Abstract
Background
Depression has been associated with episodes of musculoskeletal pain. However, it is not clear whether such relationships could be mitigated according to the physical activity level.
Aim
To describe, during the COVID-19 pandemic, the relationship between depression and musculoskeletal pain according to the physical activity levels.
Design
Cross-sectional study.
Methods
This research was conducted in Brazil between May 5 and March 17, 2020. Participants (N = 1872; 58% women) were invited through social media to answer a structured online questionnaire. Depressive symptoms were assessed through self-report of perception of depression during quarantine. Musculoskeletal pain was assessed based on the Nordic questionnaire identifying nine possible pain points in the body. Physical activity was assessed based on the weekly frequency, intensity, and duration of each session of physical activity the participants engaged in during COVID-19. The logistic binary regression analyzed the associations between depressive symptoms and musculoskeletal pain according to the participants’ level of physical activity.
Results
Depressive symptoms were associated with pain in six different regions of the body in physically inactive participants. In physically inactive participants, those with depressive symptoms 1.51 (95% CI = 1.04-2.19) and 2.78 (95% CI = 1.81-4.26) times more likely to have pain in one or two and ≥three regions body regions, respectively. In active participants, depressive symptoms were not associated with pain.
Conclusion
During the COVID-19 pandemic, depression was associated with musculoskeletal pain in physically inactive participants.
Epidemiological surveys have reported that prevalence of depressive symptoms increased from 16.5% to 20.1% during the coronavirus disease (COVID-19) outbreak (
Huang and Zhao, 2020
; Wang et al., 2020
). It is hypothesized from these previous findings that poor mental health, particularly depression, is a secondary consequence of stay-at-home orders and social isolation during the COVID-19 pandemic, which has negatively affected psychological well-being of many (- Wang C.
- Pan R.
- Wan X.
- Tan Y.
- Xu L.
- Ho C.S.
- Ho R.C.
Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
International Journal of Environmental Research and Public Health. 2020; : 17
Sønderskov et al., 2020
).Depression has been associated with several health consequences, including physical pain (
IsHak et al., 2018
), mainly neck and low back pain (Angst et al., 2020
; Lobo et al., 2019
; Fernandez et al., 2017
; Zis et al., 2019
). Chronic pain has been reported as the main barrier to physical activity in adults (Boutevillain et al., 2017
), and body pain has negatively affected health-related quality of life (Kawai et al., 2017
). A high amount of daily sedentary activities is positively associated with both depressive symptoms (Stubbs et al., 2018
) and body pain (- Stubbs B.
- Vancampfort D.
- Firth J.
- Schuch F.B.
- Hallgren M.
- Smith L.
- Gardner B.
- Kahl K.G.
- Veronese N.
- Solmi M.
- Carvalho A.F.
- Koyanagi A.
Relationship between sedentary behavior and depression: A mediation analysis of influential factors across the lifespan among 42,469 people in low- and middle-income countries.
Journal of Affective Disorders. 2018; 229: 231-238
Mani et al., 2019
) among adults.Physical activity has been negatively associated with depressive symptoms (
Dugan et al., 2015
; Kim et al., 2018
) and chronic body pain (Šagát et al., 2020
; - Šagát P.
- Bartík P.
- Prieto González P.
- Tohănean D.I.
- Knjaz D.
Impact of COVID-19 quarantine on low back pain intensity, prevalence, and associated risk factors among adult citizens residing in Riyadh (Saudi Arabia): A cross-sectional study.
International Journal of Environmental Research and Public Health. 2020; 17: 7302
Geneen et al., 2017
; Puljak and Arienti, 2019
). However, evidence suggests that individuals have drastically altered their lifestyles, with a reduction in physical activity and an increase in sedentary activities, because of quarantine during COVID-19 (Hall et al., 2021
). It is possible that decreasing physical activity levels during the COVID-19 pandemic could make the adult population more vulnerable to the relationship between depressive symptoms and chronic pain. This study thus aimed to analyze the relationship between feelings of depression and pain in adults, according to physical activity levels during the COVID-19 pandemic.Methods
Ethics, Sample, and Study Design
This survey research was conducted in Brazil between May 5 and May 17, 2020. Participants were invited through social media (Facebook, Twitter, Instagram, and WhatsApp) to answer a structured electronic questionnaire using the Google Forms platform. The sample of this study consists of adults aged 18 years or over. This study was approved by the Universidade Nove de Julho Ethics Committee before data collection (CAAE #30890220.4.0000.5511). Participants did not identify themselves, and their answers were included in the sample only if they signed the statement “I agree to participate in the survey” before the protocol started (
Christofaro et al., 2021
). All procedures follow the national legislation and the Declaration of Helsinki. Inclusion criteria were age higher than 18 years old and respondingto all questions of the survey.An electronic questionnaire with 70 items was developed by senior researchers with experience in different areas (science, nutrition, human movement science, physiology, neuroscience and behavior, public health). This questionnaire was divided into seven domains: (1) personal information; (2) COVID-19 personal care; (3) physical activity; (4) eating behavior; (5) health risk habits; (6) mental health; (7) overall health. For the purpose of the present study, we selected information about (1) personal information, (3) physical activity, (5) mental health, and (6) overall health domains for analysis. Below, we discuss the questions used in the present analysis (
Diniz et al., 2020
; Lofrano-Prado et al., 2021
; Christofaro et al., 2021
; Tebar et al., 2021
).Depressive Symptoms
Depressive symptoms were assessed by asking a simple question: “With the COVID-19 pandemic, have you been feeling depressed?” The answer possibilities were arrayed in a Likert scale with the following options: no; a little; sometimes; often; very often. Subsequently, participants were dichotomized into those without depressive symptoms (no; a little; sometimes) and those with depressive symptoms (often; very often).
Musculoskeletal Pain
The adapted Nordic questionnaire was used to assess the presence of musculoskeletal pain in nine different parts of the body (neck, thoracic area, shoulders, elbows, wrists/hands, low back, hips/thighs, knees, ankles/foot;
Kuorinka et al., 1987
). This questionnaire was used because it is easy to apply and has been validated for the Brazilian population (de Barros and Alexandre, 2003
; Pinheiro et al., 2002
). Owing to the variation in the time of social isolation, we adapted the question from the Nordic questionnaire to “Are you feeling any body pain? If yes, where?The questions adapted from the Nordic questionnaire for use in this study are presented in Table 1.
Table 1Adapted issues from Nordic questionnaire questions used in the present study.
| Are you feeling any body pain? If yes, where? | ||
|---|---|---|
| Neck | Yes | No |
| Shoulders | Yes | No |
| Elbows | Yes | No |
| Wrists/hands | Yes | No |
| Upper back | Yes | No |
| Low back | Yes | No |
| Hips/thighs | Yes | No |
| Knees | Yes | No |
| Ankles/feet | Yes | No |
These questions were adapted from the Nordic questionnaire:
Kuorinka et al., 1987
.Physical Activity
Weekly physical activity was assessed as previously described (
Diniz et al., 2020
; Christofaro et al., 2021
). For the weekly physical activity coding, the daily time subjects reported as having spent engaged in moderate-to-high intensity physical activities was multiplied by the number of days per week that individual reported exercising. Those participants who reached 150 minutes or more of moderate to vigorous physical activity (MVPA) were considered “physically active,” whereas those with a weekly amount below this threshold were classified as “physically inactive,” according to global recommendations for the adult population (World Health Organization 2011
).Covariates
Information about gender (woman or man) and age (DD/MM/YYYY) was obtained. Weight (in kilograms) and height (in meters) were evaluated by self-report and used to calculate body mass index (BMI = kg/m²). Participants also reported their education level (elementary school, high school, college, or postgraduate).
Statistical Analysis
The sample characterization variables were presented according to frequency. The association between depressive symptoms and pain in different body regions was verified by the X square test, according to levels of physical activity. The magnitude of these associations was verified by binary logistic regression, simultaneously adjusted by gender, age, education level, and BMI.
In addition, clusters of pain in different body regions were created [i.e., a participant who reported pain in three different places on the body (lumbar, neck and knees)]. From this cluster, the following categories were created: (1) without pain; (2) pain in one or two regions of the body; and (3) pain in three or more regions of the body. The level of significance adopted was p < .05 and the confidence interval was 95%. The statistical package used was SPSS version 24.0
Results
The sample for the present study was composed of 1,872 participants (58% women, n = 1082), with a mean age of 37.8 ± 13.2 years and a mean BMI of 25.6 ± 4.5 kg/m². The prevalence of depression symptoms was higher in women (16.5%) than men (9.3%; p ≤ .001). Pain in one or more body regions was reported by 54.8% of participants; the lower back was the body region most reported to have pain (28.5%). Approximately 30% of the participants reported engaging in at least 150 minutes of moderate-to-vigorous physical activity in the week. Table 2 shows the characteristics of the sample.
Table 2General characteristics of the sample (N = 1872).
| % | 95% CI | |
|---|---|---|
| Depressive symptoms | 13.4 | 11.8-14.8 |
| Physical activity | 28.9 | 27.0-31.1 |
| Sex | ||
| Women | 57.8 | 55.6-60.0 |
| Men | 42.2 | 39.9-44.4 |
| BMI | ||
| Normal weight | 49.7 | 47.5-52.0 |
| Overweight | 50.3 | 48.0-52.5 |
| Education level | ||
| Elementary school | 0.5 | 0.2-0.8 |
| High school | 9.5 | 8.2-10.8 |
| College | 42.0 | 39.8-44.3 |
| Postgraduate | 48.0 | 45.7-50.2 |
| Body pain | ||
| Neck | 18.2 | 16.4-19.9 |
| Thoracic | 17.5 | 15.7-19.1 |
| Shoulder | 9.7 | 8.3-10.9 |
| Elbow | 2.7 | 2.0-3.5 |
| Wrist and hands | 7.6 | 6.4-8.8 |
| Low back | 28.5 | 26.6-30.6 |
| Hip/thigh | 6.0 | 5.0-7.1 |
| Knee | 13.8 | 12.3-15.4 |
| Ankle/foot | 5.8 | 4.9-7.9 |
CI = confidence interval; BMI = body mass index.
The magnitude of associations between depression symptoms and pain in different body regions according to physical activity level is shown in Table 3. Among physically inactive participants, it was observed that reporting pain in six of the nine body regions was associated with having depressive symptoms, with shoulders and knees being associated with the highest risk. Among physically active participants, reporting pain in only three of the nine body regions was associated with depressive symptoms (neck, thoracic area, and wrist and hands).
Table 3Association between depressive symptoms in adults and pain in different body regions according to level of physical activity during COVID-19 pandemic (N = 1872).
| OR | 95% CI | p value | |
|---|---|---|---|
| Inactive | |||
| Neck | 1.48 | 1.04-2.13 | .032 |
| Thoracic | 1.95 | 1.37-2.77 | ≤.001 |
| Shoulder | 2.41 | 1.55-3.75 | ≤.001 |
| Elbow | 1.96 | 0.84-4.55 | .118 |
| Wrist and hands | 1.44 | 0.87-2.42 | .159 |
| Low back | 1.42 | 1.07-2.07 | .018 |
| Hip/Thigh | 2.00 | 1.10-3.61 | .022 |
| Knee | 2.35 | 1.53-3.54 | ≤.001 |
| Ankle/foot | 1.30 | 0.69-2.43 | .411 |
| Active | |||
| Neck | 2.10 | 1.02-2.32 | .043 |
| Thoracic | 2.40 | 1.18-4.89 | .015 |
| Shoulder | 1.44 | 0.52-3.98 | .474 |
| Elbow | 2.24 | 0.45-11.13 | .321 |
| Wrist and hands | 2.71 | 1.06-6.87 | .037 |
| Low back | 1.03 | 0.52-2.03 | .926 |
| Hip/thigh | 0.53 | 0.12-2.30 | .397 |
| Knee | 0.67 | 0.29-1.57 | .365 |
| Ankle/foot | 0.94 | 0.27-3.28 | .923 |
Adjusted by sex, age, education level, and body mass index. OR = odds ratio; CI = confidence interval.
In this sample, participants who reported depressive symptoms and who were physically inactive presented a higher prevalence of pain in three or more body regions when compared to those participants who reported depression symptoms and were physically active (p ≤ .001).
In the multivariate analysis (Table 4), physically inactive participants with depressive symptoms were more likely to have pain in one or two regions of the body and ≥ three regions of the body, respectively. In physically active participants with depressive symptoms, no association was observed between depressive symptoms and pain.
Table 4Association between depressive symptoms and sum of the number of body regions with pain according to physical activity levels.
| Odds ratio | 95% CI | p value | |
|---|---|---|---|
| Inactive | |||
| No pain | 1.00 | 1.00 | |
| 1-2 regions of pain | 1.51 | 1.04-2.19 | .030 |
| ≥3 regions of pain | 2.78 | 1.81-4.26 | ≤.001 |
| Active | |||
| No pain | 1.00 | 1.00 | |
| 1-2 regions of pain | 1.07 | 0.57-2.01 | .821 |
| ≥3 regions of pain | 1.88 | 0.80-4.38 | .145 |
Adjusted by sex, age, education level, and body mass index.
Discussion
This study found that the presence of depressive symptoms during the COVID-19 quarantine was associated with musculoskeletal pain, both in physically inactive and physically active adults. However, participants who were physically inactive reported twice the number of body regions with pain. Depressive symptoms were associated with clustered pain in different body regions in physically inactive subjects, while in physically active subjects no association was observed.
This study was carried out during the COVID-19 quarantine, in which social isolation was mandated, and we observed a prevalence of 13.4% of depression symptoms. This prevalence was lower than that observed in a study with 7,236 Chinese participants, in which the prevalence of depressive symptoms was approximately 20% in the period under study (
Huang and Zhao, 2020
). It is possible that data collection for our study in Brazil occurred in a period of less spread of the disease than in China, where the pandemic started.With this elevated prevalence of depressive symptoms, along with mental health impairments, physical problems such as musculoskeletal pain can also arise, since an association between clinical depression and musculoskeletal pain of the low back, hip, or knee has been previously reported (
Angst et al., 2020
; Schwarze et al., 2019
). This association between depression and pain was reinforced in this study's findings, mainly in participants who were physically inactive, who were more likely to show an association of depression symptoms with pain in different body regions. Some mechanisms that can explain this relationship could be linked to neurotransmitters, such as serotonin and norepinephrine, which would make the connection between depression and pain (Sheng et al., 2017
). Another factor is that depressive symptoms could be linked to kinesiophobia, in which the fear of movement could predict disability (Bilgin et al., 2019
). Such relationships may have gotten stronger during COVID-19, with increase in mental health problems (Wang et al., 2020
).- Wang C.
- Pan R.
- Wan X.
- Tan Y.
- Xu L.
- Ho C.S.
- Ho R.C.
Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
International Journal of Environmental Research and Public Health. 2020; : 17
Encouraging physical activity is necessary, since it has been inversely correlated with depression symptoms (
Aguilar et al., 2021
; Ribeiro et al., 2020
; Yasunaga et al., 2018
) and pain (Geneen et al., 2017
; Scarabottolo et al., 2019
; Saraiva et al., 2020
). In our study, participants with depressive symptoms, but who were physically active during quarantine, reported pain in fewer body regions and were less likely to show association of depressive symptoms with body pain when compared to those who were physically inactive. Similar findings during the COVID-19 quarantine were also observed in a study of 463 adults in Saudi Arabia, in which low back pain was associated with insufficient physical activity (- Saraiva B.
- Pinto R.Z.
- Oliveira C.B.
- Zanuto E.F.
- Scarabottolo C.C.
- Delfino L.D.
- Suetake V.
- Gil F.
- Christofaro D.
Continuity of physical activity practice from childhood to adolescence is associated with lower neck pain in both sexes and lower back pain in girls.
Journal of Back and Musculoskeletal Rehabilitation. 2020; 33: 269-275
Šagát et al., 2020
). One possible reason for these findings is that physical activity contributes to the maintenance of muscle tone and strength, thus decreasing the chances of episodes of pain (- Šagát P.
- Bartík P.
- Prieto González P.
- Tohănean D.I.
- Knjaz D.
Impact of COVID-19 quarantine on low back pain intensity, prevalence, and associated risk factors among adult citizens residing in Riyadh (Saudi Arabia): A cross-sectional study.
International Journal of Environmental Research and Public Health. 2020; 17: 7302
Steffens et al., 2016
).Another possible reason for the protective role of physical activity in the association of depression symptoms and body pain is the release of pleasurable substances through physical activity, such as endorphins, which could cause analgesia to episodes of pain (
Chaudhry and Gossman, 2021
). In addition, the practice of physical activities, especially those with aerobic characteristics, could provide improvements in blood flow and successively decrease muscle stiffness (Gordon and Bloxham, 2016
).Several studies have reported the importance of maintaining physical activity during the COVID-19 pandemic (
Chen et al., 2020
; Jurak et al., 2020
). Based on the findings of our study, we reinforce the importance of the practice of physical activity for mental and musculoskeletal health benefits in addition to its potential to act on this relationship between mind and body. Social distancing remains important, but staying at home must be accompanied by physical activities, either through online guidance or in places without close proximity between people, for good health maintenance. Digital physical therapy for musculoskeletal pain care may also be an important alternative in social isolation periods (Dantas et al., 2020
).This study has some limitations. The cross-sectional design precludes our ability to know about depressive symptoms and pain of participants prior to COVID-19 pandemic, so it is not possible to assume that these relationships are a consequence of the quarantine period. The application of the questionnaire in an online and self-reported manner is another limitation, but we emphasize that it was necessary to do so in order to avoid contact with the participants, and to comply with the imposed quarantine and avoid possible risks of transmission of COVID-19. The fact that depressive symptoms were assessed by a single self-reported question can be considered another limitation. Positive aspects include the large sample size and the fact that, evaluating behaviors and symptoms during the quarantine period helps to better understand this phenomenon.
We suggest that future studies evaluate the relationship between pain and depressive symptoms longitudinally, considering these characteristics before the pandemic to verify a possible cause-and-effect relationships. Measuring physical activity objectively by means of accelerometry would be another way to improve data accuracy.
We observed that the relationship between depressive symptoms and pain was weaker in physically active subjects. We suggest that even during quarantine, the population should try to maintain the practice of physical activity at home, respecting the safety rules for COVID-19 provided by health agencies.
Declaration of Competing Interest
None.
Acknowledgements
To carry out the present study, a massive effort was necessary. The dissemination of the study on social media, as well as online data collection, was carried out in Brazil to evaluate the practice of physical activity, musculoskeletal pain, and depressive symptoms during the quarantine period during COVID-19. DGDC, WRT, GCRS, MDO, GGC, JPB, MAC, RMRD, MLP, and WLP participated with substantial contributions to the conception and design or acquisition of data or analysis and interpretation of data, as well as with the writing of the article or critical review of the intellectual content. It should be noted that all authors approved the final version of the manuscript.
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Article info
Publication history
Published online: August 08, 2021
Accepted:
July 31,
2021
Received in revised form:
July 5,
2021
Received:
February 3,
2021
Identification
Copyright
© 2021 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.
