Abstract
This is the prepublication, author-produced version of a manuscript accepted for publication in Annals of Internal Medicine. This version does not include post-acceptance editing and formatting. The American College of Physicians, the publisher of Annals of Internal Medicine, is not responsible for the content or presentation of the author-produced accepted version of the manuscript or any version that a third party derives from it. Readers who wish to access the definitive published version of this manuscript and any ancillary material related to this manuscript (e.g., correspondence, corrections, editorials, linked articles) should go to Annals.org or to the print issue in which the article appears. Those who cite this manuscript should cite the published version, as it is the official version of record.
Background
The employment of patients with back pain has implications for both the factors causing or contributing to the pain and the impacts of the pain, but few estimates of the proportion of back pain that is related to work in the United States are available (1). In 2015, the National Health Interview Survey (NHIS) collected supplemental data about the work-relatedness and work impacts of back pain–specifically, low back pain (LBP)–among U.S. workers for the first time since 1988.
Objective
The objective of this study was to estimate the burden of LBP among U.S. workers, its work-relatedness, and its impact on work.
Methods and Findings
The NHIS is a nationally-representative health survey (2). This study is limited to the 19,441 randomly-selected sample adults who were employed during the week prior to interview (i.e., workers) and answered an initial question about LBP and supplemental items on LBP and work. Former workers were excluded. Survey items from NHIS that were used to define LBP, job characteristics, and impacts of LBP on ability to work are presented in the Supplement. The final response rate of the 2015 NHIS Sample Adult component was 55.2%
The overall prevalence of any LBP was 26.4%, frequent and severe LBP was 8.1%, and LBP attributed to work was 5.6% (Table 1). The prevalence of all three LBP outcomes was lowest among workers employed in Computer and Mathematical Occupations. The prevalence of any LBP and LBP attributed to work was highest in Construction and Extraction Occupations, while the prevalence of frequent and severe LBP was highest in Building and Grounds Cleaning and Maintenance Occupations. Workers who reported frequent exertion or frequent standing were more likely than those who did not to report all three LBP outcomes.
Table 1.
Prevalence of Any Low Back Pain, Frequent and Severe Low Back Pain, and Low Back Pain Attributed to Work in the Past Three Months in the U.S. Working Population, by Demographic and Job Characteristics
| Total Worke rs |
Any Low Back Pain | Frequent & Severe Low Back Pain |
Any Low Back Pain Attributed to Work by Health Professional |
||||
|---|---|---|---|---|---|---|---|
| n | n | Weighted Prevalence (95% CI) |
n | Weighted Prevalence (95% CI) |
n | Weighted Prevalence (95% CI) |
|
| All Workers | 19,441 | 5,272 | 26.4% (25.5-27.3%) | 1,652 | 8.1% (7.6-8.6%) | 1,205 | 5.6% (5.2-6.1%) |
| Sex | |||||||
| Men | 9,661 | 2,533 | 25.6% (24.5-26.8%) | 747 | 7.5% (6.8-8.2%) | 684 | 6.4% (5.7-7.1%) |
| Women | 9,780 | 2,739 | 27.3% (26.1-28.5%) | 905 | 8.8% (8.0-9.6%) | 521 | 4.8% (4.3-5.4%) |
| Age (yrs.) | |||||||
| 18-29 | 3,987 | 878 | 20.5% (18.8-22.3%) | 254 | 5.8% (4.8-6.9%) | 161 | 3.8% (3.1-4.7%) |
| 30-44 | 6,511 | 1,722 | 25.5% (24.2-26.9%) | 527 | 7.8% (6.9-8.7%) | 377 | 5.3% (4.6-6.1%) |
| 45-64 | 7,609 | 2,281 | 30.3% (28.9-31.7%) | 742 | 9.6% (8.7-10.5%) | 601 | 7.3% (6.5-8.1%) |
| ≥65 | 1,334 | 391 | 29.2% (25.8-32.7%) | 129 | 8.6% (6.8-10.7%) | 66 | 3.8% (2.7-5.2%) |
| Race and ethnicity | |||||||
| Non-Hispanic white | 12,131 | 3,490 | 28.0% (26.9-29.1%) | 1,136 | 8.8% (8.1-9.5%) | 727 | 5.3% (4.7-5.9%) |
| Non-Hispanic black | 2,446 | 630 | 24.5% (22.3-26.8%) | 181 | 6.9% (5.7-8.2%) | 156 | 6.3% (5.1-7.7%) |
| Non-Hispanic other race | 1,451 | 292 | 18.8% (16.1-21.8%) | 77 | 4.6% (3.3-6.2%) | 79 | 5.2% (3.7-7.0%) |
| Hispanic | 3,413 | 860 | 24.7% (22.8-26.7%) | 258 | 7.5% (6.4-8.7%) | 243 | 6.7% (5.6-8.0%) |
| Occupational category* | |||||||
| Management | 1910 | 473 | 25.4% (22.7-28.2%) | 124 | 6.9% (5.4-8.7%) | 89 | 4.2% (3.0-5.5%) |
| Business and Financial Operations | 979 | 224 | 25.4% (21.4-29.7%) | 48 | 6.1% (4.2-8.5%) | 39 | 4.5% (3.0-6.5%) |
| Computer and Mathematical | 627 | 117 | 17.2% (13.8-21.1%) | 31 | 4.6% (2.7-7.2%) | 17 | 2.8% (1.5-4.7%) |
| Architecture and Engineering | 370 | 80 | 23.8% (18.1-30.3%) | † | † | 8 | 2.1% (0.7-4.6%) |
| Life, Physical, and Social Science | 229 | 63 | 26.0% (18.1-35.3%) | † | † | † | † |
| Community and Social Services | 428 | 119 | 24.5% (18.7-31.0%) | 39 | 6.2% (3.6-9.9%) | † | † |
| Legal | 247 | 59 | 26.3% (19.1-34.6%) | † | † | † | † |
| Education, Training, and Library | 1279 | 302 | 24.8% (21.5-28.4%) | 85 | 5.7% (4.1-7.7%) | 43 | 3.4% (2.2-5.0%) |
| Arts, Design, Entertainment, Sports | 418 | 106 | 23.6% (18.6-29.2%) | 27 | 4.9% (2.7-8.1%) | 22 | 6.0% (3.3-9.9%) |
| Healthcare Practitioners and Technical | 1117 | 338 | 29.4% (26.0-33.0%) | 92 | 7.5% (5.8-9.6%) | 75 | 6.6% (4.7-8.9%) |
| Healthcare Support | 493 | 145 | 27.7% (22.5-33.4%) | 58 | 10.8% (7.4-15.1%) | 45 | 7.9% (5.1-11.6%) |
| Protective Service | 353 | 103 | 25.8% (19.8-32.5%) | 31 | 6.6% (4.1-10.0%) | 36 | 8.3% (5.0-12.8%) |
| Food Preparation and Serving | 999 | 284 | 25.3% (21.4-29.5%) | 91 | 8.2% (6.1-10.7%) | 74 | 4.9% (3.5-6.6%) |
| Building and Grounds Cleaning & Maintenance | 843 | 265 | 30.3% (26.2-34.6%) | 98 | 11.4% (8.7-14.6%) | 83 | 7.6% (5.4-10.3%) |
| Personal Care and Service | 675 | 206 | 30.0% (25.4-35.0%) | 79 | 9.9% (7.3-13.0%) | 50 | 9.1% (5.9-13.2%) |
| Sales and Related | 1786 | 470 | 24.3% (21.7-27.0%) | 168 | 8.5% (6.9-10.3%) | 91 | 4.2% (3.1-5.6%) |
| Office and Administrative Support | 2369 | 679 | 29.1% (26.6-31.7%) | 226 | 9.8% (8.2-11.6%) | 112 | 4.8% (3.7-6.2%) |
| Farming, Fishing, and Forestry | 179 | 33 | 17.8% (10.8-26.8%) | † | † | 10 | 2.6% (0.9-5.7%) |
| Construction and Extraction | 960 | 312 | 31.6% (27.5-35.9%) | 99 | 9.9% (7.5-12.8%) | 121 | 12.3% (9.3-15.8%) |
| Installation, Maintenance, and Repair | 616 | 192 | 29.9% (25.1-35.1%) | 69 | 10.4% (7.2-14.3%) | 60 | 8.8% (6.0-12.3%) |
| Production | 1171 | 329 | 26.3% (22.9-29.9%) | 111 | 10.5% (7.9-13.6%) | 79 | 5.8% (4.2-7.7%) |
| Transportation and Material Moving | 1063 | 319 | 29.3% (25.6-33.2%) | 106 | 9.0% (6.9-11.4%) | 113 | 9.1% (7.0-11.6%) |
| Frequent Exertion at Work | |||||||
| Yes | 8056 | 2661 | 32.1% (30.7-33.6%) | 926 | 11.1% (10.2-12.0%) | 798 | 8.9% (8.0-9.8%) |
| No | 11360 | 2604 | 22.4% (21.3-23.5%) | 723 | 5.9% (5.3-6.5%) | 405 | 3.3% (2.9-3.8%) |
| Frequent Standing at Work | P<0.01 | P<0.01 | P<0.01 | ||||
| Yes | 12919 | 3746 | 27.9% (26.8-29.0%) | 1230 | 8.9% (8.2-9.6%) | 959 | 6.6% (6.0-7.2%) |
| No | 6498 | 1521 | 23.5% (22.1-25.0%) | 419 | 6.5% (5.7-7.4%) | 244 | 3.7% (3.2-4.3%) |
Data: National Health Interview Survey (NHIS), 2015; NHIS items on LBP and its relatedness to work are presented in the Supplement. Analyses were performed using
SAS-callable SUDAAN software version 11.0, and weighted using final NHIS sample adult weights to achieve national representation.
Abbreviations: n=sample size, CI= Korn-Graubard 95% Confidence Interval
Results are not reported for the military-specific occupational group because the NHIS sample is based on the civilian population.
Estimate does not meet standards of precision.
Approximately 21.4% of workers with any LBP and 23.7% of workers with frequent and severe LBP reported being told by a health professional that their LBP was probably work-related (Table 2). However, most workers with LBP did not recall ever discussing with a health professional whether their LBP was probably work-related. Overall, 6.0% of current workers with any LBP, 10.2% of workers with frequent and severe LBP, and 18.4% of workers with LBP attributed to work by a health professional had ever filed a workers’ compensation claim.
Table 2.
Recognition of Work-relatedness and Impact on Work among Employed U.S. Adults with Low Back Pain
| Any Low Back Pain (n=5,272*) | Frequent & Severe Low Back Pain (n=1,652*) |
Any Low Back Pain Attributed to Work by Health Professional (n=1,205*) |
||||
|---|---|---|---|---|---|---|
| n | Weighted Proportion (95% CI) |
n | Weighted Proportion (95% CI) |
n | Weighted Proportion (95% CI) |
|
| Recognition of work-relatedness | ||||||
| Told by health professional that LBP was probably work-related | 1,205 | 21.4% (19.8-23.1%) | 446 | 23.7% (21.0-26.5%) | ||
| Ever discussed with a health professional whether LBP was probably work-related, but not told LBP was work-related | 400 | 7.9% (6.9-8.9%) | 154 | 10.3% (8.3-12.6%) | ||
| Never discussed with a health professional whether LBP was probably work-related | 3,646 | 70.7% (68.9-72.4%) | 1,042 | 66.0% (62.9-69.0%) | ||
| Workers’ compensation | ||||||
| Ever filed a workers' compensation claim for LBP | 349 | 6.0% (5.1- 6.9%) | 170 | 10.2% (8.3-12.4%) | 236 | 18.4% (15.5-21.6%) |
| Missed work | ||||||
| Missed ≥1 full day of work in past three months because of LBP | 901 | 16.9% (15.5-18.3%) | 327 | 19.0% (16.5-21.7%) | 234 | 20.1% (17.1-23.4%) |
| Changed jobs/activities | ||||||
| Stopped working, changed jobs, or made a major change in work activities in past three months because of LBP | 321 | 6.1% (5.3-7.0%) | 176 | 10.7% (8.7-12.9%) | 135 | 11.0% (8.8-13.5%) |
Data: National Health Interview Survey (NHIS), 2015; NHIS items on LBP and its relatedness to work are presented in the Supplement. Analyses were performed using
SAS-callable SUDAAN software version 11.0, and weighted using final NHIS sample adult weights to achieve national representation.
Abbreviations: n=sample size, CI= Korn-Graubard 95% Confidence Interval, LBP=low back pain
Row totals may not add up to the total sample size due to missing data for specific questions.
Regardless of the cause of LBP, 16.9% of workers with any LBP and 19.0% of workers with frequent and severe LBP missed at least one full day of work in the past three months because of LBP. Furthermore, 6.1% of workers with any LBP and 10.7% of workers with frequent and severe LBP had stopped working, changed jobs, or made a major change in work activities in the past three months because of their LBP. The proportions of workers with LBP attributable to work that missed work (20.1%) or changed jobs or activities (11.0%) were only slightly higher than the proportions of all workers with frequent and severe LBP.
Discussion
We found that in 2015 the three-month prevalence of any LBP among U.S. workers was approximately 26.4%, representing almost 40 million workers. Many of these cases were attributed to work by a healthcare professional, but most affected workers did not discuss work-relatedness with their providers. We also found that LBP had impacted many current workers’ ability to work. However, our study may greatly underestimate the total occupational impact of LBP in the population due to the short recall period and exclusion of former workers, some of whom may have left the workforce because of work-related LBP.
This study has several limitations. First, the data are cross-sectional. Second, the accuracy and reliability of assessing occupational causality of health conditions through respondent-report are unknown. Third, relying on reported attribution of LBP to work by a health professional likely underestimates work-relatedness. The main strength of this study is its large, nationally-representative sample of U.S. workers.
LBP has been linked to both physical and psychosocial occupational factors in many studies (3, 4). Diagnosing an occupational etiology may improve the chances of a patient's recovery if an occupational exposure precipitating the pain can be reduced or eliminated, and may allow the patient to apply for workers' compensation to cover medical costs and any lost wages (5).
Supplementary Material
Acknowledgments
Funding Source: All authors are federal government employees, with the exception of Ms. Gonzales, who was a medical student at the time of this study, and the NHIS and preparation of this manuscript were completely funded by the U.S. Government.
Disclaimer: The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the National Institute for Occupational Safety and Health or the National Center for Health Statistics.
Footnotes
Reproducible Research Statements
Protocol: National Center for Health Statistics’ Ethics Review Board Protocol #2015-08
Statistical Code: Available to interested readers by contacting Dr. Dahlhamer at jdahlhamer@cdc.gov
Data: Available online at https://www.cdc.gov/nchs/nhis/nhis_2015_data_release.htm.
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