What can be done about the increasing prevalence of low back pain and associated comorbid factors?

Abstract

Pain ManagementVol. 5, No. 3 EditorialFree AccessWhat can be done about the increasing prevalence of low back pain and associated comorbid factors?Laxmaiah Manchikanti & Joshua A HirschLaxmaiah Manchikanti*Author for correspondence: E-mail Address: drlm@thepainmd.com Pain Management Center of Paducah, 2831 Lone Oak Rd, Paducah, KY 42003, USA & University of Louisville, Louisville, KY 40292, USASearch for more papers by this author & Joshua A Hirsch Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USASearch for more papers by this authorPublished Online:14 May 2015https://doi.org/10.2217/pmt.15.10AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail Keywords: chronic low back paincomorbid factorsdisabilityeconomic impactergonomicsformative stagepreventionrisk factorsLow back pain continues to be the leading cause of global disability; its effect on patient's health and the economy continues to escalate [1–3]. It has a mean point prevalence of 18%, 1-year prevalence of 38% and lifetime prevalence of 39% [1]. Perhaps not surprisingly, in terms of direct and indirect costs, low back pain is the most expensive disorder [4,5]. Freburger et al. [6] showed a rising prevalence of chronic low back pain over a 14-year interval in North Carolina, USA, from 3.9% in 1992 to 10.2% in 2006 – a stunning 162% increase. Even though the clinical course of episodic low back pain is benign for many patients, some will not recover. These patients might then develop chronic low back pain lasting for 3 months or longer. The reported proportion of patients developing chronic low back pain ranges from 24–80% with an average of 50% [7,8]. Thus, the overall burden of chronic low back pain has been described as costly with high impact on healthcare [4–5,8–9], most years lived with disability [2,3] and significantly higher comorbidity burden [5]. Utilization of various modalities of treatments also have escalated, starting with over-the-counter medications, legalization of marijuana, use of high-dose opioids, interventional techniques and finally, complex fusion surgeries, even though disability due to low back pain continues to be number one.Low back pain is a multifactorial disorder with many possible etiologies, risk factors and co-morbidities [1,5,7–8]. Pathophysiologically, low back pain may be caused by lumbar intervertebral discs, facet joints, sacroiliac joints, ligaments, fascia, muscles or nerve root dura which are capable of transmitting pain in the lumbar spine. The resulting symptoms can be low back pain and/or lower extremity pain [9]. Unfortunately, obvious causes of pathology correlating with symptomatology are identified in only approximately 15% of the population. While all else is classified as nonspecific low back pain, by utilizing controlled diagnostic blocks, intervertebral discs, facet joints and sacroiliac joints have been shown to be causative factors in approximately over 50% of the patients who do not have disc herniation, spinal stenosis or other identifiable pathology [9,10]. However, the research community continues to face challenges in finding appropriate diagnostic strategies, with continuing debate on methodology applied in diagnosis of chronic low back pain [9–11].The main predictors of low back pain include physical stress such as prolonged lifting, driving, forceful or repetitive movements involving the back and awkward postures [12–14]; psychosocial stressors including a high-perceived workload and time pressure, low control and lack of social support at work [8,14]; personal characteristics including psychological status and smoking; physical characteristics including height and weight [8,12,15]; and emotional and psychological status [9,16]. Other predictors also include an active lifestyle, socioeconomic status, education and an understanding of body mechanics. Even though, with few exceptions, the majority of attention is focused in the literature on occupational and degenerative factors during adolescence and adulthood (essentially during working years of life focusing exclusively on ergonomic and psychosocial working conditions), only few relevant longitudinal data on risk factors in the formative stage and adult low back pain have been described [12,17–18]. Thus, early life factors include social class at birth; growth patterns; social and emotional status; physical characteristics such as height and weight.Consequently, researchers and clinicians alike have faced challenges for centuries in finding prevention strategies to reduce the burden of chronic low back pain. Thus, we believe that, in order to reduce the increasing prevalence of chronic low back pain, it is of paramount importance to identify the risk factors and co-morbidities from the formative stage, namely early childhood and control them rather than focusing on policies and treatments only during adult life. With the current systems and approach, including rewards for disability from low back pain, co-morbid factors, and fear and anxiety playing crucial roles, prevention is difficult, if not impossible. A focus on early health education, environmental, occupational and psychosocial aspects from childhood must play a central role in avoiding the development of chronic low back pain and its resulting impact.A British study of 1958 birth cohorts included 17,414 births [12], including five subsequent follow-up studies conducted when cohort members were aged 7, 11, 16, 23 and 33. The most recent survey in 1991 included 11,407 cohort members [17]. Power et al. [12] showed a significant association of heavy smoking and psychological distress with increased levels of pain. Further, occupational factors and poor emotional status showed significant association with incident pain in men. In contrast, in women, somatization and social class at birth were significantly associated with incident pain. In addition, BMI and job satisfaction failed to show significant sustained correlation. Thus, based on the evidence from this prospective cohort, psychological distress more than doubles the later risk of low back pain, with smoking having a modest independent effect.Mustard et al. [18], in the Ontario child health study, looked at the formative stage of childhood and early adult predictors of the risk of incident back pain. Similar to Power et al.'s [12] study, Mustard et al. [18] showed an association with incident pain in young adults to psychological distress and persistent moderately heavy smoking. Other factors predicting a risk of low back pain were lower levels of parental education and emotional or behavioral disorders in childhood. Behavior, socioeconomic status and work environment were associated with an increased risk of incident back pain.Thus, a reasonably clear picture emerges illustrating the linkage of multiple complex causal pathways in the formative stage to adult health status. Psychological distress was an important risk factor for incident back pain in both studies of the formative stage [12,18] and also has been highlighted by numerous authors [5,7–8,14,16]. Multiple psychological factors have been implicated in the development and enhancement of chronic low back pain. They include anxiety and depression, catastrophizing, kinesiophobia (fear of movement) and somatization (the expression of distress as physical symptoms or their persistence) [7–8,14,16]. Ergonomic factors related to heavy lifting, pushing, pulling, prolonged walking or standing and awkward postures have been identified as predictors of future back pain [7–8,13–14]. In addition, physical workload, job demands, lack of control over the job, stressful and monotonous work, dissatisfaction with work and vibration have been described as causative factors of low back pain [14]. A number of demographic, lifestyle and social factors, including obesity, smoking, physical activity, social class, low levels of education and low income have been linked to new onset and persistent chronic low back pain. Social issues such as sexual and physical abuse or deterioration in social life and even financial issues have been shown to be associated with increased levels of new onset and chronic sustained low back pain. Age and multiple degenerative conditions have been attributed to a higher incidence of low back pain along with a higher prevalence of low back pain in women.In discussing the prevention of chronic low back pain, resultant disability and multiple co-morbid factors, attention must be focused from the formative stage of childhood. Age, gender and genetics have variable influence and cannot be modified. However, environmental and ergonomic factors are modifiable with appropriate education in reference to maintaining health and avoiding disability. Power et al. [12] and Mustard et al. [18] have provided temporal evidence with inclusion of multiple risk factors from early life in relation to pain onset in early adulthood. Both studies [12,18] showed the influence of psychological distress and smoking as risk factors for the onset of low back pain. Further, Mustard and colleagues [18] have also shown that early life factors of low-level parental education, low socioeconomic status and the presence of a childhood mental health disorder are associated with an increased risk of back pain onset. Thus, parental and childhood education, prevention of smoking, avoidance of psychological and social distress, and health lifestyle and health education must be the focus of primary preventive measures of chronic low back pain.Generally, the prevention of chronic low back pain has been limited to managing acute low back pain with interventions focusing on either biomechanics, fear avoidance, work and social factors, or exercise. However, not only these approaches, but numerous other modalities of treatments, have not been successful. Multiple studies have identified characteristics of patients who are at risk of developing chronic low back pain [7–8,12,18–20]. Thus, education and exercises have been recommended universally to avoid chronic pain. The educational approach must be initiated in the formative stages of development with an understanding of the anatomy of the spine, pathophysiology of pain, biomechanics, fear avoidance and perceptions of well being.In conclusion, chronic low back pain is complex with increasing prevalence and escalating disability despite numerous modalities of treatments. Primary prevention starting in the formative stage focusing on education, psychosocial and social factors, healthy lifestyles with exercises and avoidance of smoking are crucial factors in lowering the overall prevalence of low back pain, specifically, chronic low back pain and associated co-morbidities.Financial & competing interests disclosureL Manchikanti has provided limited consulting services to Semnur Pharmaceuticals, Incorporated, which is developing nonparticulate steroids. JA Hirsch is a consultant for Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.Papers of special note have been highlighted as: • of interest; •• of considerable interest.References1 Hoy DG, Bain C, Williams G et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum. 64(6), 2028–2037 (2012).Crossref, Medline, Google Scholar2 US Burden of Disease Collaborators. The state of US health, 1999–2010: burden of diseases, injuries, and risk factors. JAMA 310(6), 591–608 (2013).•• Provides extensive data on burden of diseases, injuries and risk factors in the USA showing low back pain as the number one cause and neck pain also among the top five conditions causing the disability.Crossref, Medline, Google Scholar3 Vos T, Flaxman AD, Naghavi M et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380(9859), 2163–2196 (2012).Crossref, Medline, Google Scholar4 Martin BI, Turner JA, Mirza SK, Lee MJ, Comstock BA, Deyo RA. Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine 34(19), 2077–2084 (2009).Crossref, Medline, Google Scholar5 Gore M, Sadosky A, Stacey BR, Tai KS, Leslie D. The burden of chronic low back pain: clinical comorbidities, treatment patterns, and health care costs in usual care settings. Spine 37(11), E668–E677 (2012).• Describes in a comprehensive manner the burden of chronic low back pain with multiple co-morbid conditions, as well as increasing burden of costs compared with patients without low back pain.Crossref, Medline, Google Scholar6 Freburger JK, Holmes GM, Agans RP et al. The rising prevalence of chronic low back pain. Arch. Intern. Med. 169(3), 251–258 (2009).Crossref, Medline, Google Scholar7 Hoy D, Brooks P, Blyth F, Buchbinder R. The epidemiology of low back pain. Best Pract. Res. Clin. Rheumatol. 24(6), 769–781 (2010).Crossref, Medline, CAS, Google Scholar8 Manchikanti L, Singh V, Falco FJE, Benyamin RM, Hirsch JA. Epidemiology of low back pain in adults. Neuromodulation 17(Suppl. 2), 3–10 (2014).Crossref, Medline, Google Scholar9 Manchikanti L, Abdi S, Atluri S et al. An update of comprehensive evidence-based guidelines for interventional techniques of chronic spinal pain: part II: guidance and recommendations. Pain Physician 16(Suppl 2), S49–S283 (2013).Medline, Google Scholar10 Bogduk N. On diagnostic blocks for lumbar zygapophysial joint pain. F1000 Med. Rep. 2, 57 (2010).Crossref, Medline, Google Scholar11 Carragee EJ, Haldeman S, Hurtwitz E. The pyrite standard: the Midas touch in the diagnosis of axial pain syndromes. Spine J. 7(1), 27–31 (2007).Crossref, Medline, Google Scholar12 Power C, Frank J, Hertzman C, Schierhout G, Li L. Predictors of low back pain onset in a prospective British study. Am. J. Public Health 91(10), 1671–1678 (2001).Crossref, Medline, CAS, Google Scholar13 van Oostrom SH, Verschuren M, de Vet HC, Boshuizen HC, Picavet HS. Longitudinal associations between physical load and chronic low back pain in the general population: the Doetinchem Cohort Study. Spine 37(9), 788–796 (2012).Crossref, Medline, Google Scholar14 Yilmaz E, Dedeli O. Effect of physical and psychosocial factors on occupational low back pain. Health Science J. 6(4), 598–609 (2012).Google Scholar15 Mikkonen P, Laitinen J, Remes J et al. Association between overweight and low back pain: a population-based prospective cohort study of adolescents. Spine 38(12), 1026–1033 (2013).Crossref, Medline, Google Scholar16 Hasenbring MI, Chehadi O, Titze C, Kreddig N. Fear and anxiety in the transition from acute to chronic pain: there is evidence for endurance besides avoidance. Pain Manag. 4(5), 363–374 (2014).Link, Google Scholar17 Ferri E. Life at 33: The Fifth Follow-Up of the National Child Development Study. National Children's Bureau, London, UK (1993).Google Scholar18 Mustard CA, Kalcevich C, Frank JW, Boyle M. Childhood and early adult predictors of risk of incident back pain: Ontario Child Health Study 2001 follow-up. Am. J. Epidemiol. 162(8), 779–786 (2005).Crossref, Medline, CAS, Google Scholar19 Traeger AC, Moseley GL, Hübscher M et al. Pain education to prevent chronic low back pain: a study protocol for a randomised controlled trial. BMJ Open 4(6), e005505 (2014).Crossref, Medline, Google Scholar20 da C, Menezes Costa L, Maher CG, Hancock MJ et al. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ 184(11), E613–E624 (2012).Crossref, Medline, Google ScholarFiguresReferencesRelatedDetailsCited ByYoung people’s low back pain and awareness of postural habits: A cross-sectional studyJournal of Back and Musculoskeletal Rehabilitation, Vol. 35, No. 5Use of a passive lumbar back exoskeleton during a repetitive lifting task: effects on physiologic parameters and intersubject variability12 November 2021 | International Journal of Occupational Safety and ErgonomicsPrevalence of Back Pain and Idiopathic Scoliosis in Adolescents From the Semiarid Region of Brazil: A Cross-sectional StudyJournal of Chiropractic Medicine, Vol. 20, No. 3Evidence for the Effectiveness of the Feldenkrais MethodKinesiology Review, Vol. 9, No. 3Prevalence of low back pain in young Brazilians and associated factors: Sex, physical activity, sedentary behavior, sleep and body mass indexJournal of Back and Musculoskeletal Rehabilitation, Vol. 33, No. 2Perturbações músculo-esqueléticas em adolescentes: estudo da prevalência e dos fatores determinantesActa Paulista de Enfermagem, Vol. 33The comorbidity of mental and physical disorders with self-reported chronic back or neck pain: Results from the China Mental Health SurveyJournal of Affective Disorders, Vol. 260Lumbosacral Radiculopathy: Inciting Events and Their Association with Epidural Steroid Injection Outcomes17 May 2019 | Pain Medicine, Vol. 20, No. 12Increased spinal height using propped slouched sitting postures: Innovative ways to rehydrate intervertebral discsApplied Ergonomics, Vol. 66Questionnaire on body awareness of postural habits in young people: construction and validation7 June 2018 | Fisioterapia em Movimento, Vol. 31, No. 0Chronic low back pain and the risk of depression or anxiety symptoms: insights from a longitudinal twin studyThe Spine Journal, Vol. 17, No. 7Research Priorities in the Field of Posttraumatic Pain and Disability: Results of a Transdisciplinary Consensus-Generating WorkshopPain Research and Management, Vol. 2016 Vol. 5, No. 3 Follow us on social media for the latest updates Metrics History Published online 14 May 2015 Published in print May 2015 Information© Future Medicine LtdKeywordschronic low back paincomorbid factorsdisabilityeconomic impactergonomicsformative stagepreventionrisk factorsFinancial & competing interests disclosureL Manchikanti has provided limited consulting services to Semnur Pharmaceuticals, Incorporated, which is developing nonparticulate steroids. JA Hirsch is a consultant for Medtronic. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.No writing assistance was utilized in the production of this manuscript.PDF download