Completeness and quality of low back pain prevalence data in the Global Burden of Disease Study 2017

Temporal stability in the prevalence and pattern of co-occurring musculoskeletal pain among people with persistent low back pain: population-based data from the Norwegian HUNT Study, 1995 to 2019

ABSTRACT

People with persistent low back pain (LBP) often report co-occurring persistent musculoskeletal (MSK) pain in other body regions that may influence prognosis as well as treatment approaches and outcomes. This study describes the prevalence and patterns of co-occurring persistent MSK pain among people with persistent LBP based on consecutive cross-sectional studies over 3 decades in the population-based HUNT Study, Norway. The analyses comprised 15,375 participants in HUNT2 (1995-1997), 10,024 in HUNT3 (2006-2008), and 10,647 in HUNT4 (2017-2019) who reported persistent LBP. Overall, ∼90% of participants in each of the HUNT surveys with persistent LBP reported persistent co-occurring MSK pain in other body sites. The age-standardized prevalence of the most common co-occurring MSK pain sites was consistent across the 3 surveys: 64% to 65% report co-occurring neck pain, 62% to 67% report shoulder pain, and 53% to 57% report hip or thigh pain. Using latent class analysis (LCA), we identified 4 distinct patterns of persistent LBP phenotypes that were consistent across the 3 surveys: (1) "LBP only," (2) "LBP with neck or shoulder pain," (3) "LBP with lower extremity or wrist or hand pain," and (4) "LBP with multisite pain," with conditional item response probabilities of 34% to 36%, 30% to 34%, 13% to 17%, and 16% to 20%, respectively. In conclusion, 9 of 10 adults in this Norwegian population with persistent LBP report co-occurring persistent MSK pain, most commonly in the neck, shoulders, and hips or thighs. We identified 4 LCA-derived LBP phenotypes of distinct MSK pain site patterns. In the population, both the prevalence and pattern of co-occurring MSK pain and the distinct phenotypic MSK pain patterns seem stable over decades.

"I felt uncertain about my whole future"-a qualitative investigation of people's experiences of navigating uncertainty when seeking care for their low back pain

ABSTRACT

Uncertainty pervades low back pain (LBP). This study aimed to explore individuals' experiences of navigating uncertainty when seeking care for their LBP, with a view to better understanding the contexts in which they experience uncertainty and gaining insight into how uncertainty may be better navigated during clinical encounters. We conducted 15 semistructured interviews with people who have experienced LBP. Interviews were audio-recorded, transcribed, and analysed using reflexive thematic analysis. Analysis produced 4 themes. To reflect the unsettled nature of participants' discussions of navigating uncertainty, themes are framed as questions: (1) What will happen over time?; (2) Can clinicians help me? Are they willing to?; (3) What are clinicians talking about?; and (4) Am I being taken seriously? Participants also discussed how clinicians could better navigate these uncertainties. Suggestions included making time to (actively) listen to, and acknowledge, patients' concerns; asking open-ended questions; being honest about uncertainty; creating management plans and returning to them; challenging assumptions; remaining curious about patients' context; and providing guidance on how to manage LBP rather than simply giving certainty that symptoms will worsen, lessen, or continue. These findings indicate that many of the uncertainties individuals with LBP experience are intertwined with relational aspects of their interactions with clinicians. Clinicians therefore may need to consider these broader and relational aspects of care when navigating uncertainty with people who experience LBP, bringing attention to the importance of drawing from knowledge produced outside of the usual hierarchy of evidence (eg, systematic reviews and randomised controlled trials).

The burden of rheumatoid arthritis and low back pain in North Africa and Middle East from 1990 to 2019: Results from the Global Burden of Disease Study 2019

BACKGROUND

Rheumatoid arthritis (RA) and low back pain (LBP) are among the most prevalent musculoskeletal disorders (MSDs). The need for investigation of regional and local patterns of these two MSDs seems inevitable for better policy-making. The current study presents updated results of the Global Burden of Disease (GBD) Study 2019 and reports the burden of RA and LBP in North Africa and Middle East (NAME) countries from 1990 to 2019.

METHODS

Incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and risk factors, including high body mass index, occupational ergonomic factors, and smoking, were extracted based on the GBD 2019 data.

RESULTS

The age-standardized prevalence and mortality of RA were 120.6 (95% uncertainty interval [95% UI] 107.0-135.7) and 0.1 (95% UI 0.1-0.2) per 100 000 population in 2019 with 28.3% (95% UI 25.5%-30.9%) increase and 7.5% (95% UI -37.5% to 32.5%) decrease since 1990, respectively. Turkey had the highest age-standardized incidence, prevalence, and DALYs of RA in 2019. All RA burden measures were higher for women; however, the incidence was almost the same at ages greater than 65 years. The age-standardized prevalence and DALYs of LBP were 7668.2 (95% UI 6798.0-8636.3) and 862 (95% UI 605.5-1153.3) in 2019, which had decreased by 5.8% (95% UI -7.4% to -4.3%) and 6.0% (95% UI -7.7% to -4.2%) since 1990, respectively. Moreover, although Turkey had the highest incidence and prevalence in 1990, Iran was at the top in 2019. The regional age-standardized DALY rates due to RA and LBP attributed to smoking were 1.7 (95% UI 0.5-3.2) and 139.4 (95% UI 87.3-198.8) in 2019, respectively, which had decreased 2.2% (95% UI -19.2% to 13.7%) and 15.4% (95% UI -19.4% to -10.5%) since 1990, respectively.

CONCLUSION

RA still imposes a significant burden in the NAME region as the burden measures have increased from 1990 to 2019. On the other hand, regarding LBP, a decreasing pattern was observed. Differences among the countries and between ages and genders can have implications, and the results of this study may be helpful for policy-makers in the NAME countries.

'It's about time'. Dissemination and evaluation of a global health systems strengthening roadmap for musculoskeletal health - insights and future directions

Actions towards the health-related Sustainable Development Goal 3.4 typically focus on non-communicable diseases (NCDs) associated with premature mortality, with less emphasis on NCDs associated with disability, such as musculoskeletal conditions-the leading contributor to the global burden of disability. Can systems strengthening priorities for an underprioritised NCD be codesigned, disseminated and evaluated? A 'roadmap' for strengthening global health systems for improved musculoskeletal health was launched in 2021. In this practice paper, we outline dissemination efforts for this Roadmap and insights on evaluating its reach, user experience and early adoption. A global network of 22 dissemination partners was established to drive dissemination efforts, focussing on Africa, Asia and Latin America, each supported with a suite of dissemination assets. Within a 6-month evaluation window, 52 Twitter posts were distributed, 2195 visitors from 109 countries accessed the online multilingual Roadmap and 138 downloads of the Roadmap per month were recorded. Among 254 end users who answered a user-experience survey, respondents 'agreed' or 'strongly agreed' the Roadmap was valuable (88.3%), credible (91.2%), useful (90.1%) and usable (85.4%). Most (77.8%) agreed or strongly agreed they would adopt the Roadmap in some way. Collection of real-world adoption case studies allowed unique insights into adoption practices in different contexts, settings and health system levels. Diversity in adoption examples suggests that the Roadmap has value and adoption potential at multiple touchpoints within health systems globally. With resourcing, harnessing an engaged global community and establishing a global network of partners, a systems strengthening tool can be cocreated, disseminated and formatively evaluated.

Global Burden of Disease Study 2019: an opportunity to understand the growing prevalence and impact of hip, knee, hand and other osteoarthritis in Australia

BACKGROUND

Understanding population-level trends in osteoarthritis (OA) is critical for planning health services and disease prevention initiatives.

AIM

To examine trends in the burden of hip, knee, hand and other OA related conditions in Australia from 1990 to 2019 and consider the OA burden in the context of other common conditions associated with older age.

METHODS

Global Burden of Disease Study 2019 data for Australia on OA prevalence, OA-related years lived with disability (YLDs) and OA-related YLDs attributable to high body mass index (BMI) were sourced for 1990-2019. Age-standardised YLD data for ischaemic heart disease, stroke, dementia, type 2 diabetes and chronic obstructive pulmonary disease were obtained for comparison.

RESULTS

Overall, 3.20 million Australians were estimated to have OA in 2019, with substantial growth in the prevalence of hip (+171%), knee (+126%), hand (+110%) and other types of OA (+130%) from 1990 to 2019. Age-standardised prevalence rates reflect the contribution of population ageing. Concomitant growth in OA-related YLDs was also evident; knee OA and hand OA demonstrated the highest disease burden in 2019 (59 684 and 41 893 YLDs respectively). The proportion of knee OA burden attributable to high BMI was 36% in 2019. In 2019, age-standardised YLD rates were higher for OA (313 per 100 000 population) than other common conditions (range: 47 per 100 000 (ischaemic heart disease) to 284 per 100 000 (type 2 diabetes)).

CONCLUSIONS

OA is an increasingly prevalent, impactful condition with a high non-fatal disease burden relative to other health conditions. Growth in OA populations and OA-related disability underscore the need for enhanced investment in prevention and management.

Do national health priorities align with Global Burden of Disease estimates on disease burden? An analysis of national health plans and official governmental websites

OBJECTIVE

To investigate the alignment of national health priorities with a country's burden of disease as measured by disability-adjusted life years (DALYs).

METHODS

We identified priorities in national health plans and the 20 most burdensome conditions measured by DALYs from the 2017 Global Burden of Disease Study. We computed point-biserial correlations (rpb) between DALYs and being nominated as a health priority and the pooled proportion (95% confidence intervals [CIs]) of the 20 most burdensome conditions nominated as a priority across countries.

RESULTS

We identified national health plans and official governmental websites in 145 countries. There was little to no correlation (rpb = 0.06, 95% CI: 0.02 to 0.09) between national DALY data and whether a condition was nominated as a health priority. The pooled proportion of the 20 most burdensome conditions nominated as priorities across countries was 46%. HIV/AIDS had the greatest number of nominations as a national health priority (62 countries) as well as the greatest match with the burden of disease (among the top 20 most burdensome conditions in 51 [82%] countries). Low back pain, headache disorders and congenital birth defects had the lowest proportion of nominations as health priorities in countries where they were in the top 20 most burdensome conditions (6%, 6% and 11%, respectively).

CONCLUSION

Globally, there were low correlations between national health priorities and GBD estimates on disease burden. Failing to prioritise health priorities according to burden may mean that insufficient resources have been directed to improve health outcomes for people with those health conditions.

Research from Low-Income and Middle-Income Countries will Benefit Global Health and the Physiotherapy Profession, but it Requires Support

Disparities in research publications are common in the physiotherapy and rehabilitation fields.1 A small proportion of published research arises from low-income and middle-income countries (LMICs),1,2 home to 85% of the world's population. Systems-level, institutional-level, and individual-level factors contribute to these disparities. With urgent and unified actions, global health and the standard of physiotherapy research in LMICs can be improved and strengthened. In this editorial, we will discuss the challenges encountered by researchers from LMICs in conducting and publishing high-quality research and propose potential strategies to address these challenges.

Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021

Background

Low back pain is highly prevalent and the main cause of years lived with disability (YLDs). We present the most up-to-date global, regional, and national data on prevalence and YLDs for low back pain from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021.

Methods

Population-based studies from 1980 to 2019 identified in a systematic review, international surveys, US medical claims data, and dataset contributions by collaborators were used to estimate the prevalence and YLDs for low back pain from 1990 to 2020, for 204 countries and territories. Low back pain was defined as pain between the 12th ribs and the gluteal folds that lasted a day or more; input data using alternative definitions were adjusted in a network meta-regression analysis. Nested Bayesian meta-regression models were used to estimate prevalence and YLDs by age, sex, year, and location. Prevalence was projected to 2050 by running a regression on prevalence rates using Socio-demographic Index as a predictor, then multiplying them by projected population estimates.

Findings

In 2020, low back pain affected 619 million (95% uncertainty interval 554-694) people globally, with a projection of 843 million (759-933) prevalent cases by 2050. In 2020, the global age-standardised rate of YLDs was 832 per 100 000 (578-1070). Between 1990 and 2020, age-standardised rates of prevalence and YLDs decreased by 10·4% (10·9-10·0) and 10·5% (11·1-10·0), respectively. A total of 38·8% (28·7-47·0) of YLDs were attributed to occupational factors, smoking, and high BMI.

Interpretation

Low back pain remains the leading cause of YLDs globally, and in 2020, there were more than half a billion prevalent cases of low back pain worldwide. While age-standardised rates have decreased modestly over the past three decades, it is projected that globally in 2050, more than 800 million people will have low back pain. Challenges persist in obtaining primary country-level data on low back pain, and there is an urgent need for more high-quality, primary, country-level data on both prevalence and severity distributions to improve accuracy and monitor change.

Funding

Bill and Melinda Gates Foundation.

Certainty of the Global Burden of Disease 2019 Modelled Prevalence Estimates for Musculoskeletal Conditions: A Meta-Epidemiological Study

Objectives: To describe and assess the risk of bias of the primary input studies that underpinned the Global Burden of Disease Study (GBD) 2019 modelled prevalence estimates of low back pain (LBP), neck pain (NP), and knee osteoarthritis (OA), from Australia, Brazil, Canada, Spain, and Switzerland. To evaluate the certainty of the GBD modelled prevalence evidence. Methods: Primary studies were identified using the GBD Data Input Sources Tool and their risk of bias was assessed using a validated tool. We rated the certainty of modelled prevalence estimates based on the GRADE Guidelines 30-the GRADE approach for modelled evidence. Results: Seventy-two primary studies (LBP: 67, NP: 2, knee OA: 3) underpinned the GBD estimates. Most studies had limited representativeness of their study populations, used suboptimal case definitions and applied assessment instruments with unknown psychometric properties. The certainty of modelled prevalence estimates was low, mainly due to risk of bias and indirectness. Conclusion: Beyond the risk of bias of primary input studies for LBP, NP, and knee OA in GBD 2019, the certainty of country-specific modelled prevalence estimates still have room for improvement.

From Local Action to Global Policy: A Comparative Policy Content Analysis of National Policies to Address Musculoskeletal Health to Inform Global Policy Development

BACKGROUND

Global policy to guide action on musculoskeletal (MSK) health is in a nascent phase. Lagging behind other non-communicable diseases (NCDs) there is currently little global policy to assist governments to develop national approaches to MSK health. Considering the importance of comparison and learning for global policy development, we aimed to perform a comparative analysis of national MSK policies to identify areas of innovation and draw common themes and principles that could guide MSK health policy.

METHODS

Multi-modal search strategy incorporating a systematic online search targeted at the 30 most populated nations; a call to networked experts; a specified question in a related eDelphi questionnaire; and snowballing methods. Extracted data were organised using an a priori framework adapted from the World Health Organization (WHO) Building Blocks and further inductive coding. Subsequently, texts were open coded and thematically analysed to derive specific sub-themes and principles underlying texts within each theme, serving as abstracted, transferable concepts for future global policy.

RESULTS

The search yielded 165 documents with 41 retained after removal of duplicates and exclusions. Only three documents were comprehensive national strategies addressing MSK health. The most common conditions addressed in the documents were pain (non-cancer), low back pain, occupational health, inflammatory conditions, and osteoarthritis. Across eight categories, we derived 47 sub-themes with transferable principles that could guide global policy for: service delivery; workforce; medicines and technologies; financing; data and information systems; leadership and governance; citizens, consumers and communities; and research and innovation.

CONCLUSION

There are few examples of national strategic policy to address MSK health; however, many countries are moving towards this by documenting the burden of disease and developing policies for MSK services. This review found a breadth of principles that can add to this existing work and may be adopted to develop comprehensive system-wide MSK health approaches at national and global levels.

Context and priorities for health systems strengthening for pain and disability in low- and middle-income countries: a secondary qualitative study and content analysis of health policies

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care.

Major dietary patterns in relation to chronic low back pain; a cross-sectional study from RaNCD cohort

Background

Chronic low back pain (LBP) is the most common musculoskeletal pain that affects a person’s daily activities. This present study aimed at evaluating the relationship between major dietary pattern and Chronic LBP.

Methods

This cross-sectional analysis was examined 7686 Kurdish adults. The RaNCD cohort study physician diagnosed chronic LBP. Dietary patterns were derived using principal component analysis. The three identified dietary patterns derived were named: 1) the vegetarian diet included vegetables, whole grain, legumes, nuts, olive, vegetable oil, fruits, and fruit juice; 2) high protein diet related to higher adherence to red and white meat, legumes, nuts, and egg; and 3) energy-dense diet characterized with higher intake of salt, sweet, dessert, hydrogenated fat, soft drink, refined grain, tea, and coffee. Dietary pattern scores were divided into tertiles. Binary logistic regression in crude, adjusted odds ratios (OR) and 95% confidence intervals (CI) were used to determine this association.

Results

Twenty-two per cent of participants had chronic LBP. Higher adherence to high protein dietary pattern was inversely associated with chronic LBP in crude (OR: 0.79, 95% CI: 0.69–0.9) and adjusted model (for age, sex, smoking, drinking, diabetes, physical activity, body mass index, and waist circumference) (OR: 0.84, 95% CI: 0.72–0.97). In addition, after controlling for the mentioned potential confounders, participants in the highest category of energy dense diet were positively associated with chronic LBP compared with those in the lowest category (OR: 1.13, 95% CI: 1.01–1.32).

Conclusions

Higher adherence to the high protein diet was inversely related to chronic LBP prevalence. In addition, we found that following energy dense diet was positively associated with chronic LBP.

Disability burden due to musculoskeletal conditions and low back pain in Australia: findings from GBD 2019

BACKGROUND

To report the national prevalence, years lived with disability (YLDs) and attributable risk factors for all musculoskeletal conditions and separately for low back pain (LBP), as well as compare the disability burden related to musculoskeletal with other health conditions in Australia in 2019.

METHODS

Global Burden of Disease (GBD) 2019 study meta-data on all musculoskeletal conditions and LBP specifically were accessed and aggregated. Counts and age-standardised rates, for both sexes and across all ages, for prevalence, YLDs and attributable risk factors are reported.

RESULTS

In 2019, musculoskeletal conditions were estimated to be the leading cause of YLDs in Australia (20.1%). There were 7,219,894.5 (95% UI: 6,847,113-7,616,567) prevalent cases of musculoskeletal conditions and 685,363 (95% UI: 487,722-921,471) YLDs due to musculoskeletal conditions. There were 2,676,192 (95% UI: 2,339,327-3,061,066) prevalent cases of LBP and 298,624 (95% UI: 209,364-402,395) YLDs due to LBP. LBP was attributed to 44% of YLDs due to musculoskeletal conditions. In 2019, 22.3% and 39.8% of YLDs due to musculoskeletal conditions and LBP, respectively, were attributed to modifiable GBD risk factors.

CONCLUSIONS

The ongoing high burden due to musculoskeletal conditions impacts Australians across the life course, and in particular females and older Australians. Strategies for integrative and organisational interventions in the Australian healthcare system should support high-value care and address key modifiable risk factors for disability such as smoking, occupational ergonomic factors and obesity.

Low Back Pain in Low- and Middle-Income Countries, Part 1: The Problem

Low back pain (LBP) is the leading cause of disability in the low- and middle-income countries (LMICs), imposing substantial burden on individuals and health systems. The societal burden of LBP in LMICs challenges the United Nations' Sustainable Development Goals of eliminating poverty and improving health and well-being by pushing the people with the lowest socioeconomic position on the planet to greater poverty and more disability. This LBP in LMICs Series aims to (1) summarize the current state of LBP management in LMICs, (2) propose what best care for LBP in LMICs may look like, and (3) provide policy recommendations and a call to action. In this first paper, we summarize the extent of the problem: the prevalence, disability, and costs of LBP in LMICs. J Orthop Sports Phys Ther 2022;52(5):233-235. doi:10.2519/jospt.2022.11145.