key: cord-0733647-6ci4k9ka authors: Carpintero-Rubio, Carlos; Torres-Chica, Bárbara; Guadrón-Romero, María Alexandra; Visiers-Jiménez, Laura; Peña-Otero, David title: Perception of musculoskeletal pain in the state of confinement: associated factors date: 2021-06-28 journal: Revista latino-americana de enfermagem DOI: 10.1590/1518-8345.4894.3454 sha: 91a1b463ba1f3be1a0603ddb50d98398df254f96 doc_id: 733647 cord_uid: 6ci4k9ka OBJECTIVE: to describe the perception of musculoskeletal pain in the population and how the state of confinement (adopted as a measure to control contagion by COVID-19) has interfered with it, as well as identifying the sociodemographic, occupational, physical, and psychosocial factors involved. METHOD: an observational, cross-sectional and analytical study, with simple random probabilistic sampling, aimed at residents in Spain over 18 years old during the confinement period. An ad hoc survey was conducted, consisting in 59 items. RESULTS: a total of 3,247 surveys were answered. Persistent musculoskeletal pain or significant episodes thereof increased 22.2% during confinement. The main location was the spine (49.5%). The related factors were decreased physical activity, increased seated position, and use of electronic devices. The psychological impact of confinement was also related to the perception of musculoskeletal pain. CONCLUSION: the state of confinement causes an increase in the perception of musculoskeletal pain. The identification of a particularly sensitive population profile, as well as that of the related factors, allows establishing multidisciplinary approaches in health promotion. Musculoskeletal pain has a high prevalence in the population and some of its manifestations such as low back pain or neck pain are among the main causes of disability worldwide (1) (2) (3) . Its prevention and treatment constitute an important social and health challenge due to the deterioration that it generates in quality of life, the labor costs that it causes, and the health care required by people who suffer from it (4) (5) . Pain is an unpleasant sensory and emotional experience, associated with actual or potential tissue damage. It is subjected to the subjectivity of those who suffer it (6) and is multi-factorial, which requires a biopsychosocial and interdisciplinary approach (7) . In musculoskeletal pain there are multiple elements that can be involved, from damage in tissues of the locomotor system that triggers nociceptive pain, to others of a neuropathic or psychosocial nature. The latter influence the perception and experience of pain. Chronification of the painful experience can lead to central sensitization and allodynia (8) . To minimize transmission of the SARS-CoV-2 coronavirus, contain the progression of the COVID-19 disease and strengthen the public health system, on March 14 th , 2020, the Spanish Government declared the State of Alarm throughout the Spanish territory, according to Royal Decree 463/2020 (9) . Among the containment measures adopted was limiting the movement of people through public spaces, a situation that was strictly maintained until the entry into force of the "Plano de Desescalada" [De-escalation Plan] approved on April 28 th , 2020. In such a prolonged state of confinement, several elements can favor the appearance of musculoskeletal pain episodes or increase them if they are already present. On the one hand, physical inactivity, which causes atrophy of the skeletal muscles and supporting connective tissues (10) (11) . A pathognomonic relationship has been suggested between the severity of muscle atrophy and the development, for example, of low back pain (11) . Apart from that, sedentarism and immobility are factors that increase the stiffness of tendons, fasciae, ligaments, and muscles. Muscle stiffness has also been related to pain in conditions such as low back pain and neck pain (12) (13) . Another negative effect associated with sedentarism has to do with the impairment of somatosensory stimulation in the locomotor system. Poor proprioceptive stimulation favors the development of dystonias (14) (15) and of changes in neuromuscular control, situations that can cause excess muscle tension, restrictions in joint mobility, overloads and, pain (16) . In addition, as a consequence of sedentarism, body weight tends to increase, something that also conditions the perception of pain. It is known that the symptomatic treatment of overweight people lasts longer than that of normal weight subjects (17) , in addition to requiring higher analgesic doses (6) . During confinement there have been changes in the eating habits and behaviors mainly characterized by the increase in the intake of hypercaloric products (18) , which promotes an increase in the Body Mass Index (BMI) (19) . Another trigger for musculoskeletal pain is poor posture habits. Remote work or a leisure model based on the consumption of multimedia content and the use of mobile devices, favor the maintenance of deficient ergonomic positions during sustained periods, which can cause overloads and pain (20) . On the other hand, the implementation of extemporaneous exercises or sports activities, a generalized situation during confinement as an alternative to the usual physical activity (21) , can constitute another situation that generates overloads, injuries, and pain. The recommendations and advice focused on maintaining physical fitness have been very numerous during this period, so that a large number of people have begun to perform activities without proper conditioning or exceeding their functional abilities (22) . Finally, factors of a psychological nature such as anxiety or catastrophism also negatively modify the perception of pain (23) (24) (25) . Confinement has made it necessary to combine family care, remote work and domestic tasks, an unusual and complex reality for many families that has been able to increase the levels of anxiety and stress in both the child and adult populations. To this situation, on the one hand, a high degree of economic and labor uncertainty has been added (26) (27) and, on the other, the fear and insecurity generated by living with a health crisis of planetary magnitude, whose epidemiological data at a global level are alarming. The fear of resuming social interaction and habits prior to the pandemic can also increase stress, anxiety, and depression in the population (28) . In view of all the above, the objective of this study was to describe the perception of musculoskeletal pain in the population and how the state of confinement (adopted as a control measure for contagion by has interfered with it, as well as to identify the sociodemographic, labor, physical and psychosocial factors involved. An observational, cross-sectional and analytical study, with simple random and probabilistic sample, conducted in Spain. The recruitment period and field study Carpintero-Rubio C, Torres-Chica B, Gualdron-Romero MA, Visiers-Jiménez L, Peña-Otero D. with dissemination and subsequent answer to the survey was from May 1 st to May 11 th , 2020. The population studied consisted in individuals over 18 years old living in Spain. The selection criteria adopted were the following: people over 18 years of age living in Spain, with access to an electronic device with Internet (computer, tablet, mobile phone, etc.) and who voluntarily agreed to participate in the study after being invited to collaborate by answering The 95% confidence intervals were determined using the standard methods. A total of 3,247 surveys were received. The sociodemographic characteristics of the participants are presented in Table 1 . Rev. Latino-Am. Enfermagem 2021;29:e3454. Carpintero-Rubio C, Torres-Chica B, Gualdron-Romero MA, Visiers-Jiménez L, Peña-Otero D. with less duration and intensity. Table 3 presents the data related to the physical factors studied before and during confinement. In turn, the number of people who perceived symptomatic worsening increased in all the symptoms analyzed (Table 4) , consequently increasing the concern about whether these symptoms would disappear. Carpintero-Rubio C, Torres-Chica B, Gualdron-Romero MA, Visiers-Jiménez L, Peña-Otero D. According to the data presented in Table 5 , the relationship between the variables studied and pain before and during confinement is statistically significant (p<0.05). In turn, the existence of a positive correlation between pain during confinement and all the sociodemographic, physical, and psychosocial factors studied is observed (Table 5 ). prior to confinement and those corresponding to that period will be independently analyzed. Musculoskeletal pain prior to confinement and associated factors. The results obtained in relation to the main location of musculoskeletal pain converge with the epidemiological data published to date, which place low back pain and neck pain among the ten disorders with the highest incidence in the world population (30) . The least symptomatic locations were chest, abdomen, and head. It should be noted that, in more than half of the cases, pain was chronic, that is, lasting more than 6 months (31) , and with high intensity. These data reveal a problem that is often underestimated (32) (33) . The low percentage of individuals who, despite living with severe symptoms, resorted to Physiotherapy or Nursing professionals to receive treatment or consult their ailments is noteworthy. Chronic pain is especially striking in the aged population, where incidence is very high (34) (35) . The data obtained in this On the other hand, unskilled jobs carry a higher level of workload and physical demand than skilled jobs, which could have a negative effect on the musculoskeletal level. However, some characteristics of highly qualified jobs such as sedentarism or stress could be considered equally harmful to the locomotor system (36) . Regarding the relationship of pain with physical activity, the results obtained indicate that maintaining a regular level of activity constitutes an effective strategy in pain management (37) . In addition, high intensity training was more effective in pain control than light training. allostatic adaptations that increase their resistance to physical stress (38) , although too intense a training load could cause cumulative harms to the musculoskeletal system (39) . In the analyzed population, the presence of numerous psychosocial factors favoring the development of musculoskeletal symptoms was found, namely: restlessness, impatience, irritability, lack of concentration, fatigability, and sleep disorders. These elements are Carpintero-Rubio C, Torres-Chica B, Gualdron-Romero MA, Visiers-Jiménez L, Peña-Otero D. clearly related to usual pain in the population studied. The contextual factors of a psychosocial nature are valued in the management of musculoskeletal pain, coming to be considered as "yellow flags" on which social health care should fall (8) . In certain conditions such as chronic nonspecific low back pain, cognitive-behavioral treatment has come to be proposed as a priority therapeutic line (40) . factors. In general terms, the incidence of musculoskeletal women, and the existing gap has been reinforced (41) . It is likely that this situation, rather than having a direct impact on the physical load, has triggered or increased stressors of a psychological nature clearly related to the perception of pain. With regard to physical and sports activity, the musculoskeletal pain perceived during confinement shows a clear association with the increase, first of all, in the use of electronic devices (more than 8 hours a day); secondly, by staying in a seated position (more than 8 hours a day); and, finally, meager sports practice (less than 1 hour a day). These elements can be considered indicators of sedentarism (42) , a condition that causes, among other disorders, muscle atrophy and of the supportive skeletal tissues, increased myofascial stiffness, somatosensory deficits and, linked to all of the above, musculoskeletal pain (43) . During confinement, the practice of anaerobic activities and disciplines such as Yoga or Pilates increased, while the practice of aerobic activities decreased. It is worth noting the benefit of having a garden The most used non-pharmacological strategy was muscle stretching followed by the application of cold or heat. This indicates, on the one hand, the increased perception of muscle tension in the participants, something that could be related to psychological factors such as stress or sleep disorders, as well as to an increase in sedentary behaviors and prolonged posture maintenance (44) (45) . On the other hand, the perception of inflammation, hence the therapeutic resource of cryotherapy. These non-traumatic inflammatory processes can derive from the adoption of certain postures for a long time, for example, the seated position (46) . However, a traumatic origin of these conditions cannot be ruled out since, on numerous occasions, sports activities began to be practiced within the home inspired by generic recommendations from social networks or television programs (47) . It is possible that people were not sufficiently conditioned for this type of exercise or that the basic recommendations for a good practice without risk of injury were not followed. The onset, in some cases, and the increase in others, of the psychological symptoms in the population studied during confinement is very striking, that is, the influence that both the pandemic and the associated confinement have had on the emotional and behavioral stability of people (18) . A number of research studies during previous infectious outbreaks have revealed psychological repercussions on the population (48) . Feelings of loss of control and of being trapped in confinement are likely to substantially intensify the symptoms (48) . It is also necessary to highlight, as unavoidable, instability and uncertainty at the work level (a large majority of the participants were forced to work remotely, suffered some contractual regulation, or were fired), as well as the need to combine work/school obligations and recreational activities for all members of the family nucleus at home. In many cases, the insufficiency or obsolescence of computer equipment and Internet coverage would have to be added to the aforementioned, something that would only increase the levels of tension and perceived stress. Among the study limitations are both sample dispersion and female predominance. However, the high number of answers obtained makes it possible to define numerous features of the Spanish population that usually perceive musculoskeletal pain, as well as the influence that confinement has had on it. The present study provides new evidence on the high prevalence of musculoskeletal pain in the healthy population, as well as its complex multi-factoriality. It has been proven that many of the causal factors involved in the onset or aggravation of this type of symptoms are inherently present in a state of home confinement such as that which occurred during the COVID-19 pandemic in 2020. Rev. Latino-Am. Enfermagem 2021;29:e3454. The results obtained in this study will make it possible to adapt health promotion and prevention strategies from a biopsychosocial perspective that ultimately improve the quality of life of the population. Likewise, these could be extrapolated internationally, across populations with similar characteristics, given that the pandemic continues to require more or less restrictive confinement measures worldwide, in order to contain the spread of the virus. Confinement has caused an increase in the perception of lumbar and cervical pain in women, especially in those over 65 years of age, with the following related factors: reduction in the intensity and duration of aerobic physical activity, increase in the use of electronic devices, increase in the permanence in a seated position, and worsening of the psychosocial symptoms. 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