Low back pain and the social determinants of health: a systematic review and narrative synthesis

Co-creating a Choosing Wisely leaflet supporting the reduction of imaging usage in low back pain management - A multi-method study

OBJECTIVE

The objective was to co-create an information resource in the form of a leaflet, to be distributed in clinical settings, websites or social media targeting people with low back pain.

METHODS

This multi-method study was conducted in four stages: literature search, input from practice consultants, program theory development, and think-aloud interviews with people experiencing low back pain. Each stage was followed by a consensus meeting in which the steering group refined the leaflet based on the emerging knowledge.

RESULTS

The literature search highlighted patients' need for easy-to-understand information about their back pain diagnosis, management strategies, social activities, work and solutions for supported self-management strategies. Practice consultants emphasized concise, relatable content. The program theory identified potential mechanisms for content creation, development, and implementation of the leaflet, such as addressing patient concerns, reducing diagnostic uncertainty, insights into management options, and validation. Think-aloud interviews with 18 people living with low back pain informed the iteration of the leaflet, enhancing language clarification and content comprehension.

CONCLUSIONS

We co-created a new Choosing Wisely leaflet, created with end-users in mind, specifically focused on reducing unnecessary imaging for low back pain.

PRACTICE IMPLICATIONS

This leaflet may support clinical settings in delivering evidence-based approaches and supporting self-management.

Haves and have-nots: socioeconomic position improves accuracy of machine learning algorithms for predicting high-impact chronic pain

ABSTRACT

Lower socioeconomic position (SEP) is associated with increased risk of developing chronic pain, experiencing more severe pain, and suffering greater pain-related disability. However, SEP is a multidimensional construct; there is a dearth of research on which SEP features are most strongly associated with high-impact chronic pain, the relative importance of SEP predictive features compared to established chronic pain correlates, and whether the relative importance of SEP predictive features differs by race and sex. This study used 3 machine learning algorithms to address these questions among adults in the 2019 National Health Interview Survey. Gradient boosting decision trees achieved the highest accuracy and discriminatory power for high-impact chronic pain. Results suggest that distinct SEP dimensions, including material resources (eg, ratio of family income to poverty threshold) and employment (ie, working in the past week, number of working adults in the family), are highly relevant predictors of high-impact chronic pain. Subgroup analyses compared the relative importance of predictive features of high-impact chronic pain in non-Hispanic Black vs White adults and men vs women. Whereas the relative importance of body mass index and owning/renting a residence was higher for non-Hispanic Black adults, the relative importance of working adults in the family and housing stability was higher for non-Hispanic White adults. Anxiety symptom severity, body mass index, and cigarette smoking had higher relevance for women, while housing stability and frequency of anxiety and depression had higher relevance for men. Results highlight the potential for machine learning algorithms to advance health equity research.

Developing consensus on the most important equity-relevant items to include in pain research: a modified e-Delphi study

ABSTRACT

There is increasing recognition of the need for routine measurement and reporting of data that can reveal social factors that contribute to health inequities for people with pain. Prioritising what data to collect and understanding how to collect it can be challenging, and no clear guidance exists. We conducted a 3-round Delphi study to develop consensus on the most important items to include in a minimum dataset of equity-relevant variables. An international panel of experts and interest-holders were invited to participate based on expertise in pain, social determinants of health and health equity, or a lived experience of persistent pain. In round 1, 168 participants rated the importance of an initial set of 43 equity-relevant items and categorised them according to the PROGRESS-Plus Framework. Twenty-nine items reached agreement for inclusion (based on a threshold of panel median of ≥7 of 9); none of the items were excluded. Participant comments were collated, and 21 new items were proposed. In round 2, 152 participants (90% of round 1) voted on 35 items, 25 of which reached agreement for inclusion. In round 3, 142 participants (93% of round 2) prioritised the 54 items that reached the threshold for inclusion within each category and rated the PROGRESS-Plus category importance. Our results indicated consistent agreement that it is important to collect data on a wide range of social factors and provide rich data to inform the development of a consensus-derived, globally applicable, "minimum dataset" that will be recommended for routine use in all human pain research.

Investigating the Prevalence and Level of Pain Experienced by Australian Farmers

OBJECTIVES

This study evaluated the prevalence and level of pain in Australian farmers and how these compare to the general working population. We also explored factors related to the interference of pain on farmers' work.

DESIGN

Logistic regressions were used to examine the prevalence of chronic pain and pain interference with normal work among farmers compared to the general working population, and also to examine the factors associated with pain interference in farmers. A multinomial logistic regression model was used to examine the level of bodily pain among farmers compared to the general working population.

SETTING

The nationally representative HILDA (Household, Income, and Labour Dynamics Australia) survey data (wave 21) was used.

PARTICIPANTS

The final sample included 168 (1.6%) farmers and 10 318 (98.4%) people in the general working population.

RESULTS

There was a higher prevalence of chronic pain (p < 0.001), higher levels of bodily pain (p < 0.001), and pain interference with normal work (p < 0.001) in farmers than in the general working population. Age, gender, Body Mass Index (BMI), education level, remoteness, and personal social cohesion were not associated with pain interference with normal work in farmers.

CONCLUSION

The prevalence of chronic pain, level of bodily pain, and pain interference with normal work in Australian farmers is higher than the general working population. However, information is lacking on the factors that influence pain for this unique group. Further exploration is needed into why factors that are commonly associated with pain are not associated with pain in the farming population.

Disparities, Inequities, and Injustices in Populations With Pain: Nursing Recommendations Supporting ASPMN's 2024 Position Statement

The American Society for Pain Management Nursing (ASPMN) upholds the principle that all persons with pain have equal rights to evidence-based, high quality pain assessment, management, and treatment. This practice recommendation's goals are to 1) summarize known pain-related disparities, inequities, and injustices among commonly marginalized and at risk groups, 2) offer recommendations to ascertain that just and equitable pain care is provided to all people, and 3) outline a call to action for all nurses to embrace diversity, equity, inclusion, and a sense of belonging in order to mitigate pain-related disparities, inequities, and injustices within clinical environments and the nursing profession. This paper provides background and rationale for the 2024 ASPMN position statement on disparities, inequities and injustices in people with pain.

Trends in chronic neck and low back pain prevalence in Spain (2006-2020): differences by sex, age, and social class

PURPOSE

To analyze the evolution of chronic neck and low back pain prevalence in the general Spanish population (≥ 15 years) from 2006 to 2020, examining differences by sex, age, social class, and the potential influence of the COVID-19 pandemic.

METHODS

A repeated cross-sectional observational study was conducted based on data from six health surveys conducted in Spain between 2006 and 2020, with samples ranging from 21,007 to 29,478 subjects per survey, reported by the European Statistical System and the National Statistical Institute. Overall and specific prevalence rates were calculated, and linear trends were assessed over time. The potential influence of the COVID-19 pandemic was evaluated using the Mann-Kendall test, along with prevalence forecasts up to 2020, derived from S-curve models.

RESULTS

Between 2006 and 2020, the prevalence of chronic neck pain ranged from 23.64 to 12.3%, while chronic low back pain ranged from 24.01 to 14.73%. A decreasing trend was observed in both conditions, slightly more pronounced for neck pain. This trend persisted even when excluding 2020 data, which was potentially influenced by the COVID-19 pandemic, and was independent of health surveys. Forecasts indicated that the actual 2020 prevalence rates were lower (by 3.1-4.4%) than predicted. The prevalence was consistently higher among women, older individuals, and lower social classes, though all subgroups showed similar decreasing trends.

CONCLUSION

The prevalence of chronic neck and low back pain in the Spanish population declined between 2006 and 2020. Subgroup analyses revealed consistent decreases across sex, age, and social class. The COVID-19 pandemic may have impacted the 2020 prevalence rates.

The acceptability, feasibility, and usability of a virtual reality pain education and rehabilitation program for Veterans: a mixed-methods study

Introduction

Persistent pain is a leading cause of medical discharges for Veterans. Pain science education (PSE) aims to better people's understanding about pain and is effective at reducing pain and depressive symptoms in Veterans. Preliminary evidence suggests virtual reality (VR)-delivered PSE has clinical benefits for people with persistent pain. This study investigated the acceptability, feasibility, and usability for VR-PSE for Veterans with persistent pain.

Methods

Veterans (n = 7) and healthcare professionals (HCPs) experienced in treating Veterans (n = 5) participated in workshops that involved working through the VR-PSE program, online questionnaires, and a focus group. Quantitative data were analysed by descriptive statistics. Qualitative data were analysed using a framework analysis according to the Theoretical Framework of Acceptability (TFA). A mixed-methods analysis combined the quantitative and qualitative data via triangulation, with the findings presented according to the TFA domains.

Results

The VR-PSE program was considered easy to use, engaging, and adaptable for different functional capabilities. Appropriate screening for contraindications prior to using the VR-PSE program was considered important by HCPs. Both Veterans and HCPs emphasized the need for a trusting client-clinician relationship to improve the acceptability of the VR-PSE program.

Discussion

Overall, the VR-PSE program was found to be acceptable, feasible, and usable and may be a useful tool to incorporate into the clinical management of Veterans with persistent pain. Further research is needed to investigate the efficacy of VR-PSE programs on clinical outcomes for Veterans with persistent pain.

Reporting and incorporation of social risks in low back pain and exercise studies: A scoping review

BACKGROUND

Exercise is a common intervention for low back pain, but its effect sizes are small to modest. Social risk factors significantly influence health outcomes, yet their consideration in randomized controlled trials on exercise for low back pain is often neglected. Determining their relationship to outcomes may provide better insight into exercise effectiveness.

OBJECTIVES

To assess the reporting of social risk factors (SRFs) in randomized controlled trials (RCTs) of exercise interventions for low back pain (LBP) in adults and explore associations between SRFs and outcomes.

DESIGN

Scoping Review.

METHODS

The databases MEDLINE, CINAHL and Cochrane were searched for studies published between January 2014 to March 2025. RCTs were included if exercise was the primary intervention for LBP treatment and had a minimum follow-up of 12 weeks. A planned analysis of SRF and outcome associations was not conducted due to insufficient data.

RESULTS

A total of 10,292 studies were identified and 157 studies included. Fewer than half (47.1 %) reported any SRFs at baseline. Socioeconomic position (42.7 %) was most frequently reported, followed by social relationships (17.8 %), race/ethnicity/cultural context (8.3 %), residential/community context (1.3 %), and gender (0.6 %). Four studies incorporated SRFs in their outcome analyses; one examined associations with outcomes and found no significant association.

CONCLUSION

SRFs are underreported in RCTs of exercise interventions for LBP and are rarely analyzed in relation to primary outcomes, limiting our understanding of their impact. Future trials should prioritize collecting and reporting SRFs at baseline and incorporating them in outcome analyses to assess their influence on outcomes.

Sociodemographically Differential Patterns of Chronic Pain Progression Revealed by Analyzing the All of Us Research Program Data

The differential progression of ten chronic overlapping pain conditions (COPC) and four comorbid mental disorders across demographic groups have rarely been reported in the literature. To fill in this gap, we conducted retrospective cohort analyses using All of Us Research Program data from 1970 to 2023. Separate cohorts were created to assess the differential patterns across sex, race, and ethnicity. Logistic regression models, controlling for demographic variables and household income level, were employed to identify significant sociodemographic factors associated with the differential progression from one COPC or mental condition to another. Among the 139 frequent disease pairs, we identified group-specific patterns in 15 progression pathways. Black or African Americans with a COPC condition had a significantly increased association in progression to other COPCs (CLBP->IBS, CLBP->MHA, or IBS->MHA, OR≥1.25, adj.p≤4.0x10-3) or mental disorders (CLBP->anxiety, CLBP->depression, MHA->anxiety, MHA->depression, OR≥1.25, adj.p≤1.9x10-2) after developing a COPC. Females had an increased likelihood of chronic low back pain after anxiety and depression (OR≥1.12, adj.p≤1.5x10-2). Additionally, the lowest income bracket was associated with an increased risk of developing another COPC from a COPC (CLBP->MHA, IBS->MHA, MHA->CLBP, or MHA->IBS, OR≥1.44, adj.p≤2.6x10-2) or from a mental disorder (depression->MHA, depression->CLBP, anxiety->CLBP, or anxiety->IBS, OR≥1.50, adj.p≤2.0x10-2), as well as developing a mental disorder after a COPC (CLBP->depression, CBLP->anxiety, MHA->anxiety, OR=1.37, adj.p≤1.6x10-2). To our knowledge, this is the first study that unveils the sociodemographic influence on COPC progression. These findings suggest the importance of considering sociodemographic factors to achieve optimal prognostication and preemptive management of COPCs.

'Despite the Pain, I Keep Moving Forward': A Qualitative Study on Brazilian Older Adults' Experiences With Chronic Low Back Pain

OBJECTIVE

The burden of chronic low back pain (CLBP) is increasing rapidly along with the global population ageing. Such an increase will occur more rapidly in low- and middle-income countries (LMICs). Yet, few studies have explored the experiences of older adults with CLBP, and these are primarily conducted in high-income countries. To address this concern, we explored the experiences of older Brazilian adults with CLBP.

METHODS

We used a descriptive qualitative study and gathered data through interviews and drawings from participants representing their experiences. Data were analysed using reflexive thematic analysis principles.

RESULTS

We interviewed 22 participants and identified the following themes: (1) Low back pain: an intense sensory and emotional experience; (2) causes of pain: wear and tear due to ageing, physical overload and emotional overload; (3) seeking treatment and not improving; (4) health professionals with a biomedical and pessimistic view; (5) the impact of pain on life: functional limitations and social repercussions; and (6) dealing with pain through movement, resilience and passive strategies.

CONCLUSIONS

Participants described CLBP as a sensory and emotional experience that impacts various aspects of their lives. Wear and tear due to ageing, physical and emotional overload were highlighted as causes of pain, and health professionals as a source of pessimism. Despite this, many participants discussed coping through movement, resilience, and passive strategies. Health professionals should address the emotional aspects associated with CLBP, explore its impact on their patients' lives and provide information that aligns with current evidence, promoting reassurance and a multidimensional understanding of CLBP.

Accessing care within team-based models of primary care for the management of chronic low back pain in Ontario, Canada: a qualitative study of patient experiences

PURPOSE

To understand experiences accessing care within team-based primary care models among adults with chronic low back pain (LBP).

MATERIALS & METHODS

We conducted an interpretive description qualitative study and collected data using one-to-one semi-structured interviews. Participants were recruited from publicly funded, team-based primary care models in Ontario, Canada.

RESULTS

We completed interviews with 16 adults with chronic LBP (9 women; median age of 66). Participants expressed a desire to access care from team-based models of primary care in hopes of alleviating pain and its impacts on daily life. Due to no direct out-of-pocket costs, co-location of healthcare providers, and the use of technology and virtual care, participants described an ease of accessing interprofessional care within team-based primary care models. Finally, participants described experiences with and expectations for timely access to care, being heard and understood by healthcare providers, and receiving coordinated care by an interprofessional team.

CONCLUSIONS

Adults living with chronic LBP described overall positive experiences and specific expectations when accessing care within team-based models of primary care, whereby they experienced an ease of accessing interprofessional care with the hope of alleviating pain and its impacts. Results may be transferable to other chronic pain conditions and health system contexts.

Multi-ancestry meta-analysis of genome-wide association studies discovers 67 new loci associated with chronic back pain

This multi-ancestry meta-analysis of genome-wide association studies (GWAS) investigated the genetic factors underlying chronic back pain (CBP) in a sample from the Million Veteran Program comprised of 553,601 Veterans of African (19.2%), European (72.6%), and Hispanic (8.2%) ancestry. The results revealed novel (N = 67) and known (N = 20) genome-wide significant loci associated with CBP, with 43 independent variants replicating in a non-overlapping contemporary meta-GWAS of the spinal pain dorsalgia phenotype. The most significant novel variant was rs12533005 (chr7:114416000, p = 1.61 × 10-20, OR = 0.96 (95% CI: 0.95-0.97), EA = C, EAF = 0.39), in an intron of the FOXP2 gene. In silico functional characterization revealed enrichment in brain and pituitary tissues. Mendelian randomization analysis of 62 variants for CBP-MVP revealed 48 with causal links to dorsalgia. Notably, four genes (INPP5B, DRD2, HTT, SLC30A6) associated with these variants are targets of existing drugs. Our findings more than double the number of previously reported genetic predictors across all spinal pain phenotypes.

How Is Chronic Pain Managed in Rural Australia? A Qualitative Study Exploring Rural Healthcare Professional and Consumer Experiences

INTRODUCTION

Guideline-based care for chronic pain is variably provided. Existing data on chronic pain management in Australia come primarily from metropolitan samples. As the initial investigations for a wider needs assessment, we sought to understand how chronic pain is managed in rural Australia, focused on investigating the gap between guideline-recommended care and provided care.

METHODS

We conducted semistructured interviews with rural healthcare professionals who treat patients with chronic pain and rural consumers affected by chronic pain. We asked healthcare professionals what treatments they deliver to patients with chronic pain. We asked consumers to describe the healthcare service providers they had accessed for pain care and the treatments they received from these providers. We utilised content analysis to gain an understanding of what care for chronic pain is being provided and compared these findings to guideline recommendations.

RESULTS

We interviewed 15 healthcare professionals and 27 consumers. Both healthcare professionas and consumers reported minimal use of most first-line management strategies. We also found differences between healthcare professional and consumer reports of pain care. Healthcare professionals frequently described delivering guideline-aligned pain care and consumers frequently described receiving care that contradicted guidelines. We identified challenges with rural access to pain care services, including minimal usage of telehealth services.

CONCLUSIONS

Given the identified gaps in care, future research may consider ways of improving rural access to pain care services, including investigating ways to increase uptake of telehealth services, and how to shift consumer expectations of pain care.

Increasing access to pain care services to improve rural pain management: a realist review investigating factors affecting uptake, implementation, and sustainability

ABSTRACT

Guideline-based care for chronic pain is challenging to deliver in rural settings. Evaluations of programs that increase access to pain care services in rural areas report variable outcomes. We conducted a realist review to gain a deep understanding of how and why such programs may, or may not, work. Our review incorporated interest-holder input in all review phases. We conducted CLUSTER searching to identify literature relevant to understanding the factors affecting the uptake, implementation, and sustainability of programs offering pain care services to rural general practitioners. We used retroductive analysis to generate and test context-mechanism-outcome configurations. Our results are informed by 74 studies. We identified that awareness of the program, provision of necessary resources, and positive attitudes towards the program are required to enable program uptake. When looking for suitable patients to refer, general practitioners need to trust their ability to discuss a referral with a patient in their allocated appointment time. Program sustainability requires clear roles for all providers and sufficient program coordination. Increased access to pain care services enabled interprofessional learning that increased local providers' confidence to manage chronic pain. Many barriers can interfere with successful uptake, implementation, and sustainability of programs that increase access to pain care services in rural settings. It is important to tailor rural workforce programs to local community needs to increase the likelihood of success. Our findings include recommendations for future program planners to consider.

Pain as a Symptom of Mental Health Conditions Among Undocumented Migrants in France: Results From a Cross-Sectional Study

Objectives

This study aimed to explore the associations between mental health status and experienced pain among undocumented migrants (UMs) in France.

Methods

We used data from the multicentric cross-sectional "Premier Pas" study conducted in the Parisian and Bordeaux regions from February to April 2019. Participants over 18 years of age were recruited from sixty-three sites. Pain was assessed through two variables: overall pain and musculoskeletal pain. Mental health conditions, including anxiety, sleep disorders, depression, and posttraumatic stress disorder (PTSD) were evaluated. Logistic regression models were used to explore associations, controlling for social determinants of health (SDHs).

Results

Our findings revealed significant associations between mental health status and pain among the 1,188 included participants. Sleep disorder was associated to higher odds of musculoskeletal pain (aOR = 2.53, 95% CI [1.20-5.33], p = 0.014). Stratified results indicated that among women, depression was associated to higher odds of pain (aOR = 4.85, 95% CI [1.53-13.36], p = 0.007).

Conclusion

This large study confirms the connection between mental health status and pain among UMs, providing valuable evidence for clinicians to address mental health issues in this population.

Low back pain prevalence, capacity, and performance according to sociodemographic variables, population-based study in Chile

BACKGROUND

Low back pain (LBP) is one of the main causes of disability and need for rehabilitation services. It is necessary to have a better understanding about the association of sociodemographic factors with the disability related to individuals with LBP.

OBJECTIVE

Assess the prevalence of LBP and its association with capacity, performance, and sociodemographic variables in Chilean population.

METHODS

Cross-sectional study was performed with data from the population survey from Chile, 2015. People over 17 years old were selected for the analysis (n = 12,265 people). The variables chosen were: presence of LBP, place of living in Chile, sex, age, marital status, education, income, work status, and type of home. Capacity and performance levels were assessed by the Model Disability Survey. The population characteristics, performance, and capacity values were presented through means or frequencies. A generalized linear model with logarithmic linkage and gamma distribution was employed to assess the associations between the explanatory variables and the outcomes, considering the distribution of the variables, while adjusting for all study variables.

RESULTS

22 % of the population reported having LBP. People with LBP had worse levels of capacity and performance. Being female, older age, having worse education level, and worse health classification, were factors associated with worse capacity and performance in those with LBP. Conversely, being employed in the last week was correlated with improved capacity in this group.

CONCLUSION

Individuals with LBP demonstrated poorer capacity and performance outcomes, with sociodemographic variables influencing their functioning.

The Pace of Biological Aging Partially Explains the Relationship Between Socioeconomic Status and Chronic Low Back Pain Outcomes

Introduction

Having a lower socioeconomic status (SES) is a predictor of age-related chronic conditions, including chronic low back pain (cLBP). We aimed to examine whether the pace of biological aging mediates the relationship between SES and cLBP outcomes - pain intensity, pain interference, and physical performance.

Methods

We used the Dunedin Pace of Aging Calculated from the Epigenome (DunedinPACE) software to determine the pace of biological aging in adults ages 18 to 85 years with no cLBP (n = 74), low-impact pain (n = 56), and high-impact pain (n = 77).

Results

The mean chronological age of the participants was 40.9 years (SD= 15.1); 107 (51.7%) were female, and 108 (52.2%) were Black. On average, the pace of biological aging was 5% faster [DunedinPACE = 1.05 (SD = 0.14)] in the sample (DunedinPACE value of 1 = normal pace of aging). Individuals with higher levels of education had a significantly slower pace of biological aging than those with lower education levels (F = 5.546, p = 0.001). After adjusting for sex and race, household income level significantly correlated with the pace of biological aging (r = -0.17, p = 0.02), pain intensity (r = -0.21, p = 0.003), pain interference (r = -0.21, p = 0.003), and physical performance (r = 0.20, p = 0.005). In mediation analyses adjusting for sex, race, and body mass index (BMI), the pace of biological aging mediates the relationship between household income (but not education) level and cLBP intensity, interference, as well as physical performance.

Discussion

Results indicate that lower SES contributes to faster biological aging, possibly contributing to greater pain intensity and interference, as well as lower physical performance. Future interventions slowing the pace of biological aging may improve cLBP outcomes.

Relationship between pain severity and self-perceived health among United States adults: A cross-sectional, retrospective database study

Self-perceived health is related to outcomes such as morbidity and mortality. However, little is known about the relationship between pain severity and self-perceived health, which could be useful to know to help improve health. This study assessed the association of pain severity and other contributing factors with self-perceived health among United States adults. This cross-sectional, retrospective database study used 2019 Medical Expenditure Panel Survey data and included United States adults aged ≥18 years who responded to the pain item in the survey. The independent variable was self-reported pain severity, and the dependent variable was self-perceived health. Various potentially confounding variables were controlled for in the analysis. Adjusted logistic regression models were used to identify statistical associations between each variable and self-perceived health. The complex survey design was maintained, while nationally representative estimates were obtained. Among the sample of 17,261 United States adults, 88.1% (95% confidence interval, 87.4%-88.8%) reported excellent, very good, or good self-perceived health, while 11.9% (95% confidence interval, 11.2%-12.6%) reported fair or poor self-perceived health. In adjusted analyses, there were significant associations between fair or poor self-perceived health and any level of pain severity versus no pain, age 40 to 64 versus 18 to 39 years, male versus female, Hispanic versus non-Hispanic, high school diploma or less versus more than high school, unemployed versus employed, poor, near poor, or low versus middle or high income, fair or poor versus excellent, very good, or good mental health, exercising <5 times versus ≥5 times per week, smoker versus nonsmoker, and ≥2 versus <2 comorbid conditions. This study found that greater levels of pain severity (and several other variables) were associated with greater odds of reporting fair or poor self-perceived health. These associations provide greater insight into the variables associated with self-perceived health, which may be useful targets to improve health.

Psychophysiological biomarkers to assess the effectiveness of surface electromyography biofeedback as an alternative therapy to reduce chronic low back pain: protocol for a randomised controlled trial

The prevalence of chronic low back pain (CLBP) among the Pakistani population is reported to be as high as 78%, leading towards different physiological and psychosocial alterations, with the worst cases suffering from disabilities. This study protocol will be a randomised controlled trial designed to compare the effectiveness of biofeedback surface electromyography (sEMG) for CLBP in the Pakistani population. This will be a single-centre study to be conducted on patients with CLBP randomised into two groups, namely, Group A (intervention group) and Group B (control group) to receive biofeedback sEMG therapy as an intervention or no intervention, respectively. All participants will receive treatment for 8 weeks virtually. The primary and secondary outcomes will be assessed during the study, including the pain intensity and interference (Brief Pain Inventory), anxiety and depression (State-Trait Anxiety Inventory (STAI)), disability (The Oswestry Disability Index (ODI)) and quality of life. Further, physiological parameters, including altered cortisol levels, beta-endorphins and substance P, will also be measured. All outcomes will be assessed at baseline, immediately post-intervention and 3 months follow-up.

Empowering Self-Management for Chronic Low Back Pain: A Human-Centered Design Study of Spanish- and Cantonese-Preferring Patients in the United States

Introduction

Chronic low back pain (cLBP) is a leading cause of disability with disproportionately high impacts on marginalized populations, including non-English-preferring patients. These patients face significant barriers to accessing care and adhering to self-management strategies due to language barriers, socioeconomic challenges, and cultural differences. Despite the emphasis on self-management for cLBP, limited research has focused on understanding the specific needs and preferences of Spanish- and Cantonese-preferring patients.

Objective

This study aimed to explore the self-management priorities of Spanish- and Cantonese-preferring patients with cLBP. Using a human-centered design approach, we sought to identify patient preferences for self-management support materials and strategies that could be tailored to their unique needs.

Design

Qualitative research using thematic analysis of focus groups conducted in participants' preferred language.

Setting

Urban, academic-affiliated county hospital between March and May 2024.

Patients

Spanish- and Cantonese-preferring patients with cLBP.

Interventions

Not applicable.

Main outcome

Key themes in participants' experiences with cLBP care, barriers to self-management, and preferences for educational materials.

Results

Fifteen patients participated across six focus groups (three focus group in each language). Four primary themes emerged from the focus groups: (1) the need for empathic, tailored educational supports that fit into patients' lives, (2) a desire for self-management plans that account for social and economic constraints, (3) recognition of mental health and social isolation as factors that influence cLBP experience, and (4) a need for clearer guidance on self-management strategies and trustworthy resources. Both Spanish- and Cantonese-preferring participants expressed a preference for video-based resources, plain-language materials, and support for understanding the causes and management of their pain.

Conclusion

Spanish- and Cantonese-preferring patients with cLBP face significant barriers to self-management and would benefit from culturally and linguistically appropriate resources. This study highlights the need for healthcare systems to develop and deliver tailored, accessible self-management support materials that address the unique challenges faced by minoritized populations. Human-centered design offers a promising approach to reducing disparities in cLBP outcomes by creating patient-driven solutions that prioritize empathy, practicality, and cultural relevance.

Low Back Pain Disparities in Portugal: A Population-Based Study Analysing the Role of Social Determinants of Health

INTRODUCTION

Despite growing research, the relationship between social determinants of health (SDoH) and low back pain (LBP) remains inconsistent. This study aimed to investigate the associations between SDoH and self-reported LBP in the Portuguese population in 2019 and explore potential differences between rural and urban areas.

METHODS

This is a cross-sectional study that includes 13,230 participants from the 2019 Portuguese National Health Interview Survey. Multivariable logistic regression models were used to assess the associations between SDoH and LBP. Interaction effects were examined to determine whether these relationships are modified by the degree of urbanisation/rurality.

RESULTS

The regression model for demographic and economic determinants showed associations between LBP and sex, age, marital status, education and financial capacity, with older rural residents having a higher likelihood of reporting LBP. The psychosocial model revealed that poor health status, sleep disturbances, fatigue, and dissatisfaction with life course were positively associated with LBP. In the behavioural model, obesity and history of smoking increased the probability of reporting LBP, whereas exercise behaviours reduced it and significantly varied across urban and rural regions. Health-system factors, including hospital visits, medication use, consultations with rehabilitation professionals, delayed healthcare access, and unmet health needs due to financial constraints, were associated with LBP. Rural residents were more likely to seek outpatient care at hospitals.

DISCUSSION

These findings emphasise the importance of integrating the evaluation of SDoH into healthcare settings to develop tailored interventions for LBP management.

CONCLUSION

LBP was influenced by several SDoH, but differences between rural and urban areas were limited.

Associations of preterm birth and neonatal stress exposure with chronic pain in adulthood - Results from the Gutenberg prematurity study

Although the effect of early childhood stress on central nervous pain processing is well known, studies on the association of prematurity and chronic pain are scarce. This study used data from a single-centre retrospective cohort study followed by a prospective clinical examination and pain assessment. The study was based on data from the local birth registry. Newborns born between 1969 and 2002 who had reached adulthood were eligible .. Using a selection algorithm, a study cohort stratified by gestational age (GA) was recruited. Chronic pain conditions were assessed using questionnaire and standardized pain drawings. Data on the pre-, peri- and postnatal clinical course was assessed from medical records. Multivariable logistic regression analyses were conducted to investigate associations between prematurity and chronic pain with adjustment for age, gender, socioeconomic status, and perinatal stress factors. 427 participants born preterm and full-term were included (age 28.5 ± 8.7 years). Chronic pain conditions were similarly common between groups with different levels of prematurity (GA ≥ 37 weeks: 34.5 %, GA33-36 weeks: 37.6 %, GA32-29 weeks: 25.2 %, GA < 29 weeks: 30.4 %, p = 0.20). In multivariable analyses, no association between low GA and the presence of chronic pain was found (OR = 0.99 (CI95 %: 0.94-1.04, p = 0.63); this was also true for a subanalysis of widespread pain. While neither fetal nutritional status nor perinatal stressors were associated with pain, exposure to maternal but not paternal smoking during pregnancy was associated with increased risk to develop pain (OR = 2.77 (CI95 %: 1.31-5.88, p = 0.008) in adults born preterm and full-term. This study suggests that prematurity by itself does not increase the risk of chronic pain later in life, but provides preliminary evidence for maternal smoking during pregnancy as risk factor.

Evaluating associations between social risks and health care utilization in patients with chronic low back pain

Introduction

Care and outcomes for patients with chronic low back pain (cLBP) are influenced by the social risk factors that they experience. Social risk factors such as food insecurity and housing instability have detrimental effects on patient health and wellness, healthcare outcomes, and health disparities.

Objectives

This retrospective cross-sectional study examined how social risk factors identified in unstructured and structured electronic health record (EHR) data for 1,295 patients with cLBP were associated with health care utilization. We also studied the impact of social risk factors, controlling for back pain-related disability on health care utilization.

Methods

Included patients who received outpatient spine and/or physical therapy services at an urban academic medical center between 2018 and 2020. Five identified social risks were financial insecurity, housing instability, food insecurity, transportation barriers, and social isolation. Outcomes included 4 categories of health care utilization: emergency department (ED) visits/hospitalizations, imaging, outpatient specialty visits related to spine care, and physical therapy (PT) visits. Poisson regression models tested associations between the presence of identified social risks and each outcome measure.

Results

Identified social risks in 12.8% of the study population (N = 166/1,295). In multivariate models, social isolation was positively associated with imaging, specialty visits, and PT visits; housing instability was positively associated with ED visits/hospitalizations and imaging; food insecurity was positively associated with ED visits/hospitalizations and specialty visits but negatively associated with PT visits; and financial strain was positively associated with PT visits but negatively associated with ED visits/hospitalization.

Conclusion

These associations were seen above and beyond other factors used as markers of socioeconomic marginalization, including neighborhood-level social determinants of health, race/ethnicity, and insurance type. Identifying and intervening on social risk factors that patients with cLBP experience may improve outcomes and be cost-saving.

Predicting persistent back pain causing severe interference with daily activities among community-dwelling older adults: the OPAL cohort study

BACKGROUND

Many older adults experience disabling back and leg pain. This study aimed to identify factors associated with back pain causing severe interference with daily activities over 2 years.

METHODS

Participants were 2,109 community-dwelling adults (aged 65-100 years; mean age 74.2 (SD 6.3)) enrolled in a prospective cohort study who reported back pain at baseline and provided back pain data at 2 years follow-up. Baseline data included demographics, socio-economic factors, back pain presentation and age-associated adverse health states (e.g. frailty, falls, walking confidence). At 2 years follow-up, we asked if they were currently experiencing back pain and if so, asked participants to rate how much their back pain interfered with their daily activities on a scale of 0-10. Severe back pain interference was defined by a rating of 7 or more. The association between baseline factors and severe back pain interference at two years was assessed using logistic regression models.

RESULTS

At two years, 77% of participants (1,611/2,109) still reported back pain, 25% (544/2,083) also reported leg pain and 14% (227/1,611) reported severe back pain interference with activities. Improvements in symptoms were observed over the two years follow-up in 880/2,109 participants (41.7%), 41.2% (869/2,109) of participants report no change and worsening symptoms was reported by 17.1% (360/2109) of participants. After adjusting for back pain troublesomeness at baseline, factors associated with reporting severe interference were adequacy of income (careful with money [OR 1.91; 95% CI 1.19-3.06]; prefer not to say [OR 2.22; 95% CI 1.11-4.43]), low endorsement of exercise in later life (OR 1.18; 95% CI 1.02-1.37), neurogenic claudication symptoms (OR 1.68 (95% CI 1.15-2.46)], multisite pain (OR 1.13; 95% CI 1.02-1.24) and low walking confidence (OR 1.15; 95% CI 1.08-1.22).

CONCLUSION

After adjusting for baseline pain severity, we identified five factors that were associated with severe pain limitation at two years follow-up among a cohort of community dwelling older people reporting back and leg pain. These included other pain characteristics, walking confidence and attitude to activity in later life. We also identified a socioeconomic factor (perceived adequacy of income). Future research should focus on whether identifying individuals using these risk factors in order to intervene improves back pain outcomes for older people.

Strategies to optimise the health equity impact of digital pain self-reporting tools: a series of multi-stakeholder focus groups

BACKGROUND

There are avoidable differences (i.e., inequities) in the prevalence and distribution of chronic pain across diverse populations, as well as in access to and outcomes of pain management services. Digital pain self-reporting tools have the potential to reduce or exacerbate these inequities. This study aimed to better understand how to optimise the health equity impact of digital pain self-reporting tools on people who are experiencing (or are at risk of) digital pain inequities.

METHODS

This was a qualitative study, guided by the Health Equity Impact Assessment tool-digital health supplement (HEIA-DH). We conducted three scoping focus groups with multiple stakeholders to identify the potential impacts of digital pain self-reporting tools and strategies to manage these impacts. Each group focused on one priority group experiencing digital pain inequities, including older adults, ethnic minorities, and people living in socio-economically deprived areas. A fourth consensus focus group was organised to discuss and select impact management strategies. Focus groups were audio-recorded, transcribed verbatim, and analysed using a framework approach. We derived codes, grouped them under four pre-defined categories from the HEIA-DH, and illustrated them with participants' quotes.

RESULTS

A total of fifteen people living with musculoskeletal pain conditions and thirteen professionals took part. Participants described how digital pain self-reports can have a positive health equity impact by better capturing pain fluctuations and enriching patient-provider communication, which in turn can enhance clinical decisions and self-management practices. Conversely, participants identified that incorrect interpretation of pain reports, lack of knowledge of pain terminologies, and digital (e.g., no access to technology) and social (e.g., gender stereotyping) exclusions may negatively impact on people's health equity. The participants identified 32 strategies, of which 20 were selected as being likely to mitigate these negative health equity impacts. Example strategies included, e.g., option to customise self-reporting tools in line with users' personal preferences, or resources to better explain how self-reported pain data will be used to build trust.

CONCLUSION

Linked to people's personal and social characteristics, there are equity-based considerations for developing accessible digital pain self-reporting tools, as well as resources and skills to enable the adoption and use of these tools among priority groups. Future research should focus on implementing these equity-based considerations or strategies identified by our study and monitoring their impact on the health equity of people living with chronic pain.

Job stress and chronic low back pain: incidence, number of episodes, and severity in a 4-year follow-up of the ELSA-Brasil Musculoskeletal cohort

ABSTRACT

We investigated the association between job stress, as assessed by the effort-reward imbalance model, and the incidence of chronic low back pain (CLBP) over a 4-year period. A total of 1733 participants from the ELSA-Brasil Musculoskeletal cohort, who were free from LBP at baseline (2012-2014), were included. Episodes of LBP in the past 30 days, intensity, and the presence of disability were investigated in annual telephone follow-ups (2015-2018). Chronic LBP was defined as episodes of LBP lasting >3 months with at least moderate intensity. We analyzed the incidence of at least one episode of CLBP (yes/no), the number of CLBP episodes (0, 1, ≥2), and CLBP severity/disability (absent, nondisabling, severe/disabling). The association between these outcomes and tertiles of the effort-to-reward ratio, as well as each dimension of the effort-reward imbalance model, was investigated using multinomial logistic and Poisson regression models adjusting for sociodemographic and occupational variables. The cumulative incidence of CLBP over 4 years was 24.8%. High effort-reward imbalance increased the chances of experiencing multiple CLBP episodes and severe/disabling CLBP by 67% (95% confidence interval [CI]: 1.12-2.47) and 70% (95% CI: 1.14-2.53), respectively. High overcommitment increased the incidence of CLBP by 23% (95% CI: 1.01-1.50) and the chances of multiple CLBP episodes and severe/disabling CLBP by 67% (95% CI: 1.11-2.50) and 57% (95% CI: 1.05-2.34), respectively. These results indicate that exposure to job stress is associated with a higher incidence, a greater number of episodes, and increased severity of CLBP over a 4-year period. If this association is causal, measures aimed at reducing exposure to job stress are likely to alleviate the burden of CLBP.

Social determinants of health and youth chronic pain

OBJECTIVES

To identify the relationships between social determinants of health (SDOH) and chronic pain among U.S. youth (referring to children and adolescents).

METHODS

Data including a national sample of U.S. youth were retrieved from the 2022 National Survey of Children's Health. Twenty indicators within five SDOH-related domains (e.i., economic stability, social and community context, neighborhood and built environment, health care access and quality, and education access and quality) were included. The presence of chronic pain was assessed using a self-reported question, answered by the main caregiver. Associations of SDOH-related indicators and youth chronic pain were estimated using multi-variable logistic regression models, while adjusting for covariates (e.g., age, sex, ethnicity, weight status, and movement behaviors).

RESULTS

Data from 30,287 U S. youth aged 6-17 years (median [SD] age, 11.59 [3.30] years; 14,582 girls [48.97 %]) were collected. In 7.5 % of the final sample size, caregivers reported that they had chronic pain. Youth grow up in conditions with diverse SDOH profiles, including food insufficiency (OR = 1.46, 95 % CI: 1.01 to 2.10) and parental unemployment (OR = 1.56, 95 % CI: 1.15 to 2.12); low school engagement (OR = 1.48, 95 % CI: 1.14 to 1.92) and low school safety (OR = 1.65, 95 % CI: 1.14 to 2.39); limited access to quality health care (OR = 2.56, 95 % CI: 2.12 to 3.09), a high frequency of hospital visits (OR = 4.76, 95 % CI: 1.82 to 12.44), and alternative health care (OR = 2.57, 95 % CI: 2.07 to 3.20); bullying victimization (OR = 1.37, 95 % CI: 1.11 to 1.68) and community-based adverse childhood experiences (OR = 1.64, 95 % CI: 1.32 to 2.05); and disadvantageous amenity characteristics (OR = 1.38, 95 % CI: 1.05 to 1.79); resulted in higher odds of presenting chronic pain.

CONCLUSIONS

Different indicators included in the SDOH domains were associated with a higher probability of presenting chronic pain in U.S youth. These findings have implied relationships between the SDOH and chronic pain in youth, requiring a comprehensive approach to addressing health equity to prevent and reduce the presence of youth chronic pain.

Spinal pain prevalence and associated determinants: A population-based study using the National Survey for Wales

Spinal pain (SP) remains the leading cause of disability worldwide. The present study aimed to establish a current prevalence of SP and associated determinants in Wales by retrospectively analyzing data from the National Survey for Wales Dataset (NSWD). The NSWD is a large-scale cross-sectional, representative sample of adults across Wales, UK. A univariable and multivariable regression analysis was carried out on self-reported answers to health and well-being questions contained within the NSWD (2016-2020) to determine the strength of association of various determinants and comorbidities related to spinal pain. A total population of 38,954 of adults were included in the analysis. The study population included interview responses of 21,735 females and 17,219 males. The prevalence of SP in Wales was 4.95% (95% CI: 4.74%-5.15%) with a total of 847 males (4.92%, CI: 4.60%-5.24%) and 1082 females (4.98%, CI: 4.69%-5.27%) reporting spinal pain. The age group with the highest prevalence of SP was in the 70+ years age group for both males (5.44%, CI: 4.82%-6.07%) and females (5.95%, CI: 5.37%-6.54%). The strength of association between age and SP reaches its peak at 50-59 years with an adjusted Odds Ratio (aOR) of 3.74 (p = <0.001), that decreases slightly at 60-69 years and 70+ years. For various comorbidities included in the NSWD, significant associations with SP were confirmed for: mental illness (aOR = 1.42, p = <0.001), migraine (aOR = 2.73, p = <0.001), nervous system issues (aOR = 1.61, p = <0.001), arthritis (aOR = 1.30, p = <0.001) and issues with bones/joints/muscles (aOR = 1.93, p = <0.001). For lifestyle factors, associations were confirmed for current smokers (aOR = 1.41, p = <0.001) and ex-smokers (aOR = 1.23, p = 0.003). This study demonstrates a low prevalence of SP in Wales when compared to global estimates and strong associations to a variety of determinants. This still represents a significant societal burden and these findings may help inform public health initiatives to encourage prevention and evidence-based interventional strategies and ultimately, improve the quality of life for those suffering with SP in Wales.

Strengthening the pain care ecosystem to support equitable, person-centered, high-value musculoskeletal pain care

ABSTRACT

Improving health and wellbeing outcomes for people experiencing chronic musculoskeletal pain requires collective efforts across multiple levels of a healthcare ecosystem. System-wide barriers to care equity must however be addressed (eg, lack of co-designed services; overuse of low value care/underuse of high value care; inadequate health workforce; inappropriate funding models; inequitable access to medicines and technologies; inadequate research and innovation). In this narrative review, utilizing a systems' thinking framework, we synthesize novel insights on chronic musculoskeletal pain research contextualized through the lens of this complex, interconnected system, the "pain care ecosystem." We examine the application of systems strengthening research to build capacity across this ecosystem to support equitable person-centred care and healthy ageing across the lifespan. This dynamic ecosystem is characterized by three interconnected levels. At its centre is the person experiencing chronic musculoskeletal pain (micro-level). This level is connected with health services and health workforce operating to co-design and deliver person-centred care (meso-level), underpinned further upstream by contemporary health and social care systems (macro-level context). We provide emerging evidence for how we, and others, are working towards building ecosystem resilience to support quality musculoskeletal pain care: at the macro-level (eg, informing musculoskeletal policy and health strategy priorities); at the meso-level (eg, service co-design across care settings; health workforce capacity); and downstream, at the micro-level (eg, person-centred care). We outline the mechanisms and methodologies utilized and explain the outcomes, insights and impact of this research, supported by real world examples extending from Australian to global settings.

Chronic pain and use of painkillers, healthcare services and long-term impairment among Syrian refugees: a cross-sectional study

BACKGROUND

The global increase in forcibly displaced populations highlights the importance of understanding their health needs. Chronic pain is prevalent among refugees, poses significant personal and public health challenges, and complicates their integration into new home countries. Understanding refugees' pain post-migration and how it is being managed is crucial for ensuring adequate and timely interventions and fostering health equity. This paper explores the associations between pain levels and the use of painkillers, healthcare services, and long-term impairment among Syrian refugees with chronic pain, one year after their resettlement in Norway.

METHODS

This cross-sectional study is based on survey data collected from 353 quota refugees in 2018-19, one year after resettlement in Norway. The primary outcomes were the use of painkillers, the use of healthcare services, and long-term impairment, according to reported chronic pain levels. Associations between these outcomes and chronic pain levels were studied using Poisson regression, adjusted by sociodemographic variables and trauma experience.

RESULTS

Of the 353 adults included, 52% were women, and the median age was 36 years. A total of 5% reported very mild/mild, 10% moderate, and 12% strong/very strong chronic pain over the last four weeks. Significant associations were found between all chronic pain levels and use of non-prescription painkillers (adjusted relative risks (aRR) (95% CI)); mild (3.1 (2.0-4.7)), moderate (1.8 (1.1-2.8)), strong (1.7 (1.1-2.6)), and prescription painkillers; mild (4.6 (2.2-9.5)), moderate (5.6 (3.2-10.0)), strong (6.7 (3.9-11.3)), compared to those without chronic pain. Use of emergency rooms, specialist care, and hospitalization were significantly associated with strong chronic pain, with aRR (95% CI) of 2.0 (1.2-3.5), 3.9 (2.1-7.0) and 2.4 (1.3-4.4), respectively. Long-term impairment was strongly associated with chronic pain across all pain levels; mild (8.6 (5.6-13.49)), moderate (6.7 (4.3-10.5)) and strong (6.6 (4.3-10.4)).

CONCLUSION

Despite their young age, more than a quarter of the Syrian refugees in our study reported chronic pain one year after resettlement in Norway. High levels of pain were related to the use of medication, healthcare services, and long-term impairment. Understanding the dynamics of pain among refugees is crucial to ensure adequate and timely management.

Social Determinants and Consequences of Pain: Toward Multilevel, Intersectional, and Life Course Perspectives

Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain remain rarely addressed in the context of pain prevention and management. In this review, we aim to 1) examine the broad scope of social determinants and consequences of pain and their interactions across multiple levels of organization, and 2) provide a framework synthesizing existing concepts and potential areas for future work on social aspects of pain, drawing upon socioecological, intersectional, and life course approaches. Integrating interdisciplinary theory and evidence, we outline pathways through which multilevel social factors and pain may affect each other over time. We also provide a brief summary of intrapersonal aspects of pain, which are thought to operate at the interface between individuals and the social context. Progressing from micro- to macrolevel factors, we illustrate how social determinants of pain can directly or indirectly contribute to pain experiences, expression, risk, prognosis, and impact across populations. We consider 1) at the interpersonal level, the roles of social comparison, social relatedness, social support, social exclusion, empathy, and interpersonal conflict; 2) at the group or community level, the roles of intimacy groups, task groups, social categories, and loose associations; and 3) at the societal level, the roles of political, economic, and cultural systems, as well as their policies and practices. We present examples of multilevel consequences of pain across these levels and discuss opportunities to reduce the burden and inequities of pain by expanding multilevel social approaches in pain research and practice. PERSPECTIVE: Despite wide endorsement of a biopsychosocial framework for pain, social aspects of pain are often unclearly defined, hindering their use in pain prevention, management, and research. We summarize the scope of social aspects of pain and provide a framework synthesizing existing concepts and potential areas for future work.

Psychosocial factors in knee osteoarthritis: Scoping review of evidence and future opportunities

OBJECTIVE

Identify, describe and produce an evidence map of studies investigating psychosocial factors association with, or effect on, clinical outcomes for people with knee osteoarthritis.

METHODS

Scoping review of interventional and observational studies was performed. Medline (Ovid), Embase (Ovid), Cumulated Index in Nursing and Allied Health Literature, PsycInfo and Web of Science were searched on the 15th May 2023. Screening, data extraction and analysis was performed by two independent researchers. Extracted information included characteristics of studies plus which psychosocial factors were used to investigate association with, or effect on, clinical outcome(s). Descriptive statistics summarized the study design, temporal trend, geographic distribution, frequency of each psychosocial factor and whether associations/effects were observed.

RESULTS

23,065 records were screened, with 108 studies selected. Eighty-two percent of studies (n = 89/108) were cross-sectional in design. Number of studies increased over time and spanned 28 countries. Most research originated from the Americas region (55 %, 59/108). Twenty-four psychosocial factors (11 psychological, 13 social) were identified. Depression (47 %, n = 48/102) and education (28 %, n = 29/102) were the most frequently reported psychological and social factors, respectively. Psychological factors were often reported to have an association with/effect on pain (81 %, n = 71/88) and physical function (75 %, n = 56/74). Social factors were less frequently reported to have an association with or effect on pain (57 %, n = 46/81) and physical function (50 %, n = 18/36).

CONCLUSION

Psychosocial factors are often associated with clinical outcomes for people with knee osteoarthritis. High-quality longitudinal studies examining a wide range of psychosocial factors across diverse cultural and geographical settings are key to continue informing the development of biopsychosocial models of care.

Methods for pragmatic randomized clinical trials of pain therapies: IMMPACT statement

ABSTRACT

Pragmatic, randomized, controlled trials hold the potential to directly inform clinical decision making and health policy regarding the treatment of people experiencing pain. Pragmatic trials are designed to replicate or are embedded within routine clinical care and are increasingly valued to bridge the gap between trial research and clinical practice, especially in multidimensional conditions, such as pain and in nonpharmacological intervention research. To maximize the potential of pragmatic trials in pain research, the careful consideration of each methodological decision is required. Trials aligned with routine practice pose several challenges, such as determining and enrolling appropriate study participants, deciding on the appropriate level of flexibility in treatment delivery, integrating information on concomitant treatments and adherence, and choosing comparator conditions and outcome measures. Ensuring data quality in real-world clinical settings is another challenging goal. Furthermore, current trials in the field would benefit from analysis methods that allow for a differentiated understanding of effects across patient subgroups and improved reporting of methods and context, which is required to assess the generalizability of findings. At the same time, a range of novel methodological approaches provide opportunities for enhanced efficiency and relevance of pragmatic trials to stakeholders and clinical decision making. In this study, best-practice considerations for these and other concerns in pragmatic trials of pain treatments are offered and a number of promising solutions discussed. The basis of these recommendations was an Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) meeting organized by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks.

Global prevalence of musculoskeletal pain in rural and urban populations. A systematic review with meta-analysis. Musculoskeletal pain in rural and urban populations

INTRODUCTION

To systematically compare the global prevalence of musculoskeletal pain and care-seeking in rural and urban populations.

METHODS

A systematic review with meta-analysis of observational studies reporting a direct comparison of rural and urban populations was conducted worldwide and included back, knee, hip, shoulder, neck pain and a broad diagnosis of 'musculoskeletal pain'. A search strategy combining terms related to 'prevalence', 'musculoskeletal pain' and 'rural' was used on the following databases: MEDLINE, Embase, CINAHL, Scopus, and rural and remote health from their inception to 1 June 2022. Random-effects meta-analysis was used to pool the data. Results were presented as odds ratios (OR) along with 95% confidence intervals (95% CI).

RESULTS

A total of 42 studies from 24 countries were included with a total population of 489 439 participants. The quality scores for the included studies, using the modified Newcastle Ottawa Scale tool, showed an average score of 0.78/1, which represents an overall good quality. The pooled analysis showed statistically greater odds of hip (OR = 1.62, 95% CI = 1.23-2.15), shoulder (OR = 1.42, 95% CI = 1.06-1.90) and overall musculoskeletal pain (OR = 1.26, 95% CI = 1.08-1.47) in rural populations compared to urban populations. Although the odds of seeking treatment were higher in rural populations this relationship was not statistically significant (OR = 0.76, 95% CI = 0.55-1.03).

CONCLUSION

Very low-certainty evidence suggests that musculoskeletal, hip and shoulder pain are more prevalent in rural than urban areas, although neck, back and knee pain, along with care-seeking, showed no significant difference between these populations. Strategies aimed to reduce the burden of musculoskeletal pain should consider the specific needs and limited access to quality evidence-based care for musculoskeletal pain of rural populations.

Perceived Community Control in Adults with Acute Low Back Pain: A Community-Based Study

BACKGROUND

Low back pain (LBP) is the leading cause of disability for individuals and societies globally. Prior investigations have predominantly centered around biological and psychological factors. Addressing social determinants is critical for enhancing the effectiveness and equity of pain interventions. We aimed to characterize social factors, sleep, and pain among adults with acute LBP, focusing on perceived community control.

METHODS

A community-based sample of adults with acute LBP was recruited from two cities in North Carolina, United States, and followed up at 3 months. We used descriptive statistics to characterize social factors, sleep, and pain, overall and by levels of perceived community control.

RESULTS

In total, 110/131 enrolled participants had data on perceived community control (lower scores indicate higher control). Overall, the median perceived community control was 14 (interquartile range [IQR] = 11, 15). People with high perceived community control also had, on average, higher perceived individual control, better-perceived neighborhood walkability, lower number of sites with bothersome comorbid pain, and higher sleep quality. A higher proportion of participants with high perceived community control were of male sex, White race, and had a higher socioeconomic position.

CONCLUSIONS

Community control and related constructs may be further explored in future intervention development as potentially modifiable social factors that may reduce pain burden.

Sociodemographic determinants of health inequities in low back pain: a narrative review

Background

Health equity is defined as the absence of unjust and avoidable disparities in access to healthcare, quality of care, or health outcomes. The World Health Organization (WHO) has developed a conceptual framework that outlines the main causes of health inequalities and how these contribute to health inequities within a population. Despite the WHO implementing health equity policies to ensure accessibility and quality of healthcare services, disparities persist in the management of patients suffering from low back pain (LBP). The objective of this study was to review the existing evidence on the impact of health inequities on the care trajectories and treatments provided to individuals with LBP.

Methods

A narrative review was performed, which included a literature search without language and study design restrictions in MEDLINE Ovid database, from January 1, 2000, to May 15, 2023. Search terms included free-text words for the key concepts of "low back pain," "health inequities," "care pathways," and "sociodemographic factors."

Results

Studies have revealed a statistically significant association between the prevalence of consultations for LBP and increasing age. Additionally, a significant association between healthcare utilization and gender was found, revealing that women were more likely to seek medical attention for LBP compared to men. Furthermore, notable disparities related to race and ethnicity were identified, more specifically in opioid prescriptions, spinal surgery recommendations, and access to complementary and alternative medical approaches for LBP. A cross-sectional analysis found that non-Hispanic White individuals with chronic LBP were more likely to be prescribed one or more pharmacological treatments. Lower socioeconomic status and level of education, as well as living in lower-income areas were also found to be associated with greater risks of receiving non-guideline concordant care, including opioid and MRI prescriptions, before undergoing any conservative treatments.

Conclusion

Persistent inequalities related to sociodemographic determinants significantly influence access to care and care pathways of patients suffering from LBP, underscoring the need for additional measures to achieve equitable health outcomes. Efforts are needed to better understand the needs and expectations of patients suffering from LBP and how their individual characteristics may affect their utilization of healthcare services.

The use of nonpharmacological interventions for chronic pain treatment in community-dwelling older adults with a certified need for care

BACKGROUND

Chronic pain is a major health issue and rapid population ageing exacerbates the burden to health systems in countries like Germany. Nonpharmacological interventions (NPIs) are essential in pain care and the prioritization of active NPIs is emphasized in guidelines. This paper examines the utilization of NPIs for chronic pain management in community-dwelling older adults with a certified need of care in Berlin, Germany.

METHODS

Cross-sectional data was collected through standardized face-to-face surveys with older adults (≥65 years), using validated instruments (e.g., Brief Pain Inventory), and structured lists for NPI utilization. Categorization into active and passive NPIs was performed through a literature-based, iterative process by an interdisciplinary team. For not normally distributed data, non-parametric tests were used as appropriate. Logistic regression was conducted for multivariate analysis.

RESULTS

In total, 250 participants were included in this analysis (aged 65-104, x̅ = 81.8, 68.8% female). Most (92%) use NPIs for chronic pain management: 85.6% use active NPIs, 50.4% active movement and only 5.6% use solely passive approaches. Most common NPIs are distraction, thermotherapy/compresses, and physiotherapy. The odds of utilizing physiotherapy are three times higher for those with high educational status when compared to those with low education while those with low educational status had higher odds of using thermotherapy/compresses.

CONCLUSIONS

In our sample, most community-dwelling older adults with a certified need of care use active NPIs for chronic pain management with about half using active movement approaches. Considering the high vulnerability of this population, physiotherapy (in the form of therapeutic exercise) is a particularly appropriate intervention, and it was the third most frequent NPI in our sample. However, there is a social gradient in the utilization of physiotherapy for chronic pain management which might be rooted in issues around awareness, appeal, and access to such measures. It is important to take socioeconomic differences into account when planning the care for older chronic pain patients but also when designing research or user-friendly guidelines for this target group.

TRIAL REGISTRATION

Ethical approval from the Ethics Committee of Charité - Universitätsmedizin Berlin (EA1/368/14) and study registration with the Central Study Register (ZSR no. 20009093).

Surgical treatment of refractory low back pain using implanted BurstDR spinal cord stimulation (SCS) in a cohort of patients without options for corrective surgery: Findings and results from the DISTINCT study, a prospective randomized multi-center-controlled trial

Background

Low back pain (LBP) is a highly prevalent, disabling condition affecting millions of people. Patients with an identifiable anatomic pain generator and resulting neuropathic lower extremity symptoms often undergo spine surgery, but many patients lack identifiable and/or surgically corrective pathology. Nonoperative treatment options often fail to provide sustained relief. Spinal cord stimulation (SCS) is sometimes used to treat these patients, but the lack of level 1 evidence limits its widespread use and insurance coverage. The DISTINCT RCT study evaluates the efficacy of passive recharge burst SCS compared to conventional medical treatment (CMM) in alleviating chronic, refractory axial low back pain.

Methods

This prospective, multicenter, randomized, study with an optional 6-month crossover involved patients who were not candidates for lumbar spine surgery. The primary and secondary endpoints evaluated improvements in low back pain intensity (NRS), back pain-related disability (ODI), pain catastrophizing (PCS), and healthcare utilization. Patients were randomized to SCS therapy or CMM at 30 US study sites.

Results

The SCS arm reported an 85.3% NRS responder rate (≥ 50% reduction) compared to 6.2% (5/81) in the CMM arm. After the 6M primary endpoint, SCS patients elected to remain on assigned therapy and 66.2% (49/74) of CMM patients chose to trial SCS (crossover). At the 12M follow-up, SCS and crossover patients reported 78.6% and 71.4% NRS responder rates. Secondary outcomes indicated significant improvements in ODI, PCS, and reduced healthcare utilization. Six serious adverse events were reported and resolved without sequelae.

Conclusion

DISTINCT chronic low back pain patients with no indication for corrective surgery experienced a significant and sustained response to burst SCS therapy for up to 12 months. CMM patients who crossed over to the SCS arm reported profound improvements after 6 months. This data advocates for a timely consideration of SCS therapy in patients unresponsive to conservative therapy.

Does pain tolerance mediate the effect of physical activity on chronic pain in the general population? The Tromsø Study

ABSTRACT

Knowledge is needed regarding mechanisms acting between physical activity (PA) and chronic pain. We investigated whether cold pain tolerance mediates an effect of leisure-time physical activity on the risk of chronic pain 7 to 8 years later using consecutive surveys of the population-based Tromsø Study. We included participants with information on baseline leisure-time PA (LTPA) and the level of cold pressor-assessed cold pain tolerance, who reported chronic pain status at follow-up as any of the following: chronic pain for ≥3 months, widespread chronic pain, moderate-to-severe chronic pain, or widespread moderate-to-severe chronic pain. We included 6834 participants (52% women; mean age, 55 years) in counterfactual mediation analyses. Prevalence decreased with severity, for example, 60% for chronic pain vs 5% for widespread moderate-to-severe chronic pain. People with one level higher LTPA rating (light to moderate or moderate to vigorous) at baseline had lower relative risk (RR) of 4 chronic pain states 7 to 8 years later. Total RR effect of a 1-level LTPA increase was 0.95 (0.91-1.00), that is, -5% decreased risk. Total effect RR for widespread chronic pain was 0.84 (0.73-0.97). Indirect effect for moderate-to-severe chronic pain was statistically significant at RR 0.993 (0.988-0.999); total effect RR was 0.91 (0.83-0.98). Statistically significantly mediated RR for widespread moderate-to-severe chronic pain was 0.988 (0.977-0.999); total effect RR was 0.77 (0.64-0.94). This shows small mediation of the effect of LTPA through pain tolerance on 2 moderate-to-severe chronic pain types. This suggests pain tolerance to be one possible mechanism through which PA modifies the risk of moderate-to-severe chronic pain types with and without widespread pain.

"I wish I knew then what I know now" - pain science education concepts important for female persistent pelvic pain: a reflexive thematic analysis

ABSTRACT

Pain science education (PSE) provides people with an understanding of "how pain works" grounded in the biopsychosocial model of pain; it has been demonstrated to improve outcomes in musculoskeletal pain conditions. Preliminary evidence suggests PSE may be effective for female individuals with persistent pelvic pain, but how the content of PSE needs to be modified for this group remains to be determined. A reflexive thematic analysis of qualitative data was performed to identify PSE concepts that female individuals with persistent pelvic pain consider important and why. Twenty individual, semistructured interviews were conducted with adult females who had engaged with PSE and had self-identified as having "improved" pelvic pain. Most participants had been diagnosed with endometriosis (n = 16). Four themes were generated capturing PSE concepts considered important by female individuals with "improved" pelvic pain: (1) "A sensitised nervous system leads to overprotective pain" validated their pelvic pain as being real; (2) "Pain does not have to mean the body is damaged (although sometimes it does)" provided reassurance that pelvic pain does not mean their condition is worsening; (3) "How I think, feel, and 'see' my pain can make it worse" enabled participants to find optimal ways to manage their pain; and (4) "I can change my pain… slowly" provided hope that pelvic pain can improve and empowered them to pursue pain improvement as a viable goal. This study generated 4 PSE learning concepts that were important to female individuals with improved pelvic pain and may be incorporated into PSE curricula for female individuals with pelvic pain.

Adverse Childhood Experiences and Chronic Low Back Pain in Adulthood: The Role of Emotion Regulation

Chronic low back pain (cLBP) is characterized by biopsychosocial determinants that collectively result in a substantial burden at the individual, community, and health care system levels. A growing body of literature suggests that childhood adversity is longitudinally associated with the development and maintenance of various chronic pain conditions in adulthood. Little research has investigated the psychological processes that might underlie the association between adverse childhood experiences (ACEs) and cLBP. Emotion regulation comprises a substantive part of the subjective experience of pain and may be a potential mechanism through which ACEs contribute to cLBP etiology and maintenance. Thus, the current study examined the extent to which emotion dysregulation mediated the relationship between ACEs and pain severity (pain at rest and movement-evoked pain) in adults with cLBP. Participants included 183 adults (53.0% female, 62.5% non-Hispanic Black) between the ages of 18 and 85 with cLBP. Participants self-reported on ACEs, pain, difficulties in emotion regulation (DER), depression, and completed brief physical function tasks. In data analytic models, sociodemographic variables were included as covariates. Analyses revealed that emotion regulation mediated the relationship between ACEs and cLBP severity at rest (indirect effect = .15 [95% CI {.06-.25}]) and with movement (indirect effect = 1.50 [95% CI {.69-2.57}]). Findings suggest ACEs are linked to cLBP severity in adulthood through DER. This aligns with research demonstrating that childhood maltreatment can lead to DER, which perpetuate over the lifespan to impact adult health outcomes. PERSPECTIVE: This study presents emotion dysregulation as a psychological pathway through which childhood adversity may contribute to cLBP in adulthood. This work may bolster our understanding of social experiences as risk factors for chronic pain, while identifying targets for clinical intervention. TRIAL REGISTRATION: This study utilized baseline data collected as part of a parent trial titled "Examining Racial and SocioEconomic Disparities in Chronic Low Back Pain" (ClinicalTrials.gov ID: NCT03338192).

Facilitators and Barriers to Implementing Interventions to Prevent Musculoskeletal Disorders in Blue-Collar Workers: A Scoping Review

PURPOSE

Blue-collar workers generally have less healthy lifestyles, poorer health, and a lower life expectancy than white-collar workers. At least in part this may be attributed to their work and working conditions. Employers increasingly provide interventions to improve health and wellbeing and prevent musculoskeletal disorders. However, they often do not reach blue-collar workers. The aim of this scoping review was to identify the facilitators for and barriers to implementing such interventions among blue-collar workers.

METHODS

A scoping review in which the study population of the selected studies consists of blue-collar workers (≥ 18 years old) in paid employment. Furthermore, included studies should report facilitators and barriers to implementing interventions to prevent musculoskeletal disorders. The literature search was conducted in six databases. The resulting studies were extracted with the help of the updated Consolidated Framework for Implementation Research.

RESULTS

15 articles were included; these were reviews, intervention studies, qualitative studies and process evaluations. A main facilitator was a participatory approach, which involves the blue-collar worker in the entire process of defining, developing, and implementing a multidimensional preventive intervention. The main barriers on the worker level were unfavorable worker characteristics and unsupportive behavior/attitudes. The main barriers on the organization level were a culture with a high production standard, a hierarchical culture, inflexible work, and an unsupportive attitude from the employer.

CONCLUSION

This review showed the multifaceted nature of implementation. A tailored implementation plan that involves the stakeholders (including workers) is important.

Musculoskeletal Disorder (MSD) Health Data Collection, Personalized Management and Exchange Using Fast Healthcare Interoperability Resources (FHIR)

With the proliferation and growing complexity of healthcare systems emerges the challenge of implementing scalable and interoperable solutions to seamlessly integrate heterogenous data from sources such as wearables, electronic health records, and patient reports that can provide a comprehensive and personalized view of the patient's health. Lack of standardization hinders the coordination between systems and stakeholders, impacting continuity of care and patient outcomes. Common musculoskeletal conditions affect people of all ages and can have a significant impact on quality of life. With physical activity and rehabilitation, these conditions can be mitigated, promoting recovery and preventing recurrence. Proper management of patient data allows for clinical decision support, facilitating personalized interventions and a patient-centered approach. Fast Healthcare Interoperability Resources (FHIR) is a widely adopted standard that defines healthcare concepts with the objective of easing information exchange and enabling interoperability throughout the healthcare sector, reducing implementation complexity without losing information integrity. This article explores the literature that reviews the contemporary role of FHIR, approaching its functioning, benefits, and challenges, and presents a methodology for structuring several types of health and wellbeing data, that can be routinely collected as observations and then encapsulated in FHIR resources, to ensure interoperability across systems. These were developed considering health industry standard guidelines, technological specifications, and using the experience gained from the implementation in various study cases, within European health-related research projects, to assess its effectiveness in the exchange of patient data in existing healthcare systems towards improving musculoskeletal disorders (MSDs).

Postural and Lumbopelvic Control: Crucial Factors in the Functionality of Patients with Low Back Pain-A Descriptive Cross-Sectional Study

Background: Low back pain (LBP) is one of the most prevalent musculoskeletal disorders in adults worldwide. Alterations in postural and lumbopelvic control and functionality appear to be determining factors in its resolution. Methods: A cross-sectional study was performed. Patients with LBP were enrolled. Lumbar pain; postural control (PC), total area of the center of pressure (TACOP), and the velocity of the center of pressure (VCOP); lumbopelvic control (LPC); and functionality were evaluated. Statistical tests were implemented to determine differences between sex and age and correlation models among the variables. Results: Thirty adult patients with LBP were analyzed. A strong relationship was found between pain and functionality [r = 0.64; p < 0.001]. A moderate relationship was found between pain and TACOP [r = 0.395; p = 0.031]. A moderate relationship was observed between TACOP and functionality [0.413; p = 0.023] and between LPC and TACOP [r = 0.416; p = 0.001]. Conclusions: This study demonstrates the significant impact of LBP on postural control, lumbopelvic control, and functionality. These results highlight the importance of addressing postural and lumbopelvic control in LBP treatment. No significant differences based on gender and age were found, but all clinical variables differed significantly between the LBP and control groups, underscoring the unique impairments associated with LBP.

Posttraumatic Stress and Opioid Use and Pain among Individuals with Probable Posttraumatic Stress Disorder and Self-Reported Chronic Pain: The Role of Health Literacy

BACKGROUND

Chronic pain and opioid misuse are a prevalent comorbidity with deleterious health outcomes. Growing work indicates that posttraumatic stress disorder (PTSD) can increase the risk for chronic pain and opioid misuse and dependence. However, there is little understanding of social determinants of health (SDoH) that may account for interrelations of PTSD with chronic pain and opioid misuse and dependence. Health literacy is one relevant SDoH construct, reflecting the ability to gather, process, and comprehend health-related information required to engage in a healthcare setting.

OBJECTIVE

The purpose of the present cross-sectional study was to examine the indirect effect of health literacy in the association between PTSD and opioid misuse, opioid dependence, pain intensity, and pain disability.

METHOD

The sample included 142 adults (Mage = 35.2, SD = 9.9; 67.4% female; 70.1% White/Caucasian) with self-reported chronic pain and probable PTSD who were using opioid medication.

RESULTS

Results demonstrated that PTSD symptom severity had a small indirect effect on opioid misuse and opioid dependence via health literacy; no indirect effects were evident for pain intensity and disability.

CONCLUSION

The present investigation provides evidence that health literacy may serve as an important explanatory factor in associations between PTSD symptom severity and opioid misuse and dependence among adults with co-occurring probable PTSD and chronic pain.

The relationship between social determinants of health and neurocognitive and mood-related symptoms in the primary brain tumor population: A systematic review

Social determinants of health (SDOH) impact cancer-related health outcomes, including survival, but their impact on symptoms is less understood among the primary brain tumor (PBT) population. We conducted a systematic review to examine the relationships between SDOH and neurocognitive and mood-related symptoms among the PBT population. PubMed, EMBASE, and CINAHL were searched using PROGRESS criteria (place of residence, race/ethnicity, occupation, gender/sex, religion, education, socioeconomic status, and social capital) on March 8th, 2022. Two individuals screened and assessed study quality using the NHLBI Assessment Tool for Observational Cohort and Cross-sectional Studies. Of 3006 abstracts identified, 150 full-text articles were assessed, and 48 were included for a total sample of 28 454 study participants. Twenty-two studies examined 1 SDOH; none examined all 8. Four studies measured place of residence, 2 race/ethnicity, 13 occupation, 42 gender, 1 religion, 18 education, 4 socioeconomic status, and 15 social capital. Fifteen studies assessed neurocognitive and 37 mood-related symptoms. While higher education was associated with less neurocognitive symptoms, and among individuals with meningioma sustained unemployment after surgery was associated with depressive symptoms, results were otherwise disparate among SDOH and symptoms. Most studies were descriptive or exploratory, lacking comprehensive inclusion of SDOH. Standardizing SDOH collection, reducing bias, and recruiting diverse samples are recommended in future interventions.