Chronic spinal pain and physical–mental comorbidity in the United States: results from the national comorbidity survey replication

Unpacking the burden: understanding the relationships between chronic pain and comorbidity in the general population

We investigated the association of chronic pain with physical and mental comorbidity in the New Zealand population by measuring chronic pain status separate from comorbid conditions. Models of allostatic load provided a conceptual basis for considering multi-morbidity as accumulated comorbid load and for using both discrete conditions and cumulative measures in analyses. The nationally representative cross-sectional survey data included self-reported doctor-diagnosed chronic physical and mental health conditions, Kessler 10-item scale scores, an independent measure of chronic pain, and sociodemographic characteristics. The population prevalence of chronic pain is 16.9%, and a quarter (26%) of the population report 2 or more comorbid physical conditions statistically associated with chronic pain (unadjusted P<0.01). Results indicate that accumulated comorbid load is independently associated with chronic pain. Six physical conditions independently associated with chronic pain (adjusted odds range from 1.4 to 3.9) increase the risk of chronic pain in an additive manner, and residual accumulated load further increases risk for 2 or more conditions (adjusted odds 1.6). Anxiety/depression interacts synergistically with arthritis and neck/back disorders to increase the odds of reporting chronic pain beyond an additive model. This synergistic effect is not apparent for other conditions or for additional comorbid load. Results imply that measurement of chronic pain independent of comorbid conditions and adjustment for comorbid conditions is important for more accurate prevalence estimates and understanding relationships between conditions. Future epidemiological research might usefully incorporate independent measurement of chronic pain alongside adjustment for specific physical and mental health conditions as well as accumulated comorbid load.

A novel massage therapy technique for management of chronic cervical pain: a case series

Background:

Neck pain is a generalized condition resulting from a complex etiology with presentation of a wide variety of symptoms. Neck pain is most often accompanied by decreased range of motion (ROM), muscle and joint stiffness, and limitations in functional capabilities. This condition may result in significant personal and societal burden.

Purpose:

We evaluated the effectiveness of a novel massage therapy intervention by following the treatment regimen and outcomes of two patients experiencing chronic neck pain.

Participants:

Two patients (46 and 53 years old) experienced chronic (>5 years) neck pain. Both patients reported pain, limited ROM, and muscle and joint stiffness. Additionally, the first patient reported a lack of sleep, and both patients stated their pain interfered with their quality of life and activities of daily living.

Intervention:

Patients received the Integrative Muscular Movement Technique (IMMT) intervention approximately twice a week for a total of eight treatments, each approximately 20 minutes in duration.

Results:

Both patients experienced a reduction in pain and an increase in cervical ROM in flexion, extension, rotation, and sidebending. The first patient also reported an increased ability to sleep. Both patients reported an increased ability to perform activities of daily living, including work-related responsibilities.

Conclusions:

For the two patients included in this report, therapist observations and patient reports indicate that inclusion of the IMMT treatment in a treatment regimen for chronic neck pain may lead to decreased pain and increased cervical ROM. These positive effects of the IMMT intervention may have a role in enhancing functional outcomes of these patients.

Face Piercing (Body Art): Choosing Pleasure vs. Possible Pain and Posture Instability

Piercings (body art, i.e., with jewelry) are more and more widespread. They can induce various complications such as infections, allergies, headaches, and various skin, cartilage, or dental problems, and represent a public health problem. We draw attention to possible side effects resulting from face piercing complications observed on four young adults such as eye misalignment, decreased postural control efficiency, and non-specific chronic back pain with associated comorbidity. We found that the origin was pierced jewelry on the face. Removing the jewelry restored eye alignment, improved postural control, and alleviated back pain in a lasting way. We suggest that pierced facial jewelry can disturb somaesthetic signals driven by the trigeminal nerve, and thus interfere with central integration processes, notably in the cerebellum and the vestibular nucleus involved in postural control and eye alignment. Facial piercings could induce sensory–motor conflict, exacerbate, or precipitate a pre-existing undetermined conflict, which leads pain and complaints. These findings are significant for health; further investigations would be of interest.

Patterns and correlates of prescription opioid use in OEF/OIF veterans with chronic noncancer pain

OBJECTIVES

Little is known about the treatment Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receive for chronic noncancer pain (CNCP). We sought to describe the prevalence of prescription opioid use, types, and doses of opioids received and to identify correlates of receiving prescription opioids for CNCP among OEF/OIF veterans.

DESIGN

Retrospective review of Veterans Affairs (VA) administrative data.

SETTING

Ambulatory clinics within a VA regional health care network.

PATIENTS

OEF/OIF veterans who had at least three elevated pain screening scores within a 12-month period in 2008. Within this group, those prescribed opioids (N = 485) over the next 12 months were compared with those not prescribed opioids (N = 277). In addition, patients receiving opioids short term (<90 days, N = 284) were compared with patients receiving them long term (≥90 consecutive days, N = 201).

RESULTS

Of 762 OEF/OIF veterans with CNCP, 64% were prescribed at least one opioid medication over the 12 months following their index dates. Of those prescribed an opioid, 59% were prescribed opioids short term and 41% were prescribed opioids long term. The average morphine-equivalent opioid dose for short-term users was 23.7 mg (standard deviation [SD] = 20.5) compared with 40.8 mg (SD = 36.1) for long-term users (P < 0.001). Fifty-one percent of long-term opioid users were prescribed short-acting opioids only, and one-third were also prescribed sedative hypnotics. In adjusted analyses, diagnoses of low back pain, migraine headache, posttraumatic stress disorder, and nicotine use disorder were associated with an increased likelihood of receiving an opioid prescription.

CONCLUSION

Prescription opioid use is common among OEF/OIF veterans with CNCP and is associated with several pain diagnoses and medical conditions.

Health-related risk factors for disability pensions due to musculoskeletal diagnoses: A 30-year Finnish twin cohort study

Aims: There is a need to better understand work incapacity due to musculoskeletal disorders (MSD) and the factors that contribute to being granted disability pension (DP) with such disorders. A twin cohort study would serve a powerful tool responding to this knowledge gap by providing information on factors affecting DP when controlling for family background. The purpose was to investigate the incidence of and risk factors for DP due to any MSD ( n = 1,819) and specifically due to osteoarthritis (OA, n = 677) in a twin cohort of 24,043 people over a 30-year follow-up. Methods: Data on twin pairs from a mailed questionnaire during the baseline year of 1975 were followed up with register data regarding DP, emigration, old-age pension, and death. For statistical analysis, univariate and multivariate Cox proportional hazard ratios were estimated. Results: Baseline musculoskeletal pain, frequency of use of analgesics, body mass index, and chronic diseases, as well as education and social class were significant risk factors for DP due to MSD at follow-up in both sexes. These factors were also the significant predictors of DP due to OA in men. In women, DP due to OA was best predicted by baseline musculoskeletal pain and lower social class. Conclusions: The risk of DP due to MSD and OA seemed to be influenced by comorbidities, educational level and social class. Analyses of twin pairs discordant for DP confirmed the results. Accumulated health problems and chronic conditions during the life course may lead to permanent work incapacity.

Higher comorbidity rates in unemployed patients may significantly impact the cost of spine surgery

Chronic back pain is commonly associated with physical and mental comorbidities, which create a considerable burden on the healthcare system. We examined the differences in comorbidity rates of 619 spinal surgery patients of employment age, and the impact of comorbidity rates on length of hospital stay and cost. The charts of patients aged >25 years and <65 years were reviewed retrospectively. Type of surgery, employment status, comorbidities, length of stay and hospital charges were studied using chi-square, Fisher, Student's t-test, Wilcoxon-Mann-Whitney test and multivariate analysis. The unemployment rate among employment-aged spinal surgery patients was 44.7%. Unemployed patients who underwent any of the three types of surgery (anterior cervical decompression and fusion, lumbar decompression and fusion, and lumbar microdiscectomy [LMD]) stayed longer in hospital but had higher hospital charges in the minimally invasive LMD group only. There were higher rates of some comorbidities in unemployed compared to employed patients: asthma (12.2% vs. 5.9%), coronary artery disease (20.4% vs. 12.8%), diabetes mellitus (58.0% vs. 47.3%), history of coronary artery bypass surgery or stent placement (18.2% vs. 11.6%), hypothyroidism (14.4% vs. 8.2%), knee joint disease (43.1% vs. 33.6%), chronic renal disease (12.9% vs. 2.9%) and opioid (55.2% vs. 45.9%) antidepressant (37.0% vs. 25.3%) anxiolytic (16.0% vs. 8.9%) use. Charlson comorbidity scores were significantly different (p<0.001) between unemployed (1.72 ± 1.90) and employed patients (1.03 ± 1.55). Multivariate analysis showed that a history of coronary artery bypass/stent procedure, chronic renal disease or preoperative opioid use had a significant impact on length of stay and hospital charges in unemployed spine surgery patients. Thus, unemployment in spinal surgery candidates is associated with higher comorbidity rates with a significant impact on healthcare cost. More research is needed into the relationship between unemployment and consumption of healthcare resources.

Protocol for the Cognitive Interventions and Nutritional Supplements (CINS) trial: a randomized controlled multicenter trial of a brief intervention (BI) versus a BI plus cognitive behavioral treatment (CBT) versus nutritional supplements for patients with long-lasting muscle and back pain

Abstract

Trial Registration

http://www.clinicaltrials.gov, with registration number NCT00463970.

Painful medical conditions and alcohol use: a prospective study among older adults

OBJECTIVE

To determine associations between older adults' baseline painful medical conditions and their 10-year drinking behavior, and whether personal and life context characteristics moderate these associations.

METHODS

At baseline, then, 1, 4, and 10 years later, late-middle-aged community residents (M = 61 years; N = 1,291) were surveyed regarding their painful medical conditions, use of alcohol, and personal and life context characteristics. Latent growth modeling was used to determine concurrent and prospective relationships between painful medical conditions and 10-year drinking behavior, and moderating effects of personal and life context characteristics on these relationships.

RESULTS

At baseline, individuals reporting more numerous painful medical conditions consumed alcohol less frequently, but had more frequent drinking problems, than did individuals with fewer such conditions. Being female and having more interpersonal social resources strengthened the association between painful medical conditions and less ethanol consumed. For men more so than women, more numerous painful medical conditions were associated with more frequent drinking problems. Baseline painful medical conditions alone had no prospective effect on 10-year change in drinking behavior, but being older and having more interpersonal social resources made it more likely that baseline painful medical conditions would predict decline over time in frequency of alcohol consumption and drinking problems.

CONCLUSIONS

Late-middle-aged individuals who have more numerous painful medical conditions reduce alcohol consumption but nonetheless remain at risk for more frequent drinking problems. Gender, age, and interpersonal social resources moderate the influence of painful medical conditions on late-life alcohol use. These results imply that older individuals with pain are at little immediate or long-term risk for increased alcohol consumption, but clinicians should remain alert to drinking problems among their older pain patients, especially men.

Comorbid subjective health complaints in patients with sciatica: a prospective study including comparison with the general population

OBJECTIVE

Chronic nonspecific low back pain is accompanied by high rates of comorbid mental and physical conditions. The aims of this study were to investigate if patients with specific back pain, that is, sciatica caused by lumbar herniation, report higher rates of subjective health complaints (SHCs) than the general population and if there is an association between change in sciatica symptoms and change in SHCs over a 12-month period.

METHODS

A multicenter cohort study of 466 sciatica patients was conducted with follow-up at 3 months and 1 year. Comorbid SHCs were measured by 27 items of the SHC inventory. Odds ratios (ORs) for each SHC were calculated with comparison to a general population sample (n=928) by logistic regression. The SHC number was calculated by summing all complaints present.

RESULTS

At baseline, the ORs for reporting SHCs for the sciatica patients were significantly elevated in 15 of the 27 items with a mean (S.D.) SHC number of 7.5 (4.4), compared to 5.2 (4.4) in the general population (P<.01). Among those who during the 1-year follow-up period fully recovered from their sciatica, the SHC number was reduced to normal levels. Among those with persisting or worsening sciatica, the number increased to a level almost double that of the general population.

CONCLUSION

Compared to the general population, the prevalence of subjective health complaints in sciatica is increased. During follow-up, the number of health complaints increased in patients with persisting or worsening sciatica.

Higher incidence of common diagnoses in patients with low back pain in primary care

Most studies on comorbidity in low back pain (LBP) have been conducted in specialized settings with the use of self-reports. This study has an original design using data from family practices: the incidence of the most frequent diseases was compared in patients with and without LBP in 2004. The database includes data from 67 family physicians in 52 family practices in Flanders, Belgium. It contains data from 160,000 different patients with 1,500,000 diagnoses during the period 1994 to 2004. The incidence of the most frequent diagnoses is presented in patients with and without LBP in 2004. The diagnoses were coded according to the ICPC-2-classification. In 2004, the incidence of LBP was 51.4‰ (95% CI: 49.8 to 53.1) in patients aged 18 or older. The incidence was slightly higher in women than in men: 53.0‰ (95% CI: 50.7 to 55.4) vs. 49.9‰ (95% CI: 47.7 to 52.3). The highest incidence was recorded in the age group of 50 to 54 years. The most frequent "other" diagnoses in patients with and without LBP are comparable, but some were more frequent in patients with LBP. Respiratory infections and diseases of the locomotor apparatus (neck syndrome, bursitis) are more frequent in patients with LBP. Low back pain is one of the most frequent diagnoses in general practice. Striking is the relatively higher frequency of common self-limiting diseases in patients with a diagnosis of LBP during the same year. To the authors' knowledge, this is the first time that medical demands for non-LBP reasons in family practice have been reported in patients with LBP.

Vertical heterophoria and postural control in nonspecific chronic low back pain

The purpose of this study was to test postural control during quiet standing in nonspecific chronic low back pain (LBP) subjects with vertical heterophoria (VH) before and after cancellation of VH; also to compare with healthy subjects with, and without VH. Fourteen subjects with LBP took part in this study. The postural performance was measured through the center of pressure displacements with a force platform while the subjects fixated on a target placed at either 40 or 200 cm, before and after VH cancellation with an appropriate prism. Their postural performance was compared to that of 14 healthy subjects with VH and 12 without VH (i.e. vertical orthophoria) studied previously in similar conditions. For LBP subjects, cancellation of VH with a prism improved postural performance. With respect to control subjects (with or without VH), the variance of speed of the center of pressure was higher, suggesting more energy was needed to stabilize their posture in quiet upright stance. Similarly to controls, LBP subjects showed higher postural sway when they were looking at a target at a far distance than at a close distance. The most important finding is that LBP subjects with VH can improve their performance after prism-cancellation of their VH. We suggest that VH reflects mild conflict between sensory and motor inputs involved in postural control i.e. a non optimal integration of the various signals. This could affect the performance of postural control and perhaps lead to pain. Nonspecific chronic back pain may results from such prolonged conflict.

Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints

OBJECTIVES

To explore GPs' considerations in decision-making regarding sick-listing of patients suffering from SHC.

DESIGN

Qualitative analysis of data from nine focus-group interviews.

SETTING

Three cities in different regions of Norway. Participants. A total of 48 GPs (31 men, 17 women; aged 32-65) participated. The GPs were recruited when invited to a course dealing with diagnostic practice and assessment of sickness certificates related to patients with composite SHCs.

RESULTS

Decisions on sick-listing patients with SHCs were regarded as a very challenging task. Trust in the patient's own story and self-judgement was deemed crucial, but many GPs missed hard evidence of illness and loss of function. Several factors that might influence decision-making were identified: the patients' ability to present their story to evoke sympathy, the GP's prior knowledge of the patient, and the GPs' own experience as a patient and their tendency to avoid conflicts. The approach to the task of sick-listing differed from patient-led cooperation to resistant confrontation.

CONCLUSION AND IMPLICATIONS

Issuing sickness certification in patients with composite health complaints is considered challenging and burdensome. It is seen as mainly patient-driven, and the decisions vary according to GPs' attitudes, beliefs, and personalities. Guiding the GPs to a more focused awareness of the decision process should be considered.

Generalized anxiety disorder, with or without co-morbid major depressive disorder, in primary care: prevalence of painful somatic symptoms, functioning and health status

BACKGROUND

Painful physical symptoms (PPS) have received little attention in patients with generalized anxiety disorder (GAD). The objective of the present study was to assess the prevalence of PPS in patients with GAD vs patients with GAD and co-morbid major depressive disorder (MDD) and a control group (patients neither with GAD nor MDD).

METHODS

This is a cross-sectional, multi-center, epidemiological study, in primary care. Patients were screened for GAD (HADS-A), followed by a diagnosis confirmation (MINI). Patients were considered to have PPS when VAS overall pain score >30. Functioning and health status was assessed (SDS, EUROQoL-5D). Relationships between the presence of PPS and functioning and health status was analyzed (ANCOVA models). Results were adjusted for confounding factors.

RESULTS

Of 7152 patients, 1546 (22%) screened positive for GAD, 981 (14%) had confirmed GAD diagnosis, of whom 559 (8%) had GAD with co-morbid MDD and 422 (6%) had GAD alone. Of the 5292 (74%) patients screened negative for GAD, 336 (5%) were confirmed as controls. PPS in patients with GAD were twice as prevalent as in the control group: 59.0% vs. 28.3%; p<0.001. The presence of co-morbid MDD was associated with a significantly higher prevalence of PPS: 78.0% vs. 59.0%; p<0.001. PPS were significantly associated with functioning and health status impairment (p<0.001) both in GAD alone and in GAD and co-morbid MDD compared with controls.

LIMITATIONS

Results do not prove causal relationships.

CONCLUSIONS

Our results support the clinical relevance of PPS in patients suffering from GAD; therefore they need to be considered when evaluating the patient.

Severe pain predicts greater likelihood of subsequent suicide

Using data from the 1999 Large Health Survey of Veterans, Veterans Affairs' medical records, and the National Death Index (N = 260,254), the association between self-reported pain severity and suicide among veterans as examined, after accounting for demographic variables and psychiatric diagnoses. A Cox proportional hazards regression demonstrated that veterans with severe pain were more likely to die by suicide than patients experiencing none, mild, or moderate pain (HR: 1.33; 95% CI: 1.15, 1.54), after controlling for demographic and psychiatric characteristics. These results indicate that pain evaluations should be included in comprehensive suicide assessments and suicide prevention efforts.

The relationship of chronic pain with and without comorbid psychiatric disorder to sleep disturbance and health care utilization: results from the Israel National Health Survey

OBJECTIVE

Chronic pain is associated with health problems including sleep difficulties and increased medical utilization. Because chronic pain is frequently comorbid with psychiatric disorders, it is unclear to what degree chronic pain itself is associated with these problems. In a large population sample, we examined the relationship between chronic pain, both alone and comorbid with psychiatric disorders, with sleep disturbance and increased medical utilization.

METHODS

We analyzed data from the Israel National Health Survey (INHS) conducted in 2003-2004 on a representative sample (N=4859) of the adult Israeli population. Data were collected in face-to-face interviews using the Composite International Diagnostic Interview. Statistical analyses were performed using multinomial logistic regression models.

RESULTS

Past year chronic pain was reported by 29.9% of all study participants (n=1453). Psychiatric disorders were more common among participants with chronic pain; adjusted odds ratios were 2.23 (95% CI 1.49-3.36) for depressive disorders and 2.94 (95% CI 2.08-4.17) for anxiety disorders. Associations of chronic pain and psychiatric disorders were stronger in men. Chronic pain was associated with both sleep problems and increased health care utilization even for individuals with no psychiatric comorbidity. Sleep difficulties but not health care utilization rates were more pronounced in the comorbid group compared to the chronic pain only group.

CONCLUSION

Chronic pain was associated with sleep problems and increased health care utilization in this sample, independent of psychiatric comorbidity. Sleep problems were significantly greater in the comorbid vs. non-comorbid group. In contrast, associations of pain with health care utilization were largely independent of psychiatric comorbidity.

Is an expert diagnosis enough for assessment of sick leave for employees with musculoskeletal and mental disorders?

PURPOSE

The aim of this study is to determine differences in self-reported work ability, work conditions, health and function between ICD-10 groups with musculoskeletal disorders (MSD), mental disorders (MDs) and MSD + MD and to determine which variables are associated with sick leave.

METHOD

A cross-sectional study of 210 employees was conducted at an occupational health service unit. Physiotherapists and physicians classified the employees' health problems according to ICD-10 and the employees answered a questionnaire with questions on demographic variables, health, functioning, work ability and work conditions.

RESULTS

Forty-four per cent of the employees had MSD, 22% had MD and 34% had a MSD + MD. The group on sick leave had worse results for all health and work measures. Belonging to the MD group, belonging to the MSD + MD group, having poor work ability and functioning were associated with being on sick leave. The value for the model explaining being on sick leave was 0.63 (Nagelkerke R²).

CONCLUSIONS

Having a diagnosis of MD based on a professional opinion and having poor work ability and functioning based on self-reports are associated with being on sick leave. The results suggest that self-reported data could be used to complement the expert-based diagnosis.

Comorbidities of migraine

Migraine is a common neurological disorder and can be severely disabling during attacks. The highest prevalence occurs between the ages of 25 and 55 years, potentially the most productive period of life. Migraine leads to a burden not only for the individual, but also for the family and society in general. Prior studies have found that migraine occurs together with other illnesses at a greater coincidental rate than is seen in the general population. These occurrences are called “comorbidities,” which means that these disorders are interrelated with migraine. To delineate the comorbidities of migraine is important, because it can help improve treatment strategies and the understanding of the possible pathophysiology of migraine. The comorbid illnesses in patients with migraine include stroke, sub-clinical vascular brain lesions, coronary heart disease, hypertension, patent foramen ovale, psychiatric diseases (depression, anxiety, bipolar disorder, panic disorder, and suicide), restless legs syndrome, epilepsy and asthma. In this paper, we review the existing epidemiological and hospital-based studies, and illustrate the connections between these illnesses and migraine.

Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes

INTRODUCTION

In an earlier study, Gatchel et al. (J Occup Rehabil 13:1-9, 2003) demonstrated that participants at high risk for developing chronic low back pain disability (CLBPD), who received a biopsychosocial early intervention treatment program, displayed significantly more symptom improvement, as well as cost savings, relative to participants receiving standard care. The purpose of the present study was to expand on these results by examining whether the addition of a work-transition component would further strengthen the effectiveness of this early intervention treatment.

METHODS

Using an existing algorithm, participants were identified as being high-risk (HR) or low-risk (LR) for developing CLBPD. HR participants were then randomly assigned to one of three groups: early intervention (EI); early intervention with work transition (EI/WT); or standard care (SC). Participants provided information regarding pain, disability, work status, and psychosocial functioning at baseline, periodically during treatment, and again 1 year following completion of treatment.

RESULTS

At 1-year follow-up, no significant differences were found between the EI and EI/WT groups in terms of occupational status, self-reports of pain and disability, coping ability or psychosocial functioning. However, significant differences in all these outcomes were found comparing these groups to standard care.

CONCLUSION

The addition of a work transition component to an early intervention program for the treatment of ALBP did not significantly contribute to improved work outcomes. However, results further support the effectiveness of early intervention for high-risk ALBP patients.

The impact of placebo, psychopathology, and expectations on the response to acupuncture needling in patients with chronic low back pain

Comorbid psychopathology is a variable not explored in the acupuncture RCTs that could explain whether subgroups of patients with chronic low back pain have differential responses to acupuncture or placebo treatments. This was a controlled, blinded, crossover trial of verum acupuncture and validated sham acupuncture in 40 CLBP patients, with a Low or High level of psychiatric comorbidity. They completed a 0 to 10 rating scale for pain at the beginning and end of each treatment session, and rated their expectations for change in pain. Verum acupuncture was performed at Large Intestine 4 on the dorsal right hand for 30 minutes by a licensed acupuncturist. Data analysis used percent improvement in pain as the primary outcome for each of the treatment sessions. Both groups (21 Low and 19 High) reported significant analgesia with verum acupuncture needling, mean 33%, P = .9 for difference between groups; and with placebo, 26%, P = .09. In both groups, expectations were only a significant predictor of verum acupuncture response, P = .002, such that those with greater expectations had greater pain relief. Psychiatric comorbidity does not significantly impact acupuncture or placebo acupuncture analgesia in CLBP. It does not affect the positive impact of expectations on reported pain relief from real acupuncture.

PERSPECTIVE

Psychiatric comorbidity may predict differences between acupuncture and placebo responses, not otherwise seen in the RCTs for low back pain. Using a blinded, crossover design, we report that it does not predict outcome, nor does it seem to modify the effect of expectancy (a known predictor) on acupuncture response.

Migraine symptomatology and major depressive disorder

Introduction and objective: Migraine and major depressive disorder (MDD) frequently co-occur, but it is unclear whether depression is associated with a specific subtype of migraine. The objective of this study was to investigate whether migraine is qualitatively different in MDD patients ( N = 1816) and non-depressed controls ( N = 3428).

Methods: Migraine symptom data were analyzed using multi-group Latent Class Analysis, and a qualitative comparison was made between the symptom profiles of MDD patients and controls, while allowing for differences in migraine prevalence and severity between groups.

Results: In both groups, three migrainous headache classes were identified, which differed primarily in terms of severity. Both mild and severe migrainous headaches were two to three times more prevalent in MDD patients. Migraine symptom profiles showed only minor qualitative differences in the MDD and non-MDD groups: in the severe migrainous headache class, significant differences were observed only in the prevalence of aggravation by physical activity (83% and 91% for the non-MDD and MDD groups, respectively) and aura (42% vs. 53%, respectively).

Conclusion: The similar overall symptom profiles observed in the MDD and non-MDD subjects suggest that a similar disease process may underlie migraine in both groups.

Back and neck pain and psychopathology in rural sub-Saharan Africa: evidence from the Gilgel Gibe Growth and Development Study, Ethiopia

STUDY DESIGN

Community-based cross-sectional analysis of the relation between symptoms of psychopathology and back pain (BP) or neck pain (NP) in rural southwest Ethiopia.

OBJECTIVE

Using data from a community-based sample, we assessed the prevalence and psychopathologic correlates of BP or NP in rural sub-Saharan Africa.

SUMMARY OF BACKGROUND DATA

BP and NP are among the most prevalent pain conditions. Psychopathology has been shown to be associated with both BP and NP in developed and urban developing contexts. Little is known about the relation between psychopathology and BP or NP in the rural, developing context.

METHODS

Data on self-reported BP and NP, symptoms of depression, anxiety, and post-traumatic stress (PTS), gender, age, and socioeconomic status were collected from a representative cohort sample (N = 900) in rural southwest Ethiopia. We calculated univariate statistics to assess the prevalence of BP and NP. We used bivariate χ2 tests and multivariate logistic regression models to assess the relation between psychopathology and BP and NP.

RESULTS

The prevalence of BP was 16.7%; that of NP was 5.0%. In χ2 analyses, symptoms of depression, anxiety, and PTS were significantly associated with increased risk for each outcome. In models adjusted for age, household assets, and gender, depression symptomatology was associated with increased risk for BP (OR = 3.44, 95% CI: 2.37-5.00) and NP (OR = 4.92, 95% CI: 2.49-9.74). Anxiety symptomatology was also associated with increased risk for BP (OR = 2.88, 95% CI: 1.98-4.20) and NP (OR = 2.67, 95% CI: 1.41-5.09). PTS symptomatology was associated with increased risk for BP (OR = 2.89, 95% CI: 1.78-4.69).

CONCLUSION

In the first known study about the relation between psychopathologic symptomatology and BP and NP in a rural context in a developing country, the prevalence of BP and NP were comparable to published data in developed and developing countries. Symptoms of depression and anxiety were correlates of BP and NP, and symptoms of PTS were a correlate of BP. Comparative studies about the relation between psychopathology and chronic pain conditions between rural and urban contexts in the global south are needed.

Chronic pain disorders and headache chronification

It is estimated that nearly half of the global adult population suffers from an active headache disorder, most of whom experience attacks on an episodic basis. The transition from episodic to chronic headache is a poorly understood process. Epidemiological findings demonstrating comorbidity and common risk factors suggest that headache progression or prognosis may be related to the presence of other chronic pain disorders. This review highlights findings from population-based studies on headache and other pain disorders and how they relate to each other, with a focus on understanding headache chronification. We also consider the limitations and methodological challenges in understanding how two different chronic pain disorders may be related.

Hypoalgesia related to elevated resting blood pressure is absent in adolescents and young adults with a history of functional abdominal pain

Elevated resting blood pressure (BP) is hypoalgesic in healthy individuals, but this effect is absent in adults with chronic somatic pain. This study tested whether BP-related hypoalgesia is similarly altered in individuals with a history of chronic visceral pain in childhood. Resting BP was assessed in 94 adolescents and young adults with a known history of childhood functional abdominal pain (FAP) and 55 comparable healthy controls. Responses to an acute heat pain stimulus were then evaluated following exposure to two laboratory stressors. A significant participant type x systolic BP (SBP) interaction (p<.005) revealed that elevated resting SBP was associated with significantly higher heat pain threshold (p<.001) in healthy controls, but was unrelated to pain threshold in the FAP group. A similar pattern was observed for heat pain tolerance, with elevated SBP linked to significantly higher pain tolerance (p<.05) in healthy controls, but unrelated to tolerance in the FAP group. Dysfunction in BP-related hypoalgesia associated with FAP was evident regardless of whether childhood FAP had resolved or still persisted at the time of laboratory testing. Subgroup analyses indicated that BP-related hypoalgesia (in healthy controls) and FAP-linked absence of this hypoalgesia was observed only among females. Result suggest that childhood visceral chronic pain may be associated with relatively long-lasting dysfunction in overlapping systems modulating pain and BP that persists even after FAP resolves. Potential implications for later hypertension risk are discussed.

The long-term costs of traumatic stress: intertwined physical and psychological consequences

The gradual emergence of symptoms following exposure to traumatic events has presented a major conceptual challenge to psychiatry. The mechanism that causes the progressive escalation of symptoms with the passage of time leading to delayed onset post-traumatic stress disorder (PTSD) involves the process of sensitization and kindling. The development of traumatic memories at the time of stress exposure represents a major vulnerability through repeated environmental triggering of the increasing dysregulation of an individual's neurobiology. An increasing body of evidence demonstrates how the increased allostatic load associated with PTSD is associated with a significant body of physical morbidity in the form of chronic musculoskeletal pain, hypertension, hyperlipidaemia, obesity and cardiovascular disease. This increasing body of literature suggests that the effects of traumatic stress need to be considered as a major environmental challenge that places individual's physical and psychological health equally at risk. This broader perspective has important implications for developing treatments that address the underlying dysregulation of cortical arousal and neurohormonal abnormalities following exposure to traumatic stress.

Understanding the co-occurrence of anxiety disorders and chronic pain: state-of-the-art

The purpose of this article is to describe the current state-of-the-art regarding the co-occurrence of the anxiety disorders and chronic pain. First, we describe the core characteristics of chronic pain and its co-occurrence with the anxiety disorders. Second, we review data on the prevalence of co-occurrence. Third, we describe the mutual maintenance and shared vulnerability models, both of which have been offered to explain the co-occurrence of posttraumatic stress disorder (PTSD) and chronic pain and may have applicability to various other anxiety disorders. Fourth, we provide an integrative review of available research addressing the postulates of these models specific to the mechanisms of anxiety sensitivity, selective attention to threat, and reduced threshold for alarm. We conclude with general recommendations for improving assessment and treatment of patients who present with an anxiety disorder accompanied by clinically significant pain. Given that most of the available evidence has come from studies of PTSD and chronic pain, we provide a detailed agenda for future investigation of the co-occurrence of chronic pain and other anxiety disorders.

Pain associated with specific anxiety and depressive disorders in a nationally representative population sample

OBJECTIVE

To examine in a nationally representative sample (a) the differential association of specific anxiety and depressive disorders defined according to DSM-IV with pain disorder (PD) and pain symptoms, and (b) whether pain-associated anxiety and depressive disorders and their comorbidity have different implications in terms of impairment, disability, health care utilization, and substance use.

METHOD

A nationally representative community study was conducted in Germany. Symptoms, syndromes and diagnoses of mental disorders, and pain were assessed in N = 4,181 participants aged 18-65 years using the DSM-IV/M-CIDI.

RESULTS

Logistic regressions revealed that pain is associated with both specific anxiety and depressive disorders, with increasing significant odds ratios (OR) for medically explained pain symptoms (EPS; OR range: 1.9-2.0), to unexplained pain symptoms (UPS; OR range: 2.4-7.3), to PD (OR range: 3.3-14.8). PD and UPS persistently showed associations after adjusting for comorbid other anxiety and depressive disorders and physical illnesses. All types of pain, particularly PD/UPS, are associated with decreased quality of life, greater impairment in role functioning, disability, health care utilization, and substance use. Depressive disorders, even more so anxiety disorders and their comorbidity account for a substantial proportion of variance in these functional correlates.

CONCLUSIONS

Pain is strongly associated with specific anxiety and depressive disorders. In light of the individual and societal burden due to pain, and the demonstrated role of comorbid anxiety or/and depression, our results call for further investigation of the underlying mechanisms for this association as well as targeted treatments for these comorbidities.

The short- and long-term effect of duloxetine on painful physical symptoms in patients with generalized anxiety disorder: results from three clinical trials

Generalized anxiety disorder (GAD) is associated with painful physical symptoms (PPS). These post hoc analyses of previous trial data assessed PPS and their response to duloxetine treatment in GAD patients. Studies 1 and 2 (n=840) were 9- to 10-week efficacy trials; study 3 (n=887) was a relapse prevention trial comprising a 26-week open-label treatment phase and a 26-week double-blind, placebo-controlled treatment continuation phase. Mean baseline visual analog scale scores (VAS, 0-100; n=1727) ranged from 26 to 37 for overall pain, headache, back pain, shoulder pain, interference with daily activities, and time in pain while awake. In studies 1 and 2, improvement on all VAS scores was greater in duloxetine-treated than in placebo-treated patients (p<or=0.01). In study 3, pain symptoms worsened in responders switched to placebo compared with those maintained on duloxetine (p<or=0.02). In conclusion, duloxetine was efficacious in the short- and long-term treatment of PPS, which are common in GAD patients.

Incidence and course of suicidal ideation and suicide attempts in the general population

OBJECTIVE

Suicidal ideation and suicide attempts are important indicators of extreme emotional distress. However, little is known about predictors of onset and course of suicidality in the general population. Our study tried to fill this gap by analyzing data from a prospectively followed community sample.

METHOD

Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a 3-wave cohort study in a representative sample (n = 4848) of the Dutch adult general population.

RESULTS

The 3-year incidence of suicidal ideation and suicide attempts was 2.7% and 0.9%, respectively. Predictors of first-onset suicidal ideation and suicide attempts were sociodemographic variables (especially the negative change in situation variables), life events, personal vulnerability indicators, and emotional (mood and anxiety) disorders. Comparison of the corresponding odds ratios and confidence intervals revealed that predictors for first-onset suicidal ideation and suicide attempts did not differ significantly. One of the strongest predictors of incident suicide attempts was previous suicidal ideation. Regarding the course of suicidal ideation, it was found that 31.3% still endorsed these thoughts and 7.4% reported having made a suicide attempt 2 years later.

CONCLUSIONS

Similar predictors were found for first-onset suicidal ideation and suicide attempts. This suggests that suicidal behaviours may be ordered on a continuum and have shared risk factors. While suicidal thoughts may be necessary for, they are not sufficient predictors of, suicidal acts. The course of suicidality in the general population can be characterized by a minority of people having suicidal experiences that develop over time with progressively increasing severity.

Characterization of health status and modifiable risk behavior among United States adults using chiropractic care as compared with general medical care

OBJECTIVE

The causes of death in the United States have moved from infectious to chronic diseases with modifiable behavioral risk factors. Simultaneously, there has been a paradigm shift in health care provisions with increased emphases on prevention and health promotion. Use of professional complementary and alternative medicine, such as chiropractic care, has increased. The purpose of this study was to characterize typical conditions, modifiable risk behaviors, and perceived changes in overall general health of patients seeing chiropractors as compared with general medical doctors in the United States.

METHODS

Secondary analyses of the National Health Interview Survey 2005 adult sample (n = 31,248) were performed. Multiple logistic regression models were applied to assess associations of health conditions/risk behaviors of patients with the doctors (chiropractors vs medical doctors) they saw within the past 12 months.

RESULTS

Respondents who saw/talked to chiropractors were 9.3%. Among these, 21.4% did not see a medical doctor. Comparing chiropractor-only with medical doctor-only patients, we found no significant difference in smoking/alcohol consumption status, but chiropractor-only patients were more likely to be physically active (odds ratio [OR], 1.5; 95% confidence interval [CI], 1.2-1.8) and less likely to be obese (OR, 0.7; 95% CI, 0.6-0.9). Respondents reporting acute neck (OR, 2.7; 95% CI, 2.2-3.2) and low back pain (OR, 2.4; 95% CI, 2.0-2.8) were more likely to have seen a chiropractor.

CONCLUSIONS

Based on these analyses, Americans seem to be using chiropractic care for acute neck and low back pain more so than for other health conditions. However, there is no marked difference in their overall health promotion habits and changes in overall general health based on health care provider types.

Long-term follow-up of disability pensioners having musculoskeletal disorders

Background

Previously we have conducted a randomised controlled trial (RCT) to evaluate the effect of a brief cognitive behavioural program with a vocational approach aiming to return disability pensioners with back pain to work, as compared to no intervention. One year after the intervention, 10 participants (22%) who received the program and 5 (11%) in the control group reported to have entered a return to work process. The aims of this study were to evaluate long-term effects of the intervention, and compare this effect to 2 reference populations not participating in the original trial.

Methods

Three groups of disability pensioners were investigated: 1) Disability pensioners having back pain (n = 89) previously participating in the RCT (randomized to either a brief cognitive behavioural intervention or to a control group), 2) 342 disability pensioners having back pain, but refusing to participate in the study and 3) 449 disability pensioners having other musculoskeletal disorders than back pain. Primary outcome was return to work, defined as a reduction in payment of disability pension.

Results

Only 2 of 89 (2.3%) participants from the RCT had reduced disability pension at 3-years follow-up, both from the control group. None of the participants that had been in a process of returning to work after 1 year had actually gained employment at 3-years follow-up. In the 2 groups not participating in the previous RCT, only 4 (1.2%) and 8 (1.6%) had returned to work after 3 years respectively.

Conclusion

The number of pensioners who returned to work was negligible in all groups regardless of having participated in a cognitive behavioural intervention or not.

Low back pain and determinants of sickness absence

BACKGROUND

Low back pain (LBP) is a frequent diagnosis for sickness absence. The process of sick-listing is complex, and the doctor must integrate information from several levels in the decision.

OBJECTIVE

The aim of this paper is to describe the main determinants of sickness absence for LBP.

METHODS

We conducted a non-systematic search in Medline and personal files to identify determinants of sickness absence, and structured these into four levels of the sick-listing process. These levels are characteristics of 1) the sick-listed worker, 2) the sick-listing doctor, 3) the workplace, and 4) the cultural and economic conditions of the society.

RESULTS

Important characteristics of the sick-listed person seem to be poor mental health, including negative beliefs about LBP. Also, comorbidity and lack of coping abilities are found associated to sickness absence. The impact of the doctors' personal beliefs about LBP is not clear. Doctors in general seem to be frustrated by their gatekeeper role and the influence of other healthcare providers on the sick-listing decision. The workplace is an important factor in the sick-listing process, but the impact of physical working conditions is of less importance than social support, job control, and demands. On the society level, the economic awards in sickness absence and the general acceptance of being sick listed seem to be of importance for the individual's decision to claim sick leave.

CONCLUSION

The sick-listing process for LBP is complex, and the determinants are mostly non-medical. It seems important to adopt a broad perspective of how a worker copes with pain and how these coping strategies interact with cultural, economic, and societal determinants of sickness certification.

[Amplified back pain and comorbidity in the population]

BACKGROUND

Chronic back pain is rarely the sole health problem. Data concerning the association between comorbidities and different stages of chronic back pain in the German adult population are lacking.

METHODS

Postal questionnaire data were collected for 3,765 persons (aged 18-75 years) in 4 German cities. Comorbidities and different stages of back pain chronification were determined.

RESULTS

The prevalence and number of comorbidities varied with the extent of back pain chronification. Approximately one-third of individuals with a high degree of back pain chronicity (stages 2 and 3) received medical treatment for three or more comorbidities compared to 5% of those without amplified back pain (stage 0).

CONCLUSION

Treatment concepts for chronic back pain have to consider comorbidities also present and focusing exclusively on the pain problem seems inappropriate.

Factors associated with pain interference in an epidemiologic sample of adults with bipolar I disorder

OBJECTIVE

Epidemiologic studies have found that major depressive disorder (MDD) and anxiety disorders are associated with pain. However, little is known regarding the prevalence and correlates of pain in bipolar I disorder (BD).

METHOD

The 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample (N=43,093) of the US adult population, was used to determine if 1) prevalence of moderate-or-greater pain interference is elevated among subjects with 12-month history of BD, and 2) psychiatric and medical comorbidities independently contribute to increased pain interference in BD.

RESULTS

Subjects with BD were significantly more likely to report pain interference of at least moderate severity compared to subjects without BD (24.8% versus 11.9%, p<0.001). Moderate or greater pain interference is also significantly more common among subjects with BD than those with MDD (20.3%) or anxiety disorders (19.3%; p<0.001). Logistic regression analyses adjusting for potential confounding variables indicated that BD is independently associated with increased pain interference (adjusted odds ratio 1.57, 95% confidence interval 1.39-1.78). Factors associated with pain interference in BD included greater age, non-white race, lower income, increased frequency of arthritis and other medical problems, comorbid anxiety disorders, and comorbid substance use disorders.

CONCLUSIONS

The prevalence of pain interference is elevated in BD, even compared to MDD or anxiety disorders, and is associated with both medical and psychiatric comorbidities. Interference from pain may be an important variable to consider in the assessment and treatment of BD. Future prospective studies are needed to determine the direction of the observed associations.

The epidemiology, burden, and comorbidities of migraine

We describe the epidemiology and comorbidities of migraine, which affects 12% of adults in occidental countries. Prevalence is three times higher in women, but 6% of men are affected, making it the most prevalent neurologic disorder in men. Although migraine is a remarkably common cause of temporary disability, many migraineurs have never consulted a physician for the problem. Many disorders are comorbid with migraine. For some such as depression, the association has been well described, but for others, the relationship has been recently suggested, such as in the case of clinical and subclinical vascular brain lesions and coronary heart disease.

Mammography-Related Breast Pain is Associated With Migraine

There is little information about the perception of experimentally induced extracephalic pain in migraine. This study investigates the associations between mammography-related pain and migraine. A neurologist clinically assessed 630 women aged 40–74 years attending a population-based breast cancer screening programme. Headache criteria proposed by the International Headache Society were used. Mammography-related pain was measured on a 100-mm visual analogue scale. High levels of mammography-related pain were associated with migraine. This association was related to mammographic examination during the early follicular phase and menopausal status, but unrelated to differences in age, compression pressure, education, current use of hormonal replacement therapy, anxiety, and recent use of analgesics and antimigraine medication. The results of the present study indicate that migraine and compression-induced breast pain are related.

Association between generalized anxiety levels and pain in a community sample: evidence for diagnostic specificity

BACKGROUND

It is unclear whether generalized anxiety disorder (GAD) has a specific relationship to pain syndromes, going beyond the established association of pain with anxiety syndromes in general.

METHODS

Mental disorders were assessed in a community sample (N=4181; 18-65 years) using the DSM-IV/M-CIDI. Several threshold definitions were used to define GAD and medically unexplained pain.

RESULTS

The association between pain and GAD (odds ratio, OR=5.8 pain symptoms; OR=16.0 pain disorder) is stronger than the association between pain and other anxiety disorders (OR=2.4 pain symptoms; OR=4.0 pain disorder). This association extends to subthreshold level definitions of GAD with some indication for a non-linear dose-response relationship. The GAD-pain link cannot sufficiently be explained by demographic factors, comorbid mental or physical disorders.

CONCLUSIONS

The association of pain and generalized anxiety is not artifactual. Compared to other anxiety syndromes, it appears to be stronger and more specific suggesting the need to explore clinical and public health implications.