The epidemiology of back pain and its relationship with depression, psychosis, anxiety, sleep disturbances, and stress sensitivity: Data from 43 low- and middle-income countries

Pain and subjective well-being among older adults in the developing world : A comprehensive assessment based on the WHO Study on Global Ageing and Adult Health

This paper studies the association of pain with subjective well-being (SWB) and time use among older adults in five low- and middle-income countries using data from the first wave of the WHO Study on Global Ageing and Adult Health. We suggest a novel use of anchoring vignettes as direct control functions to account for potentially correlated reporting behaviors such as correlated response scales when analyzing the relationship between subjective variables such as self-reported pain and SWB. Exploiting detailed data on individual time use and several complementary measures of SWB, including fine-grained activity-specific affective experiences derived from an abbreviated version of the Day Reconstruction Method, we find that both evaluative and experienced well-being are markedly lower for people living with pain compared to those without pain. These disparities persist even after controlling for possible confounding from reporting behaviors through the use of anchoring vignettes. Differences in experienced utility by pain status appear to be exclusively due to worse affective experiences during daily activities for those with pain, which seem to be partially mediated through changes in their functional limitations. Pain-related differences in time use, in turn, seem to provide only small compensating effects, underscoring important challenges to the use of changed activity patterns as a viable coping strategy for individuals enduring pain.

Responsiveness and clinically important differences of the PROMIS short form-depression 8a, anxiety 8a, and PASS-20 in individuals with chronic low back pain

Introduction

Depression and anxiety are the most commonly reported mental health conditions. The Patient-Reported Outcomes Measurement Information System Short Form v1.0-Depression 8a (PROMIS-D-8a), Anxiety 8a (PROMIS-Anx8a), and Pain Anxiety Symptoms Scale-20 (PASS-20) measures were designed to assess depression, general anxiety, and pain-related anxiety, respectively.

Objectives

To examine the responsiveness and estimate the clinically important differences (CIDs) of the Thai version of these measures in individuals with chronic low back pain (CLBP).

Methods

The study sample comprised 144 participants with CLBP. Responsiveness was evaluated by calculating the change scores, effect sizes (ESs), standardized response means (SRMs), area under the curve (AUC), and correlations between the change scores and associated Global Perceived Effect (GPE). We also estimated CIDs by the difference in mean change score between improved and unchanged groups and standard error of measurement (SEM) for each measure.

Results

Statistically significant differences in the mean change scores, ESs, and SRMs supported the responsiveness of all measures. The AUCs achieved acceptable discriminatory ability (0.71-0.72) for moderate improvement but not for any improvement (0.65-0.68). The correlations between GPE and change scores on all measures were low (r ranging 0.28-0.33). The estimated CIDs for the PROMIS-D-8a, PROMIS-Anx8a, and PASS-20 were 3.64, 4.20, and 8.80, respectively.

Conclusion

The PROMIS-D-8a, PROMIS-Anx8a, and PASS-20 measures were sensitive for detecting clinical changes over time in individuals with CLBP. The CID values can be used as reference points for assessing meaningful improvements in the domains assessed by these scales in clinical and research practice.

Barriers and facilitators to the delivery of a biopsychosocial education and exercise programme for patients with chronic low back pain in Ghana. A qualitative study

PURPOSE

Low back pain management has evolved with researchers advocating for a biopsychosocial management model. The biopsychosocial management model has been predominantly applied in high-income countries and underexplored in low- and middle-income countries including Ghana. This study aimed to explore the potential barriers and facilitators to patients with chronic low back pain (CLBP) and physiotherapists engagement with a biopsychosocial intervention (exercise and patient education) as part of a feasibility study.

MATERIAL AND METHODS

This was a qualitative study embedded within a mixed-methods, sequential, feasibility study, in Ghana, applying semi-structured interviews. Two categories of participants involved in this study were, two trained physiotherapists, and six patients with CLBP, sampled within the feasibility study.

RESULTS

Regarding the barriers and facilitators to the delivery of the BPS intervention, five interlinked themes emerged from the thematic analysis. These were: structure and process of delivery; patients' expectations; patients' health beliefs, autonomy, and engagement; external influences and personal and professional characteristics of physiotherapists.

CONCLUSION

The themes that emerged from this study demonstrated many positive facilitators based on participants' improved understanding of LBP and the clarity and purpose of the biopsychosocial intervention. The results therefore demonstrate a potential to deliver the biopsychosocial intervention in a Ghanaian context.

Exercise-induced neuroplasticity: a new perspective on rehabilitation for chronic low back pain

Chronic low back pain patients often experience recurrent episodes due to various peripheral and central factors, leading to physical and mental impairments, affecting their daily life and work, and increasing the healthcare burden. With the continuous advancement of neuropathological research, changes in brain structure and function in chronic low back pain patients have been revealed. Neuroplasticity is an important mechanism of self-regulation in the brain and plays a key role in neural injury repair. Targeting neuroplasticity and regulating the central nervous system to improve functional impairments has become a research focus in rehabilitation medicine. Recent studies have shown that exercise can have beneficial effects on the body, such as improving cognition, combating depression, and enhancing athletic performance. Exercise-induced neuroplasticity may be a potential mechanism through which exercise affects the brain. This article systematically introduces the theory of exercise-induced neuroplasticity, explores the central effects mechanism of exercise on patients with chronic low back pain, and further looks forward to new directions in targeted neuroplasticity-based rehabilitation treatment for chronic low back pain.

Patterns and correlates of mental healthcare utilization during the COVID-19 pandemic among individuals with pre-existing mental disorder

How did mental healthcare utilization change during the COVID-19 pandemic period among individuals with pre-existing mental disorder? Understanding utilization patterns of these at-risk individuals and identifying those most likely to exhibit increased utilization could improve patient stratification and efficient delivery of mental health services. This study leveraged large-scale electronic health record (EHR) data to describe mental healthcare utilization patterns among individuals with pre-existing mental disorder before and during the COVID-19 pandemic and identify correlates of high mental healthcare utilization. Using EHR data from a large healthcare system in Massachusetts, we identified three "pre-existing mental disorder" groups (PMD) based on having a documented mental disorder diagnosis within the 6 months prior to the March 2020 lockdown, related to: (1) stress-related disorders (e.g., depression, anxiety) (N = 115,849), (2) serious mental illness (e.g., schizophrenia, bipolar disorders) (N = 11,530), or (3) compulsive behavior disorders (e.g., eating disorder, OCD) (N = 5,893). We also identified a "historical comparison" group (HC) for each PMD (N = 113,604, 11,758, and 5,387, respectively) from the previous year (2019). We assessed the monthly number of mental healthcare visits from March 13 to December 31 for PMDs in 2020 and HCs in 2019. Phenome-wide association analyses (PheWAS) were used to identify clinical correlates of high mental healthcare utilization. We found the overall number of mental healthcare visits per patient during the pandemic period in 2020 was 10-12% higher than in 2019. The majority of increased visits was driven by a subset of high mental healthcare utilizers (top decile). PheWAS results indicated that correlates of high utilization (prior mental disorders, chronic pain, insomnia, viral hepatitis C, etc.) were largely similar before and during the pandemic, though several conditions (e.g., back pain) were associated with high utilization only during the pandemic. Limitations included that we were not able to examine other risk factors previously shown to influence mental health during the pandemic (e.g., social support, discrimination) due to lack of social determinants of health information in EHR data. Mental healthcare utilization among patients with pre-existing mental disorder increased overall during the pandemic, likely due to expanded access to telemedicine. Given that clinical correlates of high mental healthcare utilization in a major hospital system were largely similar before and during the COVID-19 pandemic, resource stratification based on known risk factor profiles may aid hospitals in responding to heightened mental healthcare needs during a pandemic.

Exercise interventions for nonspecific low back pain: a bibliometric analysis of global research from 2018 to 2023

Objective

This study aims to explore global research trends on exercise interventions for nonspecific low back pain from 2018 to 2023 through bibliometric analysis.

Methods

A systematic search was conducted in the Web of Science Core Collection database to select relevant research articles published between 2018 and 2023. Using CiteSpace and VOSviewer, the relationships and impacts among publications, different countries, journals, author groups, references, and keywords were analyzed in depth.

Results

The bibliometric analysis included 4,896 publications, showing a trend of initial growth followed by a decline. At the national level, the United States made the most significant contributions in this field. The journal "Lancet" had three of the top 10 most-cited articles, with an average citation count of 306.33, and an impact factor reaching 168.9 in 2023. The analysis also revealed that "disability," "prevalence," and "management" were high-frequency keywords beyond the search terms, while "rehabilitation medicine," "experiences," and "brain" emerged as new hotspots in the research.

Conclusion

This study reveals the global trends in research on exercise interventions for nonspecific low back pain over the past 5 years and highlights potential research frontiers in the field. These findings provide a solid foundation for focusing on key issues, potential collaboration directions, and trends in research development in the future, offering valuable references for further in-depth studies.

Contextual factors in persistent severe back pain: A longitudinal analysis among German employees

BACKGROUND

Chronic back pain in employees compromises participation in social and daily activities, as well as work.

OBJECTIVES

To examine the severity of back pain after 2 years and identify factors predicting stagnation at this level of pain.

METHODS

Data were derived from a prospective cohort study with randomized sampling of insurants in the German Pension Insurance using a questionnaire at baseline and follow-up after 2 years. The sample consisted of middle-aged employees (45-59 years) with strong limitations due to back pain (Chronic Pain Grade III or IV), who had not applied for disability pension and did not use medical rehabilitation in the previous 4 years before baseline. Stepwise multivariable logistic regression models with backwards selection were used to identify relevant contextual factors in the stagnation of severe back pain.

RESULTS

Of 1208 persons with severe back pain at baseline, 48% had stagnated at that pain level after 2 years. Predictors of persistent severe back pain were older age, poorer general health, more additional disabling conditions, more depressive symptoms, caregiving burden, less pain-related self-efficacy and more fear avoidance beliefs.

CONCLUSIONS

In a high-risk subgroup with several co-existing conditions, this analysis highlights (mental) health, social and personal (contextual) factors associated with long-term unfavourable back pain progression.

SIGNIFICANCE

Back pain is a condition that often has a chronic or recurrent course, threatening participation in many areas of life. In this study it was found that the unfavourable condition of severe back pain can remain stable for long periods of time in a significant proportion of sufferers. Contextual factors (self-efficacy, fear-avoidance beliefs, caregiving burden) as well as additional health problems should be considered when identifying persons with stagnating pain courses.

Emotion Regulation and Psychological Dependence on Pain Medication among Hospital Outpatients with Chronic Spinal Pain: The Influence of Rumination about Pain and Alexithymia

Objective: To examine the extent to which pain acceptance, pain catastrophising and alexithymia moderate associations between pain intensity and psychological pain medication dependence. Methods: Participants (106 hospital outpatients with chronic spinal pain) completed the Leeds Dependence Questionnaire (LDQ) to measure psychological dependence on pain medication, and the Chronic Pain Acceptance Questionnaire-8 (CPAQ-8), the Pain Catastrophising Scale (PCS) and the Toronto Alexithymia Scale-20 (TAS-20), plus the Depression, Anxiety and Stress Scale-21 (DASS-21). Results: Multiple linear regression showed that degree of psychological dependence (measured dimensionally across the range of LDQ scores) was associated with TAS subscale difficulty identifying feelings (DIF) (β = 0.249, p = <0.002) and PCS subscale rumination (β = 0.193, p = 0.030), independently of pain intensity and risk behaviors for medication misuse. The effect of pain intensity was moderated by rumination, with pain intensity more strongly associated with dependence when rumination was high (interaction β = 0.192, p = 0.004). Logistic regression showed that the effect of pain intensity on severe dependence (measured categorically as LDQ score ≥ 20) was moderated by alexithymia, so that severe dependence was independently associated with the combination of intense pain and high alexithymia (interaction odds ratio = 7.26, 95% CIs = 1.63-32.42, p = 0.009). Conclusions: Rumination and alexithymia moderated the associations between pain intensity and psychological pain medication dependence, consistent with emotion regulation theory. This raises the possibility that specifically targeting rumination about pain and symptoms of alexithymia could potentially improve the effectiveness of psychological interventions for chronic pain and help people to avoid or reduce their psychological dependence on pain medication.

Acceptance and Fear-Avoidance Mediate Outcomes of Interdisciplinary Pain Rehabilitation Programs at 12-Month Follow-Up: A Clinical Registry-Based Longitudinal Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Background

Factors that influence outcomes of interdisciplinary pain rehabilitation programs (IPRP) are poorly known. It is unclear how outcomes are influenced by pain intensity, psychological distress, and coping strategies.

Aim

This clinical registry-based longitudinal cohort study has three aims: 1) to determine the relative importance of pain intensity, psychological distress, acceptance, and fear-avoidance for changes in three outcomes of IPRP at 12-month follow-up; 2) to investigate whether the effects of pain intensity and psychological distress on the three outcomes are mediated via acceptance and fear-avoidance; and 3) to determine whether sex is a moderator.

Methods

This study uses Patient-Reported Outcome Measures (PROMs) from specialist units reporting data (2008-2016) to the Swedish Quality Registry for Pain Rehabilitation (SQRP). Adult chronic pain patients (N = 1991) answered the PROMs (background, pain, psychological distress, coping, participation, and health-related quality of life (HRQoL)). Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to explore the aims.

Results

Changes in acceptance (β:0.424-0.553; all P<0.001) were the strongest predictor of the three outcomes (changes in life control, interference, and HRQoL) at 12-month follow-up. The next strongest predictor was baseline acceptance (β: 0.177-0.233; all P<0.001) and changes in fear-avoidance (β: -0.152- -0.186; all P<0.001). Baseline pain intensity and psychological distress showed weak positive associations. Their effects on the three outcomes were mediated via acceptance aspects. Sex was not a moderator.

Discussion and Conclusion

Acceptance aspects (baseline and changes) were important predictors of IPRP outcomes. Changes in fear-avoidance were also important although to a lesser degree. Some of the effects of pain intensity and psychological distress on outcomes were mediated via acceptance at baseline. Future PLS-SEM analysis of real-world IPRP should include more potential mediators (eg, catastrophizing and more facets of psychological flexibility and fear-avoidance) and the components of IPRP.

Psychiatric disorders, diagnosed in psychiatric clinics, in patients with back pain: A cohort study

Aims: The aim of this study was to evaluate whether patients with a non-specific back pain disorder are more likely to be diagnosed with a psychiatric disorder than patients with a specific back pain disorder (such as a herniated disc or inflammatory back disorder). Methods: This was a retrospective cohort study using Danish registries. Results: Our study population included 24,518 patients younger than 61 years and 12,274 patients older than 61 years. In both subpopulations, 60% had a non-specific back pain diagnosis (BPD). In the younger subpopulation, 2.1% of the patients with a non-specific BPD and 1.3% of the patients with a specific BPD had a psychiatric diagnosis within one year of their BPD. In the older subpopulation, 0.6% of patients had a psychiatric diagnosis in both BPD groups. The most frequent psychiatric diagnoses were stress-related disorders. In the younger subpopulation, patients with non-specific back pain had a higher risk of being diagnosed with a psychiatric disorder than patients with specific back pain (adjusted odds ratio 1.56, 95% confidence interval 1.25-1.94). The type of BPD had no effect on the risk of having a psychiatric diagnosis among older patients. Conclusions: Patients with a non-specific back pain disorder younger than 61 years were more likely to be diagnosed with a psychiatric disorder than patients with a specific back pain disorder. We recommend that spine specialists pay special attention to patients younger than 61 years with a back pain disorder to prevent them from developing a psychiatric disorder.

Adherence to recommended guidelines for low back pain presentations to an Australian emergency department: Barriers and enablers

OBJECTIVE

This study sought to evaluate the adherence to guidelines for the management of mechanical Low Back Pain within a single tertiary metropolitan Emergency Department setting. Our objectives were: METHODS: A two-stage multi-methods study design was undertaken. Stage 1 involved a retrospective chart audit of patients presenting with a diagnosis of mechanical Low Back Pain to establish documented adherence to clinical guidelines. Stage 2 explored clinicians' perspectives towards factors influencing adherence to the guidelines via a study-specific survey and follow up focus groups.

RESULTS

The audit demonstrated low adherence to the following guidelines: (i) appropriate prescription of analgesia, (ii) targeted education and advice, and (iii) attempts to mobilise. Three major themes were identified as factors influencing adherence to the guidelines: (1) clinician driven influences and factors, (2) workflow processes, and (3) patient expectations and behaviours.

CONCLUSION

There was low adherence to some published guidelines and factors influencing adherence to the guidelines were multi-factorial. Understanding the factors that influence care decisions and developing strategies to address these can improve Emergency Department management of mechanical Low Back Pain.

Exercise intervention for patients with chronic low back pain: a systematic review and network meta-analysis

Purpose

Chronic low back pain (CLBP) is an aging and public health issue that is a leading cause of disability worldwide and has a significant economic impact on a global scale. Treatments for CLBP are varied, and there is currently no study with high-quality evidence to show which treatment works best. Exercise therapy has the characteristics of minor harm, low cost, and convenient implementation. It has become a mainstream treatment method in clinics for chronic low back pain. However, there is insufficient evidence on which specific exercise regimen is more effective for chronic non-specific low back pain. This network meta-analysis aimed to evaluate the effects of different exercise therapies on chronic low back pain and provide a reference for exercise regimens in CLBP patients.

Methods

We searched PubMed, EMBASE, Cochrane Library, and Web of Science from inception to 10 May 2022. Inclusion and exclusion criteria were used for selection. We collected information from studies to compare the effects of 20 exercise interventions on patients with chronic low back pain.

Results

This study included 75 randomized controlled trials (RCTs) with 5,254 participants. Network meta-analysis results showed that tai chi [standardized mean difference (SMD), -2.11; 95% CI, -3.62 to -0.61], yoga (SMD, -1.76; 95% CI -2.72 to -0.81), Pilates exercise (SMD, -1.52; 95% CI, -2.68, to -0.36), and sling exercise (SMD, -1.19; 95% CI, -2.07 to -0.30) showed a better pain improvement than conventional rehabilitation. Tai chi (SMD, -2.42; 95% CI, -3.81 to -1.03) and yoga (SMD, -2.07; 95% CI, -2.80 to -1.34) showed a better pain improvement than no intervention provided. Yoga (SMD, -1.72; 95% CI, -2.91 to -0.53) and core or stabilization exercises (SMD, -1.04; 95% CI, -1.80 to -0.28) showed a better physical function improvement than conventional rehabilitation. Yoga (SMD, -1.81; 95% CI, -2.78 to -0.83) and core or stabilization exercises (SMD, -1.13; 95% CI, -1.66 to -0.59) showed a better physical function improvement than no intervention provided.

Conclusion

Compared with conventional rehabilitation and no intervention provided, tai chi, toga, Pilates exercise, sling exercise, motor control exercise, and core or stabilization exercises significantly improved CLBP in patients. Compared with conventional rehabilitation and no intervention provided, yoga and core or stabilization exercises were statistically significant in improving physical function in patients with CLBP. Due to the limitations of the quality and quantity of the included studies, it is difficult to make a definitive recommendation before more large-scale and high-quality RCTs are conducted.

The one-week prevalence of neck pain and low back pain in post-secondary students at two Canadian institutions

BACKGROUND

Low back and neck pain are common in the general population, but the prevalence among Canadian post-secondary students is not well known. We aimed to determine the one-week prevalence of neck pain (NP) and low back pain (LBP) among postsecondary students in Canada.

METHODS

We conducted a cross-sectional study of students enrolled in the Faculty of Health Sciences and Faculty of Education at Ontario Tech University, and the Canadian Memorial Chiropractic College (CMCC) in the Fall of 2017. Neck and low back pain intensity in the past week were measured with the 11-point numerical rating scale. We report the cumulative, gender- and institution-specific one-week prevalence (95% CI) of any pain (1-10/10) and moderate to severe pain (≥ 3/10).

RESULTS

The one-week prevalence of any neck pain ranged from 45.4% (95% CI: 38.4, 52.4) in the Faculty of Education to 76.9% (95% CI: 72.9, 80.4) at CMCC. The one-week prevalence of neck pain ≥3/10 ranged from 44.4% (95% CI: 37.5, 51.4) in the Faculty of Education to 58.4% (95% CI: 54.0, 62.7) at CMCC. The one-week prevalence of any low back pain ranged from 60.9% (95% CI: 53.8, 67.5) in the Faculty of Education to 69.0% (95% CI: 64.8, 73.0) at CMCC, and the one-week prevalence of low back pain ≥ 3/10 ranged from 47.8% (95% CI: 43.4, 52.2) at CMCC to 55.1% (95% CI: 51.2, 58.9) in the Faculty of Health Sciences. The prevalence of any back or neck pain and pain ≥ 3/10 was consistently higher in females than males, with the largest difference seen for neck pain at CMCC.

CONCLUSION

Most post-secondary students in our samples experienced LBP and NP in the past week. Overall, the one-week prevalence of NP and LBP was higher among chiropractic students and among females. This study should draw attention to school administrators about the burden of NP and LBP in post-secondary students.

The influence of cultural and religious factors on cross-national variations in the prevalence of chronic back and neck pain: an analysis of data from the global burden of disease 2019 study

Introduction

Low back pain and neck pain are among the most commonly reported forms of chronic pain worldwide, and are associated with significant distress, disability and impairment in quality of life. Though these categories of pain can be analyzed and treated from a biomedical perspective, there is evidence that they are both related to psychological variables such as depression and anxiety. The experience of pain can be significantly influenced by cultural values. For example, cultural beliefs and attitudes can influence the meaning attached to the experience of pain, the responses of others to a sufferer's pain, and the likelihood of seeking medical care for particular symptoms. Likewise, religious beliefs and practices can influence the both experience of pain and the responses to it. These factors have also been associated with variations in the severity of depression and anxiety.

Methods

In the current study, data on the estimated national prevalence of both low back pain and neck pain, obtained from the 2019 Global Burden of Disease Study (GBD 2019), is analyzed in relation to cross-national variations in cultural values, as measured using Hofstede's model (n =115 countries) and in religious belief and practice, based on the most recent Pew Research Center survey (n = 105 countries). To address possible confounding factors, these analyses were adjusted for variables known to be associated with chronic low back or neck pain, namely smoking, alcohol use, obesity, anxiety, depression and insufficient physical activity.

Results

It was found that the cultural dimensions of Power Distance and Collectivism were inversely correlated with the prevalence of chronic low back pain, and Uncertainty Avoidance was inversely correlated with the prevalence of chronic neck pain, even after adjustment for potential confounders. Measures of religious affiliation and practice were negatively correlated with the prevalence of both conditions, but these associations were not significant after adjusting for cultural values and confounders.

Discussion

These results highlight the existence of meaningful cross-cultural variations in the occurrence of common forms of chronic musculoskeletal pain. Psychological and social factors that could account for these variations are reviewed, along with their implications for the holistic management of patients with these disorders.

The association between psychosocial factors and mental health symptoms in cervical spine pain with or without radiculopathy on health outcomes: a systematic review

BACKGROUND

Neck pain, with or without radiculopathy, can have significant negative effects on physical and mental wellbeing. Mental health symptoms are known to worsen prognosis across a range of musculoskeletal conditions. Understanding the association between mental health symptoms and health outcomes in this population has not been established. Our aim was to systematically review the association between psychosocial factors and/or mental health symptoms on health outcomes in adults with neck pain, with or without radiculopathy.

METHODS

A systematic review of published and unpublished literature databases was completed. Studies reporting mental health symptoms and health outcomes in adults with neck pain with or without radiculopathy were included. Due to significant clinical heterogeneity, a narrative synthesis was completed. Each outcome was assessed using GRADE.

RESULTS

Twenty-three studies were included (N = 21,968 participants). Sixteen studies assessed neck pain only (N = 17,604 participants); seven studies assessed neck pain with radiculopathy (N = 4,364 participants). Depressive symptoms were associated with poorer health outcomes in people with neck pain and neck pain with radiculopathy. These findings were from seven low-quality studies, and an additional six studies reported no association. Low-quality evidence reported that distress and anxiety symptoms were associated with poorer health outcomes in people with neck pain and radiculopathy and very low-quality evidence showed this in people with neck pain only. Stress and higher job strain were negatively associated with poorer health outcomes measured by the presence of pain in two studies of very low quality.

CONCLUSIONS

Across a small number of highly heterogenous, low quality studies mental health symptoms are negatively associated with health outcomes in people with neck pain with radiculopathy and neck pain without radiculopathy. Clinicians should continue to utilise robust clinical reasoning when assessing the complex factors impacting a person's presentation with neck pain with or without radiculopathy.

PROSPERO REGISTRATION NUMBER

CRD42020169497.

Self-reported physical function is strongly related to pain behavior and pain interference and weakly related to physical capacity in people with chronic low back pain

BACKGROUND

Inclusion of self-reported and capacity-based measures may help to further elucidate the interactive link between how people think and move.

OBJECTIVE

To characterize the relationship between self-reported factors of physical function and pain with objective physical capacity measures.

DESIGN

Cross-sectional study of 328 adults with chronic low back pain (CLBP).

METHOD

Spearman correlations assessed the relationship between pairs of measures. Multiple linear regression models assessed the association between self-reported measures of physical function and the grouping of physical capacity measures. Self-reported measures included Roland Morris Disability Questionnaire (RMDQ), PROMIS Physical Function, Pain Behavior, and Pain Interference; Fear-Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), and Chronic Pain Acceptance Questionnaire (CPAQ). Capacity measures included walking speed and endurance, lower extremity functional strength, lumbopelvic range of motion, and trunk endurance.

RESULTS

PROMIS Physical Function was directly and weakly correlated with walking speed (ρ = 0.26, 2-min walk) and inversely and weakly correlated with lower extremity strength (ρ = -0.29, 5x sit-to-stand). RMDQ was not correlated with any of the capacity-based measures. PROMIS Physical Function was inversely and moderately correlated with Pain Interference (ρ = -0.48) and Pain Behavior (ρ = -0.43), PCS (ρ = -0.36), and FABQ (ρ = -0.31). The RMDQ was strongly correlated with PROMIS Physical Function (ρ = -0.56), Pain Behavior (ρ = 0.51) and Pain Interference (ρ = 0.49); and moderately correlated with PCS (ρ = 0.37) and FABQ (ρ = 0.33). PROMIS Physical Function and RMDQ were not correlated with CPAQ. Lower scores on PROMIS Physical Function were weakly associated with lower measures of lower extremity strength (-0.30, 95% CI: -0.51 to -0.09, p = 0.005). Higher scores on RMDQ were also weakly associated with lower measures of lower extremity strength (0.26, 95% CI: 0.11 to 0.41, p = 0.001).

CONCLUSIONS

A strong association emerged between self-reported limitations in physical function, pain behavior, and pain interference. A weak association emerged between self-reported physical function and lower extremity strength.

Pain intensity and psychological distress show different associations with interference and lack of life control: A clinical registry-based cohort study of >40,000 chronic pain patients from SQRP

Background

Both chronic pain and depressive and/or anxiety symptoms are associated with negative impacts on daily living, including interference and lack of life control. However, little is known about how pain and psychological distress affect these impacts.

Aim

The first aim was to assess how pain intensity, psychological distress, and social support interact with interference and lack of life control. A second aim was to investigate whether the strength of these relationships is moderated by the presence or absence of depression and/or anxiety.

Subjects and methods

Patient-Reported Outcome Measures (PROMs), which are available in the Swedish Quality Registry for Pain Rehabilitation (SQRP), were retrieved for patients with chronic pain (N = 40,184). A theoretical model with the constructs/latent variables pain intensity, psychological distress, interference, lack of life control, and social support was proposed and analyzed using Partial Least Squares Structural Equation Modelling (PLS-SEM). Indicators for these constructs were identified from the PROMs of the SQRP. Two models of the total cohort, which differed with respect to the causal relationship between pain intensity and psychological distress, were investigated. The moderating effects of anxiety and/or depression were also analyzed.

Results

Relatively low correlation and explanatory power (R ²= 0.16) were found for the pain intensity-psychological distress relationship. Pain intensity had a stronger effect on interference than on lack of life control. The reverse was found for psychological distress - i.e., psychological distress seemed to have a higher negative influence on function than on interference. The underlying assumption of the causal relationship between pain intensity and psychological distress determined how strong pain intensity and psychological distress influenced interference and lack of life control. Social support showed very similar absolute significant correlations with interference and lack of life control. Interference and lack of life control showed relatively weak associations. The psychological distress level was a moderating factor for several of the paths investigated.

Discussion and conclusion

A clinical treatment consequence of the low correlation between pain intensity and psychological distress may be that clinically treating one may not reduce the effect of the other. The relative importance of pain intensity and psychological distress on interference and lack of life control depends on the underlying assumption concerning the pain intensity-psychological distress relationship. Interference and lack of life control showed relatively weak associations, underscoring the need to clinically assess them separately. Social support influenced both impact constructs investigated. The cohort display heterogeneity and thus presence of definite signs of anxiety and/or depression or not was a moderating factor for several of the associations (paths) investigated. The results are important both for the assessments and the design of treatments for patients with chronic pain.

Effects of Tai Chi on insomnia in elderly people with chronic non-specific low back pain: A study protocol for a randomized controlled trial

Introduction

Chronic non-specific low back pain (CNLBP) is a complex condition characterized by pain, dysfunction, disturbed sleep, anxiety, and depression, all of which impair the quality of life. Previous studies showed that practicing Tai Chi had effects on chronic low back pain. However, there is a lack of evidence on its impact on sleep. The trial will evaluate the use of Tai Chi as a treatment for insomnia in elderly people with CNLBP.

Methods

The study design will be a randomized, controlled, open-label trial. Participants (n = 106) will be recruited from the Hospital of Chengdu University of Traditional Chinese Medicine, Qing Yang District University for the Elderly, and Ci Tang Street Community. Participants will be randomly assigned to the Tai Chi group (n = 53) and the control group (n = 53). The Tai Chi group will undergo a Yang-style 24-form Tai Chi program for 8 weeks. The control group will have a waiting period of 8 weeks, followed by 8 weeks of Tai Chi practice. The primary outcomes of this study will be changes in sleep quality and pain intensity. Secondary outcomes of interest will include changes in the quality of pain, range of motion, physical performance, social support, and overall quality of life. Any adverse events and attendance rates will also be reported in this study.

Clinical trial registration

ChiCTR2200064977.

The effect of mindfulness on the inflammatory, psychological and biomechanical domains of adult patients with low back pain: A randomized controlled clinical trial

Objective

This study aims to study the effect of mindfulness-based program on the psychological, biomechanical and inflammatory domains of patients with chronic low back pain.

Methods

A multicentre randomized and controlled clinical trial of parallel groups in patients with chronic low back pain between March 2019 to March 2020. Participants with no experience in mindfulness based intervention, were randomized to receive (36 patients) or not (34 patients) mindfulness-based stress reduction program for chronic back pain (MBSR-CBP). The program was performed in 9 sessions. Patients with chronic low back pain due to symptomatic discopathy (degenerative disc disease or herniated disc) were included. The principal outcome was changes in the blood level of cortisol and cytokines (tumor necrosis factor- α (TNF- α), interleukin-1β (IL-1β), interleukin-6 (IL-6) and interleukin-17 (IL-17)). Secondary outcomes (psychological factors, pain, and quality of life) were measured by validated questionnaires.

Results

Of the 96 randomized patients, 70 who completed the study were included in the analysis (mean [range] age: 53 [33–73] years; 66% females). MBSR-CBP stopped the increase in cortisol, and reduced pro-inflammatory cytokine IL-1β (p = 0.05). It reduced depression (p = 0.046) and stress (p = 0.0438), perceived pain (p < 0.0001), and limitations related to health (p < 0.0001). It also increased the physical function (p = 0.002) and sleep quality (p = 0.05). Furthermore, it significantly increased life satisfaction (0.006), well-being (p = 0.001) and vitality (p < 0.0001). It also increased self-compassion (p < 0.0001) and significantly reduced the overidentification (p<0.0001) and catastrophization (p = 0.002).

Conclusions

MBSR-CBP could be part of a multidisciplinary approach in the management of patients suffering from chronic low back pain.

Differences in pain, disability, and psychological function in low back pain patients with and without anxiety

Objectives: Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Chronic low back pain (LBP) reduces working hours, increases comorbidities, and increases rehabilitation needs. The aim of this study was to evaluate whether there were differences in pain, dysfunction, and psychological factors between two groups. The supplementary demonstrated the relationship between these influencing factors and anxiety.

Methods: A cross-sectional study was designed to analyze the differences in pain, disability, and psychological function in non-specific LBP patients with and without anxiety. In total, 60 subjects were divided into two groups based on self-rated anxiety scores: 30 patients with SAS score ≥50 were in the low back pain with anxiety group, and 30 for the LBP without anxiety group with SAS score &lt;50. The pain intensity was assessed using the Visual Analog Scale; psychological function, using the Pain Anxiety Symptoms Scale, the Tampa Scale for Kinesiophobia, and the Fear Avoidance Beliefs Questionnaire; functional disability, using the Oswestry Disability Index and the Roland–Morris Disability Questionnaire; quality of life using 36-Item Short-Form Health Survey questionnaire; and the quality of sleep using Pittsburgh Sleep Quality Index, and the relationships between variables and anxiety scores were estimated using Spearman correlation analysis.

Results: A total of 60 participants were enrolled after self-rated anxiety was assessed and the full investigation was finished. The analyses showed significant differences of pain intensity (p = 0.034, disability (ODI, p = 0.007; RMDQ, p = 0.012) and psychological function (TSK, p = 0.000; PASS, p = 0.009; FABQ, p = 0.000; SF-36, p = 0.000; and PSQI, p = 0.000) between the two groups. Spearman correlation analysis showed that the anxiety score had significant positive correlations with functional disability (ODI, p = 0.004 and 95% CI = 0.112–0.573; RMDQ, p = 0.003, 95% CI = 0.135–0.586) and psychological function (TSK, p = 0.001, 95% CI = 0.174–0.612), excellent positive correlation with quality of sleep (PASS, p = 0.025, 95% CI = 0.031–0.512), and strongly negative correlations with the quality of life (SF-36, p = 0.000, 95% CI = 0.761–0.433).

Conclusion: We recognized that anxiety in low back pain patients was mainly due to interaction with the intensity of pain, disability level, and a mass of psychological function. The future research direction could be to alleviate the anxiety on the comprehensive efficacy of patients with low back pain.

Does Back Pain Go on Holiday in the Summer?

Back pain is one of the leading causes of disability among adults worldwide [...].

Association of back pain with major depressive disorder among older adults in six low- and middle-income countries: A cross-sectional study

OBJECTIVES

Back pain is one of the leading causes of disability and decreased quality of life. In this study, we examined the association between back pain and major depressive disorder (MDD) in six low- and middle-income countries. We also examined the association of back pain duration and severity with MDD among middle-aged and older adults in these countries.

METHODS

Nationally representative data from the World Health Organization's Study on global AGEing and adult health (WHO-SAGE) consisting of 33,878 middle-aged and older adults aged 50 years or above were analysed. The linkages of back pain, pain duration and severity with MDD were examined using multivariable logistic regression analyses.

RESULTS

Across six countries, the prevalence of MDD was higher among middle-aged and older adults who reported back pain than those who did not report back pain (14.5 % vs 4.5 %). In the pooled data, middle-aged and older adults who suffered from back pain had higher odds of depression [adjusted odds ratio (aOR): 2.41, confidence interval (CI): 2.19-2.64] compared to those with no back pain. Particularly, the association was stronger in Ghana [aOR: 4.78] and South Africa [aOR: 2.42]. Further, the association was stronger for those who experienced back pain for >2 weeks as well as those who reported severe and extreme back pain than those with no back pain across all the countries.

CONCLUSION

In this study, the association of back pain and its duration and severity with MDD is consistent and significant among middle-aged and older adults in six countries. Government policies should consider the role of back pain in improving the mental health of middle-aged and older adults.

Brain structure, psychosocial, and physical health in acute and chronic back pain: a UK Biobank study

ABSTRACT

Brain structure, psychosocial, and physical factors underpin back pain conditions; however, less is known about how these factors differ based on pain duration and location. We examined, cross-sectionally, 11,106 individuals from the UK Biobank who (1) were pain-free (n = 5616), (2) had acute back pain (n = 1746), (3) had chronic localised back pain (CBP; n = 1872), or (4) had chronic back pain and additional chronic pain sites (CWP; n = 1872). We found differences in structural brain measures in the chronic pain groups alone. Both CBP and CWP groups had lower primary somatosensory cortex {CBP mean difference (MD) (95% confidence interval [CI]): -250 (-393, -107) mm3, P < 0.001; CWP: -170 (-313, -27)mm3, P = 0.011} and higher caudate gray matter volumes (CBP: 127 [38,216]mm3, P = 0.001; CWP: 122 [33,210]mm3, P = 0.002) compared with pain-free controls. The CBP group also had a lower primary motor cortex volume (-215 [-382, -50]mm3, P = 0.005), whereas the CWP group had a lower amygdala gray matter volume (-27 [-52, -3]mm3, P = 0.021) compared with pain-free controls. Differences in gray matter volumes in some regions may be moderated by sex and body mass index. Psychosocial factors and body mass index differed between all groups and affected those with widespread pain the most (all, P < 0.001), whereas grip strength was only compromised in individuals with widespread pain (-1.0 [-1.4, -0.5] kg, P < 0.001) compared with pain-free controls. Longitudinal research is necessary to confirm these interactions to determine the process of pain development in relation to assessed variables and covariates. However, our results suggest that categorised pain duration and the number of pain sites warrant consideration when assessing markers of brain structure, psychosocial, and physical health.

Is There a Difference in Fear-Avoidance, Beliefs, Anxiety and Depression Between Post-Surgery and Non-Surgical Persistent Spinal Pain Syndrome Patients?

Introduction

Patients with post-surgery persistent spinal pain syndrome (PSPS) or non-surgical PSPS might be affected by sustained fear-avoidance beliefs (FAB), anxiety and depression. In this scenario, this study aimed to describe those aspects in patients with post-surgery PSPS and non-surgical PSPS.

Methods

This study included patients with PSPS, and non-surgical PSPS, over 18 years, with quarterly evaluations at the Chronic Pain Clinic. After evaluation, demographic and clinical characteristics were obtained. The Beck Depression Inventory-II, Beck Anxiety Inventory, Douleur neuropathique 4 questions, Visual Analog Pain Scale, and Fear-Avoidance Beliefs Questionnaire-Brazilian Version (FABQ-Brazil) were used to evaluate psychological aspects.

Results

Forty-six patients were included, 23 patients with post-surgery PSPS and 23 with non-surgical PSPS. Both groups had high scores in the physical and work domains of the FABQ, high rates of absenteeism and most patients in these groups had moderate-to-severe neuropathic pain and some degree of anxiety and/or depression. The groups showed no statistically significant difference (p > 0.05) when comparing all questionnaires.

Discussion

This is one of the first studies to evaluate FAB and other associated psychological factors, such as anxiety and depression, in patients with post-surgery PSPS in a follow-up several years after surgery and compare with patients diagnosed with non-surgical PSPS. In this study, most patients in both groups had high scores in the FABQ domains, not having statistically relevant difference between groups.

Conclusion

Even though there was no statistically relevant difference between the PSPS patient with or without surgical history in terms of the assessed outcome measures, the described scores for fear-avoidance beliefs, pain, anxiety and depression were high, showing an interference in the daily life activities of those patients.

Subthreshold depression - concept, operationalisation and epidemiological data. A scoping review

Purpose: In diagnostic systems (e.g., DSM-5, ICD-10), depression is defined categorically. However, the concept of subthreshold depression (SD) has gained increasing interest in recent years. The purpose of the present paper was to review, based on a scoping review, the relevant papers in this field published between October 2011 and September 2020.Materials and methods: Of the 1,160 papers identified, 64 records could be included in further analysis. The scoping review was conducted using both electronic and manual methods.Results: The main result of the analysis is that the operationalisation criteria used are highly heterogeneous, which also leads to very heterogenous epidemiological data.Conclusions: Clear conclusions are not possible scrutinising the reported results. Most definitions seem to be arbitrary, with considerable overlap (e.g., between SD and minor depression). The review also revealed that the impact of SD on quality of life and related parameters appear to be in the range of the respective impact of major depression (MD) and therapeutic approaches might be helpful for SD and also for the prevention of conversion from SD to MD. Keeping the presented difficulties in mind, a proposal for the definition of SD is made in the present paper in order to facilitate the discussion leading to more homogeneous criteria.

Kinesiotape effectiveness in mechanical low back pain: A randomized clinical trial

BACKGROUND: Low back pain (LBP) is the most common musculoskeletal disorder work-related health problem in Europe, affecting millions of workers. It is estimated that 60–80% of the population will suffer at least one episode of mechanical LBP during their life. OBJECTIVE: To evaluate the kinesiotape (KT) effectiveness in mechanical LBP. METHODS: This was a double blinded, randomized-controlled clinical trial. Twenty-eight nursing and cleaning auxiliaries from Salamanca received a manual therapy program and a bandage of KT or false kinesiotape (FKT). They received two sessions a week for three weeks and a follow-up one month after the last session. Pain, range of motion and function were measured at baseline, at the end of each session and a month after the last session. RESULTS: Work-related musculoskeletal disorders and LBP are responsible for a high prevalence of sick-leave and absenteeism. Manual therapy and KT has demonstrated to reduce pain and to increase range of motion and function being effective in this population. There are statistically significant results in both groups in all measurements for all variables. KT seems to be superior, however, both have a positive effect on LBP. Although benefits decrease, long-term treatments focusing on pain alleviation and functional recovery is needed to maintain the benefits achieved. CONCLUSION: KT was an effective complement for this treatment. Although both show improvements, KT is recommended. Future studies are needed to demonstrate KT properties, to establish a treatment protocol to prevent chronic LBP and to avoid sick leave and absenteeism.

Sleep problems and subjective cognitive complaints among middle-aged and older adults in 45 low- and middle-income countries

BACKGROUND

Currently, a small body of evidence suggests that sleep problems are positively associated with subjective cognitive complaints (SCC). However, no studies on this topic exist from low- and middle-income countries (LMICs). Thus, we investigated the association between sleep problems and SCC in a large sample of middle-age and older adults from 45 LMICs.

METHODS

Cross-sectional, predominantly nationally representative, community-based data were analyzed from the World Health Survey. Sleep problems (such as difficulties falling asleep, waking up frequently during the night or waking up too early in the morning) in the last 30 days were self-reported. Two questions on subjective memory and learning complaints in the past 30 days were used to create a SCC scale ranging from 0 (No SCC) to 100 (worse SCC). Multivariable linear regression was conducted to explore the association between sleep problems (exposure) and SCC (outcome).

RESULTS

Data on 60,228 adults aged ≥ 50 years were analyzed [mean (SD) age 61.4 (9.9) years; 53.9% females]. After adjustment for potential confounders, compared to those without sleep problems, the mean SCC score for the multivariable model was 13.32 (95% CI 12.01, 14.63), 19.46 (95% CI 17.95, 20.98), 24.17 (95% CI 22.02, 26.33), and 31.39 (95% CI 28.13, 34.65) points higher for mild, moderate, severe, and extreme sleep problems, respectively. Similar results were found for analyses stratified by age and country-income level.

CONCLUSION

Sleep problems were positively associated in a dose-response manner with SCC among middle-aged and older adults in multiple LMICs. Addressing sleep problems may aid in the prevention of SCC and ultimately dementia, pending future longitudinal research.

Association of objective and subjective far vision impairment with perceived stress among older adults in six low- and middle-income countries

OBJECTIVES

To assess the association between far vision impairment (objective and subjective) and perceived stress among older adults from six low- and middle-income countries (LMICs, i.e., China, Ghana, India, Mexico, Russia, and South Africa).

METHODS

Data from the WHO Study on global AGEing and adult health were analyzed. Objective visual acuity was measured using the tumbling E LogMAR chart and was used as a four-category variable (no, mild, moderate, and severe visual impairment). Subjective visual impairment referred to difficulty in seeing and recognizing an object or a person across the road. Using two questions from the Perceived Stress Scale, a perceived stress variable was computed, and ranged from 0 (lowest stress) to 100 (highest stress). Multivariable linear regression with perceived stress as the outcome was conducted.

RESULTS

Data on 14,585 adults aged ≥65 years [mean (SD) age 72.6 (11.5) years; 55.0% females] were analyzed. Only severe objective visual impairment (versus no visual impairment) was significantly associated with higher levels of stress (b = 6.91; 95% CI = 0.94-12.89). In terms of subjective visual impairment, compared with no visual impairment, mild (b = 2.67; 95% CI = 0.56-4.78), moderate (b = 8.18; 95% CI = 5.84-10.52), and severe (b = 11.86; 95% CI = 9.11-14.61) visual impairment were associated with significantly higher levels of perceived stress.

CONCLUSIONS

This large study showed that far vision impairment was associated with increased perceived stress levels among older adults in LMICs. Increased availability of eye care services may reduce stress among those with visual impairment in LMICs, while more research is needed to better characterize the directionality of the far vision impairment-perceived stress relationship.

Subjective social status moderates back pain and mental health in older men

OBJECTIVES

Back pain and poor mental health are interrelated issues in older men. Evidence suggests that socioeconomic status moderates this relationship, but less is known about the role of subjective social status (SSS). This study examined if the association between back pain and mental health is moderated by SSS.

METHOD

We used a sample of community-dwelling older men (≥65 years) from the Osteoporotic Fractures in Men Study (N = 5994). Participants self-reported their back pain severity and frequency over the past 12 months. SSS was assessed with the MacArthur Scale of SSS. Mental health was assessed with the SF-12 Mental Component Summary (MCS).

RESULTS

Severe back pain was associated with lower SF-12 MCS scores (p = .03). Back pain frequency was not associated with SF-12 MCS scores. SSS moderated the back pain and mental health relationship. Among men with higher national or community SSS, the association between back pain severity and SF-12 MCS scores was not significant. However, among men with lower national or community SSS, more severe back pain was associated with lower SF-12 MCS scores (p's < .001). Among those with lower national or community SSS, greater back pain frequency was also associated with lower SF-12 MCS scores (p's < .05).

CONCLUSION

Where one ranks oneself within their nation or community matters for the back pain and mental health relationship. Higher SSS may be a psychosocial resource that buffers the negative associations of severe and frequent back pain on mental health in older men.

Pain Is Widespread and Predicts Poor Mental Health Among Older Adults in Rural Malawi

Background and Objectives

Pain is common among older persons and has been documented as an important predictor of disability, health, and economic outcomes. Evidence about its prevalence and relationship to well-being is scarce in rural sub-Saharan Africa (SSA), where work is frequently physically demanding, and pain prevention or treatment options are limited. We investigate the prevalence of pain and its association with mental health and subjective well-being in a population-based study of older adults in rural Malawi.

Research Design and Methods

We estimate the prevalence, severity, and duration of pain along with its sociodemographic distribution in a sample of 1,577 individuals aged 45 and older. We assess the association of pain with clinically validated measures of mental health, including depression and anxiety, and subjective well-being.

Results

Pain is widespread in this mature population with an average age of 60 years: 62% of respondents report the experience of at least minor pain during the last year, and half of these cases report severe or disabling pain. Women are more likely to report pain than men. Pain is a strong predictor of mental health and subjective well-being for both genders. More severe or longer pain episodes are associated with worse mental states. Individuals reporting pain are more likely to suffer from depression or express suicidal thoughts.

Discussion and Implications

Our study identifies key subpopulations such as older women in a SSA low-income context who are particularly affected by the experience of pain in daily life and calls for interventions targeting pain and its consequences for mental health and subjective well-being.

Non-Medical Factors Associated with the Outcome of Treatment of Chronic Non-Malignant Pain: A Cross-Sectional Study

BACKGROUND

Chronic pain is a global public health issue with increasing prevalence. Chronic pain causes sleep disorder, reactive anxiety, and depression, impairs the quality of life; it burdens the individual and society as a whole. The aim of this study was to examine non-medical factors related to the outcome of the treatment of chronic non-malignant pain.

METHODS

A cross-sectional study with two groups of patients was conducted using a questionnaire with biological, psychological, and social characteristics of patients. Since this study was cross-sectional, it was not possible to determine whether some factors were the cause or the consequence of unsuccessful treatment outcome, which is at the same time one of the disadvantages of cross-sectional studies.

RESULTS

The poor outcome of the treatment of chronic non-malignant pain in a multivariate binary logistic regression model was statistically significantly associated with the lower quality of life (OR = 0.95 (95% CI: 0.91-0.99; p = 0.009), and higher depression level OR = 1.08 (95% CI: 1.02-1.14; p = 0.009). The outcome of the treatment was not directly related to social support measured by the multivariate binary logistic regression model (OR = 1.04, 95% CI: 0.95-1.15, p = 0.395), but solitary life (without partner) was (OR = 2.16 (95% CI: 1.03-4.53; p = 0.043).

CONCLUSION

The typical patient with a poor pain management outcome is retired, presents depressive behavior; their pain disturbs general activity and sleeping. Moreover, they have a physically disturbed quality of life and require self-treatment due to the inaccessibility of doctors and therapies. The principle of treatment of patients with chronic, non-malignant pain should take into account a biopsychosocial approach with individually adjusted procedures.

Clinician education unlikely effective for guideline-adherent medication prescription in low back pain: systematic review and meta-analysis of RCTs

BACKGROUND

Effectiveness of implementing interventions to optimise guideline-recommended medical prescription in low back pain is not well established.

METHODS

A systematic review and random-effects meta-analyses for dichotomous outcomes with a Paule-Mandel estimator. Five databases and reference lists were searched from inception to 4^th August 2021. Randomised controlled/clinical trials in adults with low back pain to optimise medication prescription were included. Cochrane Risk of Bias 2 tool and GRADE were implemented. The review was registered prospectively with PROSPERO (CRD42020219767).

FINDINGS

Of 3352 unique records identified in the search, seven studies were included and five were eligible for meta-analysis (N=11339 participants). Six of seven studies incorporated clinician education, three studies included audit/feedback components and one study implemented changes in medical records systems. Via meta-analysis, we estimated a non-significant odds-ratio of 0·94 (95% CI (0·77; 1.16), I² = 0%; n=5 studies, GRADE: low) in favour of the intervention group. The main finding was robust to sensitivity analyses.

INTERPRETATION

There is low quality evidence that existing interventions to optimise medication prescription or usage in back pain had no impact. Peer-to-peer education alone does not appear to lead to behaviour change. Organisational and policy interventions may be more effective.

FUNDING

This work was supported by internal institutional funding only.

Efficacy and safety of treating chronic nonspecific low back pain with radial extracorporeal shock wave therapy (rESWT), rESWT combined with celecoxib and eperisone (C + E) or C + E alone: a prospective, randomized trial

BACKGROUND

To investigate whether respectively radial extracoporeal shock wave therapy (rESWT) or a combination of rESWT, celecoxib and eperisone (rESWT + C + E) are superior in reducing pain in patients with chronic nonspecific low back pain (cnsLBP) compared to C + E alone (a standard treatment of this condition in China).

METHODS

140 patients with cnsLBP were randomly allocated to rESWT (n = 47), rESWT + C + E (n = 45) or C + E alone (n = 48) for four weeks between November 2017 and March 2019. Outcome was evaluated using the Pain Self-Efficacy Questionnaire (PSEQ), Numerical Rating Scale (NRS), Oswestry Low Back Pain Disability Questionnaire and Patient Health Questionnaire 9, collected at baseline as well as one week (W1), W2, W3, W4 and W12 after baseline.

RESULTS

All scores showed a statistically significant improvement over time. The PSEQ and NRS scores showed a significant Time × Treatment effect. Patients treated with rESWT had significantly lower mean NRS values than patients treated with rESWT + C + E at W1 and W3, as well as than patients treated with C + E alone at W3 and W4. No severe adverse events were observed.

CONCLUSIONS

rESWT may not be inferior to respectively rESWT + C + E or C + E alone in reducing pain in patients with cnsLBP.

LEVEL OF EVIDENCE

Level I, prospective, randomized, active-controlled trial.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier NCT03337607. Registered November 09, 2017, https://www.clinicaltrials.gov/ct2/show/NCT03337607 .

LEVEL OF EVIDENCE

Level I; prospective, randomized, controlled trial.

Relative contributions of the nervous system, spinal tissue and psychosocial health to non-specific low back pain: Multivariate meta-analysis

BACKGROUND AND OBJECTIVES

Nervous system, psychosocial and spinal tissue biomarkers are associated with non-specific low back pain (nsLBP), though relative contributions are unclear.

DATABASES AND DATA TREATMENT

MEDLINE, EMBASE, CINAHL, PsycINFO and SPORTDiscus were searched up to 25 March 2020. Related reviews and reference lists were also screened. Observational studies examining structural and functional nervous system biomarkers (e.g. quantitative sensory tests, structural and functional brain measures), psychosocial factors (e.g. mental health, catastrophizing) and structural spinal imaging biomarkers (e.g. intervertebral disc degeneration, paraspinal muscle size) between nsLBP and pain-free controls were included. For multivariate meta-analysis, two of three domains were required in each study. Random-effects pairwise and multivariate meta-analyses were performed. GRADE approach assessed evidence certainty. Newcastle-Ottawa scale assessed risk of bias. Main outcomes were the effect size difference of domains between nsLBP and pain-free controls.

RESULTS

Of 4519 unique records identified, 33 studies (LBP = 1552, referents = 1322) were meta-analysed. Psychosocial state (Hedges' g [95%CI]: 0.90 [0.69-1.10], p < 0.001) in nsLBP showed larger effect sizes than nervous system (0.31 [0.13-0.49], p < 0.001; difference: 0.61 [0.36-0.86], p < 0.001) and spine imaging biomarkers (0.55 [0.37-0.73], p < 0.001; difference: 0.36 [0.04-0.67], p = 0.027). The relationship between domains changes depending on if pain duration is acute or chronic.

CONCLUSIONS

Psychosocial effect sizes in nsLBP are greater than that for spinal imaging and nervous system biomarkers. Limitations include cross-sectional design of studies included and inference of causality. Future research should investigate the clinical relevance of these effect size differences in relation to pain intensity and disability.

STUDY REGISTRATION

PROSPERO-CRD42020159188.

SIGNIFICANCE

Spinal imaging (e.g. intervertebral disc degeneration), psychosocial (e.g. depression) and nervous system (e.g. quantitative sensory tests, structural and functional brain measures) biomarkers contribute to non-specific low back pain. However, psychosocial factors may be more compromised than nervous system and spinal imaging biomarkers. This relationship depends on if the pain is acute or chronic. These findings underscore that the 'non-specific' label in back pain should be reconsidered, and more specific multidimensional categories evaluated to guide patient management.

Patient-reported factors associated with degree of pain medication dependence and presence of severe dependence among spinal outpatients

Aim: To identify risk factors for pain medication dependence. Materials & methods: Chronic spinal pain outpatients (n = 106) completed the Leeds Dependence Questionnaire (LDQ) and measures of potential risk factors. Participants with high (n = 3) and low (n = 3) dependence were interviewed. Results: Mean LDQ score was 11.52 (standard deviation 7.35) and 15/106 participants (14.2%) were severely dependent (LDQ ≥20). In linear regression, pain intensity (β = 0.313, p < 0.001), being disabled by pain (β = 0.355, p < 0.001), borrowing pain medication (β = 0.209, p = 0.006), and emergency phone calls or clinic visits (β = 0.169, p = 0.029) were associated with degree of dependence across the range of LDQ scores. In logistic regression, pain intensity (p = 0.001) and borrowing pain medication (p = 0.004) increased the odds of severe dependence. Interviewees described how their pain influenced their pain medication use and one described pain medication addiction. Conclusion: Interventions to reduce pain intensity and pain-related disability may reduce pain medication dependence.

Increased Expression of Integrin Alpha 6 in Nucleus Pulposus Cells in Response to High Oxygen Tension Protects against Intervertebral Disc Degeneration

The destruction of the low oxygen microenvironment in nucleus pulposus (NP) cells played a critical role in the pathogenesis of intervertebral disc degeneration (IVDD). The purpose of this study was to determine the potential role of integrin alpha 6 (ITG α6) in NP cells in response to high oxygen tension (HOT) in IVDD. Immunofluorescence staining and western blot analysis showed that the levels of ITG α6 expression were increased in the NP tissue from IVDD patients and the IVDD rat model with mild degeneration, which were reduced as the degree of degeneration increases in severity. In NP cells, the treatment of HOT resulted in upregulation of ITG α6 expression, which could be alleviated by blocking the PI3K/AKT signaling pathway. Further studies found that ITG α6 could protect NP cells against HOT-induced apoptosis and oxidative stress and protect NP cells from HOT-inhibited ECM protein synthesis. Upregulation of ITG α6 expression by HOT contributed to maintaining NP tissue homeostasis through the interaction with hypoxia-inducible factor-1α (HIF-1α). Furthermore, silencing of ITG α6 in vivo could obviously accelerate puncture-induced IVDD. Taken together, these results revealed that the increase of ITG α6 expression by HOT in NP cells might be a protective factor in IVD degeneration as well as restore NP cell function.

Team Approach: Management of an Acute L4-L5 Disc Herniation

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Lumbar disc herniation is one of the most common spinal pathologies, often occurring at the L4-L5 and L5-S1 levels. The highest incidence has been reported in patients between the fourth and sixth decades of life.

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The severity of symptoms is influenced by the patient's risk factors, the location, and the extent and type of disc herniation.

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Lumbar disc herniation can be effectively treated with multiple treatment protocols. In most cases, first-line treatment includes oral analgesic medication, activity modification, and physical therapy. When nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection. A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy.

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The treatment algorithm for symptomatic lumbar disc herniation often is a stepwise approach: failure of initial nonoperative measures leads to more aggressive treatment when symptoms mandate and, as such, necessitates the use of a multidisciplinary team approach. The core team should consist of an interventional physiatrist, an orthopaedic surgeon, a physician assistant, and a physical therapist. Additional team members may include nurses, radiologists, neurologists, anesthesiologists, spine fellows, psychologists, and case managers.

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This review article describes a case scenario that uses a multidisciplinary team approach for the treatment of an acute L4-L5 disc herniation in a 31-year-old patient without any major comorbidities.

Pain drawing as a screening tool for anxiety, depression and reduced health-related quality of life in back pain patients: A cohort study

Background

Back pain patients are more likely to suffer from depression, anxiety and reduced quality of life. Pain drawing is a simple, frequently used anamnesis tool that facilitates communication between physicians and patients. This study analysed pain drawings to examine whether pain drawing is suitable as a screening tool for signs of anxiety, depression or reduced quality of life, as the detection of these symptoms is essential for successful treatment.

Methods

Pain drawings of 219 patients with lower back pain were evaluated retrospectively. Pain drawings are a schematic drawing of a human being. Six variables of the pain drawing were analysed. Subscales of the Hospital Anxiety and Depression Scale (HADS) and the Mental Component Summary (MCS) of the Short Form 12 (SF-12) were used to measure anxiety, depression and quality of life, respectively. Descriptive statistics, uni- and multivariate linear regression analyses and analysis of variance were performed. Logistic regression analyses were conducted for suitable variables.

Results

We revealed significant positive correlations between the variables "filled body surface" and "number of pain sites" and the anxiety (HADS-A) and depression subscales (HADS-D) of the HADS (p<0.01). The same predictors had significant negative correlations with the MCS (p<0.01). However, the sensitivity and specificity of the variable "number of pain sites" were too low compared to those for existing screening tests to consider it as a screening tool for anxiety, depression and quality of life (HADS-A: sensitivity: 45.2%, specificity: 83.3%; HADS-D: sensitivity: 61.1%, specificity: 51%; MCS: sensitivity: 21.2%, specificity: 85.7%).

Conclusions

There were significant correlations between the amount of filled body surface and the number of pain sites in the pain drawing and anxiety, depression and quality of life. Although useful in routine clinical practice, pain drawing cannot be used as a screening tool based on our results.

Effects of Age and Sex on Properties of Lumbar Erector Spinae in Healthy People: Preliminary Results From a Pilot Study

Background: The influences of age and sex on properties of lumbar erector spinae have not been previously studied. Changes in the performance of lumbar erector spinae properties associated with age represent a valuable indicator of risk for lower-back-related disease.

Objective: To investigate the lumbar erector spinae properties with regard to age and sex to provide a reference dataset.

Methods: We measured muscle tone and stiffness of the lumbar erector spinae (at the L3–4 level) in healthy men and women (50 young people, aged 20–30 years; 50 middle-aged people, aged 40–50 years; and 50 elderly people, aged 65–75 years) using a MyotonPRO device.

Results: In general, there are significant differences in muscle tone and stiffness among young, middle-aged, and elderly participants, and there were significant differences in muscle tone and stiffness between men and women, and there was no interaction between age and sex. The muscle tone and stiffness of the elderly participants were significantly higher than those of the middle-aged and young participants (P < 0.01), and the muscle tone and stiffness of the middle-aged participants were significantly higher than those of the young participants (P < 0.01). In addition, the muscle tone and stiffness of men participants were significantly higher than that of women participants (P < 0.01).

Conclusion: Our results indicate that muscle tone and stiffness of the lumbar erector spinae increase with age. The muscle tone and stiffness of the lumbar erector spinae in men are significantly higher than in women. The present study highlights the importance of considering age and sex differences when assessing muscle characteristics of healthy people or patients.

Perspectives of emergency department clinicians on the challenges of addressing low back pain in the emergency setting: A qualitative study

OBJECTIVE

To identify and explore ED clinician perspectives on: (i) why patients with low back pain (LBP) present to the ED and are admitted into hospital from ED; (ii) barriers and enablers they face when providing care to patients with LBP; and (iii) strategies to improve the care of patients with LBP, and associated care processes, in the ED.

METHODS

We undertook a qualitative exploratory study with ED clinicians (medical officers, nurses and physiotherapists) at a tertiary-level public hospital in New South Wales, Australia, using focus groups and individual interviews. We used thematic analysis to synthesise participant responses to answer the predefined research questions.

RESULTS

Twenty-one clinicians participated (two individual interviews, 19 focus groups). Perceptions about better access to the ED and advanced care within ED were thought to drive presentations to the ED for LBP. Barriers and enablers to optimal patient care included patient-, clinician- and service-level factors. The main strategies to improve care included a department LBP pathway, modernised patient and clinician resources, better follow-up options post-discharge and improved communication between ED and primary care.

CONCLUSION

We identified a range of targets to improve LBP management in ED. Clinicians perceived internal and external factors to the ED as influences of ED presentation and hospital admission. Clinicians also reported that patient-, clinician- and service-level barriers and enablers influenced patient management in ED. Strategies suggested by clinicians included improved follow-up options, access to resources and an 'LBP pathway' to support decision making.

The Effect of Short-Wave Diathermy and Exercise on Depressive Affect in Chronic Low Back Pain Patients

Objective:

The aim of this study was to compare exercise, continuous short-wave diathermy (SWD) and intermittent SWD treatment modalities and to evaluate the effects of these treatments on chronic back pain and depression.

Methods:

This study is an intervention trial which evaluated patients who applied to our clinic due to chronic low back pain between 2008-2009. The study group consisted of 90 patients between the ages of 40-65 who had had low back pain for more than 6 months. The patients were randomized into three groups. The first group received placebo short-wave diathermy, the second group received continuous short-wave diathermy, and the third group received pulsed short-wave diathermy. Pain was evaluated by Visual Analog Scale (VAS) and the Pain Disability Index (PDI).The Modified Oswestry Low Back Pain Disability Questionnaire Form was used for the measurement of functional deficiency and the Beck Depression Inventory (BDI) was used for the evaluation of depression.All scales were performed before the treatment, immediately after treatment and 3 months after treatment.

Results:

Significant decreases in PDI and VAS scores were found in all groups (p<0.05 for each). Similarly, there was a significant improvement in all groups in terms of functional deficiency(p<0.001 for each), while no differences were found between groups (p = 0.895). In terms of BDI scores, there was no improvement in those receiving only exercise, while Group 2 and 3 had significant improvements (p <0.05). When groups were compared for BDI scores, no differences were found between any of the groups (p = 0.189).

Conclusion:

Continuous SWD treatment with exercise was found to be more effective in reducing pain in patients with chronic low back pain than other treatment modalities used in our study. Although there was no significant difference between the groups in terms of depressive mood, it was found that those receiving continuous and pulsed SWD treatment had significant improvements in depression as measured by the BDI.

Acute and chronic back pain in adults and elderly in southern Brazil

Aims: to determine the prevalence of acute and chronic back pain and associated factors and identify the consequences of this pain in adults and the elderly in southern Brazil.Methods: cross-sectional study conducted in 2019, in Criciúma, Santa Catarina, in individuals aged 18 and over. Acute back pain was pain in the cervical, thoracic, or lumbar regions not exceeding 3 months and chronic pain as pain for 3 months or more. Bivariate analyzes and multinomial logistic regression were performed.Results: among the 820 participants, the prevalence of back pain was 67.0%, acute pain 39.3% (95% CI: 35.5% to 43.3%) and chronic pain 27.4% (95% CI: 24.5% to 30.4%). Acute back pain was associated with women, overweight, obesity, and with WMSD/RSI, while chronic pain chronic pain was found mostly in women, being related to leisure inactivity ...were female, leisure inactivity, falls, Work-related musculoskeletal disorder/repetitive strain injury, and arthritis/rheumatism.Conclusions: acute pain was greater among overweight/obese and chronic pain contribute to absenteeism and demand for health services.

Sleep and neighborhood socioeconomic status: a micro longitudinal study of chronic low-back pain and pain-free individuals

Individuals with chronic low back pain (cLBP) frequently report sleep disturbances. Living in a neighborhood characterized by low-socioeconomic status (SES) is associated with a variety of negative health outcomes, including poor sleep. Whether low-neighborhood SES exacerbates sleep disturbances of people with cLBP, relative to pain-free individuals, has not previously been observed. This study compared associations between neighborhood-level SES, pain-status (cLBP vs. pain-free), and daily sleep metrics in 117 adults (cLBP = 82, pain-free = 35). Neighborhood-level SES was gathered from Neighborhood Atlas, which provides a composite measurement of overall neighborhood deprivation (e.g. area deprivation index). Individuals completed home sleep monitoring for 7-consecutive days/nights. Neighborhood SES and pain-status were tested as predictors of actigraphic sleep variables (e.g., sleep efficiency). Analyses revealed neighborhood-level SES and neighborhood-level SES*pain-status interaction significantly impacted objective sleep quality. These findings provide initial support for the negative impact of low neighborhood-level SES and chronic pain on sleep quality.

Association between food insecurity and fall-related injury among adults aged ≥65 years in low- and middle-income countries: The role of mental health conditions

PURPOSE

We investigated the association between food insecurity and fall-related injury among older adults from six low- and middle-income countries (LMICs), and the extent to which this association is mediated by mental health.

METHODS

Cross-sectional, community-based, nationally representative data from the WHO Study on global AGEing and adult health (SAGE) were analyzed. Past 12-month food insecurity was assessed with two questions on frequency of eating less and hunger due to lack of food. Fall-related injury referred to those that occurred in the past 12 months. Multivariable logistic regression analysis and mediation analysis were conducted to assess associations.

RESULTS

Data on 14,585 adults aged ≥65 years [mean (SD) age 72.5 (11.5) years; 54.9% females] were analyzed. After adjustment for potential confounders, severe food insecurity (versus no food insecurity) was associated with 1.95 (95%CI = 1.11-3.41) times higher odds for fall-related injury. Moderate food insecurity was not significantly associated with fall-related injury (OR = 1.34; 95%CI = 0.81-2.25). The mediation analysis showed that 37.3%, 21.8%, 17.7%, and 14.0% of the association between severe food insecurity and fall-related injury was explained by anxiety, sleep problems, depression, and cognition, respectively.

CONCLUSION

Severe food insecurity was associated with higher odds for injurious falls among older adults in LMICs, and a large proportion of this association may be explained by mental health complications. Interventions to improve mental health among those who are food insecure and a strong focus on societal and government efforts to reduce food insecurity may contribute to a decrease in injurious falls.

The use and benefits of Craniosacral Therapy in primary health care: A prospective cohort study

BACKGROUND

Patients frequently use treatments complementary to standard primary care. This prospective cohort-study examined the use, benefits, and safety of Craniosacral Therapy (CST).

METHODS

Consecutive out-patients utilizing CST from 2015 to 2019 were asked to provide anonymized data on symptom intensity, functional disability, and quality of life before and after treatment using an adapted 11-point numerical rating scale (NRS) version of the Measure Yourself Medical Outcome Profile (MYMOP). Treatment expectations were assessed as were concurrent therapies/medication and safety. Mean differences were analyzed using paired sample t-tests with 95 % confidence intervals (CI), predictors of treatment response using linear regression modelling.

RESULTS

CST therapists submitted 220 patient records (71.4 % female) including 15.5 % infants and toddlers, 7.7 % children, and 76.8 % adolescents and adults. Patients received on average 7.0 ± 7.3 CST sessions to treat 114 different, acute and chronic conditions. Symptom intensity significantly decreased by -4.38 NRS (95 %CI=-4.69/-4.07), disability by -4.41 NRS (95 %CI=-4.78/-4.05), and quality of life improved by 2.94 NRS (95 %CI = 2.62/3.27). Furthermore, CST enhanced personal resources by 3.10 NRS (95 %CI = 1.99/4.21). Independent positive predictors of change in the adapted total MYMOP score included patients' expectations (p = .001) and therapists' CST experience (p = .013), negative predictors were symptom duration (p < .002) and patient age (p = .021); a final categorical predictor was CST type (p = .023). Minor but no serious adverse events occurred.

CONCLUSIONS

In primary care, patients and parents of underage children use CST for preventive and therapeutic purposes. Considering the design limitations, CST appears to be overall effective and safe in infants, children, and adults.

Moderators and Mediators of Activity Intolerance Related to Pain

BACKGROUND

There is wide variation in activity intolerance for a given musculoskeletal pathophysiology. In other words, people often experience illness beyond what one would expect given their level of pathophysiology. Mental health (i.e., cognitive bias regarding pain [e.g., worst-case thinking] and psychological distress [symptoms of anxiety and depression]) is an important and treatable correlate of pain intensity and activity intolerance that accounts for much of this variation. This study tested the degree to which psychological distress accentuates the role of cognitive bias in the relationship between pain intensity and activity intolerance.

METHODS

We enrolled 125 adults with musculoskeletal illness in a cross-sectional study. Participants completed measures of activity intolerance related to pain (Patient-Reported Outcomes Measurement Information System [PROMIS] Pain Interference Computer Adaptive Test [CAT]) and in general (PROMIS Physical Function CAT]), measures of psychological distress (PROMIS Depression CAT and PROMIS Anxiety CAT), a numeric rating scale (NRS) for pain intensity, measures of pain-related cognitive bias (4-question versions of the Negative Pain Thoughts Questionnaire [NPTQ-4], Pain Catastrophizing Scale [PCS-4], and Tampa Scale for Kinesiophobia [TSK-4]), and a survey of demographic variables. We assessed the relationships of these measures through mediation and moderation analyses using structural equation modeling.

RESULTS

Mediation analysis confirmed the large indirect relationship between pain intensity (NRS) and activity intolerance (PROMIS Pain Interference CAT and Physical Function CAT) through cognitive bias. Symptoms of depression and anxiety had an unconditional (consistent) relationship with cognitive bias (NPTQ), but there was no significant conditional effect/moderation (i.e., no increase in the magnitude of the relationship with increasing symptoms of depression and anxiety).

CONCLUSIONS

Psychological distress accentuates the role of cognitive bias in the relationship between pain intensity and activity intolerance. In other words, misconceptions make humans ill, more so with greater symptoms of depression or anxiety. Orthopaedic surgeons can approach their daily work with the knowledge that addressing common misconceptions and identifying psychological distress as a health improvement opportunity are important aspects of musculoskeletal care.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Impact of Pharmacological and Non-Pharmacological Interventions to Improve Physical Health Outcomes in People With Schizophrenia: A Meta-Review of Meta-Analyses of Randomized Controlled Trials

(Reprinted with permission from World Psychiatry 2019;18:53-66).

Epidemiology of chronic back pain among adults and elderly from Southern Brazil: a cross-sectional study

BACKGROUND

Chronic back pain (CBP) can negatively affect one's quality of life and health condition, posing significant social and economic burdens.

OBJECTIVES

(1) To determine the prevalence of CBP and analyze associated factors in adult and elderly individuals in a municipality in southern Brazil; (2) to verify who sought medical attention or missed work because of back pain; and (3) to estimate the impact of CBP on selected health outcomes.

METHODS

This was a population-based cross-sectional study conducted with individuals aged 18 years and older. CBP was defined as "pain for three consecutive months in the cervical, thoracic, or lumbar regions in the last year." Demographic, socioeconomic, behavioral, and physical and mental health information was collected. The impact of CBP was assessed by the etiological fraction method.

RESULTS

The prevalence of CBP was 20.7% (95% CI: 18.3, 23.0) among the 1300 study participants. The factors associated with CBP were women, elderly, smokers, obesity, and sleeping fewer hours per night, as well as those with higher mental stress levels, history of fracture, arthritis/rheumatism, and work-related musculoskeletal disorder/repetitive strain injury. One-third of those with CBP missed work (31%) and 68% visited the physician over a 12-month period. All health outcomes analyzed (poor or very poor sleep quality, regular or poor health perception, worsened quality of life, depressive symptoms, perceived sadness) were significantly associated with CBP.

CONCLUSION

One in five adults or elderly reported having CBP over the previous 12 months. This condition was associated with poorer health perception, poorer quality of life, and depressive symptoms.