Family Practice Advance Access published online on May 15, 2007
Family Practice, doi:10.1093/fampra/cmm012
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece
a Clinic of Social and Family Medicine, Department of Social Medicine, School of Medicine, University of Crete, Crete, Greece
b Spili Health Centre
c Anogeia Health Centre, Regional Health and Welfare System of Crete, Crete, Greece
d Department of Orthopaedics and Traumatology, School of Medicine, University of Crete, Crete, Greece
Correspondence to: Maria Antonopoulou, Clinic of Social and Family Medicine, University of Crete, PO Box 2208, Heraklion 71003, Crete, Greece; Email: antonopm{at}uoc.gr
Received 3 June 2006; Revised 3 February 2007; Accepted 18 March 2007.
 |
Abstract |
|---|
 Top Abstract IntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Background. Musculoskeletal disorders (MSDs) account as a reason for frequent consultations in primary care. However, the magnitude of the problem at the GP's clinic, the patterns of pain and the consulting behaviour has not been sufficiently explored.
Objectives. The aim of this study was to report on patterns of pain relevant to MSDs and explore the co-morbidities and consulting behaviour in rural primary care settings in Crete.
Methods. Three primary care centres (PCCs) of Crete were selected for a study period of 2 weeks. Every visitor, aged 20–75 years, regardless of the reason for visiting the facility was invited to participate. The Greek version of the general Nordic questionnaire for the analysis of musculoskeletal disorders (NMQ) was used for data collection.
Results. A total of 455 subjects answered the NMQ. Three hundred and seventy-six (82.6%) of the study population reported having one or more symptoms during the previous year. Low back (56.9%), neck (34.1%), shoulder (29.9%) and knee (27.9%) were the commonest sites of pain. In almost half cases (48.6%), the complaints about pain were accompanied by activity restrictions. Multivariate statistical analysis showed significant correlations with increasing age and female gender (P < 0.05). Common chronic conditions were associated with co-morbidities from the musculoskeletal system. Only one-third of those who reported MSDs had consulted their GPs for the same problems within the previous year.
Conclusions. MSDs are highly prevalent among rural population in Crete but fewer patients seek care than those who report symptoms.
Keywords. Greece, musculoskeletal disorders, pain patterns, primary care, rural.
|
Introduction |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Musculoskeletal disorders (MSDs) comprise a major health problem for the general population, affecting their quality of life, demanding increased health care and organization.1 According to reports from Canada and the Netherlands,2,3 the prevalence of musculoskeletal problems range from 29% to 74.5%, respectively. However, the annual consultation rate by health care professionals of musculoskeletal problems is about 20%.4 MSDs often cause pain and significant disability, especially in the elderly population, signifying a heavy community burden.5 Furthermore, working conditions correlate well with MSDs.6 In family practice settings, MSDs often co-exist with multiple medical conditions, addressing special care needs.7
In Greece, although MSDs have been considered as common reasons for patients' visits to GPs in rural areas,8,9 issues of pain patterns and consulting behaviour are still unexplored. This paper reports on the magnitude of musculoskeletal problems within the primary care setting with emphasis on co-morbidities and consulting behaviour and intends to discuss its implications for GPs in a southern European country.
|
Methods |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Setting
Data were gathered from three PCCs in rural Crete. These PCCs provide around the clock outpatient care for a rural district, serving a population of approximately 37 000 inhabitants10 with most of them being farmers [International Standard Classification of Occupations, 88 (ISCO-COM 6) and craft and related trades sectors (ISCO-COM 7)]. People are also employed in restaurant services and travel-related services (ISCO-COM 5), since a lot of tourists are visiting these areas. The unemployment rate is nearly 12%, slightly higher, as compared to 10% in the rest of the country. The educational status is low with more than 50% of the general population being either illiterate or with primary education only [International Standard Classification of Education 1997 (ISCED 0 + 1)].
Sampling
All consecutive visitors (20–75 years of age) in the three PCCs during a period of 10 working days in November 2002 participated in the study. A written consent was obtained and the study protocol was applied by health professionals. The month of November was selected because most agricultural tasks in the fields take place during this period throughout the catchment area of the PCCs. During that period, farmers are engaged in intensive harvesting of grapes and olives, demanding hard manual work with the spine in a bend over position for a prolonged period of time. Other awkward positions during farming can also extract musculoskeletal strain. Moreover, at this time there are no tourists visiting the PCCs, so the study population comes from the permanent inhabitants served by these PCCs. The sample collected was further scrutinized for clinical co-morbidities and the consulting behaviour, using the medical records of one PCC.
Methods
The Greek version of the general form of the standardized Nordic questionnaire for the analysis of musculoskeletal symptoms (NMQ) was used for data collection. NMQ had been previously translated and validated in the Greek language.11 Apart from a few general demographic questions, it contains a picture of the back aspect of the human body divided in nine anatomical areas (neck, shoulders, elbows, wrists/hands, upper back, low back, hips/thighs, knees and ankles/feet) (Fig. 1). The rest of the questions are distributed in three columns. There are nine screening questions in the first column. For example, ‘have you at any time during the last 12 months had trouble i.e. ache, pain or discomfort in this area?’. In case of a positive answer, the respondents answer whether or not they had been prevented from doing their normal work at home or away from home, during the same period because of that ailment. They are also asked if they had experienced that symptom during the previous 7 days (questions in the second and the third column). Therefore, the questionnaire's structure investigates the prevalence of different MSDs and examines which of the particular problems are the more debilitating (i.e. prohibited patients from engaging in their normal work routine within the previous 12 months). Even though, NMQ is self-administered, because of the special features of the study population (mean age of 51.9 years and education level between 0 and 6 years), trained health professionals assisted the subjects with the completion of the questionnaire.
Additional data concerning age, sex, body mass index (BMI) and working records were extracted by the NMQ. BMI was classified into four categories: underweight (BMI < 20 kg/m2), normal (BMI 
20 and < 25 kg/m2), overweight (BMI 25 and < 30 kg/m2) and obese (BMI 30 kg/m2).12 To determine the extent to which NMQ identified musculoskeletal symptoms during primary care visits, we carried out a medical audit in one of the participating PCCs and all medical records of the subjects were reviewed. Co-morbidities (according to International Classification for Primary Care 2), education level (according to ISCED 1997), type of occupation (according to ISCO-COM 88), cohabitation status (any kind of cohabitation or living alone) and consultation patterns were also collected using a pre-tested questionnaire.
Statistical analyses
Statistical analyses were performed using SPSS version 12.0. A P-value of P < 0.05 was accepted as significant. For the nine anatomical areas, the 1-year period prevalence, the prevalence of daily limitations due to reported symptoms and the point prevalence (musculoskeletal symptoms during last week) were calculated. Those were the dependent variables. Independent variables were age, gender, BMI, working time at present work and working hours per week. Adjusted odds ratios (ORs) were calculated. Multiple logistic regression analysis was performed to evaluate the association between each exposure variable and musculoskeletal symptoms. This method was applied stepwise in an enter approach. The association between education level, type of occupation, cohabitation status, co-morbidities and the patterns of pain was also measured. To study the effects of different occupations to limitations in daily activities, the total score of positive answers for each patient and for each question was calculated. Wilcoxon paired and unpaired (Mann–Whitney) tests were used to compare these scores into the same and among different occupational groups. Chi-square test was used to compare those who had consulted their physicians for MSDs with those who did not.
|
Results |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Sample characteristics
Overall, 455 subjects completed the questionnaire at the three PCCs with participation rate at 95.2%. Table 1 shows the general demographic characteristics. Two hundred and sixty (57.2%) of the respondents were females and the mean age was 51.9 [95% confidence interval (CI): 50.3–53.7] years.
|
Patterns of pain
Three hundred and seventy-six subjects (82.6%) reported at least one musculoskeletal problem during the previous year, while 219 (48.1%) subjects reported limitations of activities due to their symptoms during the same period of time. Low back pain was the commonest complaint (56.9%), followed by neck (34.1%), shoulder (29.9%) and knee (27.9%) problems. Two musculoskeletal co-morbidities were present in 24% of patients (n = 109); one in 23.3% (n = 105), while 3.3% (n = 15) reported widespread pain in all nine regions of the body. Low back pain was also the most debilitating symptom reported (28.6%), causing limitations in daily activities. Low back and neck pain was the commonest combination reported (n = 124, 27.5%), resulting in the higher disability rate (11.0%). Although the co-existence of more than two symptoms was not frequent, this seemed to be associated with more disability but without statistical significance. The reported patterns of pain by age groups and gender are presented in Table 2.
|
The prevalence of the reported symptoms was statistically related to increasing age (P < 0.05) for neck, elbow, low back, hip and knee pain. Multiple musculoskeletal symptoms were also related to aging. Patients with shoulder and low back pain reported also more disability in terms of limitation in their daily activities.
Morbidity patterns also differed between women and men. While low back pain was the commonest symptom in both genders, female patients reported higher prevalence for every symptom (P < 0.05) except for elbow and foot (Table 2). Women reported more pain conditions than men 11.9/10.7 (P < 0.05) and more disability.
In the questions about working schedules, the majority of the sample reported 20 (95% CI: 18.6–21.8) years of work for 45.6 (95% CI: 43.6–47.6) hours per week. Men worked longer hours but this tended to decrease, as they grew older. Women worked mainly at home or at the farms, fewer hours per week than men (men/women ratio: 1.1). Working for a period of more that 15 years was related to higher morbidity mainly from shoulder and elbow pain (Table 3). Limitations in daily activities due to neck, shoulder, low back and foot complaints were related to longer working schedule per week. Multiple regression analysis for the most frequent patterns of pain is presented in Table 3.
|
Further analysis from the sample in one PCC showed that occupation did not constitute a statistically significant risk factor for the presence of MSDs. Thirty-one per cent of the sample were farmers (ISCO-COM 6), 11% were employed in restaurant services and travel-related services (ISCO-COM 5) and 27%—almost half of all the women—were housewives. Comparing the total scores in the three questions of the NMQ among various occupational groups, it came out that the majority kept their usual everyday activities during the previous year, even though they reported a great number of musculoskeletal symptoms (P < 0.001). Different occupations did not statistically affect this result.
Cohabitation and educational status did not significantly differ in the patterns of reported symptoms.
Co-morbidities
Half of the study population (55.4%) for both sexes were overweight (BMI > 25 kg/m2) with mean BMI = 29.0 (95% CI: 28.6–29.9), especially women in advanced age (BMI > 30 kg/m2 in 24.6% of females) (Pearson R correlation, Rp = 0.328, P < 0.001 of correlation between overweight women and age). Overweight (BMI > 25) and obese (BMI > 30) patients had a tendency to report more musculoskeletal symptoms but not of statistical significance. However, they reported more activity limitations as a result of shoulder, elbow, wrist and foot pain.
Review of medical records in one PCC revealed that the most common diagnoses co-existing with MSDs were hypertension (64/176, 36%), osteoarthritis (OA) of hip and/or knee (56/176, 32%), coronary artery disease (CAD) (21/176, 12%) and mental disorders (20/176, 11%). The number of co-morbidities was increasing with age without statistical significance. Mental disorders, mainly depression, ranked as the medical conditions with the highest proportion of musculoskeletal symptoms (95.0%), followed by chronic obstructive pulmonary disease (COPD) (92.8%), CAD (90.4%), OA (84.0%), diabetes (83.3%) and hypertension (82.8%). The multiple logistic regression analysis of the most common co-morbidities in correlation to the reported symptoms highlighted strong correlations, especially with arthritic conditions. Shoulder pain was statistically associated with COPD (adjusted OR = 8.94, 95% CI 1.47–54.17, P = 0.017) and OA (adjusted OR = 4.25, 95% CI 1.67–10.81, P = 0.002), whereas wrist pain was more frequent in subjects with diabetes (adjusted OR = 3.87, 95% CI 1.09–13.68, P = 0.035). The prevalence of elbow pain was correlated to CAD (adjusted OR =5.01, 95% CI 1.01–24.87, P = 0.048). Patients with OA also reported statistically significant activity restriction (P < 0.05) due to neck, shoulder, upper back, hip, knee and foot symptoms, unlike diabetic patients who did not complain for many daily restrictions. Cancer of any form, mental disorders or stomach problems were not statistically correlated to MSDs.
Consulting behaviour
Data from one PCC showed that although the prevalence of reported MSD was measured at 71.4% (125 out of 176), only 56 subjects (32%) had reported the same symptoms to their GP during previous consultations. These symptoms originated mainly from low back, neck, knee and hip areas. Patients with multiple co-morbidities were more likely to have previously consulted their GPs for those problems (adjusted OR = 2.21, 95% CI 1.6–2.9, P < 0.0001). Seventy-four of the participants (41.7%) reported symptoms during the last week (question in the third column of the NMQ), but only 13 (17.5%) visited their GP complaining for musculoskeletal symptoms. When comparing those visiting GPs with those who did not (chi-square test) during the previous year, we found that younger patients of both genders with limited education did not consult their physician due to MSDs. A patient with knee or shoulder pain was seeking care more often regardless of age. Older patients and patients suffering from OA or hypertension reported significantly more consultations. Other factors like gender, BMI, working time or occupation were not found to have statistical significance.
|
Discussion |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Summary of results
There are several interesting points revealed by this study such as the patterns and distribution of pain, the differences between genders and the consulting behaviour. Low back pain was the commonest reported site among all age groups. Low back pain, followed by neck and shoulder pain, was also the main symptom for daily living limitations. This finding is in accordance with the results of a recent systematic review in general practice of work-related diseases.13 Age was found to be a risk factor for many musculoskeletal symptoms. Younger patients (20–39 years) reported fewer symptoms and less frequently, as compared with older patients (66.2% prevalence of any MSDs versus 90% for the older group over 60 years of age, P < 0.05).
Pain patterns also differed between genders. In our study, women reported on average more symptoms and more disability. Women to a greater extent than men blamed musculoskeletal pain in neck, wrist, low back, hip or knee for restrictions in daily activities. The tendency for MSDs to affect more women than men has been shown in other epidemiological studies.3,14 Reasons for gender differences, apart from the apparent biological differences (genetics, physiology, hormones, etc.), include different psychosocial aspects of symptoms and care. Women also seem to visit more promptly health care facilities and recall health problems to a greater extent than men.15 However, in our study, such gender preference was not revealed.
In our study, overweight or obesity, a common public health problem in contemporary Crete,16 showed significant correlations only with the reported disabilities due to pain of upper limb and foot. According to other studies, obesity has been related to hip and low back pain in middle-aged men,17 whereas in rural communities, it causes more disability to patients with knee OA.18
Working for many years was correlated to shoulder and elbow pain. More comprehensive surveys that included physical and psychosocial work factors, such as work intensity or working postures, have previously shown associations with MSDs,6 but these were not explored in our study.
Unlike other epidemiological evidence which relates MSDs to physically demanding professions like farming,19 occupation did not statistically relate to any MSD. However, analysing the positive answers for all occupational groups, we found that the majority of participants carried on with their daily functions, independently of their job, despite the occurrence of multiple musculoskeletal problems. Cultural or local social network variables, not included in this study, could play a role in the perceived limitations of activity for this population.20
Other social factors, such as living alone or low education, were not found to affect the reported patterns of pain, which comes in agreement with other studies.21
The clinical co-morbidity rate was high. Patients with OA, COPD, diabetes, hypertension or CAD tended to report more musculoskeletal symptoms. Co-morbidities with MSDs were also shown to prevent their daily activities. Co-morbidity for OA in general practice has also been found to be extensive with musculoskeletal as well as non-musculoskeletal conditions in the UK.22 Patterns of co-morbidity in the Dutch population have shown that MSDs were most likely to coincide with lung and heart diseases, neurological disorders, diabetes and cancer.23 The explanation for the perceived co-morbidity lies beyond the present study in shared pathology of diseases or the impact which one condition might have in the occurrence of another. However, the recognition of this large extent of co-morbidity has implications for the way in which primary care should be organized. The burden is on primary care physicians to provide the majority of care, not only for the target condition but also for all co-morbid conditions.
Another interesting point was that only 13 out of 74 who reported musculoskeletal symptoms were actually seeking care at the time of the study. On an annual basis, 32% of this sample had contacted a primary care physician because of musculoskeletal pain which can be considered high in comparison with other studies,4 although it corresponds to less than half of the same population reporting MSDs in the NMQ. The more concurrent chronic conditions they had, the more likely they were to have consulted their GP and complain for MSDs, too. Those were mainly older patients with higher education suffering from OA and hypertension that came complaining for knee or shoulder pain. Similarly, another study in a rural Swedish population showed that only one-fifth of those reporting current neck and/or low back pain had a primary care consultation.24 Possible explanations could be either the poor registration rates of primary care physicians who underestimate the symptoms or that symptoms are not severe enough to be reported. A recent report on primary care consultations due to indigestion problems in the same district showed under diagnosis of functional gastrointestinal disorders by physicians.25 However, a recent European study involving eight countries regarding musculoskeletal pain showed that up to 27% of people with pain do not seek medical care in spite of constant or daily pain.26 The disbelief or ignorance of effective treatments for MSDs could prevent patients from consulting a health professional.23 Even when they do seek help, this is often limited to prescription for non-steroidal anti-inflammatory drugs (NSAIDS), which result in non-compliance to their treatment.26 In fact, according to a previous study conducted in the same district, prescriptions for painkillers and NSAIDS ranked second accounting for 19% of prescriptions during 1-year period.27 To overcome the doctors' difficulty in identifying those diseases, a change in doctor–patient communication with an emphasis on patients' perceptions and needs seems as a promising option.26
Strengths and weakness
Several concerns should be raised when discussing study findings. Overestimating prevalence due to sampling method is one issue: our sample was probably overrepresented by patients with multiple morbidities waiting to see their physicians. High prevalence of MSDs has been documented in many studies, especially when self-administered questionnaires are being used for data collection.28 People tend to recall the most recent or most debilitating painful conditions when asked to complete questionnaires. Whether or not the reported symptoms were major or minor cannot be explored through the NMQ.
Although the NMQ has been used in a great number of studies in different countries,29 it still has several limitations. Since NMQ is counting symptoms throughout the human body, the estimated prevalence is expected to be high. Most general population studies focus on special anatomic sites, while others deal with specific occupational groups.30,31 The used questionnaire seems to be appropriate for general screening in occupational groups, without permitting further discrimination. For example, the pain in the hips, considering the area marked as ‘hip/thighs’ in the picture of NMQ is unclear if it is actually a hip problem or originates from the low back area and reflects at the hips. Moreover, the use of a picture of the back aspect of the body may not allow problems in the frontal aspect to be revealed.
The timing of data collection did not seem to have an effect on the measured prevalence. Data from one PCC that was collected during 10 working days in spring did not show a seasonal variation for the reported MSDs.
Although the sample size reflected the underlying population i.e. the general population of rural primary care in Crete (95% confidence level and 95% CI 7%), limitations should be taken into account interpreting the results for co-morbidities and consulting behaviour since the data came only from one PCC (n = 175).
Conclusions
In conclusion, this study showed that musculoskeletal pain is very common in the rural population of Crete. GPs need to be alert and well skilled in order to prevent or identify early the musculoskeletal problems. The observed patterns of co-morbidity highlight the need for primary care oriented towards patients' overall health care. Patients, especially women and elderly, who suffer from hypertension or diabetes, could also suffer from musculoskeletal problems, even if this does not come up as their major complain, and they should be treated accordingly. Further evaluation of the consequences of MSDs to this population in terms of disability or effect in the quality of life should contribute towards that effort.
|
Declaration |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
Funding: None.
Ethical approval: Approval of a specific scientific committee of the University of Crete.
Conflicts of interest: None.
|
Notes |
|---|
Antonopoulou M, Antonakis N, Hadjipavlou A and Lionis C. Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece. Family Practice 2007; Pages 1–8 of 8.
|
References |
|---|
|
TopAbstractIntroductionMethodsResultsDiscussionDeclarationReferences |
|---|
1 Woolf AD, Pfleger B. Burden of major musculoskeletal conditions. Bull World Health Organ (2003) 81:646–656.[Web of Science][Medline]
2 Badley EM, Webster GK, Rasooly I. The impact of musculoskeletal disorders in the population: are they just aches and pains? Findings from the 1990 Ontario Health Survey. J Rheumatol (1995) 22:733–739.[Web of Science][Medline]
3 Picavet HSJ, Schouten JSAG. Musculoskeletal pain in the Netherlands: prevalences, consequences and risk groups, the DMC3-study. Pain (2003) 102:167–178.[CrossRef][Web of Science][Medline]
4 Badley EM, Rasooly I, Webster GK. Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability and health care utilization: findings from the 1990 Ontario Health Survey. J Rheumatol (1994) 21:505–514.[Web of Science][Medline]
5 Makela M, Heliovaara M, Sievers K, Knekt P, Maatela J, Aromaa A. Musculoskeletal disorders as determinants of disability in Finns aged 30 years or more. J Clin Epidemiol (1993) 46:549–559.[CrossRef][Web of Science][Medline]
6 Cole DC, Ibrahim SA, Shannon HS, Scott F, Eyles J. Work correlates of back problems and activity restriction due to musculoskeletal disorders in the Canadian national population health survey (NPHS) 1994–5 data. Occup Environ Med (2001) 58:728–734.
7 Martin F, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med (2005) 3:223–228.
8 Tzimis L, Katsantonis N, Leledaki A, Vasilomanolakis K, Kafatos A. Antibiotics prescription for indigent patients in primary care. J Clin Pharm Ther (1997) 22:227–235.[CrossRef][Web of Science][Medline]
9 Koutis AD, Isacsson A, Lionis C, Lindholm LH, Svenninger K, Fioretos M. Differences in the diagnose panorama in health care in Dalby, Sweden and Spili, Crete. Scand J Soc Med (1993) 21:51–58.[Web of Science][Medline]
10 General Secretariat of National Statistical Service of Greece. (2001) http://www.statistics.gr (accessed on 6 January 2005).
11 Antonopoulou M, Ekdahl C, Sgantzos M, Antonakis N, Lionis C. Translation and validation into Greek of the standardised general Nordic questionnaire for the musculoskeletal symptoms. Eur J Gen Pract (2004) 10:35–36.[Medline]
12 Measuring Obesity: Classification and Description of Anthropometric Data. Report on a WHO Consultation on the Epidemiology of Obesity, Warsaw, 21–23 October, 1987 (1988) Copenhagen: WHO Regional Office for Europe. (document EUR/ICP/NUT 125).
13 Weevers HJ, van der Beek AJ, Anema JR, van der Wal G, van Mechelen W. Work-related disease in general practice: a systematic review. Fam Pract (2005) 22:197–204.
14 Leroux I, Dionne CE, Bourbonnais R, Brisson C. Prevalence of musculoskeletal pain and associated factors in the Quebec working population. Int Arch Occup Environ Health (2005) 78:379–386.[CrossRef][Web of Science][Medline]
15 Fillingim R, Edwards R, Powell T. Sex-dependent effects of reported familial pain history on recent pain complaints and experimental pain responses. Pain (2000) 86:87–94.[CrossRef][Web of Science][Medline]
16 Mamalakis G, Kafatos A. Prevalence of obesity in Greece. Int J Obes Relat Metab Disord (1996) 20:488–492.[Web of Science][Medline]
17 Bergerudd H, Nillson B. The prevalence of locomotor complaints in middle age and their relationship to health and socioeconomic factors. Clin Orthop (1994) 308:264–270.[Medline]
18 Jordan JM, Luta G, Renner JB, et al. Self-reported functional status in osteoarthritis of the knee in a rural southern community: the role of sociodemographic factors, obesity, and knee pain. Arthritis Care Res (1996) 9:273–278.[Web of Science][Medline]
19 Holmberg S, Stiernstrom EL, Thelin A, Svardsudd K. Musculoskeletal symptoms among farmers and non-farmers: a population-based study. Int J Occup Environ Health (2002) 8:339–345.[Web of Science][Medline]
20 Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychosocial factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (2002) 27:E109–E120.[CrossRef][Medline]
21 Saastamoinen P, Leino-Arjas P, Laaksonen M, Lahelma E. Socio-economic differences in the prevalence of acute, chronic and disabling chronic pain among ageing employees. Pain (2005) 114:364–371.[CrossRef][Web of Science][Medline]
22 Kadam UT, Jordan K, Croft PR. Clinical comorbidity in patients with osteoarthritis: a case control study of general practice consulters in England and Wales. Ann Rheum Dis (2004) 63:408–414.
23 Westert GP, Satariano WA, Schellevis FG, Van de Bos GA. Patterns of comorbidity and the use of health services in the Dutch population. Eur J Public Health (2001) 11:365–372.
24 Holmberg SA, Thelin AG. Primary care consultation, hospital admission, sick leave and disability pension owing to neck and low back pain: a 12-year prospective cohort study in a rural population. BMC Musculoskelet Disord (2006) 7:66.[CrossRef][Medline]
25 Lionis C, Olsen-Faresjo A, Anastasiou F, Wallander MA, Johansson S, Faresjo T. Measuring the frequency of functional gastrointestinal disorders in rural Crete: a need for improving primary care physicians' diagnostic skills. Rural Remote Health (2005) 5:409.[Medline]
26 Woolf AD, Zeidler H, Haglund U, et al. Musculoskeletal pain in Europe: its impact and a comparison of population and medical perceptions of treatment in eight European countries. Ann Rheum Dis (2004) 63:342–347.
27 Antonakis N, Tsoulou S, Peios D, Simeonidis P, Lyraraki E, Lionis C. Drug prescribing in primary health. Part II: drugs for cardiovascular, musculoskeletal and central nervous system diseases. Arch Hell Med (2001) 18:50–57. (in Greek).
28 Picavet HS, Hazes JM. Prevalence of self reported musculoskeletal disease is high. Ann Rheum Dis (2003) 62:644–650.
29 Bao S, Winkel J, Shahnavaz H. Prevalence of musculoskeletal disorders at workplaces in the People's Republic of China. Int J Occup Saf Ergon (2000) 6:557–574.[Medline]
30 Mansfield NJ, Marshall JM. Symptoms of musculoskeletal disorders in stage rally drivers and co-drivers. Br J Sports Med (2001) 35:314–320.
31 Hagen KB, Magnus P, Vetlesen K. Neck/shoulder and low-back disorders in the forestry industry: relationship to work tasks and perceived psychosocial job stress. Ergonomics (1998) 41:1510–1518.[Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  D. Mosshammer, G. Lorenz, S. Meznaric, J. Schwarz, R. Muche, and K. Morike Statin use and its association with musculoskeletal symptoms--a cross-sectional study in primary care settings Fam. Pract., April 1, 2009; 26(2): 88 - 95. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||