Abstract
Background
Arthritis imposes serious health consequences, including substantial disability and increased risk of all-cause mortality. Prior studies have reported that pain was associated with decreased health-related quality of life (HRQoL) among individuals with arthritis, yet the association between joint pain severity and HRQoL remains unclear.
Methods
This study analyzed pooled data from 362,366 U.S. adults with arthritis in the 2015–2019 Behavioral Risk Factor Surveillance Survey, categorizing joint pain severity as no/mild (0–3), moderate (4–6), or severe (7–10) via the Numerical Rating Scale. HRQoL was assessed using four domains: self-rated health, physical/mental unhealthy days, and activity limitation. Multivariable logistic regression examined the association between joint pain severity and loss of HRQoL in overall and across demographic subgroups.
Results
Compared to no/mild pain, moderate pain was associated with higher odds of poor self-rated health (OR = 2.18, 95%CI = 2.08–2.27), physical unhealthiness (2.46, 2.35–2.58), mental unhealthiness (2.05, 1.93–2.17), and activity limitation (2.33, 2.20–2.47). Severe pain showed stronger associations (e.g., poor self-rated health: OR = 4.61, 4.40–4.83; physical unhealthiness: 6.74, 6.41–7.09). Subgroup analyses revealed stronger associations in women, Non-Hispanic Whites, and adults aged 45–64 years. Joint pain severity was associated with worse HRQoL, with heterogeneous effects by demographic subgroups.
Conclusions
Moderate-to-severe joint pain is associated with poorer HRQoL across all domains, with severity-correlated HRQoL decline and subgroup variations. Targeted pain management strategies, particularly for severe pain and vulnerable populations, are critical to improving outcomes in arthritis.
Supplementary Information
The online version contains supplementary material available at 10.1186/s13075-025-03712-7.
Keywords: Arthritis, Pain, Quality of life
Background
Arthritis is joint inflammation disorders characterized by the coexistence of pain and structural damage [1]. Osteoarthritis (OA), the most common form [2], accounted for an estimated 21.3 million years lived with disability (YLDs) in 2021 [3]. In developed countries such as the United States (US), the number of adults with doctor-diagnosed arthritis increased from 52.5 million in 2002–2014 [4] to 54.4 million in 2017 [5], and is projected to reach 78.4 million by 2040 [4].
Because of pain, stiffness, and restricted joint mobility, arthritis is associated with immobility, chronic physical and mental health conditions, vascular diseases, all-cause mortality [6, 7], and diminished health-related quality of life (HRQoL). HRQoL reflects physical and mental well-being, social relationships, and functional capacity [8, 9], Studies have demonstrated that impaired HRQoL is associated with higher risks of mortality and hospitalization [10], underscoring the critical need to improve HRQoL. However, current disease management for arthritis patients remains suboptimal, as evidenced by the high prevalence of arthritis-attributed severe joint pain, which was approximately 30% in 2017 [5, 11]. Existing evidence shows a negative association between pain intensity and HRQoL [12–14], as well as a link between arthritis progression and increased pain frequency. [15]
Among individuals with diagnosed arthritis, pain is associated with decreased HRQoL across different subtypes [16–18]. For example, knee pain has been shown to limit mobility in Australian adults [19]. Another study in Chinese OA patients revealed a strong association between pain severity and HRQoL [20]. However, many prior studies have relied on small or non-representative samples, and few have focused specifically on joint pain, a prominent and burdensome symptom in arthritis [21]. The extent to which mild, moderate, and severe joint pain are differentially associated with HRQoL, and whether these associations vary by age, sex, and race/ethnicity, remains unclear.
In this study, we aimed to examine the association between joint pain and HRQoL among individuals with arthritis, using pooled data from three waves of the Behavioral Risk Factor Surveillance Survey (BRFSS) conducted in 2015, 2017 and 2019. We sought to examine the associations between the joint pain severity (mild, moderate and severe) and distinct domains of HRQoL, and to examine whether these associations vary by age, sex and race/ethnicity.
Methods
Study design and participants
We retrieved data from the BRFSS, a state-representative telephone surveillance system using random-digit-dial (RDD) selection of landline and cellular telephone numbers. BRFSS was designed to collect data on health-related risk behaviors, chronic health conditions and preventive health practices associated to morbidity and mortality among the civilian, noninstitutionalized population in all 50 U.S. states and the District of Columbia. It employs a complex, multistage cluster sample design and is the largest health telephone survey globally, completing over 400,000 adult interviews annually. Most items in the BRFSS core modules achieve at least moderate reliability and validity [22–24]. This activity was reviewed by CDC and deemed not to constitute research. It was conducted in full compliance with applicable federal law and CDC policy [25]. Moreover, data have been de-identified after collection. Therefore, no additional ethical approval was required for this study.
Data were pooled from three waves of the BRFSS survey (2015, 2017 and 2019) for statistical analysis. During 2015–2019, the BRFSS primarily collected data through telephone surveys, while trained staff in a subset of states conducted physical measurements (e.g., height, weight). We used self-reported demographics, health behaviors and chronic conditions from questionnaires, and body mass index (BMI) calculated from measured height and weight.
In this study, we excluded participants without arthritis, as well as data that lacked information on severity of joint pain or four domains of HRQoL. We defined whether the study participants had arthritis by the question: “(Ever told) you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia?”, which was used to define arthritis in previous studies [26, 27]. The sensitivity and specificity of this question was 70.8% and 70.3%, respectively. The agreement between the telephone and written responses indicating self-reported arthritis was high (kappa = 0.68) [28]. Those with missing values for any covariates of interest were also excluded. Our final analytical sample included a total of 362,366 adults with arthritis (Fig. 1). We compared the baseline characteristics between the overall population of arthritis patients and the final analytical sample (Supplementary eTable 1).
Fig. 1.
Flow diagram of sample selection
Assessment of joint pain severity
Joint pain severity was assessed using the following question: “During the past 30 days, how bad was your joint pain on average on a scale of 0 to 10, where 0 is no pain and 10 is the worst possible pain or aching?” Based on responses to the Numerical Rating Scale (NRS), pain levels were classified into three categories: no/mild (scores 0–3), moderate (scores 4–6), and severe joint pain (scores 7–10) [29–31].
Assessment of health-related quality of life
HRQoL was assessed using the CDC Healthy Days (HRQoL-4) scale, by standard 4-item set of healthy days questions including self-rated health, mentally unhealthy days, physically unhealthy days and activity limitation days.
Self-rated health was assessed through the question: “Would you say that in general your health is—excellent, very good, good, fair, or poor?”. According to the response of the question, participants were divided as “having fair or poor health” (reported ‘fair’ or ‘poor’); “not having fair or poor health” (reported ‘excellent good’, ‘very good’ or ‘good’). Mental health was calculated by mentally unhealthy days, which asked: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?”. Those who had emotional problems for ≥ 14 days [32] were assigned for having poor mental health; for those less than 14 days, it equaled to have good mental health. Participants were asked “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?” Those who had problems on physical health for ≥ 14 days were classified as having poor physical health; for those less than 14 days, it equaled to have good physical health. Participants were dichotomized as “having activity limitation” if they reported having 14–30 days of poor physical or mental health that keep them from doing usual activities, self-care, work, or recreation. Otherwise, participants were classified as “having no activity limitation”.
Covariates
Covariates included age (18–44 years, 45–64 years and ≥ 65 years), sex (men and women), race/ethnicity (Hispanic, Non-Hispanic white, non-Hispanic black and non-Hispanic Other), marital status (married, divorced/separated/widowed, and never married), education (less than high school, high school graduate, and above high school) and employment status (employed, unemployed, and retired). Chronic conditions were assessed as the number of self-reported physician-diagnosed comorbidities (no chronic condition, one chronic condition, and two or more chronic conditions), including cancer, chronic obstructive pulmonary disease, kidney disease, diabetes, hypertension, coronary heart disease, or stroke. Each condition was coded as binary variables. In sensitivity analysis, we further included behavioral variables, including alcohol consumption (heavy drinker: ≥14 drinks/week for men, ≥ 7 drinks/week for women; non-heavy drinker), smoking status (never, former, currently smoking), BMI category (underweight: <18.5, normal: 18.5–24.9, overweight: 25–29.9, obesity: ≥30 kg/m²) and leisure-time physical activity (had physical activity or exercise, no physical activity or exercise). Leisure time physical activity was defined by participants’ yes/no responses to a 30-day physical activity question:“During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?” [33, 34].
Statistical analysis
Baseline characteristics were compared across pain severity groups using chi-square tests. All variables were treated as categorical and reported as counts and percentages. The analysis yields valid estimates with stratification, clustering and weighting taken into account.
Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of joint pain severity with poor self-rated health, physical health, mental health, and activity limitation. Model 1 was crude model with no covariates adjusted. Model 2 was used to adjust for age, sex, race/ethnicity, marital status, education attainment, and employment status. Finally, model 3 was further adjusted for variables in model 2 in addition to numbers of chronic diseases. We did subgroup analyses to evaluate the differences in associations across age, sex, and race/ethnicity, with the interaction term tested using likelihood ratio tests (P < 0.05 for significance). We also calculated the absolute risk of impaired HRQoL by estimating the events of each individual HRQoL outcome among no/mild, moderate and severe joint pain groups.
To assess the robustness of results, we performed three sensitivity analyses. Firstly, we further adjusting for smoking status, alcohol intake, leisure-time physical activity and BMI into the model 3 [35–37]. Second, we additionally adjusted survey year based on Model 3. Third, missing data of covariates were retained in the sample, and coded as an independent category. Fourth, we adjusted age as a continuous variable in Model 3.
For all the analysis, statistical significance was defined as a 2-sided P-value of less than 0.05. All analyses were performed using Stata SE 17.
Results
Population characteristic
The characteristics of the total study population according to the severity of joint pain is shown in Table 1. Among 362,366 participants with arthritis that aged 18 years and older, the proportion of those with no/mild, moderate, and severe joint pain was 34.8% (141,709), 33.8% (126,300), and 31.5% (94,357), respectively. Those who were 40–64 years (34.2%), women (33.1%), non-Hispanic Black (47.5%), divorced/separated or widowed (37.1%), unemployed (52.0%), and had two or more chronic conditions (39.2%) had a higher proportion of severe joint pain.
Table 1.
Participants characteristics by joint pain severity among 362,366 arthritis adults in BRFSS (2015, 2017, 2019)
| No/mild | Moderate | Severe joint pain | |
|---|---|---|---|
| N = 141,709 (34.8%) | N = 126,300 (33.8%) | N = 94,357 (31.5%) | |
| Age group | |||
| 18 ~ 44 | 10535 (34.2) | 10543 (35.0) | 8838 (30.8) |
| 45 ~ 64 | 49012 (33.4) | 46268 (32.4) | 43621 (34.2) |
| ≥65 | 82162 (40.1) | 69489 (35.4) | 41898 (24.5) |
| Sex | |||
| Men | 60559 (42.1) | 44331 (33.2) | 28294 (24.7) |
| Women | 81150 (32.3) | 81969 (34.6) | 66063 (33.1) |
| Race/ethnicity | |||
| Hispanic | 3571 (25.1) | 4469 (31.2) | 5972 (43.7) |
| Non-Hispanic white | 125398 (39.3) | 107585 (35.5) | 68645 (25.2) |
| Non-Hispanic black | 6747 (25.0) | 8221 (27.5) | 13137 (47.5) |
| Non-Hispanic others | 5993 (35.0) | 6025 (32.4) | 6603 (32.6) |
| Marital status | |||
| Married | 85389 (40.8) | 67687 (35.0) | 39584 (24.2) |
| Divorced/Separated/Widowed | 45258 (29.8) | 48118 (33.1) | 44326 (37.1) |
| Never married | 11062 (31.5) | 10495 (31.7) | 10447 (36.8) |
| Education | |||
| Less than high school | 5279 (18.7) | 8461 (30.0) | 14152 (51.3) |
| High school graduate | 34099 (31.1) | 39331 (35.8) | 33271 (33.1) |
| Above high school | 102331 (43.3) | 78508 (34.1) | 46934 (22.6) |
| Employment classification | |||
| Employed | 56475 (45.1) | 41450 (34.7) | 20867 (20.2) |
| Unemployed | 14832 (17.9) | 25038 (30.1) | 39520 (52.0) |
| Retired | 70402 (40.4) | 59812 (36.2) | 33970 (23.4) |
| Chronic disease | |||
| None | 49552 (45.6) | 33444 (33.7) | 17544 (20.7) |
| One chronic condition | 51740 (37.3) | 44562 (34.8) | 29512 (27.9) |
| Two or more chronic conditions | 40417 (27.2) | 48294 (33.6) | 47301 (39.2) |
| Alcohol consumption | |||
| Non-heavy drinker | 128879 (36.2) | 115830 (34.1) | 86790 (29.7) |
| Heavy drinker | 8053 (39.7) | 6188 (35.5) | 3689 (24.8) |
| Missing | 4777 (32.8) | 4282 (31.4) | 3878 (35.8) |
| Smoking status | |||
| Never | 75741 (40.9) | 59148 (33.2) | 38822 (25.9) |
| Former | 49972 (37.2) | 45913 (35.8) | 30545 (27.0) |
| Currently smoking | 13038 (23.1) | 18625 (33.3) | 22622 (43.7) |
| Missing | 2958 (32.3) | 2614 (31.6) | 2368 (36.2) |
| Physical activity | |||
| Had physical activity | 31532 (25.1) | 39756 (33.1) | 43017 (41.8) |
| No physical activity | 106017 (42.0) | 82695 (34.6) | 47689 (23.4) |
| Missing | 4160 (31.9) | 3849 (32.2) | 3651 (35.9) |
| BMI classification | |||
| Underweight | 1559 (32.3) | 1543 (33.5) | 1545 (34.2) |
| Normal | 37667 (42.0) | 27774 (33.1) | 17984 (24.9) |
| Overweight | 50768 (40.4) | 41126 (34.0) | 26459 (25.6) |
| Obesity | 43684 (30.0) | 48265 (34.6) | 42371 (35.4) |
| Missing | 8031 (33.9) | 7592 (34.2) | 5998 (31.9) |
Association of joint pain severity with health-related quality of life
We documented 18,619, 37,491 and 53,270 cases of fair or poor self-rated health among adults in no or mild, moderate, and severe joint pain, respectively. Correspondingly, the number of cases for having poor physical health were 13,177, 28,683 and 47,567; the number for having mental problems were 8,745, 17,794 and 28,511; and those for having activity limitations were 7,387, 17,279 and 34,861 (Table 2; Fig. 2).
Table 2.
Associations between joint pain severity and each component of HRQoL estimated by multivariable logistic regression
| Events | Number | Coefficient | Std.Err (SE) | OR (95%CI) | P value | |
|---|---|---|---|---|---|---|
| Model 1 | ||||||
| Fair/poor self-rated health | ||||||
| Joint pain severity | ||||||
| No/mild | 18,619 | 141,709 | Reference | |||
| Moderate | 37,491 | 126,300 | 0.986 | 0.021 | 2.68 (2.57–2.80) | < 0.001 |
| Severe | 53,270 | 94,357 | 2.081 | 0.022 | 8.02 (7.68–8.36) | < 0.001 |
| Frequent physical unhealthy days | ||||||
| Joint pain severity | ||||||
| No/mild | 13,177 | 141,709 | Reference | |||
| Moderate | 28,683 | 126,300 | 1.062 | 0.024 | 2.89 (2.76–3.03) | < 0.001 |
| Severe | 47,567 | 94,357 | 2.282 | 0.024 | 9.80 (9.35–10.26) | < 0.001 |
| Frequent mental unhealthy days | ||||||
| Joint pain severity | ||||||
| No/mild | 8,745 | 141,709 | Reference | |||
| Moderate | 17,794 | 126,300 | 0.890 | 0.028 | 2.43 (2.30–2.57) | < 0.001 |
| Severe | 28,511 | 94,357 | 1.801 | 0.027 | 6.06 (5.74–6.39) | < 0.001 |
| Frequent activity limitation days | ||||||
| Joint pain severity | ||||||
| No/mild | 7,387 | 141,709 | Reference | |||
| Moderate | 17,279 | 126,300 | 1.060 | 0.029 | 2.89 (2.72–3.06) | < 0.001 |
| Severe | 34,861 | 94,357 | 2.353 | 0.028 | 10.51 (9.95–11.11) | < 0.001 |
| Model 2 | ||||||
| Fair/poor self-rated health | ||||||
| Joint pain severity | ||||||
| No/mild | 18,619 | 141,709 | Reference | |||
| Moderate | 37,491 | 126,300 | 0.846 | 0.022 | 2.33 (2.23–2.43) | < 0.001 |
| Severe | 53,270 | 94,357 | 1.659 | 0.023 | 5.25 (5.02–5.49) | < 0.001 |
| Frequent physical unhealthy days | ||||||
| Joint pain severity | ||||||
| No/mild | 13,177 | 141,709 | Reference | |||
| Moderate | 28,683 | 126,300 | 0.953 | 0.025 | 2.59 (2.47–2.72) | < 0.001 |
| Severe | 47,567 | 94,357 | 2.004 | 0.025 | 7.42 (7.06–7.80) | < 0.001 |
| Frequent mental unhealthy days | ||||||
| Joint pain severity | ||||||
| No/mild | 8,745 | 141,709 | Reference | |||
| Moderate | 17,794 | 126,300 | 0.751 | 0.029 | 2.12 (2.00–2.24.00.24) | < 0.001 |
| Severe | 28,511 | 94,357 | 1.441 | 0.030 | 4.22 (3.99–4.48) | < 0.001 |
| Frequent activity limitation days | ||||||
| Joint pain severity | ||||||
| No/mild | 7,387 | 141,709 | Reference | |||
| Moderate | 17,279 | 126,300 | 0.899 | 0.030 | 2.46 (2.32–2.61) | < 0.001 |
| Severe | 34,861 | 94,357 | 1.973 | 0.030 | 7.19 (6.78–7.62) | < 0.001 |
| Model 3 | ||||||
| Fair/poor self-rated health | ||||||
| Joint pain severity | ||||||
| No/mild | 18,619 | 141,709 | Reference | |||
| Moderate | 37,491 | 126,300 | 0.778 | 0.022 | 2.18 (2.08–2.27) | < 0.001 |
| Severe | 53,270 | 94,357 | 1.528 | 0.024 | 4.61 (4.40–4.83) | < 0.001 |
| Frequent physical unhealthy days | ||||||
| Joint pain severity | ||||||
| No/mild | 13,177 | 141,709 | Reference | |||
| Moderate | 28,683 | 126,300 | 0.901 | 0.025 | 2.46 (2.35–2.58) | < 0.001 |
| Severe | 47,567 | 94,357 | 1.908 | 0.026 | 6.74 (6.41–7.09) | < 0.001 |
| Frequent mental unhealthy days | ||||||
| Joint pain severity | ||||||
| No/mild | 8,745 | 141,709 | Reference | |||
| Moderate | 17,794 | 126,300 | 0.716 | 0.029 | 2.05 (1.93–2.17) | < 0.001 |
| Severe | 28,511 | 94,357 | 1.371 | 0.030 | 3.94 (3.72–4.18) | < 0.001 |
| Frequent activity limitation days | ||||||
| Joint pain severity | ||||||
| No/mild | 7,387 | 141,709 | Reference | |||
| Moderate | 17,279 | 126,300 | 0.846 | 0.030 | 2.33 (2.20–2.47) | < 0.001 |
| Severe | 34,861 | 94,357 | 1.874 | 0.030 | 6.52 (6.14–6.91) | < 0.001 |
Model 1 is crude model with no covariates adjusted
Model 2 are adjusted for age, sex, race/ethnicity, marital status, education attainment, and employment status
Model 3 are additionally adjusted for chronic conditions based on model 2
Fig. 2.
Odds ratios (ORs) (95% CI) for HRQoL components in relation to joint pain severity estimated by multivariable regression. A: Poor self-rated health; B: Poor physical health; C: Poor mental health; D: Having activity limitation
The general pattern of associations of severity of joint pain with four domains of HRQoL were similar among unadjusted, minimally adjusted, and fully-adjusted models. After adjusting for age, sex, race/ethnicity, marital status, education attainment, employ status, and presence of chronic diseases, the OR and 95% CI when adults of moderate joint pain were compared with adults of no or mild joint pain were 2.18 (2.08 to 2.27) for having fair or poor self-rated health, 2.46 (2.35 to 2.58) for having poor physical health, 2.05 (1.93 to 2.17) for having poor mental health, and 2.33 (2.20 to 2.47) for having activity limitation. Among individuals reporting severe joint pain, the associations between joint pain and odds of poor HRQoL were significantly stronger. Experiencing severe joint pain was associated with higher odds of fair or poor self-rated health (OR, 4.61; 95%CI, 4.40 to 4.83), decreased physical health (6.74, 6.41 to 7.09), decreased mental health (3.94, 3.72 to 4.18), and loss of activity capacity (6.52, 6.14 to 6.91).
The OR was particularly high for physical unhealthiness and activity limitation, especially among individuals with severe joint pain. A significant increase in the absolute number of cases of fair/poor self-rated health and physical unhealthiness was observed between the no/mild joint pain group and the severe joint pain group. Specifically, the no/mild joint pain group comprised 141,709 participants, among whom 18,619 reported fair/poor self-rated health and 13,177 were having poor physical health. In contrast, the severe joint pain group included 94,357 individuals, with 53,270 and 47,567 cases of poor general health and physical unhealthiness, respectively.
Subgroup analysis
Subgroup analyses stratified by age, sex, and race/ethnicity showed that the positive association between joint pain severity and self-rated fair or poor health was stronger in women than in men (P for interaction < 0.001). For moderate to severe joint pain, the association was strongest among Non-Hispanic White (OR = 2.22; 95% CI, 2.13–2.33 for moderate joint pain; OR = 5.08; 95% CI, 4.84–5.34 for severe joint pain, P for interaction < 0.001). Among adults with moderate joint pain, the fully-adjusted OR for poor physical health was higher in men (OR = 2.62) than in women (OR = 2.33); however, the opposite pattern was observed for severe joint pain (ORs = 6.79 for women, 6.48 for men; P for interaction = 0.003). The association between joint pain severity and odds of poor mental health was stronger among those aged 45–64 years (ORs = 2.13 [1.95–2.32] for moderate pain; 4.18 [3.83–4.55] for severe pain), with significant interaction effects (P for interaction < 0.001). (Fig. 2 and Supplemental eTable 2)
Sensitivity analysis
In the sensitivity analysis, multivariate models further adjusted for behavioral variables (smoking, alcohol consumption, and BMI) showed that joint pain severity was associated with an increased odds of having poor HRQoL. Results remained unchanged when survey year as a category variable was additionally included in the models. Similar findings were observed in analyses retaining missing values for all covariates. Including age as a continuous variable in the model yield similar results to the main analysis. (Supplemental eTable 6)
Discussion
We assessed the association between joint pain severity and HRQoL among adults with arthritis using the state-representative BRFSS data. The HRQoL outcome in self-rated health, mental health, physical health and activity limitation was measured through the CDC Healthy Days (HRQoL-4) scale. We found an association between moderate to severe joint pain and loss of HRQoL across all of the four domains. The odds of impaired HRQoL increased as the joint pain was greater. To our knowledge, this is the first study to assess the relationship between severity of joint pain and four individual domains of HRQoL.
Over the past three decades, the global burden of arthritis has risen steadily [38]. In 2020, the most recent year available, people living with OA and RA in globally were estimated to be 595 million and 17.6 million, respectively [39]. The impact of chronic diseases on HRQoL is heterogeneous [40], and rheumatoid arthritis is linked to large reductions compared with many other physical conditions [41]. Treatment appears to yield greater gains in HRQoL for osteoarthritis than for type 2 diabetes, cardiovascular disease, or COPD. Reducing pain, fatigue, and functional limitations across arthritis subtypes is therefore essential to preserve physical and mental HRQoL [42–44].
Several studies have demonstrated an inverse association between pain and HRQoL among individuals with arthritis. For example, a cross-sectional study [20] among patients with knee OA found that higher pain levels were significantly associated with lower HRQoL scores, as measured by the 36-item Short Form Health Survey (SF-36) [20]. A recent systematic review and meta-analysis further identified pain as the main determinant of HRQoL decline in OA [45]. In a randomized clinical trial among patients with RA, reductions in pain were also significantly associated with HRQoL improvement [46]. However, existing studies of pain in arthritis have rarely focused on joint pain severity, a common and burdensome symptom in persons with arthritis. This gap limits the development of precision interventions targeting pain subtypes [47–50].
Our study showed that adults with moderate or severe joint pain had poorer self-rated health, physical health, mental health, and greater activity limitation than those with no or mild joint pain. These associations are consistent with previous studies. A cross-sectional study in former elite and recreational cricketers reported that persistent upper or lower extremity joint pain was associated with impaired physical components of HRQoL [51]. Previous longitudinal study of OA patients found a negative association of having joint pain comorbidity with HRQoL [52]. We also observed stronger associations in those with severe joint pain than in those with moderate joint pain. Our findings are consistent with previous studies reporting that greater pain severity is associated with greater declines in HRQoL. For example, in individuals with symptomatic knee OA, pain severity was proved to be the important determinants of functional limitation [53]. Another analysis used data across six European cohorts to examine the within-person pain in people with OA, the results revealed that people with more severe pain experienced higher odds of having anxiety and depressive symptoms [54].
We further examined age-, sex-, and race/ethnicity-specific variations in the association between joint pain severity and loss of HRQoL. The strongest associations were observed among adults aged 45–64 years. Possible explanations include high work demands [31] and family responsibilities [5] during this life stage, as well as weight gain, onset of metabolic abnormalities, and reduced physical activity, which may increase joint load and pain. [55, 56] Therefore, the early identification and intervention of joint pain in this age group may be particularly important. We also found that the association between joint pain severity and the mental component of HRQoL was stronger among those aged 45–64 years than among younger adults, which contrasts with a previous study of patients with inflammatory joint complaints reporting greater HRQoL impairment in individuals younger than 50 years [57].
Regarding sex differences, the association between joint pain severity and self-rated health was stronger in men than in women. However, sex-specific associations with poor physical health varied by pain severity. In people with moderate joint pain, men have higher odds of reporting physical unhealthiness, whereas women with severe joint pain showed greater odds of physical health impairment. Prior work has shown that women with RA experience poorer general, physical, and mental health [58], potentially related to a higher prevalence of osteoporosis and depression in women [59]. Contrary to the former study, a study related to digital self-management intervention of OA reported better outcomes in women [60]. Additionally, we calculated absolute risks within subgroups showing large relative disparities (Supplementary eTable 3–5). These heterogeneities by age, sex, and race/ethnicity suggest that differentiated, subgroup-specific strategies may be needed to mitigate the impact of joint pain on HRQoL.
A major strength of this study is the use of BRFSS, the world’s largest ongoing public health telephone survey. Its multimode design and complex sampling methods support high data quality and account for regional and sociodemographic variation, and continuous monthly collection provides up-to-date information. For outcome assessment, we employed the Centers for Disease Control and Prevention’s HRQoL-4 measure, a validated instrument that evaluates physical and mental health through the Healthy Days Measures. All analyses incorporated survey weights from the stratified multistage design to yield population-representative estimates and reduce sampling bias, and multiple sensitivity analyses supported the robustness of our findings. Our results also have clear clinical implications: the graded, dose-response association between joint pain severity and HRQoL supports routine assessment of pain intensity in arthritis care and the use of individualized, multidimensional management strategies, combining pharmacologic and nonpharmacologic approaches with targeted screening for high-risk subgroups [5].
Our study has several limitations. First, the cross-sectional design precludes inference about temporal or causal relationships between joint pain severity and HRQoL, thus, longitudinal studies are warranted to clarify directionality. Second, the diagnosis of arthritis may be imprecise because it was based on self-reported physician diagnosis rather than clinical examination or imaging, which may lead to misclassification. Joint pain, covariates, and HRQoL were also self-reported and therefore subject to recall and reporting bias. Third, the CDC HRQoL-4 scale assesses HRQoL using general day-count indicators and does not capture specific domains in detail [8]. Its day-count approach may be insensitive to subtle clinical changes [61, 62], and the lack of a standardized scoring algorithm limits comparability across studies. [63] Fourth, although we adjusted for a wide range of sociodemographic and health-related factors, residual confounding from unmeasured factors cannot be excluded. Fifth, we categorized some of continuous variables into discrete groups (e.g., age), which may lead to the loss of statistical power and masking of non-linear relationships between variables and joint pain severity. Finally, we focused on the severity of joint pain and neglect other important aspects such as joint pain location, quality, or temporal patterns. These unexamined dimensions of joint pain may independently affect HRQoL and should be considered in future investigations.
Conclusion
In conclusion, this large, population-based study of adults with arthritis shows that greater joint pain severity is strongly associated with poorer HRQoL across physical, mental, and activity domains. Moderate and severe joint pain were linked to higher odds of fair/poor self-rated health, worse physical and mental health, and greater activity limitation. We also observed important differences in these associations by sex, age, and race/ethnicity. These findings highlight the need for targeted interventions that reduce joint pain severity and for tailored management strategies in high-risk subgroups to help prevent further deterioration in HRQoL among people living with arthritis.
Supplementary Information
Acknowledgements
The authors appreciate the U.S. Centers for Disease Control and Prevention for sharing the Behavioral Risk Factor Surveillance System (BRFSS) data, and thank all the members who contributed to BRFSS and the survey teams.
Use of artificial intelligence (Al) tools
AI tools were only used to improve the readability and English grammar.
Abbreviations
- OA
Osteoarthritis
- RA
Rheumatoid arthritis
- YLDs
Years lived with disability
- HRQoL
Health-related quality of life
- BRFSS
Behavioral Risk Factor Surveillance Survey
- RDD
Random-digit-dial
- BMI
Body mass index
- NRS
Numerical Rating Scale
- ORs
Odds ratios
- CIs
Confidence intervals
Authors’ contributions
Gang Zhao and Yunqi Chu developed the conceptual model; Yunqi Chu, Yafeng Wang, Yuqian Feng, Panying Sun and Dan Zhao collected and analyzed the data. Yunqi Chu and Gang Zhao wrote the article. Gang Zhao, Yafeng Wang, Gerson Ferrari and Leandro F. M. Rezende contributed to the drafting and revision of the paper. All authors revised the final version of the article.
Funding
This work was partly supported by grants from the Wuxi “Taihu light” Science and Technology Research Project (Medical and Health), No. Y20242210.
Data availability
The data used in this study are publicly available from the BRFSS website (https://www.cdc.gov/brfss/). The original source of data that used in this study: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2015,2017 and 2019].
Declarations
Ethics approval and consent to participate
This activity was reviewed by CDC and deemed not to constitute research. It was conducted in full compliance with applicable federal law and CDC policy.
Consent for publication
Data have been de-identified after collection. Therefore, no additional ethical approval was required for this study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Gang Zhao and Yunqi Chu are contributed equally to this work and are co-first authors.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The data used in this study are publicly available from the BRFSS website (https://www.cdc.gov/brfss/). The original source of data that used in this study: Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2015,2017 and 2019].