Gary J. Macfarlane

Low back pain in schoolchildren: Occurrence and characteristics

&NA; Low back pain in adolescents is perceived to be uncommon in the clinic setting. However, previous studies have suggested that it may be an important and increasing problem in this age‐group. The aim of this study was to determine the prevalence and important symptom characteristics of low back pain such as duration, periodicity, intensity, disability and health seeking behaviour at young ages. A population‐based cross‐sectional study was conducted including 1446 children aged 11–14 years in the North‐West of England. A self‐complete questionnaire was used to assess low back pain prevalence, symptom characteristics, associated disability and health seeking behaviour. An additional self‐complete questionnaire amongst parents sought to validate pain reporting. The 1‐month period prevalence of low back pain was 24%. It was higher in girls than boys (29 vs. 19%; &khgr;2=14.7, P<0.001) and increased with age in both sexes (P<0.001). Of those reporting low back pain, 94% experienced some disability, with the most common reports being of difficulty carrying school bags. Despite this high rate of disability, few sought medical attention. Adolescent low back pain is common although medical attention is rarely sought. Such symptoms in childhood, particularly as they are so common, may have important consequences for chronic low back pain in adulthood.

Risk factors for neck pain: a longitudinal study in the general population

&NA; The objective of the study was to examine the 1‐year cumulative incidence of episodic neck pain and to explore its associations with individual risk factors, including a history of previous neck injury. A baseline cross‐sectional survey of an adult general population sample made up of all 7669 adults aged 18–75 years, registered with two family practices in South Manchester, United Kingdom, identified the study population of adults with no current neck pain. This study population was surveyed again 12 months later to identify all those who had experienced neck pain during the follow‐up period. At follow‐up, cumulative 1‐year episode incidence of neck pain was estimated at 17.9% (95% confidence interval 16.0–19.7%). Incidence was independent of age, but was more common in women. A history of previous neck injury at baseline was a significant risk factor for subsequent neck pain in the follow‐up year (risk ratio 1.7, 95% confidence interval 1.2–2.5), independent of gender and psychological status. Other independent baseline risk factors for subsequent neck pain included number of children, poor self‐assessed health, poor psychological status and a past history of low back pain. We have carried out a prospective study in a general population sample and demonstrated that established risk factors for chronic pain predict future episodes of neck pain, and shown that in addition a history of neck injury is an independent and distinct risk factor. This finding may have major public health and medicolegal implications.

Risk of malignancy among patients with rheumatic conditions

Previous studies have described an increased risk of malignancy in subjects diagnosed with rheumatic conditions, most notably rheumatoid arthritis (RA). Our aim was to quantify and compare risks for site‐specific malignancy among hospitalized patients with RA, osteoarthritis (OA) and other rheumatic conditions in a nationwide, population‐based cohort. Subjects were identified from Scottish hospital in‐patient records from 1981 to 1996 and followed up by computer linkage of the Scottish Cancer Registry and the national registry of deaths. Expected cancer incidence was calculated from national cancer rates and related to the observed incidence by the standardized incidence ratio (SIR). Among RA patients, there was an increased risk for hematopoietic [males SIR= 2.13, 95% confidence interval (CI) 1.7–2.7; females SIR = 1.76, 95% CI 1.5–2.1], lung (males SIR = 1.32, 95% CI 1.2–1.5; females SIR = 1.44, 95% CI 1.3–1.6) and prostate (SIR = 1.26, 95% CI 1.0–1.6) cancers. Reduced risk were seen for colorectal cancer (males SIR = 0.87, 95% CI 0.7–1.1; females SIR = 0.71, 95% CI 0.6–0.9) and, among females, stomach cancer (SIR = 0.70, 95% CI 0.5–1.0). The excess risk for hematopoietic cancer and the reduced risk for colorectal and stomach cancers were sustained over 10 years of follow‐up. An overall decreased risk of cancer was observed for patients with OA; the greatest reductions were observed for colorectal (males SIR = 0.88, 95% CI 0.8–1.0; females SIR = 0.84, 95% CI 0.8–0.9), stomach (males SIR = 0.79, 95% CI 0.7–0.9; females SIR = 0.66, 95% CI 0.6–0.8) and lung (males SIR = 0.72, 95% CI 0.7–0.8; females SIR = 0.84, 95% CI 0.8–0.9) malignancies, with decreased risks generally still evident at 10 years of follow‐up. Our results support several previous findings regarding the incidence of hematopoietic and colorectal malignancies in RA patients. In addition, we have shown a large decrease in stomach cancer among patients with OA and females with RA that warrants further investigation since it may provide clues to possible prevention strategies. To further our knowledge about the underlying mechanisms of altered risk in cancer patients with rheumatic conditions, population studies requiring primary data collection are required. Int. J. Cancer 88:497–502, 2000.

Features of somatization predict the onset of chronic widespread pain: Results of a large population-based study

OBJECTIVEnChronic widespread pain, the clinical hallmark of the fibromyalgia syndrome, is associated with other physical and psychological symptoms both in patients studied in a clinical setting and in those identified in the community. The present study was undertaken to examine the hypothesis that psychological and physical indicators of the process of somatization predict the development of new chronic widespread pain.nnnMETHODSnIn this population-based prospective study, 1,658 adults ages 18-65 years completed a detailed pain questionnaire, which included a pain drawing. They also completed the following psychosocial instruments: General Health Questionnaire, Somatic Symptom Checklist, Fatigue Questionnaire, and Illness Attitude Scales. Individuals were followed up at 12 months, at which time 1,480 (93% of subjects still living at their baseline address) provided data on pain status, using the same instruments.nnnRESULTSnAt baseline, 825 subjects were classified as pain free and 833 as having pain not satisfying criteria for chronic widespread pain. Of those, 18 (2%) and 63 (8%), respectively, were classified as having chronic widespread pain at followup. After adjustment for age and sex, there were strong relationships between baseline test scores and subsequent risk of chronic widespread pain (odds ratio for the Somatic Symptom Checklist 3.3; odds ratio for the Illness Behavior subscale of the Illness Attitude Scales 9.0). All 95% confidence intervals excluded unity. These associations were independent of baseline pain status.nnnCONCLUSIONnSubjects who are free of chronic widespread pain are at increased future risk of its development if they display other aspects of the process of somatization. Data from this population-based prospective study lend powerful support to the hypothesis that chronic widespread pain can be one manifestation of the somatization of distress.

Widespread body pain and mortality: prospective population based study.

Abstract Objective: To determine whether there is excess mortality in groups of people who report widespread body pain, and if so to establish the nature and extent of any excess. Design: Prospective follow up study over eight years. Mortality rate ratios were adjusted for age group, sex, and study location. Setting: North west England. Participants: 6569 people who took part in two pain surveys during 1991-2. Main outcome measures: Pain status at baseline and subsequent mortality. Results: 1005 (15%) participants had widespread pain, 3176 (48%) had regional pain, and 2388 (36%) had no pain. During follow up mortality was higher in people with regional pain (mortality rate ratio 1.21, 95% confidence interval 1.01 to 1.44) and widespread pain (1.31, 1.05 to 1.65) than in those who reported no pain. The excess mortality among people with regional and widespread pain was almost entirely related to deaths from cancer (1.55 (1.09 to 2.19) for regional pain and 2.07 (1.37 to 3.13) for widespread pain). The excess cancer mortality remained after exclusion of people in whom cancer had been diagnosed before the original survey and after adjustment for potential confounding factors. There were also more deaths from causes other than disease (for example, accidents, suicide, violence) among people with widespread pain (5.21, 0.94 to 28.78). Conclusion: There is an intriguing association between the report of widespread pain and subsequent death from cancer in the medium and long term. This may have implications for the long term follow up of patients with “unexplained” widespread pain symptoms, such as those with fibromyalgia. What is already known on this topic Widespread body pain, the cardinal symptom of fibromyalgia, is common An organic basis for symptoms is found in only a small proportion of people Treatment is difficult, and studies with short term follow up have shown that symptoms commonly persist What this study adds This was the first study with long term follow up of people with widespread pain in the community These people experience an increased mortality and the excess is principally related to deaths from cancer

Development and validation of a questionnaire to assess disabling foot pain

Abstract This study outlines the design and validation of a new self‐administered instrument for assessing foot pain and disability. The 19‐item questionnaire was tested on 45 rheumatology patients, 33 patients who had attended their general practitioner with a foot‐related problem and 1000 responders to a population survey of foot disorders. Levels of reported disability were found to be greatest for rheumatology patients and least for community subjects. In addition, the instrument was able to detect differences in disability levels reported by community subjects who did and did not consult with a health care professional and those who did and did not have a history of past and current foot pain. A good level of agreement was found when items on the questionnaire were compared with similar items on the ambulation sub‐scale of the Functional Limitation Profile questionnaire. A Cronbachs alpha value of 0.99 and item‐total correlation values between 0.25 and 0.62 confirmed the internal consistency of the instrument. Finally the results of a principal components analysis identified three constructs that reflected disabilities that are associated with foot pain: functional limitation, pain intensity and personal appearance. The design of the foot disability questionnaire makes it a suitable instrument for assessing the impact of painful foot conditions in both community and clinical populations.

Low back pain in schoolchildren: the role of mechanical and psychosocial factors

Background: Low back pain (LBP) in schoolchildren with no apparent clinical cause is known to be a common problem, but considerably less is understood regarding the aetiology of such pain. Aim: To assess the role of both mechanical and psychosocial factors (including emotional and behavioural problems and other somatic pain complaints) in childhood LBP. Methods: A cross sectional study was carried out in a population of 1446 schoolchildren aged 11–14 years. Information on these potential risk factors for LBP was sought using a self complete questionnaire and a five day bag weight diary. Results: Mechanical factors such as physical activity and school bag weight were not associated with LBP. However, strong associations with LBP were observed for emotional problems, conduct problems, troublesome headaches, abdominal pain, sore throats, and daytime tiredness. Conclusion: Results suggest that psychosocial factors rather than mechanical factors are more important in LBP occurring in young populations and could possibly be a reflection of distress in schoolchildren.

Alcohol, tobacco, diet and the risk of oral cancer: a pooled analysis of three case-control studies

This combined analysis of data from three large case-control studies of oral cancer confirms the important effect of tobacco in the aetiology of the disease. The studies have been conducted in the United States, Italy and China and results for risks associated with tobacco smoking were generally consistent across centres, while those for alcohol were not; increased risks amongst alcohol drinkers were evident in two centres but not in the study conducted in Turin, Italy. In addition, the combined analysis had large enough numbers to analyse the risk of tobacco consumption in non-drinkers. In females these showed increased risks while in males the effect of tobacco alone was weaker. Given the popularity of tobacco smoking, and its consequent high attributable risk in terms of oral cancer it is reassuring, in terms of public health, that cessation will result in a substantial reduction in risk; a 30% reduction in risk for those stopping smoking between 1 and 9 years, and a 50% reduction for those stopping more than 9 years. Although encouraging smokers to stop should be the principal aim, decreases in risk for everyone could be achieved by encouraging high fruit and vegetable consumption.

Predictors of early improvement in low back pain amongst consulters to general practice: the influence of pre-morbid and episode-related factors.

Low back pain symptoms are extremely common. affecting as many as 80% of the population at some time in their lives. However, the majority of the medical costs arise from the minority of patients whose symptoms become chronic. The authors propose a model in which chronicity is determined not only by factors related to the episode of low back pain, but also factors prior to the onset of symptoms (pre-morbid factors). No previous study has collected information on predictors of low back pain chronicity prior to the onset of symptoms. Participants in the South Manchester Low Back Pain Study, recruited by means of a cross-sectional population survey were followed prospectively over 18 months to identify those who consulted their general practitioner with a new episode of low back pain. At interview, 1-2 weeks post-consultation, it was determined whether or not subjects symptoms had improved. In males, low levels of psychological distress, a higher than average reported level of physical activity, being in employment, and being satisfied with current work status were associated with a quick improvement in symptoms. In addition factors related to the episode, namely a short duration before consultation and symptoms with a sudden onset and confined to the lower back area, also strongly predicted a good early outcome. Using information on both pre-morbid and episode related factors, groups of male patients were identified whose probability of an early resolution of symptoms ranged between 0.25 and 1. Few factors, either pre-morbid or episode-related, were strongly associated with outcome amongst females. This large population-based study has shown, despite the known heterogeneity in the origin of low back pain and the pathologies associated with symptoms, an early improvement in symptoms amongst male attenders at general practice can be predicted on the basis of a small number of variables.

The Cheshire Foot Pain and Disability Survey: a population survey assessing prevalence and associations.

&NA; Previous foot studies have consistently reported high prevalence estimates in self‐reported foot disorders. Few population studies, however, have attempted to assess the impact of foot problems in terms of pain and disability so that the burden associated with foot pain is unknown. A cross‐sectional postal survey was conducted on a random community sample of 4780 individuals with 3417 (84%) responding. Subjects reporting foot pain in the past month, current pain and marking one item on the Manchester Foot Pain and Disability Index were classified as having disabling foot pain. Those with disabling foot pain and a random sample with no symptoms (matched for age and gender) received a follow‐up interview and standardised foot examination. Self‐reported nail problems, corns and callosities, swollen feet, foot deformities and recent foot injuries were found to be associated with disabling foot pain. Foot disability was also associated with pain in the shoulder, axial skeleton, hip/upper leg and knee along with other indicators of poor general health. Clinician diagnosed foot problems associated with disabling foot pain were swollen feet, knee and foot joint tenderness. Only 36% of persons with disabling foot pain received professional foot treatment in the 6 months preceding the survey. The results showed that 323/3417 (9.5%) reported symptoms of disabling foot pain and that this condition is likely to be multi‐factorial in origin. Further work is necessary to understand more about the extent and type of unmet need and on how patients presenting with symptoms of disabling foot pain should best be managed.