Family Practice Advance Access originally published online on June 29, 2007
Family Practice 2007 24(4):308-316; doi:10.1093/fampra/cmm027
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Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations
a Centre for Health Sciences, Barts and the London, Queen Mary's School of Medicine and Dentistry
b Institute for Musculoskeletal Research and Clinical Implementation, Anglo-European College of Chiropractic
c School of Rehabilitation, Keele University
d Medical Research Council's General Practice Research Framework
e Department of Psychology, Royal Holloway, University of London
f The Research Centre, The British School of Osteopathy
Correspondence to: Suzanne Parsons, Senior Health Researcher, Picker Institute Europe, King's Mead House, Oxpens Road, Oxford OX1 1RX, UK; Email: suzanne.parsons{at}pickereurope.ac.uk
Received 1 August 2006; Revised 11 April 2007; Accepted 30 April 2007.
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Abstract |
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 Top Abstract BackgroundPatients and methodsResultsDiscussionDeclarationReferences |
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Background. Chronic pain has large health care costs and a major impact on the health of those affected. Few studies have also considered the severity of pain in different parts of the body across all age groups.
Objectives. To measure the prevalence and troublesomeness of musculoskeletal pain in different body locations and age groups, in a consistent manner, without using location specific health outcome measures.
Methods. A cross-sectional postal survey of 4049 adults registered with 16 MRC General Practice Research Framework practices. Frequency of chronic pain overall and troublesome pain by location and age was calculated. Logistic regression was undertaken to explore the relationship between chronic pain and demographic factors.
Results. We received 2504 replies; response rate 60%. The prevalence of chronic pain was 41%. The prevalence of chronic pain rose from 23% in 18–24 year olds reaching a peak of 50% in 55–64 year olds. Troublesome pain over the last 4 weeks was commonest in the lower back (25%), neck (18%), knee (17%) and shoulder (17%). Troublesome wrist, elbow, shoulder, neck and lower back pain were most prevalent in the 45- to 64-year-age groups. Troublesome hip/thigh, knee and ankle/foot pain were most prevalent in those aged 75 or more.
Conclusions. Great efforts have been made to develop and test treatments for low back pain. Our findings suggest that the overall prevalence of troublesome neck, knee and shoulder pain approaches that of troublesome low back pain and that similar efforts may be required to improve the management these pains.
Keywords. Age, chronic pain, epidemiology, surveys.
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Background |
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TopAbstractBackgroundPatients and methodsResultsDiscussionDeclarationReferences |
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Chronic pain has large health care costs and has a major impact on the health of those affected.1,2 Estimates of its prevalence vary from 11% to 55% for chronic pain and 10% to 30% for severe chronic pain.3–6 Estimates vary as some studies have measured overall prevalence, others have considered prevalence in a location or system-specific manner and others have estimated pain prevalence in specific age groups.7–9 Studies focusing on pain in specific locations normally report its presence or absence and not the extent to which it troubles an individual, and few studies have also considered the severity of pain in different parts of the body across all age groups.10
The approach used in these studies may have been driven partly by the researchers' recognition of the needs of the UK National Health Service, where many services have been developed dedicated to pains in particular parts of the body. For example, the focus on developing specific referral pathways for low back pain that has been driven by an increase in its perceived economic importance rather than its actual health impact.11 Measuring the comparative health impact of pains in different body locations in a consistent manner will provide data to inform rational service planning; improving the appropriateness of referral pathways and helping to make the best use of health services resources.
We describe a cross-sectional survey of the prevalence of chronic pain that measures the comparative troublesomeness of pains in different body locations.
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Patients and methods |
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Participant identification and sample size
We planned to sample 330 people from each of 18 Medical Research Council General Practice Research Framework (MRC GPRF) practices in the South East quadrant of England (http://www.mrc-gprf.ac.uk/). As around 98% of the UK population are registered with a general practice, this provided a suitable sampling frame.12 To increase the generalizability of our sample, we selected practices with different levels of social deprivation as measured by the Jarman Index.13,14 The mean score of the Jarman Index is 0 with a higher positive score indicating a more socially deprived district. The driver for our sample size was the need to identify participants for a nested qualitative study of chronic musculoskeletal pain.
In each practice, we generated a random sample of patients' aged 18 years or above from the practice computerized register using the MRC GPRF's random sampling programme. Patients were excluded by their GP if they had a terminal illness; severe psychiatric disorder or severe dementia; if they had requested not to be involved in research or if their GPs felt it was inappropriate for them to be approached. All participants received a postal questionnaire, with two reminders. We sent the second reminder by recorded delivery to enable us to identify those patients who were no longer resident at their recorded address. The London Multi-Centre Research Ethics Committee provided ethical review.
Questionnaire content
For this analysis, we considered chronic pain to be present if the respondent reported any ‘pain which has lasted for 3 months or longer and currently troubles respondents either all of the time or on and off.7‘
We measured overall health status using the following:
- The Chronic Pain Grade, which measures intensity and disability of pain and produces an overall pain grading, where 0 = no pain and IV equals highly disabling and severely limiting pain.15,16 In addition to the overall Chronic Pain Grade, we present here its individual pain and disability scores.16
- The GHQ 12 which measures psychological distress.17
- The EQ 5D which measures overall health utility.18
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The concept of troublesomeness may be particularly useful for classifying patients who do not have a clear aetiology for their symptoms, as it is concerned with symptoms and not with classifying patients according to the presence or absence of disease.19 We have reported our validation of this measure elsewhere.21 We found it to have high face, content and criterion-related validity and good test–retest reliability. Based on this work and findings from a related qualitative study,21,22 we concluded that at least moderately troublesome pain had an important health impact at an individual level, and we have used this as a cut-off for this analysis.21,22
As well as the troublesomeness questions, we also collected data on pain location using a pain drawing; analysis of these data will be presented elsewhere.
Finally, we coded participants' social class into three groups (i) managerial and professional occupations; (ii) intermediate occupations and (iii) routine and manual occupations based on their self-reported occupation using the National Statistics Socio-Economic Classification analytic classes self-coded method.21,23
Analysis
We excluded patients who were not at their registered address from our analyses.24 The main focus of this analysis is the comparative troublesomeness of pain in different body locations. However, we have examined the prevalence of chronic pain and its relationship with socio-demographic variables and health outcomes to describe our sample, facilitate comparison with other population surveys and to provide a context within which to understand our troublesomeness findings.
Description of sample
We described and compared our sample overall and those with chronic pain in terms of socio-demographic factors (age, gender, ethnicity, education, working status and social class) and health outcomes (health-related quality of life, psychological distress, pain severity and pain intensity and pain-related disability). We calculated means for continuous data and percentage with a particular characteristic for categorical data.
We calculated the crude prevalence of chronic pain and the prevalence adjusted for age, sex and practice. We calculated unadjusted odds ratios and 95% confidence intervals for the relationship between socio-demographic variables and chronic pain.
Describing the comparative troublesomeness of pain in different body locations
We explored the comparative troublesomeness of pain by calculating the frequency of at least moderately troublesome pain in each of the stated locations across the whole sample. This approach allows us to describe the prevalence and degree of troublesome pain over the last 4 weeks in each body location across the population. We considered it appropriate not to limit this analysis just to those with chronic pain, as we hypothesized that the majority of respondents reporting troublesome pain would also be likely to have chronic pain. We also explored the prevalence of extremely, very and moderately troublesome pain by body location and age to identify whether age trends existed in troublesome pain. Again, we calculated these frequencies across the whole sample. We did this by calculating the frequency of moderately, very and extremely troublesome pain in each location and in seven age bands corresponding to those used in the General Household Survey.25 Non-response to a single troublesomeness question was considered to indicate that no pain was present in that body region. Data were managed using SPSS for Windows version 11, ACCESS and EXCEL.
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Results |
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Response rate
The study took place between December 2001 and March 2003 in 16 practices whose Jarman scores ranged from –12.6 to 18.5. We received replies from 2504 of our eligible population of 4171 (60%) (Fig. 2).
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Response rates by practice ranged from 35% to 71% with more deprived areas having lower response rates.
Overview of respondents
Respondents' mean age was 52 (range 18–102). Fifty-six per cent (1374/2451) were female, 55% (1342/2448) had left school aged 16 years or less, 61% (1506/2464) were currently working and 7% (168/2464) were from a non-white ethnic group. There were no significant differences in age and gender between responders and non-responders across all practices, although the general trend was for responders to be older and female (Table 1).
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Chronic pain prevalence
The crude prevalence of chronic pain was 38% (960/2504). A further 51% (670/1300) of respondents, who did not report meeting our definition of chronic pain, indicated that they had pain on the chronic pain grade; 13% (167/1300) with grade II or more pain. The prevalence of chronic pain increased progressively with age from 23% in those aged 18–24, reaching a peak of 50% in the 55–64 age group and reducing to 42% in the 65–74 age group and to 46% in the
75 age group (Fig. 3).
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In a univariate analysis, we found statistically significant associations between the presence of chronic pain and being female, leaving school at age 16 or less, lower social class and not currently working (Table 2).
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As expected, chronic pain sufferers were more likely to have a lower quality of life; to be psychologically distressed and to have higher mean pain intensity and pain-related disability (Table 3).
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Troublesome pain by body region
The most prevalent troublesome pain regions were low back (25%, 624/2494), neck (18%, 449/2494), shoulder and knee (17%, 424/2494), head ache (16%, 399/2494) and ankle (13%, 324/2494). Only 18% (112/614) of those with troublesome low back pain, 18% (76/412) of those with troublesome shoulder pain and 15% (64/425) of those with troublesome knee pain did not have chronic pain. Therefore, we feel that it was appropriate to include the entire sample reporting troublesome pain in our analysis, as more than 80% of those reporting troublesome pain also had chronic pain.
Troublesome pain prevalence by body location according to age. Age trends existed for the prevalence of troublesome pain in some body regions (Fig. 4, Table 4). No age trends existed for upper back, neck and chest pain, but trends existed for all other locations. Lower back, wrist, elbow and shoulder pain reached a peak in the 55- to 64-year-age group (30%, 21%, 8%, 21%) and decreased in the oldest age groups (24%, 15%, 6%, 16%). Knee, ankle and hip/thigh pain were all the more prevalent as people got older, reaching a peak in those aged 75 or above (26%, 24%, 19%). In the younger age groups, headache had a relatively stable prevalence between the ages of 18 and 54 and decreased to 5% in the oldest age group. Abdominal pain was most prevalent in the 18–24 year olds (15%). It reached its second highest peak in the 45–54 age groups (10%), and decreased to 5% in the oldest age group.
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Discussion |
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TopAbstractBackgroundPatients and methodsResultsDiscussionDeclarationReferences |
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Prevalence of troublesome pain by body region
One in four of our study population reported at least moderately troublesome low back pain in the previous 4 weeks.
This is consistent with previous epidemiological studies.4,26,27 However, one in six or seven of the population studied were affected by at least moderately troublesome neck, shoulder, wrist, hip/thigh and knee or ankle/foot pain. These findings concur with a recent Europe-wide survey of chronic pain, which found that along with low back pain, that knee, head, shoulder, neck and hip pain also affected a large proportion of the population.28 The troublesomeness of these pains suggests that the great emphasis placed on site-specific pain, by researchers, clinicians and in some cases patients, may result in the health needs related to other pains being inadequately addressed.
Influence of age on pain prevalence
Older people experienced more chronic pain than younger people, but contrary to expectations, neither the overall prevalence of chronic pain nor the severity of pain appeared to increase substantially beyond the 55–64 age groups (Fig. 3). The exception to this was lower limb pain. This suggests that increased pain in all body locations is not an inevitable consequence of ageing. It may also reflect a different prioritization of pain in relation to other health problems among older people. In terms of other age groups, there are distinct differences in the patterns of pain in different body locations.
Lower limb pains.
Although the overall prevalence of chronic pain was not age related, troublesome hip/thigh, knee and ankle/foot pain increased with age. Strikingly, the prevalence of troublesome ankle/foot pain increased substantially in the oldest age groups. Its prevalence in the 75-year age group was similar to that of troublesome knee pain (ankle/foot 25%, knee 28%) (Fig. 4, Table 4).
Other musculoskeletal pains. Troublesome wrist, elbow, shoulder, neck and lower back pain all peak in the 45–54 or 55–64 age bands reducing in the older age groups. This peak of prevalence has been observed previously for pain in these body locations.29 Troublesome upper back pain follows a similar pattern except for a peak in people aged more than 75 years that may represent problems related to osteoporosis. A review of studies exploring pain prevalence in people aged more than 65 years found that older people report less mild back pain than those in middle age, but that they experience a higher prevalence of severe or disabling episodes of back pain.30 In our study, the percentage of very or extremely troublesome back pain was not higher in people aged more than 65 years compared to the middle aged (25% versus 55%). Although there was a difference in those reporting chronic pain grade IV (35% of those aged 65 and above reporting chronic pain grade IV compared to 20% of those aged 45–64. This provides evidence that older people may have severe pain which they have either adapted to or accepted which they do not find troublesome (Fig. 3).
Other pains. Troublesome headache and chest pain do not show a relationship with age. Troublesome abdominal pain peaks in the youngest age group at 30% (17/56), and among those with pain, 14 were females, suggesting that this peak may be due to menstrual pain in young women (Fig. 4, Table 4).
Sample and response rates
Our sample was from a wide geographical area that is representative of the southeastern quadrant of England. We included everyone aged 18 or above from a range of areas including deprived multicultural urban areas and prosperous rural areas. Our sample size was also sufficiently large to allow for comparisons of age groups. The geographic and socio-demographic variability in the localities studied means that our results are at least as generalizable to the UK as a whole as other UK-based population surveys of chronic musculoskeletal pain.26,27,31
Previous studies have either used location-specific health outcome measures (to measure the health impact of pain in just one body location) or generic health outcome measures (to measure the overall health impact of pain in a range of locations). We believe that this is one of the first studies to measure the comparative burden of pain in different body locations in different age groups.
Our response rate of 60% is lower than most, but not all, recent UK studies.26,27,32,33,34 Typical response rates for each practice were around 65–70%, a typical response rate for a study of this nature. Lower response rates were obtained in areas with more mobile populations and large numbers of people whose first language was not English. Our sampling strategy has increased the generalizability of our findings by ensuring that all social groups have an opportunity to participate, at the cost of introducing some bias because of a lower response rate.
The prevalence of chronic pain in this study is within the range found in similar studies. In common with previous research, those with chronic pain were more likely to be female, older, not working, to be of lower social class and to have left school earlier.26 Our sample of those with chronic pain is similar to that in other community surveys, suggesting that we can make robust observations about the comparative burden of pain in different body locations.28 A substantial minority (13%) of those who did not meet our definition of chronic pain reported chronic pain grades II–IV. This might be because the Chronic Pain Grade, in part, measures acute rather than chronic pain; it may also indicate that the International Association for the Study of Pain's definition of chronic pain that we used is not sufficiently sensitive to identify all of those with chronic pain.
Limitations of the study
Retrospective reports of any condition, in a questionnaire, may be unreliable because of recall and social desirability biases. Our overall prevalence figures are based on those who replied. Therefore, although we have standardized our main pain prevalence estimates for age, sex and locality in our main analysis, residual confounding may still be present. For example, we may have overestimated the prevalence of chronic pain and of recent troublesome pain, as those with pain may be more likely to respond. Self-report questionnaires may also require a certain level of cognitive ability and we may have not collected data from those with cognitive impairments in the oldest age groups. We have insufficient data to justify standardizing our estimates of troublesome pain within age bands.
Implications
Understanding the comparative troublesomeness of pains in different body locations is a useful means of assessing their comparative health impact, which could inform future service development and delivery. It also has the potential to assist health professionals' decision making, based on patients' symptoms rather than on a diagnosis. Re-focussing the consultation on what troubles the patient rather than seeking a, often elusive, biomedical diagnosis has the potential to help resolve conflict and dissatisfaction commonly experienced, during consultations for chronic musculoskeletal pain.
The decreasing prevalence of many troublesome musculoskeletal pains with increasing age may reflect an actual reduction in musculoskeletal disorders, a reduction in activities that worsen pain, the normalization of pain by older people or greater stoicism in older people compared to younger people. Our data suggest that although older people may experience more severe pain, they may not find it to be troublesome. However, further work is needed to explore the reasons for this finding.
The high prevalence of lower limb pain among older age groups is not surprising; demographic change means that absolute numbers of people with troublesome lower limb pain is set to increase. Our data provide a measure of the prevalence of troublesome hip, knee and ankle/foot pain and will allow estimation of future health care needs. The similarity in the prevalence of troublesome ankle/foot pain and troublesome knee pain is in marked contrast to the comparative research activity and service provision for these two body locations. As well as the established need for the development of services for knee pain,35 there is a need to consider what further research and service development are needed to manage ankle/foot pain in older people.
Conclusions
A greater understanding of the comparative troublesomeness of pain in different body locations may be useful in terms of developing appropriate services for patients with pain, increasing the appropriateness of referrals and it may also have the potential to improve the success of chronic pain consultations. The relationship between troublesome pain, pain severity and age in particularly needs further exploration to gain a clearer picture of the likely future demands on the health service.
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Declaration |
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TopAbstractBackgroundPatients and methodsResultsDiscussionDeclarationReferences |
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Funders: Arthritis Research Campaign.
Ethical approval: Ethical approval was obtained from the London Multi-Centre Research Ethics Committee.
Conflict of interest: MU has received speaker fees from Pfizer, the manufacturer of valdecoxib and celecoxib, and from Menarini, the manufacturer of ketoprofen and dexketoprofen, and from the General Osteopathic Council. All other authors declare that they have no conflict of interests.
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Acknowledgments |
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Jeannett Martin commented on all study materials and manuals and Eddie Matthews and Peter Furness developed the random sample-generating programme used by the practice nurses to select the sample.
Contributions: MU was the principal investigator for the study, wrote the first draft of the paper and designed the questionnaire and the data analysis plan. SP was the study manager, organized and implemented the survey, designed the questionnaire and data analysis plan, conducted the analysis and commented on all drafts of the paper. AB, SV, NEF and TP were the study's steering group, helped design the original study, the study questionnaire and analysis plan and contributed to all drafts of the paper. LL recruited all practices for the study, commented on the design of the study materials and commented on all drafts of the paper.
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Notes |
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Parsons S, Breen A, Foster NE, Letley L, Pincus T, Vogel S and Underwood M. Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations. Family Practice 2007; 24: 308–316.
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References |
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