Smoking. A risk factor for development of low back pain in adolescents

Association between smoking and incident back pain: A prospective cohort study with 438 510 participants

Background

Although smoking is a known potential contributor to back pain, there is still a lack of quantitative studies on the effects of different doses on back pain (BP) occurrence, including a lack of a longitudinal cohorts. To address this gap, we aimed to investigate the association between various smoking-related exposures and back pain incidence to advance global efforts toward smoking cessation and guide primary prevention of BP.

Methods

In this prospective cohort study, we retrieved data on 438 510 patients from the UK Biobank who were free of back pain and who were recruited in 2006-2010, and followed them up from baseline through 1 April 2022. We extracted data on smoking-related exposures, including smoking status (SS), number of cigarettes smoked daily (CPD), and pack-years of own smoking (PY) and examined back pain incidence as an outcome. We used a Cox proportional hazard model adjusted for several covariates, multiple imputation methods, and population attribution fraction.

Results

During the median follow-up of 12.98 years, 31 467 participants developed BP, with incidence rates in former and current smokers of 1.13 (95% confidence interval (CI) = 1.10-1.16, P < 0.000) and 1.50 (95% CI = 1.45-1.56, P < 0.000), respectively. The hazard ratios (HRs) of participants who smoked more than 30 CPD and those with more than 30 PY were 1.45 (95% CI = 1.36-1.55, P < 0.000) and 1.45 (95% CI = 1.40-1.50, P < 0.000), respectively. Relative to male, female smokers were at more risk of developing BP. Not smoking, quitting smoking, and reducing CPD and PY could lower the BP risk by 7.8%, 5.4%, 9.8%, and 18.0%, respectively.

Conclusions

Ever smoking, higher cigarette consumption daily, and increased smoking intensity were associated with an increased BP risk. This association was stronger in female smokers. Not smoking, smoking cessation, and reducing smoking volume and intensity were effective measures to prevent BP occurrence.

The quality of care index for low back pain: a systematic analysis of the global burden of disease study 1990-2017

BACKGROUND

. Low back pain is one of the major causes of morbidity worldwide. Studies on low back pain quality of care are limited. This study aimed to evaluate the quality of care of low back pain worldwide and compare gender, age, and socioeconomic groups.

METHODS

. This study used GBD data from 1990 to 2017 from the Institute for Health Metrics and Evaluation (IHME) website. Extracted data included low back pain incidence, prevalence, disability-adjusted life years (DALYs), and years lived with disability (YLDs). DALYs to prevalence ratio and prevalence to incidence ratio were calculated and used in the principal component analysis (PCA) to make a proxy of the quality-of-care index (QCI). Age groups, genders, and countries with different socioeconomic statuses regarding low back pain care quality from 1990 to 2017 were compared.

RESULTS

The proxy of QCI showed a slight decrease from 36.44 in 1990 to 35.20 in 2017. High- and upper-middle-income countries showed a decrease in the quality of care from 43.17 to 41.57 and from 36.37 to 36.00, respectively, from 1990 to 2017. On the other hand, low and low-middle-income countries improved, from a proxy of QCI of 20.99 to 27.89 and 27.74 to 29.36, respectively.

CONCLUSION

. Despite improvements in the quality of care for low back pain in low and lower-middle-income countries between 1990 and 2017, there is still a large gap between these countries and higher-income countries. Continued steps must be taken to reduce healthcare barriers in these countries.

Prevalence of and Risk Factors for Back Pain Among Young Male Conscripts During Compulsory Finnish Military Service

INTRODUCTION

Back pain is a major reason for sick leaves and disability pension in primary health care. The prevalence of back pain among adolescents and young adults is believed to be increasing, and back pain during military service predicts unspecified back pain during later life. The aim of this study was to investigate the prevalence and risk factors of back pain among conscripts in compulsory Finnish military service during the period 1987-2005.

MATERIALS AND METHODS

The Finnish Defence Forces recruit all men aged 18 years for compulsory military service, and new conscripts enter the service twice a year. Before entering the service, all conscripts must pass a medical examination and conscripts entering the service are generally healthy.Health care in Finnish military service is organized by the public Garrison Health Center, and all medical records are stored as part of the Finnish health care operation plan. For this study, we randomly selected 5,000 men from the Finnish Population Register Centre, according to their year of birth from five different age categories (1969, 1974, 1979, 1984, and 1989).

RESULTS

We gathered 4,029 documents for the analysis. The incidence of back pain varied between 18% and 21% and remained unchanged during the examination period. The risk factors for back pain were smoking (risk ratio 1.35, P-value <.001), elementary school only as education (risk ratio 1.55, P-value <.001), and back problems reported before military service (risk ratio 2.03, P-value .002). Half of the back pain incidences occurred during the first months of service.

CONCLUSIONS

The prevalence of back pain among male Finnish military service conscripts has not changed in the last 25 years. Twenty percent of conscripts suffer from back-related problems during their military service. The majority of the visits to health centers occurred in the first service months. The risk factors for back pain include smoking, low education level, and musculoskeletal disorders in general. Educating the young people about harms of tobacco and supporting education is a way to influence the back pain prevalence. Strength of this study is a good generalized population sample of young Finnish adult males because of the fact that the Finnish military service is compulsory for all men. All medical records of all visits to the Garrison Health Care Centre were available, and all the conscripts filled the same pre-service questionnaire, minimizing the possibility of selection bias. The sample size was also large. Weakness of this study is that the service time changed during the study period and in the latest conscript group born in 1989, data collection and the data available for this cohort was limited, because nearly half of the conscripts had not yet started their service. The Finnish military service is compulsory only for men and because of the low number of female conscripts, they were excluded from this study. Diagnoses were also missing from 70% of the back-related visits, and these visits were recorded as back pain-related visits according to the reason for seeking care.

Evaluation and management of paediatric and adolescent back pain: Epidemiology, presentation, investigation, and clinical management: A narrative review

This narrative review will summarise a clinical approach to the investigation of back pain in children and adolescent patients, including a discussion of the epidemiology, presentation, investigation and clinical management of back pain in children and adolescents. This will assist the prompt and accurate diagnosis of spinal disorders that require significant medical intervention. Existing evidence suggests a relatively high incidence of non-specific back pain among young people; 27-48% of presentations of back pain in children and adolescents are attributed to non-specific back pain. Low back pain among schoolchildren is often linked to psychosocial factors and only occasionally requires medical attention, as pain is benign and self-limiting. Nonetheless, those young patients who seek medical assistance exhibit a higher incidence of organic conditions underlying the major symptom of spinal pain. A cautious and comprehensive strategy - including a detailed history, examination, radiographic imaging and diagnostic laboratory studies - should be employed, which must be accurate, reliable, consistent and reproducible in identifying spinal pathologies. A specific diagnosis can be reached in 52-73% of the cases. For cases in which a specific diagnosis cannot be made, re-evaluation after a period of observation is recommended. At this later stage, minor symptoms unrelated to underlying pathology will resolve spontaneously, whereas serious pathologies will advance and become easily identified.

Factors associated with non-specific low back pain in children aged 10-12 from Bucaramanga, Colombia: A cross-sectional study

BACKGROUND

There are no Colombian studies published that assess non-specific low back pain (NSLBP) risk factors in children.

OBJECTIVE

To determine the factors associated with NSLBP in 73 children (19.2% girls) aged 10-12 years in one military school in Bucaramanga, Colombia.

METHODS

A questionnaire was used to obtain information of risk factors. Subsequently, children's weight and height were measured. The backpack was weighed at the beginning of each day from Monday to Friday. Crude and adjusted prevalence ratios were calculated, with their respective 95% confidence interval (CI).

RESULTS

The one-month prevalence of NSLBP was 39.7% (95% CI 28.4-51.9). In the multivariate analysis, carrying backpacks wearing between 12% and 20% of body weight, having a perception that the backpack is very heavy, and being a passive smoker increase the likelihood of NSLBP, while being 11-year-old compared to 10-year-old decreases the likelihood of having NSLBP, adjusted for gender, body mass index, and history of LBP in parents.

CONCLUSIONS

High prevalence of low back pain was found in children between 10 and 12 years old. The study of the decisive factors of low back pain is important to identify children at risk, as well as to develop efficient primary prevention programs.

Potential risk factors and triggers for back pain in children and young adults. A scoping review, part II: unclear or mixed types of back pain

Background

Back pain is a global problem in terms of disability and financially, with a large burden both to the individual and to society. Back pain was previously believed to be uncommon in children. However, there is a growing body of evidence that this is not the case.

Objective

Part I of this scoping review studied risk factors of incident and episodic back pain. In this part II we aimed to identify all risk factors and triggers with unclear or mixed type back pain in young people and to identify any gaps in the literature.

Methods

A scoping review design was selected to summarise the evidence, as there are many studies on “risk factors” for back pain. The scoping review followed the PRISMSA-ScR guidelines. We considered all studies that tested potential risk factors and triggers for thoracic and/or lumbar spine pain, in children, adolescents, and young adults (≤ 24 years). PubMed and Cochrane databases were searched from inception to September 2018, to identify relevant English language articles. The results regarding potential risk factors were separated into temporal precursors and bidirectional risk factors and the studies were classified by study design.

Results

Our comprehensive search strategy identified 7356 articles, of which 83 articles were considered eligible for this review (part II). There were 53 cross-sectional studies and 30 cohort studies. Potential risk factors for back pain were: female sex, older age, later pubertal status, positive family history of back pain, increased growth, and a history of back pain, most of which are temporal precursor variables. There was limited research for the illness factors, spinal posture, and muscle endurance in the development of back pain.

Conclusion

Many of the included studies approached risk factors in similar ways and found factors that were associated with back pain but were not obvious risk factors as causality was uncertain. Future research should be more rigorous and innovative in the way that risk factors are considered. This could be through statistical approaches including cumulative exposures, or longitudinal approaches including multi-trajectory methods. Additionally, data on proposed risk factors should be collected before the onset of back pain.

Smoking Is an Independent Risk Factor of Reoperation Due to Recurrent Lumbar Disc Herniation

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The purpose of the present study is to determine if age, gender, smoking status, and body mass index (BMI) are significant risk factors of symptomatic recurrent lumbar disc herniation (rLDH) leading to reoperation.

METHODS

A cohort of 1378 consecutive patients who underwent discectomy for LDH from June 2010 to January 2015 at our institution were included. Patients who underwent reoperation due to rLDH prior to August 2015 were identified. Data on reoperations, age, gender, smoking status, and BMI were collected from our database. A comparison of age, gender, smoking status, and BMI was made between the controls (non-rLDH) and the cases (rLDH group). Binary logistic regression was performed to determine whether age, gender, smoking status, and BMI were independent risk factors for rLDH.

RESULTS

Patients in the non-rLDH group (48.2 years) were older than the rLDH group (44.7 years; P = .013). Gender distribution (54.8% vs 48.5% males; P = .222) and BMI (26.6 vs 26.6; P = .458) were similar between the 2 groups. A significantly higher prevalence of smokers was found in the rLDH group (33.1% vs 51.5%; P < .001). Binary logistic regression analysis showed that smoking was an independent risk factor of rLDH (odds ratio = 2.12; 95% confidence interval = 1.39-3.15; P < .001).

CONCLUSIONS

Neither age, BMI, nor gender had any statistical significant association with the risk of rLDH. Smoking was associated with higher risk of reoperation due to rLDH.

Are Sleep Problems a Risk Factor for the Onset of Musculoskeletal Pain in Children and Adolescents? A Systematic Review

Study Objectives

Musculoskeletal pain is a major burden on the society. Adults with sleep problems are at higher risk of musculoskeletal pain onset, but there is no evidence for this relationship in children and adolescents. This study aimed to systematically review prospective studies on the risk of musculoskeletal pain onset in children and adolescents with sleep problems.

Methods

Five databases (MEDLINE, PsycINFO, AMED, EMBASE, and HMIC) were systematically searched to identify prospective studies that investigated if children and adolescents (aged 6-19 years) with sleep problems are at higher risk of musculoskeletal pain onset. Included studies were assessed for study quality and a best evidence synthesis was carried out on extracted data.

Results

Thirteen prospective studies were identified. Overall, evidence indicates that sleep problems (quality, quantity, and day time tiredness) are not risk factors for musculoskeletal pain onset. Further analysis on specific body regions shows strong evidence that sleep problems are a risk factor for neck pain onset (only in girls) and that sleep problems are not a risk factor for the onset of widespread pain.

Conclusions

Overall, sleep problems are not a risk factor for musculoskeletal pain onset in children and adolescents. Increased risk was found for some specific body regions and subgroups, but the evidence base was less strong and generally inconsistent. This review found a lack of quality in research methodology compared to research in adults, and further research with improved methodology is required.

PRIORITIES FOR HEALTH ECONOMIC METHODOLOGICAL RESEARCH: RESULTS OF AN EXPERT CONSULTATION

BACKGROUND

The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps.

METHODS

The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps.

RESULTS

The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities.

CONCLUSIONS

The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the "-omics" approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.

Low Back Pain With Impact at 17 Years of Age Is Predicted by Early Adolescent Risk Factors From Multiple Domains: Analysis of the Western Australian Pregnancy Cohort (Raine) Study

Study Design Prospective cohort study of the Western Australian Pregnancy Cohort (Raine) Study. Background Low back pain (LBP) commonly develops in adolescence and is a significant risk factor for adult LBP. A broad range of factors have been associated with the development of adolescent LBP, but prior literature has limitations related to characterization of LBP and the scope of risk factors considered. Objective This study aimed to identify potential factors contributing to the development of LBP, with and without impact, at 17 years of age, utilizing a broad range of exposures at 14 years of age. Methods Data from 1088 participants (52.1% female) with "no LBP," "LBP with minimal impact," and "LBP with impact" at 17 years of age and a range of measures from multiple domains, including spinal pain, physical, psychological, social, and lifestyle, at 14 years of age were collected for the study. Multivariable multinomial logistic regression was used to estimate the association of potential mechanistic factors at 14 years of age with LBP at 17 years of age. Results Female sex and back pain at 14 years of age were strongly associated with LBP at 17 years of age. Potential mechanistic factors for LBP outcomes at 17 years of age included exposures from the pain (neck/shoulder pain) and physical domains (standing posture subgroup membership, back muscle endurance, throwing distance), psychological domain (somatic complaints, aggressive behavior), social domain (socioeconomic area), and lifestyle domain (exercise out of school). Conclusion The findings support the multidimensional nature of adolescent LBP and highlight the challenge this presents for epidemiological research, clinical practice, and prevention initiatives in the general population. Level of Evidence Prognosis, level 1b. J Orthop Sports Phys Ther 2017;47(10):752-762. doi:10.2519/jospt.2017.7464.

Mechanical factors and vitamin D deficiency in schoolchildren with low back pain: biochemical and cross-sectional survey analysis

OBJECTIVE

This study was designed to evaluate the role of vitamin D, muscle fatigue biomarkers, and mechanical factors in the progression of low back pain (LBP) in schoolchildren.

BACKGROUND

Children and adolescents frequently suffer from LBP with no clear clinical causes, and >71% of schoolchildren aged 12-17 years will show at least one episode of LBP.

MATERIALS AND METHODS

A total of 250 schoolchildren aged 12-16 years were randomly enrolled in this study. For all schoolchildren height, weight, percentage of daily sun exposure and and areas of skin exposed to sun, method of carrying the bag, and bag weight and type were recorded over a typical school week. Pain scores, physical activity (PA), LBP, serum vitamin 25(OH)D level, serum bone-specific alkaline phosphatase, creatine kinase (CK), and lactate dehydrogenase (LDH) activities and calcium (Ca) concentrations were estimated using prevalidated Pain Rating Scale, modified Oswestry Low Back Pain Disability Questionnaire, short-form PA questionnaire, and colorimetric and immunoassay techniques.

RESULTS

During the period of October 2013-May 2014, LBP was estimated in 52.2% of the schoolchildren. It was classified into moderate (34%) and severe (18%). Girls showed a higher LBP (36%) compared with boys (24%). In schoolchildren with moderate and severe LBP significantly higher (P=0.01) body mass index, waist, hip, and waist-to-hip ratio measurements were observed compared with normal schoolchildren. LBP significantly correlated with less sun exposure, lower PA, sedentary activity (TV/computer use), and overloaded school bags. In addition, schoolchildren with severe LBP showed lower levels of vitamin 25(OH)D and Ca and higher levels of CK, LDH, and serum bone-specific alkaline phosphatase compared with moderate and healthy schoolchildren. Stepwise regression analysis revealed that age, gender, demographic parameters, PA, vitamin D levels, Ca, CK, and LDH associated with ~56.8%-86.7% of the incidence of LBP among schoolchildren.

CONCLUSION

In children and adolescents, LBP was shown to be linked with limited sun exposure, inadequate vitamin D diets, adiposity, lower PA, sedentary lifestyles, vitamin 25 (OH) D deficiency, and lower levels of Ca, CK, and LDH.

Low Back Pain in an Urban Population in Southwest Nigeria

This cross-sectional study was designed to determine the prevalence and risk factors for low back pain in an urban community. A house-to-house enquiry was conducted using a questionnaire administered by trained interviewers. Four hundred and seventy-four respondents, 271 men (57%) and 203 women (43%) participated in the study. The 12-month prevalence of low back pain was 44%, while the point prevalence was 39%. Back pain was more prevalent among men (49%) than women (39%). It was also associated with a history of trauma and low educational status. The prevalence of back pain was highest among farmers (85%) and lowest among housewives (32%). The prevalence of low back pain in this community is comparable to levels recorded in industrialized countries. However, in this study low back pain did not feature as a main cause of morbidity, accounting for a mean of 3 days off work per person per year.

The importance of identifying and modifying unemployment predictor variables in the evolution of a novel model of care for low back pain in the general population

BACKGROUND CONTEXT

Care for low back pain (LBP) is costly, fragmented and, in non-compensation populations, rarely specifically addresses factors associated with maintaining employment status or return to work (RTW).

PURPOSE

This study aimed to identify modifiable independent risk factors for (1) a negative work status at presentation and (2) a change in work status during treatment in a cohort of LBP patients. The results are intended to inform improvement in best-evidence care pathways to maximize societal outcomes and overall value of a new model of care.

STUDY DESIGN/SETTING

A prospective observational study was carried out.

INCLUSION CRITERIA

Work-eligible, non-workers compensation patients with recurrent or persistent LBP ≥6 weeks and ≤12 months.

SETTING

The Inter-professional Spine Assessment and Education Clinics (ISAEC)-a novel Government-funded shared-care model of management for LBP.

METHODS

This study used the following methods: (1) Cross-sectional analysis of baseline data from the initial ISAEC consultation (t0) from December 2012 to April 2014. Work status at t0 was dichotomized as employed (E) or underemployed (UE; unemployed, modified work duty, or disability). Multivariate logistic regression modeling was used to determine independent predictors of UE status at t0. (2) Bivariate analysis of longitudinal data from t0 to 6 months (t1) to identify risk factors for work status change. Employment journey categorized into four groups: Et0/Et1-employed at t0 and employed at t1; Et0/UEt1-employed at t0 and underemployed at t1; UEt0/Et1-underemployed at t0 and employed at t1; UEt0/UEt1-underemployed at t0 and underemployed at t1.

RESULTS

This study yielded the following results: (1) Initial consultation data on 462 consecutive patients (Et0=344, UEt0=118). Multivariate logistic regression identified legal claim, depression, smoking, and higher STarT Back (or Oswestry Disability Index [ODI]) score as independent risk factors for UEt0. (2) Overall UE rate did not significantly change during longitudinal analysis (n=178, UEt0=25.5%, UEt1=22.9%). However, 10.5% of Et0 became UEt1 (Et0/Et1=102, Et0/UEt1=12). Bivariate analysis identified elevated baseline ODI score as the only significant predictor variable for UEt1 in Et0 cohort (p=.0101). Conversely, ISAEC improved the employment status in 41% of UEt0 to Et1 (UEt0/Et1=16, UEt0/UEt1=23), and the absence of depression was significant for predicting RTW (p=.0001).

CONCLUSIONS

From a societal perspective, employment status as an outcome measure is paramount in assessing the value of a new model of care for LBP. Mitigation strategies for the predictor variables identified will be included in ISAEC pathways to translate clinical improvement into societal added value.

Effects of Tobacco Smoking on the Degeneration of the Intervertebral Disc: A Finite Element Study

Tobacco smoking is associated with numerous pathological conditions. Compelling experimental evidence associates smoking to the degeneration of the intervertebral disc (IVD). In particular, it has been shown that nicotine down-regulates both the proliferation rate and glycosaminoglycan (GAG) biosynthesis of disc cells. Moreover, tobacco smoking causes the constriction of the vascular network surrounding the IVD, thus reducing the exchange of nutrients and anabolic agents from the blood vessels to the disc. It has been hypothesized that both nicotine presence in the IVD and the reduced solute exchange are responsible for the degeneration of the disc due to tobacco smoking, but their effects on tissue homeostasis have never been quantified. In this study, a previously presented computational model describing the homeostasis of the IVD was deployed to investigate the effects of impaired solute supply and nicotine-mediated down-regulation of cell proliferation and biosynthetic activity on the health of the disc. We found that the nicotine-mediated down-regulation of cell anabolism mostly affected the GAG concentration at the cartilage endplate, reducing it up to 65% of the value attained in normal physiological conditions. In contrast, the reduction of solutes exchange between blood vessels and disc tissue mostly affected the nucleus pulposus, whose cell density and GAG levels were reduced up to 50% of their normal physiological levels. The effectiveness of quitting smoking on the regeneration of a degenerated IVD was also investigated, and showed to have limited benefit on the health of the disc. A cell-based therapy in conjunction with smoke cessation provided significant improvements in disc health, suggesting that, besides quitting smoking, additional treatments should be implemented in the attempt to recover the health of an IVD degenerated by tobacco smoking.

Pain characteristics of adolescent spinal pain

BACKGROUND

Although adolescent spinal pain increases the risk for chronic back pain in adulthood, most adolescents can be regarded as healthy. The aim of the present study was to provide data on localization, intensity and frequency of adolescent spinal pain and to investigate which physical and psycho-social parameters predict these pain characteristics.

METHOD

On the occasion of Spine Day, an annual event where children and adolescents are examined by chiropractors on a voluntary basis for back problems, 412 adolescents (10 to 16 years) were tested (by questionnaire and physical examination). Pain characteristics (localization, intensity, and frequency) were identified and evaluated using descriptive statistics. Regression analyses were performed to investigate possible influencing psycho-social and physical influence factors.

RESULTS

Adolescents who suffered from pain in more than one spinal area reported higher pain intensity and frequency than those with pain in only one spinal area. Sleep disorders were a significant predictor for pain in more than one spinal area (p < 0.01) as well as a trend for frequent pain (p = 0.06). Adolescents with frequent pain showed impaired balance on one leg standing with closed eyes (p = 0.02).

CONCLUSIONS

Studies on adolescent spinal pain should report data on pain frequency, intensity and localization. Adolescents who present with pain in more than one spinal area or report frequent pain should be followed carefully. Reduced balance with visual deprivation might be a physical indicator of a serious back problem.

General health status and incidence of first-onset temporomandibular disorder: the OPPERA prospective cohort study

Temporomandibular disorder (TMD) overlaps with other health conditions, but no study has examined which of these conditions increase the risk of developing first-onset TMD. The authors prospectively evaluated the relationship between health status at enrollment and subsequent incidence of TMD in 2,722 men and women. Participants aged 18 to 44 years had no history of TMD and were clinically free of TMD when enrolled in 2006 to 2008 at 4 U.S. study sites in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA) prospective cohort study. First-onset examiner-classified TMD developed in 260 people over a median 2.8 years of follow-up. Cox regression estimated the association between health conditions and TMD incidence while accounting for potential confounders. Incidence of first-onset TMD was 50% higher for people with low back pain (adjusted hazard ratio [AHR] = 1.50, 95% confidence limits [CLs]: 1.08, 2.10) and 75% higher for people with genital pain symptoms (AHR = 1.75, 95% CLs = 1.04, 2.93) than people without a history of these pain disorders. Digit ratio, a marker of intrauterine exposure to sex hormones, was significantly associated with TMD incidence. Other independent predictors of first-onset TMD were sleep disturbance and cigarette smoking. These findings reveal multiple influences of health status on incidence of first-onset TMD.

PERSPECTIVE

This article examines health conditions that commonly overlap with TMD to determine which ones predict first-onset TMD. A history of low back pain and genital pain conditions at baseline were important predictors. Novel findings were that disrupted sleep and conditions in utero may increase incidence of first-onset TMD.

[Nonspecific low back pain in young adults: associated risk factors]

OBJECTIVE

The aim of the study was to evaluate potential risk factors related to low back pain in the daily routines of two sets of youths: individuals complaining of chronic low back pain and a control group.

METHODS

The sample consisted of 198 university-age students (male and female) aged between 18 and 29. In accordance with back pain diagnoses, they were separated into two groups: with or without nonspecific chronic low back pain. Both groups were evaluated by a "blinded" observer with no knowledge to the presence or otherwise of lower back pain. Questionnaires concerning clinical-demographic characteristics, life style, quality of life (SF-36 questionnaire), pain visual analogical scales (VAS), and physical examination were applied.

RESULTS

A univariate analysis showed a statistically significant association (P<0.05) with the presence of low back pain and some factors. There was a negative association between low back pain and the following variables: BMI, health self-assessment, VAS and some SF-36 domains (physical functioning, body pain, general health, vitality, social functioning). There was a positive correlation with the following variables: global pain by VAS, presence of diffuse pain and number of tender points. However, the multivariate analysis showed statistically significant correlations (P<0.05) between low back pain and few variables: global pain VAS and number of tender points.

CONCLUSION

Some variables related to chronic diffuse pain and lower quality of life might be associated to chronic low back pain in young adults. However, longitudinal studies are necessary.

Predicting transition to chronic pain

PURPOSE OF REVIEW

Most individuals who develop pain following an inciting event will return to a healthy state as the injury heals. However, a small percentage continue to suffer, that is, transition to chronic pain. Chronic pain may persist for years and is accompanied by cognitive abnormalities, as well as diminished quality of life. In animals, persistent pain is characterized by peripheral and spinal cord reorganization, and recent evidence in humans also indicates cortical reorganization. Yet, despite more than 30 years of research, there is little agreement on the neural mechanisms that mediate the transition from acute to chronic pain.

RECENT FINDINGS

In a longitudinal brain-imaging study, individuals who developed an intense back pain episode were followed over a 1-year period, during which pain and brain parameters were collected repeatedly. A smaller number of healthy individuals and chronic back pain patients were also studied concomitantly, as positive and negative controls. At the time of entry into the study, strength of synchrony between the medial prefrontal cortex and nucleus accumbens (i.e. functional connectivity) was predictive (>80% accuracy) of individuals who subsequently transition to chronicity 1 year later.

SUMMARY

Properties of the brain's emotional learning circuitry predict the transition to chronic pain. The involvement of this circuitry in pain remains mostly unexplored. Future human and animal model studies are necessary to unravel underlying mechanisms driving pain chronicity, with the potential of advancing novel therapeutics for preventing pain chronification.

Spine Day 2012: spinal pain in Swiss school children- epidemiology and risk factors

Background

The key to a better understanding of the immense problem of spinal pain seems to be to investigate its development in adolescents. Based on the data of Spine Day 2012 (an annual action day where Swiss school children were examined by chiropractors on a voluntary basis for back problems), the aim of the present study was to gain systematic epidemiologic data on adolescent spinal pain in Switzerland and to explore risk factors per gender and per spinal area.

Method

Data (questionnaires and physical examinations) of 836 school children were descriptively analyzed for prevalence, recurrence and severity of spinal pain. Of those, 434 data sets were included in risk factor analysis. Using logistic regression analysis, psycho-social parameters (presence of parental back pain, parental smoking, media consumption, type of school bag) and physical parameters (trunk symmetry, posture, mobility, coordination, BMI) were analyzed per gender and per spinal area.

Results

Prevalence of spinal pain was higher for female gender in all areas apart from the neck. With age, a steep increase in prevalence was observed for low back pain (LBP) and for multiple pain sites. The increasing impact of spinal pain on quality of life with age was reflected in an increase in recurrence, but not in severity of spinal pain. Besides age and gender, parental back pain (Odds ratio (OR)=3.26, p=0.011) and trunk asymmetry (OR=3.36, p=0.027) emerged as risk factors for spinal pain in girls. Parental smoking seemed to increase the risk for both genders (boys: OR=2.39, p=0.020; girls: OR=2.19, p=0.051). Risk factor analysis per spinal area resulted in trunk asymmetry as risk factor for LBP (OR=3.15, p=0.015), while parental smoking increased the risk for thoracic spinal pain (TSP) (OR=2.83, p=0.036) and neck pain (OR=2.23, p=0.038). The risk for TSP was further enhanced by a higher BMI (OR=1.15, p=0.027).

Conclusion

This study supports the view of adolescent spinal pain as a bio-psycho-social problem that should be investigated per spinal area, age and gender. The role of trunk asymmetry and passive smoking as risk factors as well as the association between BMI and TSP should be further investigated, preferably in prospective studies.

The relationship among smoking, sleep, and chronic rheumatic conditions commonly associated with pain in the National Health Interview Survey

Chronic rheumatic conditions are typically characterized by chronic pain and are uniquely associated with increased rates of cigarette smoking and poor sleep quality. However, no study has examined the possible additive or interactive effects of these two health behaviors in individuals diagnosed with a chronic rheumatic condition. The goal of this study is to examine the relationship between cigarette smoking and sleep in a population sample of individuals diagnosed with a chronic rheumatic condition and related functional impairment. Cross sectional survey data was obtained from the 2007 National Health Interview Survey. Individuals diagnosed with a chronic rheumatic condition were more likely to be a former or current smoker compared to non-diagnosed individuals. Individuals with a chronic rheumatic condition were more likely to report <6 h of sleep per night and endorsed significantly more insomnia and daytime sleepiness. There was no interaction between diagnosis of a chronic rheumatic condition and smoking status on any of the sleep outcomes assessed. Finally, an interaction was observed suggesting individuals with a chronic rheumatic condition who currently smoke are more likely to report averaging <6 h of sleep per night and frequent insomnia compared to individuals with a chronic rheumatic condition who never smoked. These results suggest both a unique and additive relationship between smoking and sleep in individuals with a chronic rheumatic condition. Findings can likely be generalized to other conditions commonly associated with chronic pain.

Prevalence of low back pain in children and adolescents: a meta-analysis

BACKGROUND

Low back pain (LBP) is common in children and adolescents, and it is becoming a public health concern. In recent years there has been a considerable increase in research studies that examine the prevalence of LBP in this population, but studies exhibit great variability in the prevalence rates reported. The purpose of this research was to examine, by means of a meta-analytic investigation, the prevalence rates of LBP in children and adolescents.

METHODS

Studies were located from computerized databases (ISI Web of Knowledge, MedLine, PEDro, IME, LILACS, and CINAHL) and other sources. The search period extended to April 2011. To be included in the meta-analysis, studies had to report a prevalence rate (whether point, period or lifetime prevalence) of LBP in children and/or adolescents (≤ 18 years old). Two independent researchers coded the moderator variables of the studies, and extracted the prevalence rates. Separate meta-analyses were carried out for the different types of prevalence in order to avoid dependence problems. In each meta-analysis, a random-effects model was assumed to carry out the statistical analyses.

RESULTS

A total of 59 articles fulfilled the selection criteria. The mean point prevalence obtained from 10 studies was 0.120 (95% CI: 0.09 and 0.159). The mean period prevalence at 12 months obtained from 13 studies was 0.336 (95% CI: 0.269 and 0.410), whereas the mean period prevalence at one week obtained from six studies was 0.177 (95% CI: 0.124 and 0.247). The mean lifetime prevalence obtained from 30 studies was 0.399 (95% CI: 0.342 and 0.459). Lifetime prevalence exhibited a positive, statistically significant relationship with the mean age of the participants in the samples and with the publication year of the studies.

CONCLUSIONS

The most recent studies showed higher prevalence rates than the oldest ones, and studies with a better methodology exhibited higher lifetime prevalence rates than studies that were methodologically poor. Future studies should report more information regarding the definition of LBP and there is a need to improve the methodological quality of studies.

Factors associated with adolescent chronic non-specific pain, chronic multisite pain, and chronic pain with high disability: the Young-HUNT Study 2008

The aim of this study was to assess the association of chronic pain with different lifestyle factors and psychological symptoms in a large, unselected adolescent population. Pain was evaluated as chronic non-specific pain, chronic multisite pain, and in additional analyses, chronic pain with high disability. The study was performed during 2006 to 2008 in Nord-Trøndelag County, Norway. Adolescents aged 13 to 18 years were invited to participate. The response rate was 78%. The final study population consisted of 7,373. Sedentary behavior and pain were associated only in girls. In both sexes, overweight and obesity were associated with increased odds of pain. Whereas both smoking and alcohol intoxication showed strong associations with pain, the associations were attenuated after adjustments for psychosocial factors. Symptoms of anxiety and depression showed the strongest associations with pain (odds ratio 4.1 in girls and 3.7 in boys). The odds of pain increased gradually by number of unfavorable lifestyle factors reported. This study revealed consistent associations between lifestyle factors, anxiety and depression, and chronic pain, including multisite pain and pain with high disability. The consistency across the different pain categories suggests common underlying explanatory mechanisms, and despite the cross-sectional design, the study indicates several modifiable targets in the management of adolescent chronic pain.

PERSPECTIVE

This study showed a clear and consistent relation between different lifestyle factors, anxiety and depression, and the pain categories chronic non-specific pain, multisite pain, and also pain with high disability. Independent of causality, it underlines the importance of a broad perspective when studying, preventing, and treating chronic pain in adolescents.

Prevalência e fatores associados à dor lombar em escolares

O objetivo foi verificar a prevalência de dor lombar em adolescentes e sua relação com a prática de esportes e atividades sedentárias. Realizou-se um estudo transversal com 1.236 escolares das 5ª a 8ª séries do Ensino Fundamental de Bauru, São Paulo, Brasil. Foram utilizados um protocolo estruturado e o questionário nórdico de sintomas musculoesqueléticos. A análise foi realizada mediante uma abordagem descritiva, bivariada e multivariada por regressão logística binária. Notou-se que a prevalência de dor lombar foi de 19,5%, sendo 7% nos meninos e 12,5% nas meninas, com diferença estatisticamente significante entre os gêneros (p < 0,00001), a faixa etária (p = 0,0057) e prática de esportes (p = 0,0001). Na análise bivariada e multivariada, observaram-se associações independentes entre dor lombar e o gênero feminino, horas na frente da TV e prática de esportes. A dor lombar em escolares pode ter consequências importantes para dores crônicas em adultos, e a compreensão das relações entre as variáveis oferecerá elementos úteis de medidas visando à manutenção, à melhora e à promoção do bem-estar dos estudantes.

Determination of pain intensity risk factors among school children with nonspecific low back pain

Background

Low back pain (LBP) is a common disease among people under the age of 20. To the best of our knowledge few studies have been carried out on LBP among school children in Turkey, and none of them studied the correlation between pain intensity and related variables with LBP.

Material/Methods

This cross-sectional study was carried out to investigate the risk factors and their correlations with pain intensity among 222 school children (106 girls and 116 boys) aged 10–18 years in the city of Denizli. A self-reported questionnaire was used to collect the data. The regression tree method (RTM) was used to determine the risk factors by using the STATISTICA program package. Pain intensity was the outcome variable, and 8 independent variables (body mass index (BMI), sex, regular exercise habit, studying posture, transportation to/from school, duration of studying, bag handling, and type of bed) were used to detect their effect on pain intensity.

Results

The results showed that pain intensity is significantly affected by 4 independent variables: duration of studying, type of bed, transportation to/from school, and BMI. The overall mean and standard deviation of pain intensity was 2.58±0.86 (minimum=1, maximum=5).

Conclusions

Results from the literature, as well as our study, show that taking parents’ and teachers’ concerns seriously is of vital importance. Our results indicate that parents and teachers should be informed about duration of studying, type of bed, transportation and obesity as risk factors predicting NLBP in school children.

Sports, smoking, and overweight during adolescence as predictors of sciatica in adulthood: a 28-year follow-up study of a birth cohort

Lifestyle factors such as smoking, obesity, and level of physical activity predict low back pain (LBP) and sciatica. The authors investigated whether participating in sports, smoking, and being overweight or obese at 14 years of age predicted hospitalizations due to LBP or sciatica in adulthood. In 1980, at the age of 14 years, a total of 11,399 members of the 1966 Northern Finland Birth Cohort returned the postal questionnaire. Patients from the 1966 Northern Finland Birth Cohort who were hospitalized because of LBP or sciatica were followed to the end of 2008 through the Finnish Hospital Discharge Register. Data were analyzed using Cox's proportional hazards multistate model with the Markov clock forward time scale. During follow-up, 119 females (2.7%) and 254 males (5.6%) had been hospitalized at least once because of LBP or sciatica. Among females, overweight was associated with an increased risk of second-time hospitalization for surgical treatment for sciatica (hazard ratio = 7.1, 95% confidence interval: 1.5, 34.4). Among males, smoking was associated with an increased risk of first-time nonsurgical hospitalization (hazard ratio = 1.8, 95% confidence interval: 1.2, 2.7) and second-time surgical hospitalization (hazard ratio = 3.2, 95% confidence interval: 1.2, 8.2). The authors found potentially modifiable risk factors in adolescence that predicted hospital treatments for low back disorders during adolescence and young adulthood.

Adolescent drug use, psychosocial functioning and spinal pain

This study tested whether there is an independent relationship between adolescent drug use and neck and shoulder pain (NSP) and back pain (BP) when psychosocial functioning is controlled in a community sample of 1608 14-year-old Australian adolescents. Multivariable logistic regression was used to calculate the odds ratios of alcohol and cigarette use for NSP and BP before and after adjusting for a range of psychosocial variables. Results showed that the use of alcohol, but not cigarettes or marijuana, has a significant independent association with adolescent spinal pain. Future research needs to investigate these variables longitudinally to inform interventions for adolescent spinal pain.

Daily smoking and lower back pain in adult Canadians: the Canadian Community Health Survey

Background:

Lower back pain (LBP) is one of the primary causes of disability in the Canadian community. However, only a limited number of studies have addressed the association between daily smoking and LBP in Canada. Of the studies that have explored this association, many had small sample sizes and failed to control for confounders.

Objective:

The primary objective of the study was to determine if daily smoking is associated with an increased risk of having LBP. The secondary objectives were to assess the risk for LBP among occasional smokers and to determine the prevalence of LBP in relation to different covariates.

Data and study design:

Using the Canadian Community Health Survey (cycle 3.1) data, 73,507 Canadians between the ages of 20 and 59 years were identified. LBP status, smoking level, sex, age, body mass index (BMI), level of activity and level of education were assessed in these subjects.

Methods:

Stratified analysis and logistic regression analysis were used to detect effect modifications and to adjust for covariates. Population weight and design were taken into consideration.

Results:

The prevalence of LBP was 23.3% among daily smokers and 15.7% among non-smokers. Age and sex were found to be effect modifiers. The association between LBP and daily smoking was statistically significant in all ages and genders; this association was stronger for younger age groups. The adjusted odds ratio for male daily smokers aged 20 to 29 was 1.87 (95% CI = 1.62, 2.17); findings were similar for women. Occasional smoking slightly increased the odds of having back pain.

Conclusion:

Young Canadian daily smokers are at higher risk for LBP. This study also suggests a positive correlation between smoking dose and the risk of LBP. These findings indicate that smoking behavioral modification may have an impact on reducing back pain especially among young adults.

Nonspecific low back pain during childhood: a retrospective epidemiological study of risk factors

OBJECTIVES

In contrast to what was believed in the past, nonspecific low back pain is a fairly frequent condition in children, whose pathophysiology remains unclear as yet. Although many factors have been implicated in its development, results are often contradictory.

METHODS

Our study aims to examine most of the reasons investigated in the international literature, as well as the previously unexamined impact of passive smoking in its clinical appearance. It is a retrospective study that investigates the symptom of nonspecific low back pain during a 12-month period before the visit of children to our department. The research included 692 children aged 7.5 to 14 years. The data were collected using a semi-structured questionnaire, which included a mix of open and closed questions, followed by physical examination during their visit.

RESULTS

A total of 153 children were considered to present nonspecific low back pain during the previous year. The determinant factors appear to be greater age, the male sex, larger height, increased weight, dissatisfaction with school chairs, the clinical presentation of back pain in at least 1 parent, and coexisting anatomic orthopedic conditions. On the contrary, the weight of the school bag, the way in which it was carried and participation in sports, as well as the time spent by children in front of the TV or PC playing video or play station games, did not appear to have a statistically significant correlation with its appearance. In general, passive smoking does not appear to be a risk factor (P[r] = 0.341), and does not seem to play a leading role in the etiology of the condition. Furthermore, even the heaviness of parental smoking (over 20 cigarettes a day) does not seem to alter the appearance of the disease. The effect of nonspecific low back pain in children's activities was measured using Hannover Functional Ability and Rolland Morris questionnaires, appropriately modified to childhood, where he found a moderate or severe restriction of activity in 23.52% (score >5) and 19.61% (score >6), respectively.

CONCLUSIONS

The data analysis shows that nonspecific low back pain in children is a benign disorder with an unknown pathophysiological mechanism. Many anthropometric characteristics and environmental factors are implicated, but to a different degree each time. Passive smoking as well as the heaviness thereof does not appeal to play in important role in its clinical presentation. Further investigation is deemed necessary to determine the existence of other risk factors, as well as the level of their participation in the condition's pathophysiology.

What is adolescent low back pain? Current definitions used to define the adolescent with low back pain

Adolescent low back pain (ALBP) is a common form of adolescent morbidity which remains poorly understood. When attempting a meta-analysis of observational studies into ALBP, in an effort to better understand associated risk factors, it is important that the studies involved are homogenic, particularly in terms of the dependent and independent variables. Our preliminary reading highlighted the potential for lack of homogeneity in descriptors used for ALBP. This review identified 39 studies of ALBP prevalence which fulfilled the inclusion criteria, ie, English language, involving adolescents (aged 10 to 19 years), pain localized to lumbar region, and not involving specific subgroups such as athletes and dancers. Descriptions for ALBP used in the literature were categorized into three categories: general ALBP, chronic/recurrent ALBP, and severe/disabling ALBP. Whilst the comparison of period prevalence rates for each category suggest that the three represent different forms of ALBP, it remains unclear whether they represented different stages on a continuum, or represent separate entities. The optimal period prevalence for ALBP recollection depends on the category of ALBP. For general ALBP the optimal period prevalence appears to be up to 12 months, with average lifetime prevalence rates similar to 1-year prevalence rates, suggesting an influence of memory decay on pain recall.

The association between smoking and low back pain: a meta-analysis

OBJECTIVE

To assess the association between smoking and low back pain with meta-analysis.

METHODS

We conducted a systematic search of the MEDLINE and EMBASE databases until February 2009. Eighty-one studies were reviewed and 40 (27 cross-sectional and 13 cohort) studies were included in the meta-analyses.

RESULTS

In cross-sectional studies, current smoking was associated with increased prevalence of low back pain in the past month (pooled odds ratio [OR] 1.30, 95% confidence interval [CI], 1.16-1.45), low back pain in the past 12 months (OR 1.33, 95% CI, 1.26-1.41), seeking care for low back pain (OR 1.49, 95% CI, 1.38-1.60), chronic low back pain (OR 1.79, 95% CI, 1.27-2.50) and disabling low back pain (OR 2.14, 95% CI, 1.11-4.13). Former smokers had a higher prevalence of low back pain compared with never smokers, but a lower prevalence of low back pain than current smokers. In cohort studies, both former (OR 1.32, 95% CI, 0.99-1.77) and current (OR 1.31, 95% CI, 1.11-1.55) smokers had an increased incidence of low back pain compared with never smokers. The association between current smoking and the incidence of low back pain was stronger in adolescents (OR 1.82, 95% CI, 1.42-2.33) than in adults (OR 1.16, 95% CI, 1.02-1.32).

CONCLUSIONS

Our findings indicate that both current and former smokers have a higher prevalence and incidence of low back pain than never smokers, but the association is fairly modest. The association between current smoking and the incidence of low back pain is stronger in adolescents than in adults.

Towards a theory of chronic pain

In this review, we integrate recent human and animal studies from the viewpoint of chronic pain. First, we briefly review the impact of chronic pain on society and address current pitfalls of its definition and clinical management. Second, we examine pain mechanisms via nociceptive information transmission cephalad and its impact and interaction with the cortex. Third, we present recent discoveries on the active role of the cortex in chronic pain, with findings indicating that the human cortex continuously reorganizes as it lives in chronic pain. We also introduce data emphasizing that distinct chronic pain conditions impact on the cortex in unique patterns. Fourth, animal studies regarding nociceptive transmission, recent evidence for supraspinal reorganization during pain, the necessity of descending modulation for maintenance of neuropathic behavior, and the impact of cortical manipulations on neuropathic pain is also reviewed. We further expound on the notion that chronic pain can be reformulated within the context of learning and memory, and demonstrate the relevance of the idea in the design of novel pharmacotherapies. Lastly, we integrate the human and animal data into a unified working model outlining the mechanism by which acute pain transitions into a chronic state. It incorporates knowledge of underlying brain structures and their reorganization, and also includes specific variations as a function of pain persistence and injury type, thereby providing mechanistic descriptions of several unique chronic pain conditions within a single model.

Development of a screening tool predicting the transition from acute to chronic low back pain for patients in a GP setting: protocol of a multinational prospective cohort study

BACKGROUND

Low back pain (LBP) is by far the most prevalent and costly musculoskeletal problem in our society today. Following the recommendations of the Multinational Musculoskeletal Inception Cohort Study (MMICS) Statement, our study aims to define outcome assessment tools for patients with acute LBP and the time point at which chronic LBP becomes manifest and to identify patient characteristics which increase the risk of chronicity.

METHODS

Patients with acute LBP will be recruited from clinics of general practitioners (GPs) in New Zealand (NZ) and Switzerland (CH). They will be assessed by postal survey at baseline and at 3, 6, 12 weeks and 6 months follow-up. Primary outcome will be disability as measured by the Oswestry Disability Index (ODI); key secondary endpoints will be general health as measured by the acute SF-12 and pain as measured on the Visual Analogue Scale (VAS). A subgroup analysis of different assessment instruments and baseline characteristics will be performed using multiple linear regression models. This study aims to examine: 1. Which biomedical, psychological, social, and occupational outcome assessment tools are identifiers for the transition from acute to chronic LBP and at which time point this transition becomes manifest. 2. Which psychosocial and occupational baseline characteristics like work status and period of work absenteeism influence the course from acute to chronic LBP. 3. Differences in outcome assessment tools and baseline characteristics of patients in NZ compared with CH.

DISCUSSION

This study will develop a screening tool for patients with acute LBP to be used in GP clinics to access the risk of developing chronic LBP. In addition, biomedical, psychological, social, and occupational patient characteristics which influence the course from acute to chronic LBP will be identified. Furthermore, an appropriate time point for follow-ups will be given to detect this transition. The generalizability of our findings will be enhanced by the international perspective of this study.

TRIAL REGISTRATION

[Clinical Trial Registration Number, ACTRN12608000520336].

Psychosocial factors and low back pain among college students

OBJECTIVE AND PARTICIPANTS

The authors evaluated psychosocial factors of stress and their effects on the prevalence of low back pain (LBP) among a population of college students in a major university in Colorado.

METHODS

This was a nested cross-sectional study of 973 respondents who completed the National College Health Assessment survey. The authors evaluated a subset of questions pertaining to psychosocial stressors against the presence of LBP.

RESULTS

The annual prevalence of LBP among the population studied was 42.8%. The stressful psychosocial variables of feeling very sad, exhausted, and overwhelmed were associated with the prevalence of LBP.

CONCLUSIONS

The prevalence of LBP among this younger population is significant and understudied.

Smoking and chronic back pain: analyses of the German Telephone Health Survey 2003

INTRODUCTION

Smoking represents the greatest avoidable risk for a large number of serious diseases. The goal of the present study was to investigate the connection between tobacco consumption and back pain, as such a link has yet to be clearly established.

METHODS

The analysis was based on the public use file of the German Telephone Health Survey 2003 (n = 8318), carried out by the Robert Koch Institute, Berlin. After exclusion of invalid cases, data on 7271 persons (total model) and 1998 persons (smoker model) were analyzed.

RESULTS

Multivariate data analysis clearly shows that not only daily smokers (OR 1.45, 95% CI 1.13 to 1.85) but also former smokers (OR 1.65, 95% CI 1.32 to 2.07) have a significantly higher chance of suffering from chronic back pain than non-smokers. Number of smoking years is the factor most significantly correlated with chronic back pain, while starting age and amount of tobacco consumed have no impact.

DISCUSSION

Owing to the cross-sectional design of this investigation it is not possible to conclude that smoking causes increased back pain through physical dysfunction. Nevertheless, the correlation should be analyzed in a longitudinal study because clarification of causality always represents potential for prevention.

Is smoking a risk factor for low back pain in adolescents? A prospective cohort study

STUDY DESIGN

A prospective cohort study in adolescents.

OBJECTIVE

To evaluate whether smoking in adolescence is a risk factor of low back pain (LBP) among young adults.

SUMMARY OF BACKGROUND DATA

Smoking has been found to associate with LBP among adults. Longitudinal studies performed in adolescents are few.

METHODS

The children belonging to the northern Finland Birth Cohort 1986 were examined at birth and at 16 years of age and followed up by a postal questionnaire at the age of approximately 18 years. The primary outcome was LBP during the past 6-month period. Incident cases reported LBP at 18 but not at 16 years. Persistent cases reported pain at both time points. Logistic regression analysis was used to evaluate the effect of smoking exposure on any LBP in both genders separately and multinomial regression analysis was used to evaluate the effect on the severity of LBP (No LBP, "Reporting LBP," "Consultation for LBP") in the total population. Parents' socioeconomic status, physical activity, body mass index, and depressive mood were used as confounders in the analyses.

RESULTS

Regular smoking at 16 years was associated with persistent LBP in girls (OR: 2.52; 95% CI: 1.40-4.53). Daily smoking of over 9 cigarettes at 16 was associated with persistent LBP (2.57; 1.03-6.46) and predicted incident pain in girls (2.80; 1.11-7.09). Pack-years of smoking were associated with incident and persistent LBP in the girls with an exposure-response relationship, whereas these associations were inconsistent in the boys. Pack-years of smoking at 18 years showed an exposure-response relationship with persistent Consultation for LBP, which was strongest in those with over 1.5 pack-years of exposure (5.82; 1.39-24.42).

CONCLUSION

Regular smoking in adolescence was associated with LBP in young adults. Pack-years of smoking showed an exposure-response relationship among girls.

Physical activity and low-back pain in schoolchildren

Design of the experiment is to study the cross-sectional sample with retrospective information. The objective is to identify the types of physical activity associated with the decreased occurrence of low-back pain (LBP) in schoolchildren. Physical activity may be hypothesized to possess a potential for LBP prevention. The possible connection between LBP and specific sports activities is however sparsely documented. A total of 546, 15- to 16-year-old schoolchildren filled a questionnaire on current physical activities and LBP occurrence and severity. In multiple logistic regressions, the association of LBP with exposure variables was corrected for body height and weight (data from school health service files) and for anthropometric and school furniture parameters. More than half of the children reported pain or discomfort in the low-back region during the preceding 3 months, and 1/4 experienced a decreased functioning or need of care because of LBP. LBP correlated with physical inactivity, e.g. time spent on homework and hours watching TV or video, and with a series of sports activities, e.g. jogging, handball playing and gymnastics. Among sports activities, only swimming and the number of hours per week participating in soccer were associated with a decreased LBP prevalence. With the exception of swimming and soccer, the types of sport reported by this schoolchild population do not offer themselves for consideration as tools for LBP prevention. Based on the associations found with indicators of physical inactivity, attempts to motivate the children to increase their general physical activity level should be considered for trial.

The effects of lifestyle intervention for hypertension on low back pain: a randomized controlled trial

STUDY DESIGN

Randomized controlled trial.

OBJECTIVE

To assess the effects of a lifestyle intervention for hypertension on low back pain.

SUMMARY OF BACKGROUND DATA

According to prospective etiologic studies, a causal association exists between certain lifestyle factors and low back pain. These factors are similar to those that elevate the risk for hypertension. Nevertheless, no randomized controlled trial has assessed effectiveness of lifestyle intervention for the treatment of hypertension on the prevalence of low back pain.

METHODS

A total of 731 hypertensive employees from 45 worksites were assigned to multidisciplinary lifestyle interventions for hypertension in a rehabilitation center or to routine care in occupational or primary healthcare services during 12 months. Questionnaire data on low back pain were used to assess the effects of the intervention on the extent of low back pain and disability.

RESULTS

The changes in prevalence and duration of low back pain, and related disability did not differ between the 2 groups, although there were favorable changes in some risk factors, such as body weight and physical inactivity. Subgroup analyses among patients with moderately heavy or heavy work showed that the prevalence of low back pain during the previous 12 months decreased more in the intervention than in the control group.

CONCLUSION

Multidisciplinary lifestyle intervention aimed to reduce hypertension is not effective at reducing prevalence of low back pain or disability. However, in the subgroup of persons doing moderate or heavy work, the intervention seemed to reduce prevalence of low back pain during the 1-year follow-up.

Low back pain in 15- to 16-year-old children in relation to school furniture and carrying of the school bag

STUDY DESIGN

Cross-sectional sample with longitudinal information.

OBJECTIVE

To estimate the relationship between the occurrence of low back pain (LBP) and various types of school furniture and anthropometric dimensions in schoolchildren, and physical loading by school bag carrying.

SUMMARY OF BACKGROUND DATA

Some types of school furniture may be hypothesized to prevent or cause LBP. Despite strong opinions in the public debate about a possible relationship between use of various types of school furniture and LBP, scientific research on this matter is sparse.

METHODS

Five hundred forty-six schoolchildren aged 14 to 17 years answered a questionnaire about sitting positions during school hours and the presence and severity of LBP. Furthermore, the anthropometric dimensions and the weight of the school bags were measured. The types and dimensions of the school furniture were described and measured. In multivariate analyses was adjusted for physical activity and other possible risk factors.

RESULTS

More than half of the adolescents experienced LBP during the preceding 3 months, and 24.2% reported reduced daily function or care seeking because of LBP. LBP occurrence was not associated with the types or dimensions of the school furniture or body dimensions, but was positively associated with carrying the school bag on 1 shoulder [OR: 2.06 (1.29-3.31)].

CONCLUSION

The present study does not support the hypothesis of different types of school furniture being a causative or preventing factor for LBP. Carrying the school bag in an asymmetric manner may play a role.

Epidemiology of chronic musculoskeletal pain

The rate of musculoskeletal pain in adolescent and adult populations is examined, with a focus on three commonly reported pain disorders: shoulder pain, low back pain and fibromyalgia/chronic widespread pain. There is a paucity of data on musculoskeletal pain in adolescent populations. Those studies available suggest that pain is common, although the actual rates are unclear. This is probably due to differences in study methodologies and populations. Pain is commonly reported among adult populations, with almost one fifth reporting widespread pain, one third shoulder pain, and up to one half reporting low back pain in a 1-month period. The prevalence of pain varies within specific population subgroups; group factors (including socioeconomic status, ethnicity and race) and individual factors (smoking, diet, and psychological status) are all associated with the reporting of musculoskeletal pain. However, the precise nature of these relationships, and particularly the mechanisms of association, are unclear and require further investigation.

Public health perspective--how to improve the musculoskeletal health of the population

Musculoskeletal disorders are the most common cause of long-term sick leave in several western countries and individuals with chronic musculoskeletal pain score very low on health status measurements. Musculoskeletal health is multidimensional and is best understood from a biopsychosocial perspective. Body structure and function interacts with personal and environmental factors, affecting the ability to perform activities and participate in society. Interventions aimed at the whole population must attend to the underlying causes of musculoskeletal disorders and promote a healthy lifestyle. Safe environments and activities could reduce the risk of traumatic events and also make participation possible for those with a disability. Public beliefs about musculoskeletal symptoms and consequences need to be changed in order to minimise fear and avoidance, which, together with other psychosocial factors, could lead to chronicity. Public awareness and identification of those at risk for the development of musculoskeletal problems could lead to early and properly timed management.

Associations of physical activity and inactivity with low back pain in adolescents

Low back pain (LBP) is a common health problem already in adolescence. Physical activity has been suggested as a risk factor for LBP in adolescents, but the current evidence is conflicting. This study examined the association of physical activity and amount of sitting with LBP. The study population consisted of 5999 boy and girl members of the Northern Finland 1986 birth cohort who responded to mailed questions at the age of 15-16 years. LBP during the past 6 months was classified as "no LBP,""reporting LBP" (not seeking medical help), or "consultation for LBP." Odds ratios and 95% confidence intervals obtained by multinomial logistic regression were adjusted for smoking and body mass index. Being physically very active (more than 6 h of brisk physical activity per week) was associated with increased prevalence of "consultation for LBP" in both sexes, and with "reporting LBP" in girls, compared with being moderately active (2-3 h of brisk physical activity per week). High amount of sitting associated with "consultation for LBP" and "reporting LBP" in girls, but not in boys. We conclude that very active participation in physical activities in both sexes and a high amount of sitting in girls are related to self-reported LBP.