Back and Neck Pain Exhibit Many Common Features
in Old Age: A Population-based Study of 4,486
Danish Twins 70-102 Years of AgeThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Spine (Phila Pa 1976). 2004 (Mar 1); 29 (5): 576–580 ~ FULL TEXT
Jan Hartvigsen, DC, PhD, Kaare Christensen, MD, PhD, and Henrik Frederiksen, MD, PhD
Nordic Institute of Chiropractic and Clinical Biomechanics,
Institute of Public Health,
University of Southern Denmark,
Odense C, Denmark.
j.hartvigsen@nikkb.dk
STUDY DESIGN: Cross-sectional and longitudinal analysis of data comprising 4,486 Danish twins 70-102 years of age.
OBJECTIVES: To describe the 1-month prevalence of back pain, neck pain, and concurrent back and neck pain and the development of these over time, associations with other health problems, education, smoking, and physical, and mental functioning.
SUMMARY OF BACKGROUND DATA: Back pain and neck pain are prevalent symptoms in the population; however, there is little research addressing these conditions in older age groups.
METHODS: Extensive interview data on health, lifestyle, social, and educational factors were collected in a nationwide cohort-sequential study of 70+ year-old Danish twins. Data for back pain, neck pain, lifetime prevalence of a comprehensive list of diseases, education, and self-rated health were based on self-report. Physical and mental functioning were measured using validated performance tests. Data including associated factors were analyzed in a cross-sectional analysis for answers given at entry into the study, and longitudinal analysis was performed for participants in all four surveys.
RESULTS: The overall 1-month prevalence for back pain only was 15%, for neck pain only 11%, and for concurrent back and neck pain 11%. The prevalence varied negligibly over time and between the age groups, and 63% of participants in all surveys had no episodes or only one episode of back or neck pain. Back pain and neck pain were associated with a number of other diseases and with poorer self-rated health. Back and neck pain sufferers had significantly lower scores on physical but not cognitive functioning.
CONCLUSIONS: Back pain and neck pain are common, intermittent symptoms in old age. Back pain and neck pain are associated with general poor physical health in old age.
KEYWORDS: back pain, comorbidity, education, geriatrics, neck pain, old age, prevalence, self-rated health]
From the FULL TEXT Article:
Background
Back pain and neck pain are common complaints in the population both with lifetime prevalence rates of roughly 70%. [1, 2] Specific knowledge about back pain and neck pain in seniors is, however, limited, and there is an underrepresentation of older age groups in the back pain literature. [3] Furthermore, it is unknown how back pain and neck pain develop over time in older individuals since no longitudinal studies with repeated identical prevalence measurements in the same cohort have been performed.
There is some evidence that back pain and neck pain may commonly occur together in both younger and older persons. For instance, Cote et al [1] found odds ratios (OR) >20 for severe low back pain in a Canadian population with concurrent severe neck pain, and Isacsson et al found that 23% of retired men in Sweden experienced both back pain and neck pain on a daily basis. [4] In contrast, Brochet et al, in a sample of elderly Frenchmen, found back pain to be almost three times as prevalent as neck pain with very little co-occurrence. [5] It is thus unclear to what extent back pain and neck pain in old age do occur together, and whether they might share common determinants and risk factors or merely occur together occasionally as two common, randomly associated conditions.
We present data from a large population-based prospective cohort study of Danish twins 70 to 102 years of age. We report data describing the 1-month prevalence of back pain, neck pain, and concurrent back pain and neck pain and associations with other health problems, smoking, education, self-rated health, and decreased physical and mental functioning. Further, we describe the development of back pain and neck pain over time both at the group and individual level.
Methods
Study Population and Data Collection.
The Danish Twin Registry contains information on Danish twins born since 1870. [6] The twin registry is the basis for the Longitudinal Study of Aging Danish Twins (LSADT), which has previously been described in detail. [7] In brief, data were collected using face-to-face interviews on four occasions starting in 1995 for Danish twins 75 years of age or older (regardless of whether the co-twin was alive). In 1997, intact Danish twin pairs 73 years of age and older were invited to participate, and in 1999 and 2001 age groups of 70+ years were included regardless of whether the co-twin was alive. A total of 4,731 twins participated, resulting in an overall participation rate of 80.4%; however, 245 provided answers by proxy (most often because the participant had dementia), and these answers were subsequently excluded from the analysis. Participation rates were significantly higher in men than in women, but the responders and non-responders were similar in terms of age. [8] The survey was conducted by trained interviewers with substantial experience in interviewing the elderly, was home based and consisted of an extensive battery of questions, and tests of cognitive and physical functioning.
Back pain was assessed in all four data collection waves using the same questions: “Have you during the past month suffered from back pain, acute low back pain or lumbago?” Neck pain was assessed in all waves using the question: “Have you during the past month suffered from pain or stiffness in the neck or shoulders?”
In all surveys, the participants were asked whether a physician had ever told them that they suffered from various diseases. Participants who answered “yes, previously” or “yes, currently” were subsequently asked to confirm that the diagnosis had been made by a physician before the answer was accepted as valid. Further, participants were asked about current or past smoking habits, years of school, and education after school (i.e., no further education, skilled worker, college, university), and self-rated health.
Assessment of functional abilities was based on self-report, which has generally been found to be reliable and valid. [9] The instrument used has previously been validated in Denmark and has been shown to discriminate levels of functional abilities among community-dwelling elderly persons. [10] All items were rated on a 1 to 4 scale and, after a factor analysis, averaged into a strength score, which was subsequently adjusted for age and sex. [7]
Cognitive state and function was measured using the Mini- Mental State Examination. [11]
Data AnalysisPrevalence of Back and Neck Pain. In the cross-sectional analysis, results from the four LSADT surveys were combined and answers given at entry into the study, i.e., the first time a person participated in a survey, were used. Sex-specific prevalence estimates with 95% confidence intervals (CI) were calculated for 5-year age groups for back pain alone, neck pain alone, and back pain and neck pain together.
In the longitudinal analysis, prevalence of back pain alone, neck pain alone, and back pain and neck pain together for subjects 75 to 84 years of age in 1995 and participating again in the 1997, 1999, and 2001 waves were calculated to investigate whether the prevalences tended to change over time among the survivors. Further, the number of times each individual survivor reported back pain alone, neck pain alone, or back pain and neck pain together were tabulated to study if back pain and neck pain were most often persistent or a passing symptom.
Comorbidity and Factors Associated With Back and Neck Pain. Co-morbidity and factors associated with back pain and neck pain were assessed using the cross-sectional sample, i.e., answers at intake into any of the four waves.
We compared co-occurring health indicators among participants with back pain and neck pain with participants without back pain and neck pain. The associations between cooccurring health indicators and back pain and neck pain were estimated using logistic regression models for categorical indicators (self-reported diseases, self-rated health, education, and smoking), and a multivariate linear regression model for the continuous indicators (strength score, Mini-Mental State Examination score) controlling for age and sex.
To account for the non-independence of twins (i.e., bias arising from twin pair similarities due to genetic or environmental factors), twins from complete pairs (both twins in a pair participating) were analyzed in clusters of two in all regression models.
For all analyses, the Stata statistical software package version 6.0 was used.12
Results
Prevalence
Figure 1
Figure 2
Figure 3
Table 1
Table 2 A total of 4,484 of 4,486 participants included in the analysis answered the questions regarding back and neck pain within the past month. For back pain alone, the overall 1-month prevalence was 15% (95% CI 14–16%), for neck pain it was 11% (95% CI 10–12%), and for concurrent back and neck pain it was 11% (95% CI 10–12%). Thus, the total 1-month prevalence of back pain and neck pain was 26% and 22%, respectively. For neck pain, the prevalences did not differ between men and women (10%, 95% CI 7–15% versus 11%, 95% CI 8–14%).
For back pain and concurrent back pain and neck pain, the prevalences were significantly higher in women than in men (back pain: 17%, 95% CI 15–18% versus 12%, 95% CI 10–13%; back and neck pain: 13%, 95% CI 11–14% versus 8%, 95% CI 6–9%) (Figure 1). No significant differences or consistently increasing or decreasing trends were found between the 5-year age groups in the cross-sectional analysis for any of the outcomes (Figure 1).
Results of the longitudinal analysis revealed that prevalence varied negligibly over time both for men and women among survivors from the initial 1995 wave (Figure 2). At the individual level, the vast majority of participants in all four LSADT waves had either not experienced back pain, neck pain, or both during the month before any of the interviews or one occasion only (Figure 3).
Comorbidity
Lower levels of self-rated health were associated with back pain, neck pain, and concurrent back and neck pain prevalence in statistically significant dose-response-like relationships. The association was strongest for concurrent back and neck pain (Table 1) and strongest among women (data not shown).
Back pain alone was associated with bone and joint diseases (osteoarthritis, disc prolapse, osteoporosis), migraine headaches, chronic bronchitis, heart attack, and gastric ulcer (Table 2).
Neck pain alone was associated with osteoarthritis, rheumatoid arthritis, migraine headache, cardiovascular disorders (hypertension, heart attack), and gastric ulcer (Table 2).
Concurrent back and neck pain was associated with a long list of co-occurring diseases: bone and joint disorders (osteoarthritis, disc prolapse, osteoporosis, rheumatoid arthritis), migraine headaches, chronic bronchitis, cardiovascular disorders (hypertension, coronary attack), and gastric ulcer (Table 2).
Neurologic disorders (Parkinson’s disease, epilepsy) and endocrinological disorders (diabetes, Graves’ disease, Hashimoto’s disease) were not associated with back pain or neck pain (data not shown).
Living alone, past or present smoking, higher body mass index, and years of school and education after school were not associated with back pain, neck pain, or concurrent back and neck pain (data not shown).
Poorer physical functioning was significantly associated with back pain alone (OR 1.42, 95% CI 1.28–1.58), neck pain alone (OR 1.17, 95% CI 1.04–1.32), and concurrent back and neck pain (OR 1.19, 95% CI 1.06–1.35). No associations were found between back pain, neck pain, or the two together and Mini-Mental State Examination scores.
Discussion
The results of this study add new information to the scant body of knowledge regarding back pain and neck pain in old age. First, we conclude that back pain and neck pain remain common symptoms both in the old and in the very old with 1-month prevalence rates of 15% for back pain alone and 11% for both neck pain and concurrent back and neck pain (Figure 1). The prevalence rates for back pain and concurrent back and neck pain (but not for neck pain alone) are consistently higher for women than for men. We did not find evidence for either significantly increasing or decreasing prevalence rates with increasing age after using both a cross-sectional and longitudinal analysis with identical measurements at four different time points. However, despite both back and neck pain being prevalent symptoms, the vast majority of participants had not experienced any or only one episode of back pain and/or neck pain during the month before any of the interviews (Figure 2). Thus, both back pain and neck pain appear to be common but intermittent symptoms in both men and women 70 years of age and older.
Second, we conclude that back pain and neck pain commonly occur together in old age (OR > 4 for having back pain if neck pain is also present and vice versa) and that concurrent back and neck pain is associated with extensive comorbidity (Table 2) and significantly poorer self-rated health than back pain or neck pain alone (Table 1). Previous studies support this, having found widespread musculoskeletal pain to be associated with depression, [13] low quality of life scores, [14] greater frequency of care seeking, [15] and in a recent study was shown to predict long-term work disability in younger persons while low back pain alone did not. [16] According to the results of the present study, spinal pain in more than one area also associated with poorer overall general health in the older population. This information may help to clinically categorize an otherwise heterogeneous patient population.
Back pain and neck pain share many determinants and risk factors, including co-occurring diseases, education, smoking, and increased odds for lower level of physical function. This appears to be true in middle and old age but not in childhood. Cote et al found a similar pattern of co-occurrence in Saskatchewan adults, [17] whereas Wedderkopp et al, after interviewing more than 800 Danish children and adolescents, concluded that neck pain and back pain should be regarded as specific and distinct entities early in life. [18]
Twins have to be representative of the normal singleton population for these results to be valid on a larger scale. Indeed, the representativeness of twin studies has been questionned. [19] However, twins, despite an average lower birth weight, have the same prevalence of many adult diseases, including diabetes mellitus [20] and thyroid disease, [21] and they have the same fecund ability as ordinary siblings, [22] the same ischemic heart disease mortality, [23] and general mortality rate as the general population. [24]
Furthermore, the 1-year period prevalence (46%) of back pain in younger Danish twins is comparable with the 1-year period prevalence (44–54%) found in other studies from the Nordic countries using population-based samples. [25, 26] Therefore, twins are considered to be representative of the general population, [27] and we found no reason to challenge this assumption.
The results of the current study have to be interpreted in light of several potential limitations. Most importantly, very simple outcome measures were used, namely, self-report of back pain and/or neck pain within the past month. No information regarding the duration, intensity or impact, and consequences of this pain were recorded. In spite of this, we think that these results are important for both clinicians and researchers. Clinicians should be aware of co-occurring health problems in older patients with back pain and neck pain and ensure that adequate medical attention is paid to these.
Further, older patients with both back pain and neck pain may require more extensive treatment approaches than patients suffering from only one or the other. Finally, they should inform older patients that back and neck complaints are common but intermittent complaints.
For researchers, the challenge is to further describe patterns of back pain and neck pain in old age and to address the impact and consequences of these. Such research is needed to disentangle the relationships between back pain, neck pain, and other health problems and to rationally address the issues of prevention and treatment in the older segments of the population. Further, twin samples, such as used in this study, can be used to determine genetic contributions to various back and neck pain patterns as well as interactions between genetic and environmental factors in the causality of these complaints. The authors of this paper are currently addressing these issues based on this sample, and future waves of LSADT will have expanded sections on back pain and neck pain.
Observational studies nested in large general health surveys, such as the present study, have several advantages. The investigation of back pain and neck pain specifically was not singled out to the participants as the aim of the interview, and bias arising from excessive attention to these conditions was likely avoided. In addition, the high response rate ensures representativeness of the study sample. Finally, longitudinal data covering a wide range of lifestyle and health conditions can potentially contribute to a better understanding of conditions with presumed multifactorial origins.
More research is needed to provide a better understanding of the possible interplay between spinal pain in different body regions (i.e., back or neck) and other health problems. Nevertheless, based on these results, we propose that back pain and neck pain are not independent health problems in old age but rather may be part of an overall pattern of poor health.
Conclusion
Back pain and neck pain are common symptoms in old age. In the 70+ year age group, back pain alone affects roughly 15%, neck pain alone affects approximately 10%, and both back pain and neck pain affect about 10% on a monthly basis. The majority (>70%), however, experienced only one episode or none at all before any of the four interviews. Prevalence estimates for back pain, neck pain, and concurrent back and neck pain remain constant with increasing age both in a cross-sectional analysis and a longitudinal analysis. Back pain and neck pain are associated with many co-occurring health problems and with poorer self-rated health. Both back pain and neck pain sufferers had significantly lower scores on physical functioning tests, whereas cognitive scores were unaffected.
Key Points
Back pain affects 15%, neck pain affects 11%, and concurrent back and neck pain
affects 11% of persons aged 70+ years.Prevalences of both back and neck pain change very little with increasing age
and appear to be intermittent symptoms.Back and neck pain in old age is associated with other health problems, poorer
self-rated health, and decreased physical functioning.
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