Bone health and back pain: what do we know and where should we go?

Does the risk of chronic low back pain depend on age at menarche or menopause? A population-based cross-sectional and cohort study: the Trøndelag Health Study

OBJECTIVE

In most population-based studies of low back pain (LBP), women have a higher risk than men, possibly reflecting hormonal influences. The aim of this study was to explore associations between age at menarche and menopause and risk of chronic LBP.

DESIGN

Population-based cross-sectional and cohort study designs.

SETTING

The HUNT2 and HUNT3 medical surveys of the entire population of Nord-Trøndelag County in Norway.

MAIN OUTCOME MEASURE

Prevalence or risk of chronic LBP, defined as LBP persisting at least 3 months continuously during last year.

PARTICIPANTS

Associations between age at menarche and prevalence of chronic LBP were examined in cross-sectional data from HUNT2, comprising 27 697 women aged 20-69 years, with 7300 women reporting LBP. The corresponding cohort data included 11 659 women without LBP at baseline in HUNT2, with 2353 women reporting LBP at follow-up 11 years later in HUNT3. Cross-sectional data on age at menopause or premenopausal status included 11 332 women aged 40-69 years, with 3439 women reporting chronic LBP. Corresponding cohort data included 7893 women without LBP at baseline, of whom 1100 developed LBP.

METHODS

Associations between age at menarche or menopause and risk of chronic LBP were examined by generalised linear modelling.

RESULTS

A U-shaped association was indicated between age at menarche and risk of chronic LBP, both in the cross-sectional and cohort studies. Age at menarche ≤11 years was associated with an increased risk of chronic LBP, with a relative risk of 1.32 (95% CI 1.15 to 1.52), compared with age 14 years at menarche, after relevant adjustments. Corresponding cross-sectional crude absolute risks were 32% and 25%, respectively. No association was established between age at menopause and risk of LBP. Being premenopausal had no influence on risk.

CONCLUSIONS

In contrast to results for age at menopause, the association with age at menarche suggests that hormonal factors affect the risk of LBP.

Perspectives of spinal health within the school setting in a South African rural region: A qualitative study

BACKGROUND

Spinal pain is one of the leading causes of morbidity globally. There is an increase in the number of children and adolescents who experience spinal pain and the lifetime prevalence of adolescent spinal pain varies between countries. In Africa, one in two adolescents experiences spinal pain and the prevalence is increasing.

OBJECTIVE

This study reports on the knowledge and perspectives of school-attending children, adolescents, teachers, and parents/guardians regarding spinal health.

METHODS

We conducted a descriptive qualitative case study with an interpretative and phenomenological approach. Data coding, management and analysis was done using ATLAS.ti computer software.

RESULTS

Ninety-three participants (66 women and 27 men) were enrolled in the study. The barriers associated with students' spinal health were multifactorial, including low levels of physical activity, dangerous gameplay, sports risks, poor ergonomics, school bags, insufficient knowledge, and pregnancy risks. Participants proposed strategies to improve spinal health including the provision of students' lockers, advice on appropriate school bag types, embedding spinal education in the curriculum, general advocacy for spinal health, and integration of technology in teaching and learning.

CONCLUSION

There is a need for further engagement on school-based spinal health promotion programs that consider local socio-economic, educational, and cultural factors.

Pain at Multiple Sites Is Associated With Prevalent and Incident Fractures in Older Adults

Musculoskeletal pain is common and typically occurs at multiple sites. Pain has been shown to be associated with falls risk; however, whether an increased risk for falls associated with multisite pain (MSP) translates into an increased risk of fractures has not been investigated. This study aimed to examine the association of number of painful sites with prevalent and incident fractures. Data from a longitudinal population-based study of older adults (mean age 63 years) were utilized. Follow-up was performed at 2.6, 5.1, and 10.7 years later, respectively. Presence/absence of pain at the neck, back, hands, shoulders, hips, knees, and feet was assessed by questionnaire at baseline. Participants were classified into three groups according to the total number of painful sites: zero to two, three to four, and five to seven. Fractures were self-reported at each time point. BMD was measured by DXA. Falls risk was calculated based on the Short-Form Physiological Profile Assessment. Log-binomial regression was used for the analyses. There were 450 fractures at baseline and 154 new fractures reported during a mean follow-up period of 10.7 years (range 9.2 to 12.5 years). In multivariable analyses, number of painful sites was associated with prevalent fractures at any and nonvertebral site. Furthermore, participants with five to seven painful sites had an increased risk of incident fractures at any site (RR 1.69; 95% CI, 1.13 to 2.53); major site, including the femur, radius, ulnar, vertebral, rib, and humerus (RR 2.17; 95% CI 1.12 to 4.22); and vertebral site (RR 6.44, 95% CI, 1.64 to 25.33) compared with those with pain at zero to two sites. These associations remained statistically significant after further adjustment for falls risk and BMD. Pain at multiple sites was associated with incident fracture risk in a dose-response manner, suggesting that widespread pain is an independent contributor to fracture risk. The potential for pain management in fracture prevention warrants further exploration. © 2019 American Society for Bone and Mineral Research.

Pain and falls and fractures in community-dwelling older men

BACKGROUND

Pain may reduce stability and increase falls and subsequent fractures in older men.

OBJECTIVES

To examine the association between joint pain and any pain with falls, hip and non-spine fractures in older community-dwelling men.

DESIGN

A cohort study.

SETTING AND PARTICIPANTS

Analyses included 5,993 community-dwelling men aged ≥65 years from the MrOS cohort.

MEASUREMENTS

Pain at hip, knee and elsewhere (any) was assessed by self-report. Men reported falls via questionnaires mailed 3× per year during the year following the baseline visit. Fractures were verified centrally. Mean follow-up time for fractures was 9.7 (SD 3.1) years. Logistic regression models estimated likelihood of falls and proportional hazards models estimated risk of fractures. Models were adjusted for age, BMI, race, smoking, alcohol use, medications use, co-morbidities and arthritis; fracture models additionally adjusted for bone mineral density.

RESULTS

One quarter (25%, n = 1,519) reported ≥1 fall; 710 reported ≥2 falls in the year after baseline. In multivariate models, baseline pain at hip, knee or any pain increased likelihood of ≥1 fall and ≥2 falls over the following year. For example, knee pain increased likelihood of ≥1 fall (odds ratio, OR 1.44; 95% confidence interval, CI 1.25-1.65) and ≥2 falls (OR 1.75; 95% CI 1.46-2.10). During follow-up, 936 (15.6%) men suffered a non-spine fracture (n = 217, 3.6% hip). In multivariate models, baseline pain was not associated with incident hip or non-spine fractures.

CONCLUSIONS

Any pain, knee pain and hip pain were each strong independent risk factors for falls in older men. Increased risk of falls did not translate into an increased risk of fractures.

Chronic low back pain is associated with reduced vertebral bone mineral measures in community-dwelling adults

Background

Chronic low back pain (CLBP) experienced in middle-age may have important implications for vertebral bone health, although this issue has not been investigated as a primary aim previously. This study investigated the associations between CLBP and dual energy X-ray absorptiometry (DXA)-derived vertebral bone mineral measures acquired from postero-anterior and lateral-projections, among community-dwelling, middle-aged adults.

Methods

Twenty-nine adults with CLBP (11 male, 18 female) and 42 adults with no history of LBP in the preceding year (17 male, 25 female) were evaluated. Self-reported demographic and clinical data were collected via questionnaires. Areal bone mineral density (aBMD) was measured in the lumbar spine by DXA. Apparent volumetric (ap.v) BMD in the lumbar spine was also calculated. Multiple linear regression models were used to examine associations between study group (CLBP and control) and vertebral DXA variables by gender, adjusting for height, mass and age.

Results

There was no difference between groups by gender in anthropometrics or clinical characteristics. In the CLBP group, the mean (SD) duration of CLBP was 13.3 (10.4) years in males and 11.6 (9.9) years in females, with Oswestry Disability Index scores of 16.2 (8.7)% and 15.4 (9.1)%, respectively. Males with CLBP had significantly lower adjusted lateral-projection aBMD and lateral-projection ap.vBMD than controls at L3 with mean differences (standard error) of 0.09 (0.04) g/cm² (p = 0.03) and 0.02 (0.01) g/cm³ (p = 0.04). These multivariate models accounted for 55% and 53% of the variance in lateral-projection L3 aBMD and lateral-projection L3 ap.vBMD.

Conclusions

CLBP in males is associated with some lumbar vertebral BMD measures, raising important questions about the mechanism and potential clinical impact of this association.

Vertebral bone mineral measures and psychological wellbeing among individuals with modic changes

Purpose

This case-control pilot study examined whether vertebral bone mineral measures were associated with the presence of chronic low back pain (CLBP) and Modic changes (MCs), and to compare psychological wellbeing and inflammation among individuals with CLBP and MCs, compared to individuals with no history of low back pain and without MCs.

Methods

Eleven individuals with MRI-defined MCs in the lumbar spine and CLBP (cases) and 10 individuals with no history of CLBP or MCs (controls) responded to standard questionnaires regarding pain characteristics and psychological health. Bone mineral density (BMD) was measured with postero-anterior and lateral-projection dual energy X-ray absorptiometry (DXA) to estimate areal BMD (aBMD) and apparent volumetric BMD (ap.vBMD). High sensitivity serum C-reactive protein (hsCRP) was measured as an index of inflammation.

Results

While there was no difference between the groups in measures of depression, anxiety and stress, cases reported significantly greater pain catastrophizing attitudes (P < 0.01). hsCRP concentrations did not differ between groups (P = 0.54). Among the 7 cases where MCs were identified between L3–4, significantly higher mean aBMD was observed at the affected vertebral level, compared to the adjacent, unaffected, cephalad level (P = 0.01–0.04), but not when ap.vBMD was calculated (P = 0.36).

Conclusions

Vertebral BMD is not reduced among individuals with CLBP and MCs compared to a control group, although pain catastrophizing attitudes are increased among individuals with CLBP and MCs.

Bone mineral density, body mass index, postmenopausal period and outcomes of low back pain treatment in Korean postmenopausal women

Women going through menopause experience bone loss and increased musculoskeletal pain, including low back pain. This study explored the relationships between bone mineral density (BMD) and body mass index (BMI), postmenopausal period and outcomes of treatment for low back pain in postmenopausal Korean women. On examining the medical records of 78 postmenopausal women hospitalized for low back pain, investigators found that women with low BMD were older and had been postmenopausal for longer periods than women with normal BMD. Postmenopausal length was positively correlated with pain scores at day 15 and 20 post-admission (P = 0.011 and 0.006) and negatively correlated with T-scores (P = 0.002). BMI was positively correlated with T-scores (r = 0.283, P = 0.022). In conclusion, age, postmenopausal length and BMI correlate with BMD in Korean women suffering from LBP. Larger studies investigating the associations between menopause, BMD, BMI and LBP seem desirable. Moreover, evidence-based therapeutic approaches should be explored for BMD and LBP management.

Neck/shoulder pain in adolescents is not related to the level or nature of self-reported physical activity or type of sedentary activity in an Australian pregnancy cohort

Background

An inconsistent relationship between physical activity and neck/shoulder pain (NSP) in adolescents has been reported in the literature. Earlier studies may be limited by not assessing physical activity in sufficient detail. The aim of this study was to comprehensively examine the association between NSP and the level and nature of physical activity, and type of sedentary activity in adolescents.

Methods

A cross-sectional analysis using data from 924 adolescents in the Western Australian Pregnancy Cohort (RAINE) study was performed. Complete data were available for 643 adolescents (54.6% female) at the 14-year follow-up. Physical activity was measured using a detailed self-report electronic activity diary requiring participants to input details of all physical activities over the day in segments of 5 minutes for a one-week period. Physical activity levels were categorised as: sedentary, light, moderate, or vigorous based on metabolic energy equivalents. Nature of activity was determined by assigning each activity to categories based on the amount of movement (static/dynamic) and the main posture assumed for the activity (standing/sitting/lying). Type of sedentary activity was characterised by exposure time to watching TV, using a computer, and reading. Logistic regression was used to explore the association between NSP and activity.

Results

Females reported a higher prevalence of lifetime, 1-month and chronic NSP than males (50.9 vs 41.7%, 34.1 vs 23.5%, and 9.2 vs 6.2% respectively). No consistent, dose-response relationship was found between NSP and the level, nature, and type of physical activity.

Conclusion

Self-reported one month and lifetime NSP prevalence in adolescents is not related to the level or intensity of physical activity or the type of sedentary activity over a one week period.