cshane (2001) who mentioned that in their study about disability in patients with cervical disorders, the majorty of the patient were in the age group (41-50) years old but the majority of study sample were female and also they are workers. Moreover, this result in the same line with Nadri and Fasih (2016) who reported that about (55.4%) of the study subjects was male with mean age 38.2 ± 6.6. In addition to Adedoyin etal., (2004) who mentioned that in their study about neck pain as a result of cervical disc, the age range of the study subjects that participated was between 21 and 68 years/ old and this is consistent with the age range of patients affected by neck pain in most epidemiological studies Regarding to medical data of the patients, the study finding showed that the majority of patients had neck and low back pain and suffered from; headache, neck stiffness, numbness, upper limb weakness, burning and stabbing sensation, aches, disturbance of balance and limping when walking and had history of diabetes and hypertension. These results were in the same line with Hansson and Jensen (2004) who reported that the most frequent complaints of patients with cervical disorders are neck pain, headache, burning senation, numbness as common as low back pain. Also Elowitz (2018) mentioned that patients with cervical (neck) disc suffered from neck pain that radiates down the arms to the hands, muscle spasms numbness, tingling, or weakness in the arms, hands, or fingers, balance problems and arm or leg weakness, cramping.
Regarding to level of neck disability, the finding of the study revealed that the majority of the patients suffered from fairly severe pain and, feel problem with lift anything, also had moderate problem regarding headache and concentration. For about work, driving, sleeping and recreation also the majority of the patients had fairly severe problem. Moreover the finding revealed that more than half of the patients had complete level of neck disability with highly significant p value P < 0.05. This results may be attributed to when disc is injured due to any cause, it can lead to severe neck pain due to inflammation or muscle spasm and without normal discs the spine would be very stiff during motion which affect any acivity for the patients.
These results were in the same line with Blozik etal., (2009) Who reported that the severity of cervical neck pain and the related disability can affect daily social and functional activities of the patients, ability to lift any thing, driving and reading, which may even also involve emotional and psychological aspects. Also Croft etal., (2009) reported that the physical factors that are associated with neck pain included heavy lifting, turning head during driving viewing television, carrying things and dressing, static work posture, vibrations, repetitive jobs and a high work pace.
Furthermore Leak etal., (1994) mentioned that cervical neck pain affect the main functional activities of the patients as; using phone, looking up to search things and daily work, sleep, lack of ability to concentrate, focus and feelings of anxiety. On the other hand this result was in contrast with Eftekhar etal., (2013)who mentioned that about 53.5% and 44.2% of the patients had mild and moderate disability index where they have more pain when sitting, standing and lifting, traveling and social life are difficult for resulted from neck pain, respectively.
Concerning to level of low back pain related disability. The finding of the study revealed that the majority of the patients (go up stairs more slowly than usual, avoid heavy jobs around the house, avoid heavy jobs around the house, only stand up for short periods, have to hold on to something to get out of an easy chair, change position frequently to be comfortable, walk more slowly, appetite is not very good, find it difficult to get out of a chair, lie down to rest more often, and more irritable and bad tempered with people than usual) . These results may be attributed to low back pain-related disability affects different aspects of daily life and provokes mental suffering which lead to decrease ability of the patients to keep up their professional activities and tend to take distance from social contact and avoid leisure activities.
Moreover more than three quarter of the patients had high level of disability related to low back pain with highly significant p value P < 0.05. These results were in the same line with Iorio etal., (2007) who reported that study sample of low back pain had more disability in shopping, taking a bath, doing the laundry, doing heavy household chores, cutting toenails, and carrying a shopping bag compared with participants who did not report frequent low back pain. Also Walsh etal., (2008) reported that the majority of participants experience moderate to severe disability due to low back pain, a high level inspected when compared to studies that evaluated disability in workers with musculoskeletal disorders.
In addition to Reid etal.,(2005) who mentioned that low back pain (LBP) had a negative impact on the functional status and working ability in the young and adult population. Also Kose & Hatipoglu (2012) reported that patients with low back pain experience physical disabilities due to pain. Their daily living activities such as weight lifting, self-care, and walking for the surgical treatment group and social life, sleeping, sitting, and standing are affected by these disabilities and the intensity of pain affects the level of disability. Moreover Ilyas & Dharmaji (2012) mentioned that about 74.4% and 25.6% of the studied dentists had mild to moderate disability index resulted from Low back pain which affect their ability to perform their work.
Concerning to the relationship between patients' total level of neck disability and total level of low back pain and disability. The finding of the study result revealed that majority of the patients had high level of disability due to low back pain associated with complete neck disability due to cervical disc. This result was in contrast with Guez etal., (2002) who reported that neck-related pain among population has been reported to be as high as 67% with up to 54% of the associated with low back pain. Also Iorio etal.,(2007) reported that the association between low back pain and neck pain disability was substantially weakened and no longer statistically significant when the results of performance-based tests are introduced in the models. Moreover, Misterska etal.,(2017) reported that low back pain -related disability coexists with restrictions experienced due to neck pain.
Regarding to the relationaships between sociodemographic characteristics of the studied patients and their low back pain related disability and their level of neck disability .This study showed significant relationship between age, educational level and level of neck disability where as there was no significant relationship between sex, marital status, occupation, place of residency and level of neck diability and low back diability. On other hand, there were significant relationship between age and level of low back pain and disability.
These results were in the same line with Nadri and Fasih (2016) who reported that there was no significant difference in the relationship between the prevalence of LBP and neck pain with sex, marital status and work habits, also LBP founded in 40% of patients and classified as severely disabling. In addition, severe neck pain had the highest percentage (46.5%). Also Fejer and Hartvigsen (2008) who reported that there was moderate relationship between neck pain, low back pain intensity and disability were seen in all socio-demographic variables Moreover Paul etal., (2016) reported that there were significant relation among occupations or activities of daily living Roland Morris Disability scores where patient need to decrease activity to achieve a functional state. Also Vigatto etal., (2007) reported that the mean neck disability index score observed indicates moderate disability, similar to findings in a study of a population with CLBP. Also Fejer and Hartvigsen (2008) who reported that relation between neck and low back pain and disability were moderate and increased with an increasing factors related to consequences of NP as sociodemographic charactersitics.
Regarding to correlation between total score of neck disability and total score of low back pain related disability and socio-demographic characteristics of the patients. The result showed that there was a significant correlation between age , gender, marital status, smoking, total score of neck disability and total score of low back pain and disability .While there was a high significant positive correlation between total score of neck disability and total score of low back pain related disability,there were in the same line with Misterska etal.,(2017) who reported that there were significant intercorrelations were found between cervical disc neck and lower back painrelated disability.
Moreover Emily etal.,(2011) mentioned that Correlations were found with pain, disability and driving task scores patients but duration of symptoms, age and gender did not have a significant association with NDI scores. Also Misterska etal.,(2017) who reported that significant correlation was discovered between the level of education and NDI total score. Moreover, the level of education was found to be associated with pain severity, social interaction and disability. In addition to Yue and Liu (2012) found a positive correlation between the duration of occupational sitting and occurrence of neck pain and low back pain. In contrast Fejer and Hartvigsen (2008) there was weak association between total level of neck and total level of low back pain duration and disability which indicates that pain duration is a poor indicator of the level of disability.

Conclusion
Based on the findings of the present study, it can be concluded that: -The majority of the cervical disc patients had complete level of neck disability with highly significant p value. Also more than three quarter of the patients had high level of disability due to low back pain with highly significant p value P < 0.05. -The majority of the patients had high level of disability due to low back pain associated with complete neck disability due to cervical disc. -High significant positive correlation were noted between total score of neck disability index scale and total score of roland-morrislow back pain and disability questionnaire.

Recommendations
Based on the finding of the present study, the researchers recommended: -Further research must be done to evaluate whether disability prevention or reduction interventions can minimize this problem, improving these patients' functionality.
-Clinical guideline strategies must be designed for cervical disc patients and included in the routine hospital care to help to manage of spine disabilities. -Furthermore, a deeper understanding of the dimensions of suffering and how it influences functional disability may be used to optimize treatment.

Limitations of this study:
The limitations of this study were decreased sample size who achieve inclusion criteria of the research as educated patients and able to drive which increase time for data collection.