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BMC Musculoskeletal Disorders logoLink to BMC Musculoskeletal Disorders
. 2019 May 15;20:215. doi: 10.1186/s12891-019-2477-4

Factors associated with chronic and acute back pain in Wales, a cross-sectional study

Steinthora Jonsdottir 1, Haroon Ahmed 2, Kristinn Tómasson 1, Ben Carter 3,
PMCID: PMC6521348  PMID: 31092222

Abstract

Background

Back pain is one of the most common causes for disability in the working population. Some risk factors for back pain are well known, however little is known about factors uniquely associated with acute or chronic back pain.

This study aimed to elucidate patterns uniquely associated with acute or chronic back pain.

Methods

This study performed secondary analysis of data from the Welsh Health Survey 2012, a nationwide cross-sectional survey.

A multivariable analysis was carried out for risk factors found to be significantly associated with acute and chronic back pain.

Results

We found that increased BMI (aOR 1.20, 95% Cis 1.08, 1.33; BMI > 30), mental health score below average (aOR 1.59, 95% CIs 1.47, 1.72), having a degree (aOR 1.28, 95% CIs 1.12, 1.47) and being older than 24 years (P < 0.001) were associated with increased prevalence of acute back pain.

Higher prevalence of chronic back pain was seen in individuals characterised by increased deprivation (WIMD) (aOR 1.61, 95% CIs 1.32, 1.96); increased age (aOR 7.34, 95% CIs 5.25, 10.26; for 65+); being female (aOR = 1.43, 95% CIs 1.27, 1.61); lower educational attainment (aOR 0.44, 95% CIs 0.36, 0.55) higher BMI (aOR = 1.60 95% CIs 1.38, 1.85; BMI > 30); poorer mental health score (aOR = 3.11 95% CIs 2.76, 3.51), and a sedentary lifestyle (aOR = 0.58, 95% CIs 0.49, 0.69; 3–5 days of light exercise).

Conclusion

Increased deprivation, female gender, and little exercise were uniquely associated with chronic back pain. These characteristics may help clinicians to intervene to prevent acute backpain resulting in chronic cases.

Keywords: Chronic Back pain, Acute back pain, Risk factors, Physical activity, Prevention

Background

Back pain is a common and potentially disabling condition that can lead to reductions in quality of life, time off work and long-term disability. The Global Burden of Disease Study estimated the point prevalence of low back pain to be 9.4%, and reported low back pain to be the condition responsible for the most years lived with disability [1]. Back pain is one of the most common causes for disability in the working population, and severely impacts upon work productivity and absenteeism [1]. In the UK alone, almost 3.4 million working days were lost due to work-related back pain in 2016/17, that is 13.3% of all working days lost due to ill health [2]. Low back pain is the reason for one in every seven general practice consultations [3]. The associated health care cost and burden has been reported across health care systems worldwide [4, 5]. Hong et al. [6] found that the healthcare costs of patients suffering chronic low back pain (CLBP) were double those of matched controls without CLBP.

Chronic and acute back pain

Back pain is defined as acute when it has persisted for up to 6 weeks and sub-acute when it has persisted for up to 3 months [7]. Chronic back pain is defined as back pain that is present for more than 3 months [8] and is associated with patients receiving treatment [9, 10]. Acute back pain is often the result of actual or near tissue injury or sprain [7] and individuals with acute back pain are less likely to seek care or be referred for treatment [9, 10]. Chronic pain often persists even though the initial injury has healed [7]. These cases are more likely to be referred for treatment than the more acute cases that are commonly left untreated [9, 10].

Risk factors

There is good evidence for an association between increasing age and obesity (BMI > 30) and risk of back pain [4, 1121] and that obesity is a strong predictor of disability caused by back pain [20, 22, 23]. It is also known that the prevalence and severity of back pain is higher where there is greater deprivation [4, 12, 1416, 1921, 2428]. There is conflicting evidence on the effect of physical activity (PA) on back pain. Heneweer et al. [13] suggested a U-shaped dose-response relationship between PA and back pain. Other studies have found that physical inactivity is associated with a significant increase in risk of back pain [17, 22]. There is some evidence suggesting that females have a greater risk of back pain, [4, 1121, 24] however a recent global study reported this varied by region [1].

There is limited evidence that job demands including lifting and twisting [13, 20, 26, 29]; ethnicity [18, 24]; genetic factors [14]; and mental health comorbidities [4, 14, 22, 26] are all associated with higher risk of back pain. The varying level of evidence, available literature and the lack of a standardised definition of back pain make definitive conclusions challenging [30, 31].

Methods

Aim and objectives

This study aimed to elucidate patterns uniquely associated with acute or chronic back pain. Differentiating between the two is challenging in clinical practice. Identifying risk factors associated with the pattern may help clinicians differentiate between the two conditions, manage them more appropriately and ultimately help to improve patient outcomes. In addition this could enable targeting of those at greatest risk for prevention through e.g. workplace modification strategies.

Study design

We used a population based cross-sectional survey (The Welsh Health Survey 2012). The survey collected information on health status, illnesses, lifestyle and health service use in the general population. The sampling frame includes 99% of all private households in Wales. A sample of 14,775 households were drawn, stratified by geographical area. To achieve the aim of at least 600 interviews per geographical area, a minimum of 575 households were sampled in each geographical area. Household data were collected by enumerator from each adult aged 16 years or older. Further details about collection of data can be found on the Welsh Health Survey 2013 (WHS) [32].

Outcomes

Primary outcomes in this study were:

  1. Acute back pain (episodes of untreated backache in the last 12 months) [9, 10]

  2. Chronic back pain (Back pain currently being treated) [9, 10]

For the purpose of this study back pain currently being treated was considered a measure of chronic back pain, and untreated backache in the last 12 months considered a measure of acute back pain.

Covariates

The following mechanistically plausible covariates were investigated for associations with back pain (acute, and chronic):

  • Demographic: Age (age bands 16–24, 25–44, 45–64, 65+); Gender.

  • Socioeconomic: Educational attainment (No qualification, other qualification, degree equivalent or above); Occupational status (Managerial and professional, intermediate, routine and manual, never worked/long term unemployed); Welsh index of multiple deprivation 2014 (WIMD) (Deprivation quintiles).

  • Clinical: Mental health measured by the SF-36 (< 50 vs. > 50); BMI (less than 18.5, 18.5–25, 25–30, 30 and over); Depression (treated vs. untreated); Anxiety (treated vs. untreated); Physical activity (PA) (meeting the UK PA guidelines vs. not meeting them and number of days of light, moderate or vigorous exercise per week).

Data analysis

An a priori statistical analysis plan was followed (available on request). Descriptive statistics tabulated demographic and risk factors, for acute and chronic back pain, and counts were presented. Crude logistic regression models were fitted to each risk factor and odds ratios (ORs) were presented with 95% confidence intervals (95% CI) and P-values. A multivariable logistic regression model with a forward stepping approach where a likelihood ratio test (LRT) of sequential nested models, was used to determine parsimonious independent associations with the covariates (p < 0.01). The final analyses were inclusive of all risk factors from either of the analyses. The analysis was adjusted for the clustered nature of the respondents within geographical areas within the UK, by estimating inflated standard errors using the robust cluster estimators of the variances. Stata 13 was used for all analyses.

Results

There were 19,282 eligible adults who were invited in the WHS 2013, and 15,007 were included in the analysis. The response rate was higher among women (83.1%) than men (79.4%), as well as among older individuals than younger individuals (70.3% for 16–24 years, 75.6% for 25–44 years, 85.1% for 45–64 years, 88.9% for 65 years and older). There was less than 5% missing data for any included variable.

The prevalence of acute back pain was 31.5% and the prevalence of chronic back pain was 13.4% (Table 1). The prevalence of reported acute and chronic back pain combined was 39.1%.

Table 1.

Numbers and proportions of acute and chronic back pain across all covariates

Acute back pain Chronic back pain All back pain
Total Pain (%) Total Pain (%) Total Pain (%)
Total 14,359 4519 (31.5%) 14,351 1772 (13.4%) 14,100 5520 (39.1%)
Deprivation (WIMD quintile) 14,359 14,351 14,100
 Least deprived 2839 892 (31.42) 2859 248 (8.67) 1029 1029, (36.65)
 2 3065 994 (32.43) 3053 347 (11.37) 1207 1207, (40.07)
 3 3275 1053 (32.15) 3309 409 (12.36) 1275 1275, (47.05)
 4 2762 866 (31.35) 2745 381 (13.88) 1072 1072, (45.79)
 Most deprived 2418 714 (29.53) 2385 387 (16,23) 2529 2529, (108.03)
Age (years) 14,359 14,351
 16–24 1718 387 (22.53) 1752 46 (2.63) 410 410, (24.05)
 25–44 3830 1264 (33.84) 3879 275 (7.09) 1421 1421, (37.25)
 45–64 4963 1731 (34.88) 4974 709 (14.25) 2144 2144, (43.76)
 65+ 3848 1137 (29.55) 3746 742 (19.81) 1545 1545, (41.97)
Gender 14,359 14,351
 Female 7699 2480 (32.21) 7667 1084 (14.14) 3098 3098, (41.05)
 Male 6660 2039 (30.62) 6684 688 (10.29) 2422 2422, (36.96)
Educational attainment 13,398 13,424
 No qualification 2643 752 (28.45) 2573 573 (22.27) 1077 1077, (42.27)
 Other qualification 8367 2731 (32.64) 8443 883 (10.46) 3231 3231, (39.01)
 Degree Equivalent and above 2388 774 (32.41) 2408 136 (5.65) 856 856, (36.03)
Occupational status (NS-SEC) 13,959 13,936
 Managerial and Professional occupations 5170 1605 (31.04) 5228 461 (8.82) 1868 1868, (36.52)
 Intermediate occupations 2853 964 (33.79) 2834 330 (11.64) 1143 1143, (40.88)
 Routine and manual occupations 5569 1718 (30.85) 5524 883 (15.98) 2217 2217, (40.74)
 Never worked and long-term unemployed 357 104 (29.13) 350 65 (18.57) 143 143, (41.81)
BMIa 13,387 13,391
 Less than 18.5 281 59 (21.00) 284 21 (7.39) 71 71, (26.01)
 18.5 to under 25 5176 1498 (28.94) 5213 490 (9.40) 1778 1778, (34.88)
 25 to under 30 4878 1604 (32.88) 4873 594 (12.19) 1943 1943, (40.45)
 30 and over 3052 1073 (35.16) 3021 550 (18.21) 1386 1386, (46.31)
Mental Health (SF-36 mental health score) 14,359 14,351
 Higher than average (> 50)b 8803 2421 (27.50) 8862 632 (7.13) 2783 2783, (32.15)
 Lower than average (< 50)c 5556 2098 (37.76) 5489 1140 (20.77) 2737 2737, (50.28)
Depression 13,840 14,165
 Yes 1257 488 (38.82) 1183 403 (34.07) 717 717, (59.7)
 No 12,583 3832 (30.45) 12,982 1204 (9.27) 4519 4519, (35.85)
Anxiety 13,776 14,124
 Yes 1025 392 (38.24) 959 315 (32.85) 568 568, (58.32)
 No 12,751 3904 (30.62) 13,156 1252 (9.52) 4624 4624, (36.16)
Exercise 14,136 14,139
 Meeting PA guidelinesd 4106 1291 (31.44) 4156 269 (6.47) 1432 1432, (35.33)
 Not meeting guidelines 10,030 3164 (31.55) 9983 1451 (14.53) 4001 4001, (40.64)

aBody mass index

bMental health score above the average of the general population

cMental health score below the average of the general population

dMeeting physical activity guidelines of 30 min of light to moderate exercise on at least 5 days of the week

Acute back pain

The crude analysis found that increased BMI (aOR 1.20, 95% CIs 1.08, 1.33; BMI > 30), mental health score below average (aOR 1.59, 95%CIs 1.47, 1.72; mental health score below avg), having a degree (aOR 1.28, 95% CIs 1.12, 1.47; Degree or higher) and being older than 24 years (P < 0.001) were associated with increased prevalence of acute back pain. In a multivariable analysis we found consistent results with the crude analysis (Table 2).

Table 2.

Univariable logistic regression of acute back pain and multivariable logistic regression of acute back pain, adjusted for significantly associated covariates

Univariable analysis Multivariable analysis
N Crude OR (95% CI) P value Adjusted OR (95% CI) P value
WIMD 2014 quintile 14,359
 Least deprived Reference category
 2 1.05 (0.94, 1.17) 0.405 1.03 (0.92, 1.16) 0.611
 3 1.03 (0.93, 1.15) 0.539 1.00 (0.89, 1.13) 0.940
 4 1.00 (0.89, 1.12) 0.958 0.93 (0.82, 1.05) 0.261
 Most deprived 0.91 (0.81, 1.03) 0.138 0.86 (0.76, 0.98) 0.029
Age 14,359
 16–24 Reference category
 25–44 1.69 (1.49, 1.93) < 0.001 1.64 (1.42, 1.90) < 0.001
 45–64 1.84 (1.62, 2.09) < 0.001 1.73 (1.50, 1.99) < 0.001
 65+ 1.44 (1.26, 1.65) < 0.001 1.49 (1.27, 1.73) < 0.001
Gender 14,359
 Male Reference category
 Female 1.08 (1.00, 1.16) 0.040 1.01 (0.94, 1.10) 0.761
Educational attainment 13,398
 No qualification Reference category
 Degree equivalent or higher 1.21 (1.07, 1.36) 0.002 1.28 (1.12, 1.47) < 0.001
 Other qualifications 1.22 (1.11, 1.34) < 0.001 1.32 (1.18, 1.47) < 0.001
BMIa 13,387
 Less than 18.5 0.65 (0.49, 0.87) 0.004 0.79 (0.58, 1.07) 0.127
 18.5 to under 25 Reference category
 25 to under 30 1.20 (1.11, 1.31) < 0.001 1.14 (1.04, 1.25) 0.004
 30 and over 1.33 (1.21, 1.46) < 0.001 1.20 (1.08, 1.33) 0.001
Mental health (SF-36) 14,359
 Above averageb Reference category
 Below averagec 1.60 (1.49, 1.72) < 0.001 1.59 (1.47, 1.72) < 0.001
Vigorous exercise 13,757
 0–2 days per week Reference category
 3–5 days 0.83 (0.73, 0.94) 0.03 0.91 (0.80, 1.03) 0.156
 6–7 days 0.83 (0.68, 1.02) 0.077 0.91 (0.74, 1.13) 0.406

aBody mass index

bMental health score above the average of the general population

cMental health score below the average of the general population

Chronic back pain

In the multivariable analysis higher rates of chronic back pain were seen in individuals who were characterised by increased deprivation (WIMD) (aOR 1.61, 95% CIs 1.32, 1.96; most deprived); increased age (aOR 7.34, 95% CIs 5.25, 10.26; for 65+); being female (aOR = 1.43, 95% CIs 1.27, 1.61); lower educational attainment (aOR 0.44, 95% CIs 0.36, 0.55; degree or higher) higher BMI (aOR = 1.60 95% CIs 1.38, 1.85; BMI > 30); poorer mental health score (aOR = 3.11 95% CIs 2.76, 3.51; below average), and a sedentary lifestyle (aOR = 0.58, 95% CIs 0.49, 0.69; 3–5 days of light exercise) (Table 3).

Table 3.

Univariable logistic regression of chronic back pain and multivariable logistic regression of chronic back pain, adjusted for significantly associated covariates

Univariable analysis Multivariable analysis
N Crude OR (95% CI) P value Adjusted OR (95% CI) P value
WIMD 2014 quintile 14,351
 Least deprived
 2 1.35 (1.14, 1.60) 0.001 1.32 (1.09, 1.60) 0.005
 3 1.48 (1.26, 1.75) < 0.001 1.33 (1.10, 1.61) 0.003
 4 1.70 (1.43, 2.01) < 0.001 1.42 (1.16, 1.72) < 0.001
 Most deprived 2.04 (1.72, 2.42) < 0.001 1.61 (1.32, 1.96) < 0.001
Age 14,351
 16–24
 25–44 2.83 (2.06, 3.89) < 0.001 2.42 (1.71, 3.42) < 0.001
 45–64 6.17 (4.55, 8.35) < 0.001 5.14 (3.69, 7.15) < 0.001
 65+ 9.16 (6.76, 12.41) < 0.001 7.34 (5.25, 10.26) < 0.001
Gender 14,351
 Male
 Female 1.44 (1.30, 1.59) < 0.001 1.43 (1.27, 1.61) < 0.001
Educational attainment 13,424
 No qualification
 Degree equivalent or higher 0.21 (0.17, 0.25) < 0.001 0.44 (0.36, 0.55) < 0.001
 Other qualifications 0.41 (0.36, 0.46) < 0.001 0.75 (0.65, 0.86) < 0.001
BMIa 13,391
 Less than 18.5- Underweight 0.77 (0.49, 1.21) 0.258 0.91 (0.55,1.48) 0.699
 18.5 to under 25- Normal weight
 25 to under 30- Overweight 1.34 (1.18, 1.52) < 0.001 1.20 (1.04, 1.38) 0.013
 30 and over- Obese 2.15 (1.88, 2.45) < 0.001 1.60 (1.38, 1.85) < 0.001
Mental health (SF-36) 14,351
 Above averageb
 Below averagec 3.41 (3.08, 3.79) < 0.001 3.11 (2.76, 3.51) < 0.001
Light exercise 14,014
 0–2 days per week
 3–5 days 0.43 (0.37, 0.49) < 0.001 0.58 (0.49, 0.69) < 0.001
 6–7 days 0.39 (0.35, 0.43) < 0.001 0.55 (0.48, 0.63) < 0.001

aBody mass index

bMental health score above the average of the general population

cMental health score below the average of the general population

In the crude analysis, all covariates were found predictive of chronic back pain. Increasing age and BMI were found to offer the greatest increase in odds of chronic back pain (Table 3).

Discussion

The study aimed to describe a pattern of acute and chronic back pain and examine possible risk factors in order to elucidate differences between the sub-types of back pain. We found that increasing age, higher BMI, better educational attainment and poorer mental health were independently associated with both acute and chronic back pain. However, we also found that increasing WIMD quintile (i.e., increasing deprivation), female gender, and exercising less than 2 days per week were uniquely associated with chronic back pain.

This is the first population-based study to compare independent associations for acute and chronic back pain. The strength was larger for all of the associations for chronic back pain and the associations showed a diluted effect in acute back pain in most of the covariates.

Comparison with existing literature

Educational attainment had the opposite effect on acute back pain compared to chronic back pain, and higher educational attainment was significantly associated with increased odds of acute back pain. Riskowski [33] reported a similar finding in a cross-sectional survey conducted in the U.S., in which they found that chronic back pain was more common in individuals of lower socioeconomic position and that acute back pain was more common in individuals of higher socioeconomic positions. Riskowski suggests that these unusual findings could be related to changes in socioeconomic positions over time as acute pain becomes chronic [33]. Assuming that untreated backache represents acute cases and treated back pain represents chronic cases similar suggestions might be made for this study, as educational attainment is an important marker for socioeconomic status and deprivation. Definitive explanations of these findings are difficult, although speculative suggestions can be made that cases of acute back pain in those with higher educational attainment are less likely to become chronic because of better knowledge of self-regulation or coping strategies in addition to this group having in general better means. This would result in most back pain cases in those with higher educational attainment being acute and not becoming chronic. We found obesity (BMI > 30) to be independently associated with chronic back pain, this is in line with previous studies [4, 1121]. Fransen et al. (2002) found obesity to be a significant predictor of chronicity in individuals receiving compensation for working days lost due to acute back pain [34].

A recent systematic review found that stratified programmes were effective in preventing the development of chronic back pain. Those classified at low risk of developing chronic back pain benefited from simple educational messages while those classified at medium or high risk benefited from a combination of reactivation programmes, exercise and cognitive-behavioural interventions. We have identified factors independently associated with chronic back pain only. This may help to determine the risk of patients developing chronic back pain, and in turn determine a suitable prevention intervention [35].

Our findings in general are in line with previous studies however it is the first in the UK to distinguish between acute and chronic back pain.

Strengths and limitations

This is the first population-based study of back pain in the UK, and the first to differentiate between acute and chronic back pain. The reported results cannot infer causality due to the nature of the study design. Multivariable analyses controlled for known confounders, however this doesn’t include the unknown confounders, i.e. work demands, chronic stress and genetic factors. There is a limitation in the measures for chronic and acute back pain used in this study. The evidence suggests that treated cases are likely to represent chronic cases and untreated cases are likely to represent acute cases [9, 10]. However, we anticipate that some cases may be misclassified, as acute back pain may sometimes be treated with for example, anti-inflammatories.

There is debate over these definitions and this is unlikely to be universal. Potential biases affecting the study include selection bias and reporting bias. We cannot ignore the possibility of reverse causality. Given the weaknesses, caution is needed when interpreting these findings, however, this study gives a clue about the difference in risk factors between acute and chronic back pain.

Conclusion

Chronic back pain is a considerable public health concern and risk factors for acute and chronic back pain are different. This study has identified factors associated with chronic back pain that are not associated with acute back pain. This information may help clinicians to intervene to prevent acute back pain resulting in chronic cases. More emphasis should be put on service for those in deprived areas. In addition this information can help target groups and individuals for preventive measures.

Longitudinal cohort studies are needed to make conclusions about causality regarding risk factors of back pain and to distinguish successfully between cases that progress form acute to chronic. In addition further analysis of long-term cohort studies are needed to investigate the effect of light exercise on chronic back pain as a suggested means of self-management.

Acknowledgements

The authors would like to thank the team at the Health statistics and analysis unit, Welsh Government, who provided the data used in this analysis.

Funding

We acknowledge the support of the National Institute for Health Research (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London (B. C.). The funding bodies were not party to any part of the research, analysis, interpretation, or dissemination.

Availability of data and materials

The data that support the findings of this study are available from The Welsh Government (The Welsh Health Survey) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Welsh government.

Abbreviations

aOR

adjusted Odds Ratio

BMI

Body mass index

CLBP

Chronic low back pain

LRT

Likelihood ratio test

OR

Odds Ratio

PA

Physical activity

WHS

Welsh health survey

WIMD

Welsh Index of Multiple Deprivation

Authors’ contributions

SJ and BC carried out the data collection and analysis and were major contributors in writing the manuscript. KT and HA were contributors in writing and reviewing the manuscript and all authors read and approved the final manuscript.

Ethics approval and consent to participate

The data used in this study was obtained from a cross-sectional nationwide survey and data were anonymised. Ethical approval was included in Welsh Health Survey, and a local ethics committee ruled that participants were not required to be additionally consented for this study.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Steinthora Jonsdottir, Email: steinthora.jonsdottir@gmail.com.

Haroon Ahmed, Email: ahmedh2@cardiff.ac.uk.

Kristinn Tómasson, Email: Kristinn@ver.is.

Ben Carter, Phone: (+44) 2078 480305, Email: ben.carter@kcl.ac.uk.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from The Welsh Government (The Welsh Health Survey) but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Welsh government.


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