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

Evidence-Based Scientific Data Documenting the Treatment and Cost-Effectiveness of Comprehensive Pain Programs for Chronic Nonmalignant Pain

Chronic pain is one of the most prevalent and costly problems in the United States today. Traditional medical treatments for it, though, have not been consistently efficacious or cost-effective. In contrast, more recent comprehensive pain programs (CPPs) have been shown to be both therapeutically efficacious and cost-effective. The present study reviews available evidence demonstrating the therapeutic efficacy and cost-effectiveness of CPPs, relative to conventional medical treatment. Searches of the chronic pain treatment literature during the past decade were conducted for this purpose, using MEDLINE and PSYCHLIT. Studies reporting treatment outcome results for patients with chronic pain were selected, and data on the major outcome variables of self-reported pain, function, healthcare utilization and cost, medication use, work factors, and insurance claims were evaluated. When available, conventional medical treatments were used as the benchmark against which CPPs were evaluated. This review clearly demonstrates that CPPs offer the most efficacious and cost-effective, evidence-based treatment for persons with chronic pain. Unfortunately, such programs are not being taken advantage of because of short-sighted cost-containment policies of third-party payers.

PERSPECTIVE

A comprehensive review was conducted of all studies in the scientific literature reporting treatment outcomes for patients with chronic pain. This review clearly revealed that CPPs offer the most efficacious and cost-effective treatment for persons with chronic pain, relative to a host of widely used conventional medical treatment.

Are first-time episodes of serious LBP associated with new MRI findings?

BACKGROUND

Magnetic resonance (MR) imaging is frequently used to evaluate first-time episodes of serious low back pain (LBP). Common degenerative findings are often interpreted as recent developments and the probable anatomic cause of the new symptoms. To date no prospective study has established a baseline MR status of the lumbar spine in subjects without significant LBP problems and prospectively surveyed these subjects for acute changes shortly after new and serious LBP episodes. This method can identify new versus old MR findings possibly associated with the acute symptomatic episode.

PURPOSE

To determine if new and serious episodes of LBP are associated with new and relevant findings on MRI.

STUDY DESIGN

Prospective observational study with baseline and post-LBP MRI monitoring of 200 subjects over 5 years.

OUTCOME MEASURES

Clinical outcomes: LBP intensity (visual analogue scale), Oswestry Disability Index, and work loss. MRI outcomes: disc degeneration, herniation, annular fissures, end plate changes, facet arthrosis, canal stenosis, spondylolisthesis, and root impingement.

METHODS

200 subjects with a lifetime history of no significant LBP problems, and a high risk for new LBP episodes were studied at baseline with physical examination, plain radiographs, and MR imaging. Subjects were followed every 6 months for 5 years with a detailed telephone interview. Subjects with a new severe LBP episode (LBP>or=6/10,>1 week) were assessed for new diagnostic tests. New MR imaging, taken within 6 to 12 weeks of the start of a new LBP episode, was compared with baseline (asymptomatic) images. Two independent and blinded readers evaluated each baseline and follow-up study.

RESULTS

During the 5-year observation period of 200 subjects, 51 (25%) subjects were evaluated with a lumbar MRI for clinically serious LBP episodes, and 3/51 (6%) had a primary radicular complaint. These 51 subjects had 67 MR scans. Of 51 subjects, 43 (84%) had either unchanged MR or showed regression of baseline changes. The most common progressive findings were disc signal loss (10%), progressive facet arthrosis (10%), or increased end plate changes (4%). Only two subjects, both with primary radicular complaints, had new findings of probable clinical significance (4%). Subjects having another MR were more likely to have had chronic pain at baseline (odds ratio [OR]=3.19; 95% confidence interval [CI] 1.61-6.32), to smoke (OR=5.81; 95% CI 1.99-16.45), have baseline psychological distress (OR 2.27; 95% CI 1.15-4.49), and have previous disputed compensation claims (OR=2.35; 95% CI 0.97-5.69). Subjects involved in current compensation claims were also more likely to have an MR scan to evaluate the LBP episode (risk ratio=4.75, p<.001), but were unlikely to have significant new findings. New findings were not more frequent in subjects with LBP episodes developing after minor trauma than when LBP developed spontaneously.

CONCLUSION

Findings on MR imaging within 12 weeks of serious LBP inception are highly unlikely to represent any new structural change. Most new changes (loss of disc signal, facet arthrosis, and end plate signal changes) represent progressive age changes not associated with acute events. Primary radicular syndromes may have new root compression findings associated with root irritation.

The Council on Chiropractic Education's new wellness standard: a call to action for the chiropractic profession

Background

The chiropractic profession has long considered itself to be a preventive science. Recently the Council on Chiropractic Education (CCE) has defined a set of standards that must be implemented at all US chiropractic colleges as of January of 2007. These are specific to wellness measures and health promoting efforts that should be performed by chiropractors. This will mandate traditional health promotion and prevention methods be taught to students at accredited colleges and to practicing chiropractors.

Objective

To present the idea of performing traditional health promotion and wellness-concepts in chiropractic practice as a call to action for clinicians and generate discussion on the topic.

Discussion

This manuscript discusses relevant topics of health promotion and prevention for chiropractors and other practicing clinicians that should be made priorities with patients in order to enhance both patient health and community and population health.

Conclusion

All practicing chiropractors, as well as other clinicians should take these new standards from the CCE as a call to action to begin helping patients address the removable causes of morbidity, disability and premature mortality where they exist, in addition to treating their painful spinal conditions.

Prevalencia y comorbilidad física y mental del dolor dorsal y cervical crónicos en España: resultados del estudio ESEMeD

BACKGROUND AND OBJECTIVE

Chronic back pain (CBP) and chronic neck pain (CNP) are highly prevalent among the adult population. However, less is known about its comorbidity with other diseases and its impact on global functioning. The objectives of following study, that is part of the ESEMeD-Spain study, are to estimate CBP-CNP prevalence among Spanish population, its comorbidity with other physical and mental conditions, and its impact on global functioning.

SUBJECTS AND METHOD

Cross-sectional household survey of a representative sample of the population of Spain 18 years or older. Sample size was 5,473 individuals. CBP-CNP and comorbid conditions were ascertained by self-report. Mental disorders were ascertained with the Composite International Diagnostic Interview and global functioning with the WHO Dissability Assessment Schedule. Response rate was 78.6%.

RESULTS

The one year prevalence of chronic CBP-CNP was 14.7%. A 65.7% of people with CBP-CNP reported at least one other comorbid condition, including other chronic pain conditions (49.4%), chronic physical conditions (40.7%), any mood disorders (7.9%), panic disorder (1.3%), posttraumatic stress disorder (1.5%) or generalized anxiety disorder (1.4%). Additionally, CBP-CNP negatively affected global functioning. However, comorbid conditions explained about one-third of the association between CBP-CNP and global functioning.

CONCLUSIONS

CBP-CNP is highly prevalent and comorbid with other physical and mental conditions. Comorbidity negatively affects individuals global functioning.

Prevalence and characteristics of upper or mid-back pain in Finnish men

STUDY DESIGN

Descriptive epidemiologic study.

OBJECTIVES

To examine the 1-year prevalence, severity, and frequency of mid-back pain in a general population sample of men, with comparisons to neck and low back pain.

SUMMARY OF BACKGROUND DATA

No previous studies reporting the characteristics of mid-back pain in a general population were found.

METHODS

A total of 600 Finnish men 35 to 70 years of age were drawn from a population-based twin sample and interviewed with standardized pain questions.

RESULTS

The 1-year prevalence of mid-back pain was 17.0% (95% confidence interval, 14.3-19.7) compared to 64.0% (95% confidence interval, 60.6-67.5) for neck and 66.8% (95% confidence interval, 63.4-70.3) for low back pain. The frequency of pain over the previous year among those with mid- and low back pain was less than for neck pain. The mean severity of the worst pain episode was highest for low back pain followed by mid-back and neck pain, which were similar. Associated disability tended to be less frequent from mid-back pain (23.5% vs. 30.3%-41.1%). Odds ratios for neck and low back pain when mid-back pain was reported were 2.32 and 2.86, respectively.

CONCLUSION

The prevalence of mid-back pain was approximately one fourth that of neck and low back pain and was somewhat less likely to be disabling. In cases of mid-back pain, spinal comorbidity was nearly always reported.

Comorbidity of low back pain: representative outcomes of a national health study in the Federal Republic of Germany

BACKGROUND

Unlike other biopsychosocial risk factors, the role of comorbidity in low back pain is largely unknown.

AIMS

The purpose is (1) to generate prevalence data on back pain in the total adult population and (2) to identify the most common physical comorbidities in subjects with back pain. This paper also (3) analyses the gender-specific and age-specific comorbidity structure.

METHODS

The National German Health Survey is the first study to provide the basis for a representative nationwide analysis of back pain prevalence and the associated comorbidities. The net sample comprises a total of 7124 Germans aged 18-79.

RESULTS

One in three Germans (34%) experienced back pain during the seven days prior to being interviewed. The one-year prevalence rate is 59%. All the morbidities investigated by us are more common in subjects with back pain than in individuals without back pain. The most common comorbidities associated with back pain are musculoskeletal disorders like rheumatoid arthritis, osteoarthritis and osteoporosis, followed by cardiovascular and cerebrovascular disease.

CONCLUSIONS

The present study investigating 31 physical diseases is the most extensive analysis to date on the topic of back pain and comorbidity. This is an attempt to cast light on the tangled relationships involved in developing and coping with back pain. In view of the large percentage of unspecific back pain, we believe it is important for physicians treating back pain to extend their history and diagnostic analysis skills to embrace comorbidities related to the back pain.

Comorbid subjective health complaints in low back pain

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To compare subjective health complaints in subacute patients with low back pain with reference values from a Norwegian normal population.

SUMMARY OF BACKGROUND DATA

Comorbidity is common with nonspecific low back pain. We wanted to investigate if these complaints were specific or part of a more general unspecific condition comparable to subjective health complaints in the normal population.

MATERIALS AND METHODS

The study group consisted of 457 patients sick-listed 8 to 12 weeks for low back pain. All subjects filled out questionnaires. The subjective health complaints in the study group were compared with reference values from a Norwegian normal population using logistic regression analysis.

RESULTS

Compared with the normal reference population, the patients with low back pain had significantly more low back pain, neck pain, upper back pain, pain in the feet during exercise, headache, migraine, sleep problems, flushes/heat sensations, anxiety, and sadness/depression. The prevalence of pain in arms, pain in shoulders, and tiredness was also high, but not significantly higher than in the reference population.

CONCLUSIONS

Our findings indicate that patients with low back pain suffer from what may be referred to as a "syndrome," consisting of muscle pain located to the whole spine as well as to legs and head, and accompanying sleep problems, anxiety, and sadness/depression.

Medical Problems among Adolescents in U.S. Mental Health Services: Relationship to Functional Impairment

This study provides information about the extent of comorbidity between medical and behavioral problems among adolescents in mental health services, describes the clinical and sociodemographic characteristics of adolescents with both problems, and discusses the consequences or comorbidity for service delivery. Nationally representative mental health service use data for adolescents (age 12-17) in inpatient, outpatient, and residential mental health service settings (weighted N=296,755) were used. Close to one fifth (18.9%) of the adolescents had a medical problem, and adolescents with anxiety and pervasive developmental disorders had the highest rates of medical problems. In multivariate logistic regressions, having a medical problem significantly increased the odds of serious functional impairment; having a secondary or dual psychiatric diagnosis was only significant in interaction with a medical problem. The results underscore the need for adolescent behavioral health research and practice to attend to multiple influences on functioning.

Nonspecific lower-back pain: surgical versus nonsurgical treatment

We review evidence-based treatments for patients seeking care for lower-back pain and patients who have been diagnosed with nonspecific lower-back pain. The review is based on selected systematic reviews and national and international guidelines for the treatment of lower-back pain. Additional randomized controlled trials (ie, possibly those not previously included in the latest systematic reviews) were reviewed and added based on recommended procedures for the evaluation of methodological quality (ie, strong, moderate, and weak). In acute nonspecific lower-back pain (0-4 weeks duration of pain) there is moderate to strong evidence that self-care with over-the-counter medication and maintaining activity as tolerated or treatment with a limited number of sessions of manipulative therapy is effective for pain relief. In subacute nonspecific lower-back pain (4-12 weeks duration of pain) there is weak to moderate evidence that a graded activity program including exercises and cognitive behavioral treatment in combination is more efficient than usual care with regard to return to work. There is strong evidence that these programs reduce work absenteeism. In cases of chronic nonspecific lower-back pain (> 12 weeks duration of pain) a variety of treatments are available with limited and similar efficacy on pain and disability reduction. There is moderate evidence that surgery in chronic nonspecific lower-back pain is as effective as cognitive behavioral treatment with regard to pain, function, mood and return to work. Surgical indications for chronic nonspecific lower-back pain remain ill defined.

LEVEL OF EVIDENCE

Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.

Mental and physical comorbid conditions and days in role among persons with arthritis

OBJECTIVE

To estimate the prevalence of comorbidity among people with arthritis in the US adult population and to determine the role of comorbidity in accounting for the association of arthritis with days out of role (a measure of inability to work or carry out normal activities).

METHODS

Data come from the National Comorbidity Survey Replication (NCS-R), a nationally representative household survey of 9,282 respondents ages 18 and older carried out in 2001 to 2003. Arthritis was assessed by self-report in a chronic-conditions checklist, along with a wide range of other physical conditions. Mental and substance use disorders were ascertained with the World Health Organization Composite International Diagnostic Interview (CIDI). Number of days out of role was assessed for the 30 days before the interview.

RESULTS

Arthritis was reported by 27.3% of respondents, 80.9% of whom also reported at least one other physical or mental disorder, including 45.6% with another chronic pain condition, 62.3% with another chronic physical condition, and 24.3% with a 12-month mental disorder. Arthritis was significantly associated with days out of role, but comorbidity explained more than half of this association. No significant interactions were found between arthritis and the other conditions in predicting days out of role.

CONCLUSION

Comorbidity is the rule rather than the exception among people with arthritis. Comorbidity accounts for most of the days out of role associated with arthritis. The societal burden of arthritis needs to be understood and managed within the context of these comorbid conditions.

Regular use of prescribed opioids: association with common psychiatric disorders

Use of opioids for chronic non-cancer pain is increasing, but the clinical epidemiology and standards of care for this practice are poorly defined. Psychiatric disorders are associated with increased physical symptoms and may be associated with opioid use. We performed a secondary analysis of cross-sectional data from the Health Care for Communities (HCC) survey conducted in 1997-1998 (N=9279) to determine the association of psychiatric disorders and self-reported regular use of prescribed opioids within the past year. Regular prescription opioid use was reported by 282 (3%) respondents. In unadjusted logistic regression models, respondents with common mental disorders in the past year (major depression, dysthymia, generalized anxiety disorder, or panic disorder) were more likely to report regular prescription opioid use than those without any of these disorders (OR=6.15, 95% CI=4.13, 9.14, P< 0.001). Respondents reporting problem drug use (OR=4.75, 95% CI=2.52, 8.94, P<0.001), or problem alcohol use (OR=1.89, 95% CI=1.03, 3.40, P=.041) reported higher rates of prescribed opioid use than those without problem use. In multivariate logistic regression models controlling for demographic and clinical variables, the presence of a common mental disorder remained a significant predictor of prescription opioid use (OR=3.15, 95% CI=1.69, 5.88, P<0.001), among individuals reporting low pain interference (N=8307); but not (OR=1.27, n.s.) among those reporting high pain interference (N=972). Depressive, anxiety and drug abuse disorders are associated with increased use of regular opioids in the general population. Depressive and anxiety disorders are more common and more strongly associated with prescribed opioid use than drug abuse disorders.

Virtual Pain Stimulation of Allodynia Patients Activates Cortical Representation of Pain and Emotions: A Functional MRI Study

The present study investigated neural correlates of affect processing in allodynia patients (n=8) and healthy controls (n=12) with the aid of virtual tactile stimulation. Whole brain functional magnetic resonance imaging was performed for allodynia patients and healthy volunteers while they were shown a video demonstrating light stimulation of the palm and another stimulation aimed at producing anticipation of palm stimulation. Contrasting with controls, patients displayed activation of the cortical areas related to pain and emotions: prefrontal cortex (Brodmann's area BA 10) and anterior cingulate cortex (BA 24). These findings may indicate involvement of an emotional component of pain perception in all odynia patients.

Comorbidity of migraine

PURPOSE OF REVIEW

Comorbidity refers to the greater than coincidental association of separate conditions in the same individuals. Historically, a number of conditions have been noted to be comorbid with migraine, notably psychiatric disorders (anxiety, depression, panic disorder), epilepsy, asthma, and some congenital heart defects. Migraine sufferers have increased medical costs overall compared with others of the same sex and age, even after considering the cost of specific migraine treatment. Thus, estimates of the burden of migraine often include the costs of conditions comorbid with it.

RECENT FINDINGS

Conditions may be comorbid through a variety of mechanisms. Comorbidity may be an artifact of diagnostic uncertainty when symptom profiles overlap or when diagnosis is not based on objective markers. Comorbidity may arise due to unidirectional causality, such as migraine resulting in blood pressure changes due to headache-specific treatment. Finally, conditions may be comorbid because of shared genetic or other factors that increase the risk of both conditions. In such cases, understanding these shared risk factors may lead to greater understanding of the fundamental mechanisms of migraine.

SUMMARY

In this article, we will review recent developments related to migraine comorbidity. We will emphasize findings related to the comorbidity of migraine with clinical and sub-clinical vascular brain lesions, congenital heart defects, coronary heart disease, psychiatric illness, and other pain conditions.