Sex, Gender, and Pain: A Review of Recent Clinical and Experimental Findings

Low back pain is an extremely common problem that most people experience at some point in their life. While substantial heterogeneity exists among low back pain epidemiological studies limiting the ability to compare and pool data, estimates of the 1 year incidence of a first-ever episode of low back pain range between 6.3% and 15.4%, while estimates of the 1 year incidence of any episode of low back pain range between 1.5% and 36%. In health facility- or clinic-based studies, episode remission at 1 year ranges from 54% to 90%; however, most studies do not indicate whether the episode was continuous between the baseline and follow-up time point(s). Most people who experience activity-limiting low back pain go on to have recurrent episodes. Estimates of recurrence at 1 year range from 24% to 80%. Given the variation in definitions of remission and recurrence, further population-based research is needed to assess the daily patterns of low back pain episodes over 1 year and longer. There is substantial information on low back pain prevalence and estimates of the point prevalence range from 1.0% to 58.1% (mean: 18.1%; median: 15.0%), and 1 year prevalence from 0.8% to 82.5% (mean: 38.1%; median: 37.4%). Due to the heterogeneity of the data, mean estimates need to be interpreted with caution. Many environmental and personal factors influence the onset and course of low back pain. Studies have found the incidence of low back pain is highest in the third decade, and overall prevalence increases with age until the 60-65 year age group and then gradually declines. Other commonly reported risk factors include low educational status, stress, anxiety, depression, job dissatisfaction, low levels of social support in the workplace and whole-body vibration. Low back pain has an enormous impact on individuals, families, communities, governments and businesses throughout the world. The Global Burden of Disease 2005 Study (GBD 2005) is currently making estimates of the global burden of low back pain in relation to impairment and activity limitation. Results will be available in 2011. Further research is needed to help us understand more about the broader outcomes and impacts from low back pain.

The Epidemiology of low back pain.

We conducted a large nationwide postal survey to estimate the prevalence of chronic pain with or without neuropathic characteristics in the French general population. A questionnaire aimed at identifying chronic pain (defined as daily pain for at least 3 months), evaluating its intensity, duration and body locations, was sent to a representative sample of 30,155 subjects. The DN4 questionnaire was used to identify neuropathic characteristics. Of the questionnaires, 24,497 (81.2%) were returned and 23,712 (96.8%) could be assessed. Seven thousand five hundred and twenty-two respondents reported chronic pain (prevalence=31.7%; [95%CI: 31.1-32.3]) and 4709 said the pain intensity was moderate to severe (prevalence=19.9%; [95%CI: 19.5-20.4]). Neuropathic characteristics were reported by 1631 respondents with chronic pain (prevalence=6.9%; [95%CI: 6.6-7.2]), which was moderate to severe in 1209 (prevalence=5.1% [95%CI: 4.8-5.4]). A higher prevalence of chronic pain with neuropathic characteristics was associated with middle age (50-64 years), manual professions and those living in rural areas. It was more frequently located in the lower limbs and its intensity and duration were higher in comparison with chronic pain without neuropathic characteristics. This large national population-based study indicates that a significant proportion of chronic pain patients report neuropathic characteristics. We identified distinctive socio-demographic profile and clinical features indicating that chronic pain with neuropathic characteristics is a specific health problem.

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Prevalence of chronic pain with neuropathic characteristics in the general population

BACKGROUND Osteoarthritis is the single most common cause of disability in older adults, and most patients with the condition will be managed in the community and primary care. AIM To discuss case definition of knee osteoarthritis for primary care and to summarise the burden of the condition in the community and related use of primary health care in the United Kingdom. DESIGN Narrative review. METHOD A literature search identified studies of incidence and prevalence of knee pain, disability, and radiographic osteoarthritis in the general population, and data related to primary care consultations. Findings from UK studies were summarised with reference to European and international studies. RESULTS During a one year period 25% of people over 55 years have a persistent episode of knee pain, of whom about one in six in the UK and the Netherlands consult their general practitioner about it in the same time period. The prevalence of painful disabling knee osteoarthritis in people over 55 years is 10%, of whom one quarter are severely disabled. CONCLUSION Knee osteoarthritis sufficiently severe to consider joint replacement represents a minority of all knee pain and disability suffered by older people. Healthcare provision in primary care needs to focus on this broader group to impact on community levels of pain and disability.

https://ard.bmj.com/content/annrheumdis/60/2/91.full.pdf

Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care

Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis.

BACKGROUND Epidemiologically-based rheumatology healthcare needs assessment requires an understanding of the incidence and prevalence of musculoskeletal disorders in the community, of the reasons why people consult in primary care, and of the proportion of people who would benefit from referral to secondary care and paramedical services. This paper reports the first phase of such a needs assessment exercise. SPECIFIC OBJECTIVE To estimate the relative frequency of musculoskeletal pain in different, and multiple, anatomical sites in the adult population. SETTING Three general practices in the former Tameside and Glossop Health Authority, Greater Manchester, UK, a predominantly urban area. DESIGN Population survey. METHODS An age and sex stratified sample of 6000 adults from the three practices was mailed a questionnaire that sought data on demographic factors, musculoskeletal symptoms (pain in the past month lasting for more than a week), and physical disability (using the modified Health Assessment Questionnaire- mHAQ). The areas of pain covered were neck, back, shoulder, elbow, hand, hip, knee, and multiple joints. The Carstairs index was used as a measure of social deprivation of the postcode sector in which the person lived. RESULTS The response rate after two reminders was 78.5%. Non-responders were more likely to live in areas of high social deprivation. People who lived in more deprived areas were also more likely to report musculoskeletal pain, especially backpain. After adjusting for social deprivation the rates of musculoskeletal pain did not differ between the practices and so their results were combined. After adjustment for social deprivation, the most common site of pain was back (23%; 95% CI 21, 25) followed by knee (19%; 95% CI 18, 21), and shoulder (16%; 95% CI 14, 17). The majority of subjects who reported pain had pain in more than one site. The prevalence of physical disability in the community rose with age. It was highest in those with multiple joint problems but was also high in those with isolated back or knee pain. CONCLUSION Musculoskeletal pain is common in the community. People who live in socially deprived areas have more musculoskeletal symptoms. Estimates of the overall burden of musculoskeletal pain that combine the results of site specific surveys will be too high, those that do not adjust for socioeconomic factors will be too low.

https://ard.bmj.com/content/annrheumdis/57/11/649.full.pdf

Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation

STUDY DESIGN: Multiphase cross-sectional survey of musculoskeletal pain. OBJECTIVES: To estimate the prevalence of all reported and clinically significant spinal pain. To identify independent predictors of spinal pain. METHODS: A total of 5752 adults sampled from three general practice registers were mailed a screening questionnaire. Subjects who reported the spine as a predominant site of pain were sent a site-specific questionnaire (i.e., back or neck) that asked about severity. Prevalence estimates were calculated and extrapolated to the general population. Predictors of spinal pain were identified using logistic regression with comprehensive adjustment for confounders (including pain at other anatomic sites). RESULTS: The 1-month-period prevalence of all reported spinal pain was 29% (95% confidence interval 27-31%), of which about half was intense, half was chronic, 40% was disabling, and 20% was intense, disabling, and chronic. Most people with back (75%) or neck (89%) pain also reported pain at other sites. Age, female gender (neck pain only), high body mass index, living in an area of raised material deprivation, and south Asian ethnicity were significant predictors of spinal pain with disability. The association between body mass index and deprivation and neck pain was lost after adjustment for pain at other sites. However, even after full adjustment, obesity (OR, 1.7; 95% confidence interval, 1.1-2.5) and high deprivation (OR, 1.7; 95% confidence interval, 1.1-2.7) were predictors of back pain with disability. CONCLUSIONS: Adjustment for pain at other sites enabled assessment of whether observed associations were with spinal pain itself or with the other sites of pain. Obesity is an important independent predictor of back pain and its severity. This has implications for primary prevention. The prevalence of spinal pain with disability continues to rise into old age. This has implications for healthcare planning.

http://www.pain-initiative-un.org/doc-center/en/docs/Prevalence%20and%20Predictors%20of%20Intense,%20Chronic,%20and%20Disabling.pdf

Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population

Objective: To assess the prevalence of musculoskeletal symptoms among the major ethnic minority populations of Greater Manchester. Method: The study group was a community sample of 2117 adults from the Indian, Pakistani, Bangladeshi, and African Caribbean communities. Questionnaires administered by post and by an interviewer were used to assess the presence of any musculoskeletal pain, pain in specific joints, and the level of physical function. Ethnicity was self assigned. The results were compared with those from a recent study in the local white population using the same methodology. Results: Overall response rate was 75% among the south Asian (Indian, Pakistani, and Bangladeshi community and 47% among the African Caribbean community. The profile of musculoskeletal pain among the ethnic minority groups differed from that in the white population. Although musculoskeletal symptoms were slightly more prevalent among people from ethnic minority groups than among the white population, pain in multiple sites was considerably more common among ethnic minorities. Conclusions: The finding that musculoskeletal pain is more widespread among ethnic minority communities in the UK has not previously been reported. This may reflect social, cultural, and psychological differences. The cause of the differences in the profile of pain and the health needs that follow need further investigation.

https://ard.bmj.com/content/annrheumdis/61/2/151.full.pdf

Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester

Background There is little UK-based evidence on the prevalence and predictors of knee pain associated with disability across all adult ages. We aimed to estimate the prevalence of ‘clinically significant’ knee pain, identify and assess the population impact of independent risk factors, and estimate levels of healthcare need. Methods A cross-sectional survey of three general practice populations was conducted. Adults (n � 5752) were mailed a screening questionnaire (phase I). Those reporting predominant or isolated knee pain were sent a detailed questionnaire (phase II), with a further sub-sample invited for clinical examination (phase III). Logistic regression was used to identify independent risk factors and population attributable fractions were calculated. Results The 1 month period prevalence of ‘all reported’ knee pain was 19 per cent, of which about a third was disabling and a fifth intense and disabling. Obesity, deprivation and South Asian ethnicity were each associated with a 3‐4-fold increased risk of knee pain with disability (after age/sex adjustment). The attributable fraction estimate for raised body mass index (BMI) was 36 per cent (27‐44 per cent) ‐ the population impact of being overweight was greater than that of being obese. Thirteen per cent of all adults reported a previous primary care consultation, 7 per cent reported previous secondary care referral for knee pain, and 4.5 per cent (2.7‐6.2 per cent) of the adult population were currently receiving or in need of specialist treatment. Conclusions The high population impact of being overweight (BMI 25‐29) or obese (BMI 30 or more) has implications for primary prevention. The estimates of previous healthcare usage, and of levels of met and unmet need, are useful for healthcare planning.

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Opportunities for prevention of 'clinically significant' knee pain: results from a population-based cross sectional survey.

Study Objective. To maximise the response rate in a community survey among ethnic minorities by combining postal questionnaires and interviews and to evaluate the validity of combining results from these different methods. Design. A cross-sectional community survey of a local population using postal questionnaires with interview questionnaires for non-respondents. Postal questionnaires were in English and interview questionnaires were prepared in South Asian languages. A sub-sample completed both postal and interview questionnaires. Setting. Two general practices in Tameside, Greater Manchester, UK. Participants. Questionnaires were mailed to 1,267 people. People were included if they defined their ethnicity as Indian, Pakistani, Bangladeshi or a combination of these. Fifty-five people who returned postal questionnaires were also interviewed. Main Results. Overall response rate was 75%. Comparison of questionnaire and interview responses produced values of kappa ranging from marginally below zero to one. ...

Michelle Urwin

Papers

Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation

Prevalence and predictors of intense, chronic, and disabling neck and back pain in the UK general population

Musculoskeletal pain is more generalised among people from ethnic minorities than among white people in Greater Manchester

Opportunities for prevention of 'clinically significant' knee pain: results from a population-based cross sectional survey.

Can findings from postal questionnaires be combined with interview results to improve the response rate among ethnic minority populations