Multisite Musculoskeletal Pain Research Articles

Erratum to: Associations of multisite pain with healthcare utilization, sickness absence and restrictions at work.

Despite the apparent importance of multisite musculoskeletal pain (MMP) for functioning, there is still a lack of studies that have investigated the influence of MMP on healthcare utilization (HU), sickness absence (SA) and restrictions of work (RW). This study described the HU, SA and RW due to musculoskeletal pain (MP) in different body sites and according to number of pain sites and investigated associations between number of pain sites with these three outcomes in workers from Bahia, Brazil. This study was based on two cross-sectional surveys carried out in 2010 and 2012. The response in the pooled data was 97 % (n = 1070, 228 women and 842 men). Interviewer-administered questionnaire was used with questions on HU, SA and RW due to MP. The number of pain sites is the sum score of eight body sites with pain in previous 12 months. Covariates were age, gender, physical and psychosocial work demands, leisure-time physical activities and body mass index. Cox regression models, properly applied to a cross-sectional study, determined the associations between number of pain sites with the three outcomes. Prevalence of MP in the previous 12 months is 81.2 %, and MMP accounted for two-thirds of pain. We found consistently increasing occurrence of HU, SA and RW with increasing number of pain sites. For individuals with pain in four or more body sites, the utilization of health care was 1.7-fold the utilization by workers with single-site pain. Having pain in four or more sites increased the prevalence of SA 3.6-fold and of RW 4.0-fold compared with having single-site pain, after adjustment by covariates. The functional consequences of pain depend on how much body regions are affected, i.e., the more widespread pain, the higher the likelihood of medical consumption, sickness absence and restricted work. Given the high comorbidity, the number of pain sites, instead of specific body site of pain, seems to be a useful measure to anticipate interventions at workplaces for musculoskeletal disease prevention.

Associations of multisite pain with healthcare utilization, sickness absence and restrictions at work.

PurposeDespite the apparent importance of multisite musculoskeletal pain (MMP) for functioning, there is still a lack of studies that have investigated the influence of MMP on healthcare utilization (HU), sickness absence (SA) and restrictions of work (RW). This study described the HU, SA and RW due to musculoskeletal pain (MP) in different body sites and according to number of pain sites and investigated associations between number of pain sites with these three outcomes in workers from Bahia, Brazil.MethodsThis study was based on two cross-sectional surveys carried out in 2010 and 2012. The response in the pooled data was 97 % (n = 1070, 228 women and 842 men). Interviewer-administered questionnaire was used with questions on HU, SA and RW due to MP. The number of pain sites is the sum score of eight body sites with pain in previous 12 months. Covariates were age, gender, physical and psychosocial work demands, leisure-time physical activities and body mass index. Cox regression models, properly applied to a cross-sectional study, determined the associations between number of pain sites with the three outcomes.ResultsPrevalence of MP in the previous 12 months is 81.2 %, and MMP accounted for two-thirds of pain. We found consistently increasing occurrence of HU, SA and RW with increasing number of pain sites. For individuals with pain in four or more body sites, the utilization of health care was 1.7-fold the utilization by workers with single-site pain. Having pain in four or more sites increased the prevalence of SA 3.6-fold and of RW 4.0-fold compared with having single-site pain, after adjustment by covariates.ConclusionsThe functional consequences of pain depend on how much body regions are affected, i.e., the more widespread pain, the higher the likelihood of medical consumption, sickness absence and restricted work. Given the high comorbidity, the number of pain sites, instead of specific body site of pain, seems to be a useful measure to anticipate interventions at workplaces for musculoskeletal disease prevention.

Physical and mental strain at work: Relationships with onset and persistent of multi-site pain in a four-year follow up

This study evaluates the association of physical and mental strain with the onset and persistence of multi-site musculoskeletal pain among younger and older employees in four-year follow-up. A questionnaire survey was conducted twice in a food processing company, in 2005 and 2009, with responses from 734 employees (445 younger and 289 older; 65% female). Information on musculoskeletal pain during the preceding week and perceived mental and physical strain was obtained through a structured questionnaire. The association of onset and persistent of multi-site pain with mental and physical strain was estimated with log binomial regression analysis and stratified by age group. Risk ratios (RR) with their 95% confidence intervals (CIs) are reported for the estimates. More than 56% of the employees reported multi-site pain at baseline. Among those who reported multi-site pain at baseline 70% reported persistent multi-site pain and one-third reported new onset of multi-site pain at follow-up. Mental strain at baseline strongly predicted persistence of multi-site pain among both younger and older employees (RR from for younger employees = 1.68, 95% CI = 1.01–2.83 and RR for older employees = 2.25, 95% CI 0 1.27–3.98) but the association with physical strain was not statistically significant. Mental strain predicted the risk of persistence of multi-site pain among both younger and older employees in four-year follow-up but not onset of multi-site pain. Relevance to the industryThe results of this study suggest that monitoring working conditions of all age workers can reduce physical and mental strain, thereby reducing the incidence of multi-site musculoskeletal pain and promoting workers' health.

Multisite musculoskeletal pain among young technical school students entering working life.

BackgroundThere is a need to investigate the occurrence of multisite pain in young adults and to determine potential factors contributing to the early course of multisite musculoskeletal pain. The aim of this prospective study was to assess the occurrence and change of prevalence in the number of pain sites. We also wanted to identify work-related and individual risk factors associated with the number of musculoskeletal pain sites.MethodsWe monitored musculoskeletal pain from 4 body regions, individual and work-related factors on 21 occasions over a 6.5 year period. The cohort consisted of 420 technical school students entering working life. Data were analyzed by generalized estimating equations (GEE).ResultsPain from more than one body site was prevalent in this cohort of young adults (69 % at baseline), and the number of body sites in pain was found quite stable over the 6.5 year follow-up period. Women had higher number of pain sites compared with men and gender specific risk factors were identified. Increased mechanical workload and quantitative demands and low socioeconomic status were associated with increased number of musculoskeletal pain sites among women, while tobacco use was found as a risk factor among young men. Increased perceived muscle tension was the only factor significantly associated with increased number of pain sites in both genders.ConclusionThe current study supports earlier findings and show that pain from multiple body sites are frequent also among young workers. The identification of gender specific risk factors in our study is important and may facilitate practical prevention and future research.

The brain-derived neurotrophic factor pathway, life stress, and chronic multi-site musculoskeletal pain.

IntroductionBrain-derived neurotrophic factor (BDNF) disturbances and life stress, both independently and in interaction, have been hypothesized to induce chronic pain. We examined whether (a) the BDNF pathway (val66met genotype, gene expression, and serum levels), (b) early and recent life stress, and (c) their interaction are associated with the presence and severity of chronic multi-site musculoskeletal pain.MethodsCross-sectional data are from 1646 subjects of the Netherlands Study of Depression and Anxiety. The presence and severity of chronic multi-site musculoskeletal pain were determined using the Chronic Pain Grade (CPG) questionnaire. The BDNF val66met polymorphism, BDNF gene expression, and BDNF serum levels were measured. Early life stress before the age of 16 was assessed by calculating a childhood trauma index using the Childhood Trauma Interview. Recent life stress was assessed as the number of recent adverse life events using the List of Threatening Events Questionnaire.ResultsCompared to val66val, BDNF met carriers more often had chronic pain, whereas no differences were found for BDNF gene expression and serum levels. Higher levels of early and recent stress were both associated with the presence and severity of chronic pain (p < 0.001). No interaction effect was found for the BDNF pathway with life stress in the associations with chronic pain presence and severity.ConclusionsThis study suggests that the BDNF gene marks vulnerability for chronic pain. Although life stress did not alter the impact of BDNF on chronic pain, it seems an independent factor in the onset and persistence of chronic pain.

Heightened cold pain and pressure pain sensitivity in young female adults with moderate-to-severe menstrual pain.

This study investigated the association between menstrual pain severity and psychophysical measures of cold and pressure pain sensitivity. A cross-sectional design was used with young women (n = 432) from the Western Australian Pregnancy Cohort (Raine) Study. Menstrual pain severity and oral contraception use was obtained from questionnaires at 20 and 22-year follow-ups. A visual analog scale (VAS; range from 0 [none] to 10 [unbearable]) was used to measure menstrual pain severity at both 20 and 22 years over the 3-year period, with 3 groups created: (1) no pain or mild pain (VAS 0-3), (2) at least moderate pain at a minimum of 1 of the 2 time points (hereafter named "mixed)", and (3) severe pain (VAS 8-10). Cold pain sensitivity (dorsal wrist) and pressure pain sensitivity (lumbar spine, upper trapezius, dorsal wrist, and tibialis anterior) were assessed using standardised quantitative sensory testing protocols. Confounding variables included number of musculoskeletal pain sites, oral contraceptive use, smoking, physical activity, body mass index, psychological distress, and sleep. Severe menstrual pain and mixed menstrual pain were positively associated with heightened cold pain sensitivity (distant from menstrual pain referral site) and pressure pain sensitivity (local to menstrual pain referral site). These associations remained significant after adjusting for potential confounding variables including multisite musculoskeletal pain. Our findings suggest peripheral and central neurophysiological mechanisms contributing to heightened pain sensitivity in young women with moderate and severe menstrual pain. These data highlight the need for innovative management approaches to attenuate the negative impact of severe menstrual pain in young women.

Good work ability despite multisite musculoskeletal pain? A study among occupationally active Finns.

Although multisite pain (MSP) often threatens work ability (WA), some of those with MSP retain good WA. Our aim was to identify factors associated with good WA among subjects with MSP. A nationally representative sample (the Health 2000-Study, response rate 87%) comprising 3884 occupationally active Finns aged 30-64 years. Data on WA, musculoskeletal pain, physical and psychosocial working conditions, chronic diseases, lifestyle and domestic situation were gathered by questionnaire, interview and clinical examination. Good current WA compared with the lifetime best was defined as ⩾9 on a 0-10 scale. Musculoskeletal pain in 18 body locations was combined into four sites, and thereafter pain in two or more sites was defined as MSP (N=1351). Poisson regression analysis was used to obtain prevalence rate ratios (PRR). Good WA was reported by 48% of the women and 37% of the men with MSP. In a multivariable model good WA was associated with younger age, female gender, physically non-strenuous work (PRR 1.3, 95% CI 1.1-1.5), low job strain (1.2, 1.0-1.4), high supervisor support (1.2, 1.0-1.4), and not having musculoskeletal diseases (1.3, 1.1-1.5), mental disorders (1.4, 1.1-1.9), daytime tiredness (1.4, 1.2-1.7) or economic troubles (1.5, 1.1-1.9). Age-stratified analyses revealed also associations with high coworker support (1.2, 1.0-1.4) and strenuous leisure-time physical exercise (1.2, 1.0-1.4) in those aged 30-44 and low alcohol consumption (1.8, 1.2-2.6) in the age-group 45-64. Several potentially modifiable factors related to health, work, and lifestyle were associated with good WA among occupationally active subjects with MSP.

The impact of multi-site musculoskeletal pain on work ability among health care providers.

BackgroundEpidemiologic studies have reported that multi-site musculoskeletal pain threatens work ability. However, no study has been conducted on this topic among health care providers. The aim of the present study was to determine the association between multi-site pain and poor work ability among health care providers.MethodsA cross-sectional study was conducted. Participants completed a self-administered questionnaire including basic characteristics, job satisfaction, stress screening, musculoskeletal pain at neck, upper extremities, low back, and lower extremities within the last month, and work ability index. Pain intensity was dichotomized according to a numerical pain rating scale score: less than five (no) and at least five (yes). Musculoskeletal pain was divided in three groups: 1) no pain, 2) few pain sites (one to two sites), and 3) many pain sites (three to four sites). The association of the number of pain sites with poor work ability was explored through multivariable logistic regression analysis.ResultsA total of 254 health care providers participated in the present study. The majority of participants were female (73.2 %) with mean age of 33.9 (SD 9.5) years. Few pain sites and many pain sites were reported by 79 (31.1 %) and 39 participants (15.4 %), respectively. The adjusted odds ratio for poor work ability of participants who had few pain sites and many pain sites were 1.85 (95 % CI: 0.91 – 3.76) and 2.41 (95 % CI: 1.04 – 5.58), respectively.ConclusionThe present study showed that multi-site musculoskeletal pain had an association with poor work ability. The magnitude of association was likely to increase by a higher number of pain sites.

Body Composition Is Associated With Multisite Lower Body Musculoskeletal Pain in a Community-Based Study

Population-based studies suggest that pain in the lower body is common and that pain at multiple sites is more prevalent than single-site pain. Obesity is a risk factor for multisite musculoskeletal pain, but there are limited data on the role of body composition. Therefore, we sought to determine whether body composition is associated with multisite musculoskeletal pain involving the low back, knee, and foot. A total of 133 participants were recruited for a study examining the relationship between obesity and musculoskeletal disease. Participants completed validated questionnaires that examined levels of pain at the low back, knee, and foot. Body composition was assessed using dual-energy x-ray absorptiometry. Multisite pain was common, with 26.3% of participants reporting pain at 2 sites and 31.6% at 3 sites, and only 20% were pain free. The low back was the most common site of pain (63%). Greater fat mass and fat mass index, but not fat-free mass, were associated with pain at a greater number of sites, independent of age, gender, and fat-free mass (P < .01). Longitudinal studies exploring the mechanism of action by which increased fat mass is associated with pain may provide important insights into therapeutic strategies for the prevention of multisite pain. PerspectiveGreater fat mass and fat mass index were associated with a greater number of lower body pain sites, with no association observed for fat-free mass. Understanding the mechanism by which increased fat mass is associated with pain may provide important insights into therapeutic strategies for the prevention of pain.

Biological stress systems, adverse life events and the onset of chronic multisite musculoskeletal pain: a 6-year cohort study

ObjectivesDysregulated biological stress systems and adverse life events, independently and in interaction, have been hypothesised to initiate chronic pain. We examine whether (1) function of biological stress systems, (2) adverse...

Multisite musculoskeletal pain predicts medically certified disability retirement among Finns.

Musculoskeletal pain at several sites (multisite pain) is more common than single-site pain. Little is known on its effects on disability pension (DP) retirement. A nationally representative sample comprised 4071 Finns in the workforce aged 30 to 63. Data (questionnaire, interview, clinical examination) were gathered in 2000-2001 and linked with national DP registers for 2000-2011. Pain during the preceding month in 18 locations was combined into four sites (neck, upper limbs, low back, lower limbs). Hazard ratios (HR) of DP were estimated by Cox regression. The HR of any DP (n = 477) was 1.6 (95% confidence interval 1.2-2.1) for one, 2.5 (1.9-3.3) for two, 3.1 (2.3-4.3) for three and 5.6 (4.0-7.8) for four pain sites, when adjusted for age and gender. When additionally adjusted for clinically assessed chronic diseases, the HRs varied from 1.4 (1.0-1.8) to 3.5 (2.5-4.9), respectively. When further adjusted for physical and psychosocial workload, education, body mass index, smoking, exercise and sleep disorders, the HRs were 1.3 (0.9-1.7), 1.6 (1.2-2.2), 1.8 (1.3-2.5) and 2.5 (1.8-3.6). The number of pain sites was especially strong in predicting DPs due to musculoskeletal diseases (HRs in the full model; 3.1 to 4.3), but it also predicted DPs due to other somatic diseases (respective HRs 1.3 to 2.3); pain in all four sites was also predictive of DPs due to mental disorders (full model HR 2.2). The number of pain sites independently predicted DP retirement. Employees with multisite pain may need specific support to maintain their work ability.

An Experimental Approach to Examining Psychological Contributions to Multisite Musculoskeletal Pain

The present study examined the prospective value of pain catastrophizing, fear of pain, and depression in the prediction of multisite musculoskeletal pain following experimentally induced delayed-onset muscle soreness (DOMS). The study sample consisted of 119 (63 females, 56 males) healthy university students. Measures of pain catastrophizing, fear of pain, and depression were completed prior to the DOMS induction procedure. Analyses revealed that pain catastrophizing and fear of pain prospectively predicted the experience of multisite pain following DOMS induction. Analyses also revealed that women were more likely to experience multisite pain than men. There was no significant relation between depressive symptoms and the experience of multisite pain. The discussion addresses the mechanisms by which pain catastrophizing and fear of pain might contribute to the spreading of pain. Clinical implications of the findings are also addressed. PerspectiveThe results of this experimental study suggest that pain catastrophizing and fear of pain might increase the risk of developing multisite pain following musculoskeletal injury.

Developmental trajectories of multisite musculoskeletal pain and depressive symptoms: The effects of job demands and resources and individual factors

Objective: To investigate developmental paths in multisite musculoskeletal pain (MPS) and depressive symptoms (DPS) and the effects of job demands (JD), job resources (JR), optimism and health-related lifestyle on these paths. We expected to find four trajectories – Low Symptoms, High Pain, High Depression and High Symptoms – and hypothesised that high JDs, low JRs, low optimism and adverse lifestyle predict belonging to trajectories with high symptom levels.Design: Data on Finnish firefighters (N = 360) were collected in 1996, 1999 and 2009. The effects of JDs (mental and physical workload), JRs (supervisory relations, interpersonal relations, task resources), optimism and lifestyle (alcohol consumption, smoking, physical exercise, sleeping) on MPS and DPS were assessed. Latent class growth modelling and multinomial logistic regression were applied.Results: Three trajectories emerged: Low Symptoms; High Pain; and High Depression. In a multivariable model, high mental workload (OR 2.9, 95% CI 1.5–5.5), poor interpersonal relations (2.6, 1.4–5.0), sleeping problems (2.7, 1.4–5.2) and low optimism (2.0, 1.0–3.7) predicted belonging to High Depression. Alcohol consumption (2.4, 1.4–4.1) and sleeping problems (2.1, 1.3–3.6) were related to High Pain.Conclusions: Different developmental paths in MPS and DPS are possible. Partly different factors predict the development of pain and depressive symptoms.

Reduced hypothalamic-pituitary-adrenal axis activity in chronic multi-site musculoskeletal pain: partly masked by depressive and anxiety disorders.

BackgroundStudies on hypothalamic-pituitary-adrenal axis (HPA-axis) function amongst patients with chronic pain show equivocal results and well-controlled cohort studies are rare in this field. The goal of our study was to examine whether HPA-axis dysfunction is associated with the presence and the severity of chronic multi-site musculoskeletal pain.MethodsData are from the Netherlands Study of Depression and Anxiety including 1125 subjects with and without lifetime depressive and anxiety disorders. The Chronic Pain Grade questionnaire was used to determine the presence and severity of chronic multi-site musculoskeletal pain. Subjects were categorized into a chronic multi-site musculoskeletal pain group (n = 471) and a control group (n = 654). Salivary cortisol samples were collected to assess HPA-axis function (awakening level, 1-h awakening response, evening level, diurnal slope and post-dexamethasone level).ResultsIn comparison with the control group, subjects with chronic multi-site musculoskeletal pain showed significantly lower cortisol level at awakening, lower evening level and a blunted diurnal slope. Lower cortisol level at awakening and a blunted diurnal slope appeared to be restricted to those without depressive and/or anxiety disorders, who also showed a lower 1-h awakening response.ConclusionsOur results suggest hypocortisolemia in chronic multi-site musculoskeletal pain. However, if chronic pain is accompanied by a depressive or anxiety disorder, typically related to hypercortisolemia, the association between cortisol levels and chronic multi-site musculoskeletal pain appears to be partly masked. Future studies should take psychopathology into account when examining HPA-axis function in chronic pain.

Does the association between musculoskeletal pain and sickness absence due to musculoskeletal diagnoses depend on biomechanical working conditions?

To investigate single-site and multi-site musculoskeletal pain as predictors of future sickness absence due to musculoskeletal disorders (MSD) among blue-collar employees in food industry, and to study to what extent this relationship depends on physical loading at work. Survey responses of 901 employees on working conditions and musculoskeletal pain during the past week were linked to their future sickness absence records obtained from the personnel register of a food industry company. Negative binomial regression models were computed to determine associations of pain in one and in multi-site with the number of sickness absence days due to MSD during a four-year follow-up. Analyses were made in the whole cohort and stratified by the occurrence of repetitive movements and awkward postures (low/high). Multi-site pain occurred among 59 % in the total cohort and predicted sickness absence with a rate ratio of 1.48 [95 % confidence interval (CI) 1.21-1.80], adjusted for age, gender, biomechanical and psychosocial working conditions, body mass index and physical exercise. Similar associations were seen in the sub-cohorts with a low occurrence of repetitive movements (RR 2.18, CI 1.69-2.80) and awkward postures (RR 1.78, CI 1.39-2.28), but not in the sub-cohorts with a high occurrence of these exposure. Single-site pain was not predictive of sickness absence. A very high level of sickness absence in biomechanically strenuous work was found. Multi-site pain predicted sickness absence due to MSD among the employees with low exposure, but not among those with high exposure.

0028 Multi-site musculoskeletal pain and physical working conditions as predictors of sickness absence due to musculoskeletal diagnoses

ObjectivesTo investigate the importance of multi-site musculoskeletal pain as a predictor of sickness absence days due to musculoskeletal disorders (MSD) among blue-collar employees, and to study what extent such a...

Basal inflammation and innate immune response in chronic multisite musculoskeletal pain

Dysregulation of the immune system may play a role in chronic pain, although study findings are inconsistent. This cross-sectional study examined whether basal inflammatory markers and the innate immune response are associated with the presence and severity of chronic multisite musculoskeletal pain. Data were used on 1632 subjects of the Netherlands Study of Depression and Anxiety. The Chronic Pain Grade questionnaire was used to determine the presence and severity of chronic multisite musculoskeletal pain. Subjects were categorized in a chronic multisite musculoskeletal pain group (n=754) and a control group (n=878). Blood levels of the basal inflammatory markers C-reactive protein, interleukin-6, and tumor necrosis factor-alpha were determined. To obtain a measure of the innate immune response, 13 inflammatory markers were assessed after lipopolysaccharide (LPS) stimulation in a subsample (n=707). Subjects with chronic multisite musculoskeletal pain showed elevated levels of basal inflammatory markers compared with controls, but statistical significance was lost after adjustment for lifestyle and disease variables. For some LPS-stimulated inflammatory markers, we did find elevated levels in subjects with chronic multisite musculoskeletal pain both before and after adjustment for covariates. Pain severity was not associated with inflammation within chronic pain subjects. An enhanced innate immune response in chronic multisite musculoskeletal pain may be examined as a potential biomarker for the onset or perpetuation of chronic pain.

Predictive risk factors for chronic regional and multisite musculoskeletal pain: A 5-year prospective study in a working population

The role of psychosocial and physical factors in the development of musculoskeletal pain (MSP) has now been clearly demonstrated. However, it is unclear whether these factors contribute to specific regional MSP or to multisite pain. The main goal of this study was to assess the impact of work-related factors according to gender on the development of regional and multisite MSP. A total of 12,591 subjects (65% men and 35% women) who were born in 1938, 1943, 1948, and 1953 and were participating in a French longitudinal prospective epidemiological survey (ESTEV) in 1990 to 1995 were eligible. Personal factors and work exposure were assessed by self-administered questionnaires. Statistical associations between chronic MSP (regional body site or multisite), personal factors, and occupational factors were analyzed using logistic regression modeling. The incidence of regional MSP and multisite pain in 1995 were, respectively, 17% and 25.6%. For women, highly repetitive movements predicted neck/shoulder pain; posture and vibrations predicted arm and low back pain; and effort with tools predicted arm pain. For men, forceful effort and vibrations predicted neck/shoulder pain; posture and forceful effort predicted lower limb and low back pain; and forceful effort and effort with tools predicted arm pain. Physical constraints (ie, forceful effort or vibrations) were associated with multisite pain in both genders. Only for women, psychological factors were risk factors predictive of upper limb pain and in 3 or 4 painful anatomical sites. These results support the hypothesis that some physical and psychological work-related factors are predictive of regional or multisite MSP but differ according to gender. Gender differences and risk factors for work-related musculoskeletal pain should be also taken into account to more effectively target preventive measures.

Is it all about a pain in the back?

Multisite musculoskeletal pain is common among people suffering from low back pain. Although the mechanisms behind co-occurrence of multiple somatic symptoms and musculoskeletal pain are still unknown, patients with co-morbidities and co-occurring musculoskeletal symptoms tend to have worse functional status, a poorer prognosis and respond less favourably to treatment. Evidence also suggests that the more pain sites a patient reports, the more reduced their physical and mental function will be regardless of location of pain. At the same time, evidence suggests that strategies for diagnosis and treatment of low back pain and other musculoskeletal disorders such as neck pain and lower limb osteoarthritis are very similar. In this chapter, we discuss the prevalence, consequences, and implications of commonalities between low back pain, pain in other sites and co-occurring pain. In addition, we propose a conceptual framework for a common stepwise approach to the diagnosis and management of back and musculoskeletal pain.

251 Differences in the determinants of extensive as compared with more limited musculoskeletal pain

ObjectivesTo explore whether multi-site musculoskeletal pain differs from more localised musculoskeletal pain in its association with risk factors.MethodsAs part of the CUPID study, standardised questionnaires were used to ascertain exposure...