Chronic musculoskeletal complaints as a predictor of mortality—The HUNT study

Examining the Relationship Between Chronic Pain and Mortality in U.S. Adults

Chronic pain (CP) significantly impacts quality of life and increases noncommunicable disease risk, with recent U.S. data showing a 6.3% incidence rate, surpassing diabetes, depression, and hypertension. International studies suggest higher mortality in CP populations, yet prior U.S. data are inconclusive. To investigate CP's mortality risk, we analyzed National Health Interview Survey and National Death Index data. We hypothesized that individuals with CP and high-impact CP (HICP [≥1 activity limitation]) would exhibit higher mortality rates. National Health Interview Survey provided demographics, pain reporting, lifestyle, and psychosocial data matched with National Death Index mortality records. Chi-square analyses explored the relationships between CP/HICP and demographics, lifestyle factors, psychosocial variables, and mortality. Cox proportional hazards models assessed mortality risk between groups. The weighted sample was 245,899,776; 20% reported CP and 8% HICP, both groups exhibiting higher mortality rates than pain-free individuals (CP: 5.55%, HICP: 8.79%, total: 2.82%). Hazard ratios indicated nearly double the mortality risk for CP and 2.5 times higher risk for HICP compared to those without these conditions. Adjusting for lifestyle and psychosocial factors reduced mortality risk but remained elevated compared with non-CP individuals. Heart disease, malignant neoplasms, and chronic lower respiratory diseases accounted for a higher percentage of deaths in CP cases. CP individuals showed higher rates of smoking, alcohol consumption, obesity, inactivity, depression, anxiety, emotional problems, and sleep disturbances. CP and HICP significantly influence mortality outcomes, leading to excess deaths compared with pain-free individuals. Given the relationship between pain, lifestyle, psychosocial variables, and mortality, further investigations are needed into CP causation and prevention strategies. PERSPECTIVE: This article presents evidence regarding the relationship between CP, HICP, and mortality. Additional findings are discussed regarding the impact of demographics, lifestyle, and psychosocial variables on mortality in those with versus without CP and HICP. These findings are crucial for informing future research, prevention, and healthcare management strategies.

Multisite Pain and Myocardial Infarction and Stroke: A Prospective Cohort and Mendelian Randomization Analysis

Background

Whether individuals with multisite pain had a higher risk of cardiovascular diseases is unclear.

Objectives

The purpose of this study was to investigate the longitudinal association of pain in multiple sites with incident myocardial infarction (MI) and stroke, and to disentangle the genetic causality of these associations.

Methods

A total of 281,760 participants (mean age: 56.3 years) who had no MI and stroke at baseline from UK Biobank study were included. Data on pain in the hip, knee, back and neck/shoulder, or 'all over the body' were collected. Chronic pain was defined if pain had lasted for ≥3 months. MI and stroke events were determined from hospital admission records and death registries. Cox regression and 2-sample Mendelian randomization were used for the analyses.

Results

During a median follow-up of 11.9 years, 4,854 had a first MI and 2,827 had a first stroke. In multivariable analyses, greater number of painful sites was dose-responsively associated with higher risks of incident MI and stroke, with a higher risk among participants with pain 'all over the body' (MI: HR: 1.65, 95% CI: 1.32-2.07; stroke: HR: 1.44, 95% CI: 1.13-1.85). Similar trends and associations were observed in those with chronic pain. Two-sample Mendelian randomization results supported a causal effect of multisite pain on MI risk, but not vice versa. No causal association was found between multisite pain and stroke risk.

Conclusions

Pain in multiple sites causally increases the risk of MI, highlighting that pain should be considered when assessing individuals' MI risk, and pain treatment and management may prevent MI risk.

The association between short-term, chronic localized and chronic widespread pain and risk for cardiovascular disease in the UK Biobank

AIMS

The interplay between pain of different chronicity and cardiovascular disease (CVD) is incompletely understood. We aimed to investigate the association between different levels of chronic or nonchronic pain and risk of CVD.

METHODS AND RESULTS

Participants in the UK Biobank who reported pain at baseline were divided into three groups according to pain duration and widespreadness. Participants reporting no pain were controls. Multivariable Cox regression was used to investigate the association between pain and incidence of myocardial infarction, heart failure, stroke, cardiovascular mortality, and composite CVD (defined as any of the before-mentioned cardiovascular events). Of 475 171 participants, 189 289 reported no pain, 87 830 reported short-term pain, 191 716 chronic localized pain, and 6336 chronic widespread pain (CWP). During a median of 7.0 years' follow-up, participants with chronic localized pain and CWP had, after adjustment for age, sex, established cardiovascular risk factors, physical activity, anxiety, depression, cancer, chronic inflammatory/painful disease, pain/anti-inflammatory medication, socioeconomic status, a significantly increased risk for composite CVD [hazard ratio (HR) 1.14, confidence interval (CI) 1.08-1.21, P < 0.001; and HR 1.48, CI 1.28-1.73, P < 0.001, respectively] compared with controls, with similar results when using the different specific CVDs as outcomes. Population attributable risk proportion for chronic pain as a risk factor for composite CVD was comparable with that of diabetes (8.6 vs. 7.3%, respectively).

CONCLUSION

Chronic pain is associated with an increased risk for myocardial infarction, stroke, heart failure, and cardiovascular death independent of established cardiovascular risk factors, socioeconomic factors, comorbidities and medication. Our study, the largest to date, confirms and extends our understanding of chronic pain as an underestimated cardiovascular risk factor with important public health implications.

Worse health‐related quality of life, impaired functioning and psychiatric comorbidities are associated with excess mortality in patients with severe chronic pain

Background

Severe chronic pain that interferes with daily activities is associated with an increased risk of mortality. We assessed the overall mortality of tertiary chronic pain patients in comparison with the general population, with a special aim to analyse the association of health‐related quality of life (HRQoL) and its dimensions with the risk of death.

Methods

In this prospective observational follow‐up study, patients with non‐cancer chronic pain attended an outpatient multidisciplinary pain management (MPM) episode in a tertiary pain clinic in 2004–2012 and were followed until May 2019. Mortality between the patients and the general population was compared with standardized mortality ratios (SMR) in different age groups. Causes of death and comorbidities were compared among the deceased. Association of mortality and HRQoL and its dimensions, measured with the 15D instrument, was studied with Cox proportional hazards model.

Results

During a mean of 10.4‐year follow‐up of 1498 patients, 296 died. The SMR in the youngest age group (18–49 years) was significantly higher than that of the general population: 2.6 for males and 2.9 for females. Even elderly females (60–69 years) had elevated mortality (SMR 2.3). Low baseline HRQoL at the time of MPM, as well as poor ratings in the psychosocial dimensions of HRQoL, was associated with an increased risk of death.

Conclusions

Our results support the role of HRQoL measurement by a validated instrument such as the 15D in capturing both the physical and the psychological symptom burden, and consequently, an elevated risk of death, in patients with chronic pain.

Significance

Severe chronic pain is associated with elevated mortality. In patients in chronic pain under 50 years old, the mortality was 2.5–3 times higher than in the general population. Psychological distress appears to contribute to the increased mortality. Regular follow‐up by health‐related quality of life (HRQoL) measurement could be useful in identifying patients in chronic pain who are in need of intensive symptom management and to prevent early death.

Mortality among persons experiencing musculoskeletal pain: a prospective study among Danish men and women

Background

Musculoskeletal (MSK) pain affects many people worldwide and has a great impact on general health and quality of life. However, the relationship between MSK pain and mortality is not clear. This study aimed to investigate all-cause and cause-specific mortality in relation to self-reported MSK pain within the last 14 days, including spread of pain and pain intensity.

Methods

This prospective cohort study included a representative cohort of 4806 men and women aged 16+ years, who participated in a Danish MSK survey 1990–1991. The survey comprised questions on MSK pain, including spread of pain and pain intensity. These data were linked with the Danish Register of Causes of Death to obtain information on cause of death. Mean follow-up was 19.1 years. Cox regression analyses were performed with adjustment for potential confounders.

Results

In the study population (mean age 44.5 years; 47.9% men), 41.0% had experienced MSK pain within the last 14 days and 1372 persons died during follow-up. For both sexes, increased all-cause mortality with higher spread and intensity of MSK pain was observed; a high risk was observed especially for men with strong pain (HR = 1.66; 95% CI:1.09–2.53) and women with widespread pain (HR = 1.49; 95% CI:1.16–1.92). MSK pain within last 14 days yielded c-statistics of 0.544 and 0.887 with age added. Moreover, persons with strong MSK pain had an increased cardiovascular mortality, persons with moderate pain and pain in two areas had an increased risk of cancer mortality, and persons with widespread pain had an increased risk of respiratory mortality.

Conclusions

Overall, persons experiencing MSK pain had a higher risk of mortality. The increased mortality was not accounted for by potential confounders. However, when evaluating these results, it is important to take the possibility of unmeasured confounders into account as we had no information on e.g. BMI etc.

Significance

The present study provides new insights into the long-term consequences of MSK pain. However, the discriminatory accuracy of MSK pain was low, which indicates that this information cannot stand alone when predicting mortality risk.

Widespread pain is a risk factor for cardiovascular mortality: results from the Framingham Heart Study

AIMS

With the introduction of widespread pain (WSP) as a separate diagnostic code in the ICD-11, WSP has now become an own clinical diagnosis independent of the underlying pathophysiology. Research has reported aetiological associations of WSP and cardiovascular diseases. However, studies on mortality risk in individuals with WSP have reported inconsistent results. This study investigates whether there is increased mortality in WSP individuals and establish potential determinants of mortality risk. Therefore, we evaluates the population-based prospective cohort of the Framingham Heart Study (FHS).

METHODS AND RESULTS

The FHS is a longitudinal multi-generational study. Pain status was assessed uniquely between 1990 and 1994. Cox proportional hazards modelling was used to estimate hazard ratios (HRs) of WSP on all-cause mortality controlling for sex and age, cardiovascular risk factors, cancer history, lifestyle factors and current medication. WSP examination was carried out in 4746 participants of the FHS (60.3 ± 13.5 years, 55.1% women). A total of 678 (14.5%) subjects fulfilled the criteria for WSP, whereas 4011 (85.5%) subjects did not. The follow-up time was 15 years, during which 202 persons died in the WSP group and 1144 in the no-WSP group. When adjusting for age and sex, all-cause mortality was increased by about 16% in WSP subjects. Individuals with WSP had an increased HR particularly for cardiovascular cause of death (HR adjusted by age and sex = 1.46, 95% confidence interval 1.10-1.94).

CONCLUSION

Our data show that in a large population-based cohort, WSP is associated with increased HR for cardiovascular cause of death, underlining the need for pain assessments in cardiovascular practice.

Do incident musculoskeletal complaints influence mortality? The Nord-Trøndelag Health study

Background

Musculoskeletal complaints (MSC) are common in the general population, causing a major disease burden to the individual and society. The association between MSC and mortality is still unclear. To our knowledge, no study has hitherto evaluated the association between MSC onset within the last month (incident MSC) on the one hand, and all-cause and cause-specific mortality on the other.

Methods

This prospective population-based cohort study was done using data from the second Nord-Trøndelag Health Study (HUNT2) linked with data from a comprehensive national registry of cause of death. A total of 25,931 participants at risk for incident MSC were included. Hazard ratios (HR) of mortality were estimated for participants with incident MSC using Cox regression based on a mean of 14.1 years of follow-up.

Results

Participants who reported incident MSC did not have an excess mortality compared to those with no MSC in the analyses of all-cause mortality (HR 0.99, 95% CI 0.89–1.10) and cause specific mortality. This was true also after adjustment for several potential confounding factors. No clear association between the number of MSC body sites and mortality was found.

Conclusion

Incident MSC were not associated with an increased mortality, neither for all-cause mortality, nor cause-specific mortality.

Cause-specific mortality of patients with severe chronic pain referred to a multidisciplinary pain clinic: a cohort register-linkage study

Background and aims

Almost 20% of the adult population suffers from chronic pain. Chronic pain may be linked to an elevated mortality; however, results from previous studies are inconsistent. Some studies find similar mortality levels in chronic pain patients and pain-free controls while other studies show elevated mortality levels among chronic pain patients, primarily with respect to cancer, diseases of the circulatory and respiratory systems, and suicide. These conflicting results are potentially due to different population samples and different operational definitions of chronic pain. Further research on overall and cause-specific mortality in patients with severe chronic pain is needed to inform clinical practice. The objective of this register-linkage study was to investigate whether patients with severe chronic pain referred to multidisciplinary pain treatment have higher cause-specific mortality rates than the general population.

Methods

In this register-linkage cohort study, data from 6,142 chronic pain patients (female: n=3,941, male: n=2,201, mean age: 48.2±14.2; range: 16–97 years) attending an interdisciplinary Pain Center in Odense, Denmark from 2005 to 2014 were linked to the Danish Register of Causes of Death. Age and gender standardized mortality ratios (SMRs) with their 95% confidence intervals (CI) were calculated and compared with those of the general population. Data from the general population was extracted from the Danish Register of Causes of Death, and Causes of death were classified according to national Classification of Disease (ICD-10).

Results

In all, 276 deaths (women: n=152, men: n=124) were observed among the chronic pain patients, and a six-fold higher overall mortality rate was found [SMR: 6.2 (95% CI: 5.5–7.0)] compared with the general population. Elevated cause-specific mortality rates were noted for chronic patients with respect to cancer and neoplasms [4.7 (95% CI: 3.7–5.9)], diseases of the circulatory system [5.7 (95% CI: 4.3–7.3)], diseases of the respiratory system [8.7 (95% CI: 6.2–11.9)], and suicide [7.3 (95% CI: 2.7–15.9)].

Conclusions

The overall mortality rate of patients with severe chronic pain in this study was six-fold higher than the rate of the general population in this region. This was reflected in select specific causes of death (cancer and neoplasms, diseases of the circulatory system, diseases of the respiratory system, and suicide). The results are in agreement with previous studies and emphasize the need to understand which factors causally affect this increased mortality allowing for targeted interventions in similar chronic pain populations.

Implications

Potential reasons for the excess mortality should be adequately addressed by future studies in order to better target this in the management of these patients. The chronic pain population included in this study may have several comorbidities contributing to the increased mortality. To better address these aspects, complete medical profiles are needed in future studies. In addition, implementation of management strategies towards potential risk factors such as poor diet, low levels of physical activity, smoking, and high BMI as well as sleep deprivation and morphine use previously shown associated with having pain may reduce the excess mortality ratio.

Chronic musculoskeletal pain in European older adults: Cross-national and gender differences

BACKGROUND

In an ageing Europe, chronic pain is a major public health problem, but robust epidemiological data are scarce. This study aimed to analyse the prevalence of and factors associated with chronic musculoskeletal pain by gender in older adults of 14 European countries.

METHODS

A cross-sectional study was performed from wave 5 of the Survey of Health, Ageing and Retirement in Europe (SHARE). The study included people ≥50 years residing in Austria, Belgium, Czech Republic, Denmark, Estonia, France, Germany, Italy, Luxembourg, the Netherlands, Slovenia, Spain, Sweden and Switzerland. Chronic pain was defined as being bothered by joint and/or back pain for the previous 6 months. Multivariable Poisson regression models with robust variance were performed to analyse prevalence ratio by covariates, stratified by sex.

RESULTS

A total of 61,157 participants were included. Overall prevalence of chronic musculoskeletal pain was 35.7% (28.8-31.7), ranging from 18.6% (17.1-20.1) for Switzerland to 45.6% (43.3-47.8) for France. Prevalence was higher in women than in men: 41.3% (40.2-42.4) versus 29.1% (28.0-30.3). Chronic musculoskeletal pain was lower in men aged >75 years (PR = 0.82; 0.72-0.92) than the younger (50-59) group. Separated/divorced status presented opposite effects among men (PR = 0.85; 0.76-0.96) and women (PR = 1.12; 1.03-1.21) compared with married, and unemployment was a significant factor in men (PR = 1.21; 95% CI 1.02-1.43) compared with employed.

CONCLUSIONS

Musculoskeletal pain in older European adults is very frequent, especially in women, with large differences depending on the country of residence. Health policy makers should prioritize strategies aimed at improving the prevention and management of chronic musculoskeletal pain in Europe.

SIGNIFICANCE

This study provides epidemiological data of chronic musculoskeletal pain in older adults. Reported differences contribute to highlight the relevance of considering a gender perspective in chronic musculoskeletal pain research. Cross-national comparison also offers a map of differences that improves the knowledge of this chronic condition in Europe.

Is Preoperative Patient-Reported Health Status Associated with Mortality after Total Hip Replacement?

The influence of comorbidities and worse physical status on mortality following total hip replacement (THR) leads to the idea that patient-reported health status may also be a predictor of mortality. The aim of this study was to investigate the relationship between patient-reported health status before THR and the risk of dying up to 5 years post-operatively. For these analyses, we used register data on 42,862 THR patients with primary hip osteoarthritis operated between 2008 and 2012. The relative survival ratio was calculated by dividing the observed survival in the patient group by age- and sex-adjusted expected survival of the general population. Pre-operative responses to the five EQ-5D-3L (EuroQol Group) dimensions along with age, sex, education status, year of surgery, and hospital type were used as independent variables. Results shown that, as a group, THR patients had a better survival than the general population. Broken down by the five EQ-5D-3L dimensions we observed differentiated survival patters. For all dimensions, those reporting extreme problems had higher mortality than those reporting moderate or no problems. In conclusion, worse health status according to the EQ-5-3L before THR is associated with higher mortality up to five years after surgery. EQ-5D-3L responses may be useful in a multifactorial individualized risk assessment before THR.

Persons with chronic widespread pain experience excess mortality: longitudinal results from UK Biobank and meta-analysis

Objective

It is uncertain whether persons with chronic widespread pain (CWP) experience premature mortality. Using the largest study conducted, we determine whether such a relationship exists, estimate its magnitude and establish what factors mediate any relationship.

Methods

UK Biobank, a cohort study of 0.5 million people aged 40–69 years, recruited throughout Great Britain in 2006–2010. Participants reporting ‘pain all over the body’ for >3 months were compared with persons without chronic pain. Information on death (with cause) was available until mid-2015. We incorporated these results in a meta-analysis with other published reports to calculate a pooled estimate of excess risk.

Results

7130 participants reported CWP and they experienced excess mortality (mortality risk ratio 2.43, 95%CI 2.17 to 2.72). Specific causes of death in excess were cancer (1.73adjusted age and sex, 95% CI 1.46 to 2.05), cardiovascular (3.24adjusted age and sex, 95% CI 2.55 to 4.11), respiratory (5.66adjusted age and sex, 95% CI 4.00 to 8.03) and other disease-related causes (4.04adjusted age and sex, 95% CI 3.05 to 5.34). Excess risk was substantially reduced after adjustment for low levels of physical activity, high body mass index, poor quality diet and smoking. In meta-analysis, all studies showed significant excess all-cause (combined estimate 1.59 (95% CI 1.05 to 2.42)), cardiovascular and cancer mortality.

Conclusions

Evidence is now clear that persons with CWP experience excess mortality. UK Biobank results considerably reduce uncertainty around the magnitude of excess risk and are consistent with the excess being explained by adverse lifestyle factors, which could be targeted in the management of such patients.

The Mortality Associated With Chronic Widespread Musculoskeletal Complaints: A Systematic Review of the Literature

BACKGROUND

Chronic widespread musculoskeletal complaints (CWMSC) are a prevalent condition with a large impact on quality of life and with a large burden on society. Studies investigating the relationship between CWMSC and mortality have yielded inconsistent results. The present study aimed to clarify this relationship through a systematic review of the existing literature, including meta-analyses, to estimate pooled results and heterogeneity.

METHODS

The MEDLINE, EMBASE and Science Citation Index Expanded databases were searched in February 2016. Broad search terms were used to identify as many observational studies as possible that investigated the association between CWMSC and mortality. The identified studies were evaluated according to predetermined inclusion criteria.

RESULTS

Six studies fulfilled the inclusion criteria. In pooled unadjusted analyses of three studies evaluating CWMSC, a non-significant tendency of increased overall mortality was found [mortality risk ratio (MRR) 1.69, 95% confidence interval (CI) 0.91-3.14]. However, in pooled analyses of all six studies reporting adjusted results, the non-significant tendency for higher mortality rates in those with CWMSC was nearly eliminated (MRR 1.13, 95% CI 0.95-1.34). Heterogeneity between studies was moderate to high, particularly regarding the use of confounding factors.

CONCLUSIONS

In this systematic review, based on a limited number of studies, pooled data gave no evidence of a higher mortality rate among individuals with CWMSC. The non-significant tendency for a higher mortality rate in unadjusted pooled analyses was nearly eliminated in the adjusted pooled analyses, considering lifestyle factors such as physical activity smoking. In population-based studies evaluating the relationship between CWMSC and mortality rates, we recommend that both unadjusted and adjusted analyses should be presented. Copyright © 2016 John Wiley & Sons, Ltd.

Sociodemographic disparities in chronic pain, based on 12-year longitudinal data

Existing estimates of sociodemographic disparities in chronic pain in the United States are based on cross-sectional data, often treat pain as a binary construct, and rarely test for nonresponse or other types of bias. This study uses 7 biennial waves of national data from the Health and Retirement Study (1998-2010; n = 19,776) to describe long-term pain disparities among older (age 51+) American adults. It also investigates whether pain severity, reporting heterogeneity, survey nonresponse, and/or mortality selection might bias estimates of social disparities in pain. In the process, the article clarifies whether 2 unexpected patterns observed cross-sectionally-plateauing of pain above age 60, and lower pain among racial/ethnic minorities-are genuine or artefactual. Findings show high prevalence of chronic pain: 27.3% at baseline, increasing to 36.6% thereafter. Multivariate latent growth curve models reveal extremely large disparities in pain by sex, education, and wealth, which manifest primarily as differences in intercept. Net of these variables, there is no racial/ethnic minority disadvantage in pain scores, and indeed a black advantage vis-à-vis whites. Pain levels are predictive of subsequent death, even a decade in the future. No evidence of pain-related survey attrition is found, but surveys not accounting for pain severity and reporting heterogeneity are likely to underestimate socioeconomic disparities in pain. The lack of minority disadvantage (net of socioeconomic status) appears genuine. However, the age-related plateauing of pain observed cross-sectionally is not replicated longitudinally, and seems partially attributable to mortality selection, as well as to rising pain levels by birth cohort.

Musculoskeletal Complaints (Pain and/or Stiffness) and Their Impact on Mortality in the General Population. The Tromsø Study

Background

The long-term consequences of chronic pain and/or stiffness from the musculoskeletal system (musculoskeletal complaints: MSCs) have not been well explored. The aims of this study were to investigate whether MSCs reported at baseline influence all-cause and cause-specific mortality during 21 years follow-up of a general Northern Norwegian adult population.

Methods

A total of 26,977 men and women aged 25–97 years who participated in the 1994–1995 survey of the Tromsø study (response rate 77%) were included in the present prospective cohort study. Baseline data were collected from the 1994–1995 survey and information on death and emigration was taken from the National Register of Norway. Cox regression analyses were performed to examine if MSCs predicted risk of mortality.

Results

5693 (21.1%) participants died during follow-up. Mean time between entry into the survey and death or emigration was 18.6 years (standard deviation 4.87) for all-cause mortality. There was an increased risk of death among those with MSCs at baseline in the crude Cox regression model. However, the multivariable model revealed no significant association between MSCs at baseline and all-cause mortality by sex (women: hazard ratio [HR] = 0.93, 95% confidence interval [CI]: 0.85–1.01; men: HR = 0.93, 95%CI: 0.85–1.01). Furthermore, no significant associations were found between widespread MSCs at baseline and all-cause mortality in multivariable models (women: HR = 0.90, 95%CI: 0.80–1.01; men HR = 0.87, 95%CI: 0.76–1.00). Analyses on cause-specific mortality did not reveal any significant results.

Conclusion

MSCs are not independently associated with increased risk of death from cardiovascular disease, cancer, or death from all causes.