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Musculoskeletal conditions are a major burden on individuals, health systems, and social care systems, with indirect costs being predominant. This burden has been recognized by the United Nations and WHO, by endorsing the Bone and Joint Decade 2000-2010. This paper describes the burden of four major musculoskeletal conditions: osteoarthritis, rheumatoid arthritis, osteoporosis, and low back pain. Osteoarthritis, which is characterized by loss of joint cartilage that leads to pain and loss of function primarily in the knees and hips, affects 9.6% of men and 18% of women aged > 60 years. Increases in life expectancy and ageing populations are expected to make osteoarthritis the fourth leading cause of disability by the year 2020. Joint replacement surgery, where available, provides effective relief. Rheumatoid arthritis is an inflammatory condition that usually affects multiple joints. It affects 0.3-1.0% of the general population and is more prevalent among women and in developed countries. Persistent inflammation leads to joint destruction, but the disease can be controlled with drugs. The incidence may be on the decline, but the increase in the number of older people in some regions makes it difficult to estimate future prevalence. Osteoporosis, which is characterized by low bone mass and microarchitectural deterioration, is a major risk factor for fractures of the hip, vertebrae, and distal forearm. Hip fracture is the most detrimental fracture, being associated with 20% mortality and 50% permanent loss in function. Low back pain is the most prevalent of musculoskeletal conditions; it affects nearly everyone at some point in time and about 4-33% of the population at any given point. Cultural factors greatly influence the prevalence and prognosis of low back pain.

Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP. To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001). In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

ObjectivesThis study provides an overview of the influence of occupational risk factors on the global burden of disease as estimated by the occupational component of the Global Burden of Disease (GBD) 2016 study.MethodsThe GBD 2016 study estimated the burden in terms of deaths and disability-adjusted life years (DALYs) arising from the effects of occupational risk factors (carcinogens; asthmagens; particulate matter, gases and fumes (PMGF); secondhand smoke (SHS); noise; ergonomic risk factors for low back pain; risk factors for injury). A population attributable fraction (PAF) approach was used for most risk factors.ResultsIn 2016, globally, an estimated 1.53 (95% uncertainty interval 1.39–1.68) million deaths and 76.1 (66.3–86.3) million DALYs were attributable to the included occupational risk factors, accounting for 2.8% of deaths and 3.2% of DALYs from all causes. Most deaths were attributable to PMGF, carcinogens (particularly asbestos), injury risk factors and SHS. Most DALYs were attributable to injury risk factors and ergonomic exposures. Men and persons 55 years or older were most affected. PAFs ranged from 26.8% for low back pain from ergonomic risk factors and 19.6% for hearing loss from noise to 3.4% for carcinogens. DALYs per capita were highest in Oceania, Southeast Asia and Central sub-Saharan Africa. On a per capita basis, between 1990 and 2016 there was an overall decrease of about 31% in deaths and 25% in DALYs.ConclusionsOccupational exposures continue to cause an important health burden worldwide, justifying the need for ongoing prevention and control initiatives.

Background High prevalence of low back pain (LBP) in nurses has been reported globally. Ergonomic factors and work-related psychosocial factors have been focused on as risk factors. However, evidence on the role of fear-avoidance beliefs (FABs) concerning LBP in nurses is lacking. This study examined LBP prevalence and the association between FABs and chronic disabling LBP that interfered with work and lasted ≥ 3 months. Methods Female nurses ( N  = 3066; mean age = 35.8 ± 10.6 years) from 12 hospitals in Japan participated. A self-reported questionnaire was used to collect information on sociodemographics, LBP, work-related factors, and psychological distress. FABs about physical activity were assessed using a subscale from the FAB Questionnaire (score range = 0–24). The participants were asked to choose one of four statements regarding their LBP in the past 4 weeks: 1) I did not have LBP, 2) I had LBP without work difficulty, 3) I had LBP with work difficulty but without requiring absence from work, and 4) I had LBP requiring absence from work. If the participant had LBP in the past 4 weeks, it was also inquired if the LBP had lasted for ≥ 3 months. Chronic disabling LBP was defined as experiencing LBP with work difficulty in the past 4 weeks which had lasted for ≥ 3 months. In the nurses who had experienced any LBP in the past 4 weeks, we examined the association between FABs and experiencing chronic disabling LBP using multiple logistic regression models adjusting for pain intensity, age, body mass index, smoking status, psychological distress, hospital department, weekly work hours, night shift work, and the12 hospitals where the participants worked. Results Four-week and one-year LBP prevalence were 58.7 and 75.9%, respectively. High FABs (≥ 15) were associated with chronic disabling LBP (adjusted odds ratio = 1.76, 95% confidence interval [1.21–2.57], p  = 0.003). Conclusions LBP is common among nurses in Japan. FABs about physical activity might be a potential target for LBP management in nurses. Trial registration UMIN-CTR UMIN000018087 . Registered: June 25, 2015.

Background Mendelian randomization (MR) studies have an advantage over conventional observational studies when studying the causal effect of lifestyle-related risk factors on back pain. However, given the heterogeneous design of existing MR studies on back pain, the reported causal estimates of these effects remain equivocal, thus obscuring the true extent of the biological effects of back pain lifestyle-risk factors. Purpose The purpose of this study was to conduct a systematic review with multiple meta-analyses on the associations between various lifestyle factors and low back pain. Methods We conducted a PRISMA systematic review and specifically included MR studies to investigate the associations between lifestyle factors—specifically, BMI, insomnia, smoking, alcohol consumption, and leisure sedentary behavior—and various back pain outcomes. Each meta-analysis synthesized data from three or more studies to assess the causal impact of these exposures on distinct back pain outcomes, including chronic pain, disability, and pain severity. Quality of studies was assessed according to STROBE-MR guidelines. Results A total of 1576 studies were evaluated and 20 were included. Overall, the studies included were of high quality and had a low risk of bias. Our meta-analysis demonstrates the positive causal effect of BMI (OR IVW−random effects models : 1.18 [1.08–1.30]), insomnia(OR IVW−random effects models : 1.38 [1.10–1.74]), smoking(OR IVW−fixed effects models : 1.30 [1.23–1.36]), alcohol consumption(OR IVW−fixed effects models : 1.31 [1.21–1.42]) and leisure sedentary behaviors(OR IVW−random effects models : 1.52 [1.02–2.25]) on back pain. Conclusion In light of the disparate designs and causal effect estimates presented in numerous MR studies, our meta-analysis establishes a compelling argument that lifestyle-related risk factors such as BMI, insomnia, smoking, alcohol consumption, and leisure sedentary behaviors genuinely contribute to the biological development of back pain.

Low back pain and depression have been globally recognized as key public health problems and they are considered co-morbid conditions. This study explores both cross-sectional and longitudinal comorbid associations between back pain and major depression in the adult population in the United States. We used data from the Midlife in the United States survey (MIDUS), linking MIDUS II and III with a sample size of 2358. Logistic regression and Poisson regression models were used. The cross-sectional analysis showed significant associations between back pain and major depression. The longitudinal analysis indicated that back pain at baseline was prospectively associated with major depression at follow-up (PR 1.96, CI: 1.41, 2.74), controlling for health behavioral and demographic variables. Major depression at baseline was also prospectively associated with back pain at follow-up (PR 1.48, CI: 1.04, 2.13), controlling for a set of related confounders. These findings of a bidirectional comorbid association fill a gap in the current understanding of these comorbid conditions and could have clinical implications for the management and prevention of both depression and low back pain.

IntroductionChronic low back pain (CLBP) and depressive symptoms (DS) are highly prevalent, burdensome, costly and comorbid health conditions. Osteopathic manipulative treatment (OMT) was shown to improve pain and disability in patients with CLBP; however, the effect on comorbid DS remains less certain. Interestingly, CLBP and DS seem to be associated with changes in interoception, which may be reversed by OMT.Methods and analysisThe study protocol proposes a single-blinded, parallel-group, randomised controlled trial to investigate the effect of OMT on clinical symptoms (depression, pain and disability) and interoceptive functions (interoceptive accuracy, sensibility and awareness) in patients with CLBP and comorbid DS. A sample of 60 adult subjects with CLBP and comorbid DS shall be recruited from osteopathic, orthopaedic and physiotherapeutic practices and educational institutes for osteopathy, sports science, psychology and medicine in Hamburg, Germany. Participants will be randomly allocated (1:1 ratio) to receive six 45 min treatment sessions of either OMT (standard-OMT group) or sham treatment imitating OMT (sham-OMT group). Primarily, symptoms of depression, pain and disability will be assessed with the Beck’s Depression Inventory, Second Edition (BDI-II), Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Secondarily, interoceptive accuracy, sensibility and awareness will be evaluated using the Heartbeat Tracking Task (HTT), Multidimensional Assessment of Interoceptive Awareness (MAIA-2) and confidence-accuracy correspondence (CAC). Ancillary, the therapeutic alliance will be investigated with the Helping Alliance Questionnaire. Data will be collected at baseline (t0), the first, third and sixth treatment sessions (t1, t3, t6) and at 3 months follow-up (t7). The findings will be analysed for between-group differences using descriptive (mean and SD) and inductive statistics (mixed analysis of variance). It is hypothesised that standard-OMT, compared with sham-OMT, will reduce depression, pain and disability (BDI-II, NRS, ODI) and increase interoceptive accuracy, sensibility and awareness (HTT, MAIA-2, CAC) in patients with CLBP and comorbid DS.Ethics and disseminationThe study was approved by the ethics committee of the Medical School Hamburg (MSH-2023/288). The anonymised dataset will be published in an online repository, and the results will be published in peer-reviewed scientific journals.Trial registration numberDRKS00031694.

Objective To examine primary referral patterns and return to work in patients with incident back pain due to Lumbar Disc Herniation (LDH). Methods Nationwide register-based cohort study including all Danish residents aged 18–65 who were referred from primary to specialized healthcare in 2017 with incident back pain and subsequently received a diagnosis of lumbar disc herniation (LDH), defined by ICD-10 codes DM51X.X. Patients were identified using the Danish National Patient Registry (DNPR), including both those directly diagnosed with LDH and those who initially received a diagnosis of nonspecific low back pain (ICD-10: DM54) that progressed to LDH within one year. Demographic data were obtained from the Danish Civil Registration System (CRS), and work capacity outcomes were assessed over a two-year follow-up using the Danish Register for Evaluation of Marginalization (DREAM). Results A total of 30,082 persons, corresponding to 0.8% of the Danish population aged 18–65, were referred from primary health care to specialized health care with incident back pain and a final diagnosis of LDH. Of these, 5356 (17.8%) were referred to an emergency department, 14,628 (48.6%) to a medical department, and 10,098 (33.6%) to a surgical department. However, the admission rate and the initial department referred to varied widely between regions. Overall, 1915 (6.4%) underwent surgery. Surgical departments operated more frequently on patients with previous high (11%) or intermediate (14%) work capacity than on those with low work capacity (4%), although the latter were more often referred for surgical evaluation. Over 80% of patients with high or intermediate work capacity maintained or returned to work within a year. Conclusion In Denmark, referral from primary to specialized health care of patients with incident back pain due to LDH varies considerable between regions highlighting the need for more standardized referral pathways. Specifically, ensuring a better balance between emergency, medical, and surgical referrals could reduce unnecessary emergency admissions and improve the precision of surgical referrals optimizing the use of surgical capacity and healthcare resources in general.

Background self BACK, an artificial intelligence (AI)-based app delivering evidence-based tailored self-management support to people with low back pain (LBP), has been shown to reduce LBP-related disability when added to usual care. LBP commonly co-occurs with multimorbidity (≥ 2 long-term conditions) or pain at other musculoskeletal sites, so this study explores if these factors modify the effect of the self BACK app or influence outcome trajectories over time. Methods Secondary analysis of a randomized controlled trial with 9-month follow-up. Primary outcome is as follows: LBP-related disability (Roland Morris Disability Questionnaire, RMDQ). Secondary outcomes are as follows: stress/depression/illness perception/self-efficacy/general health/quality of life/physical activity/global perceived effect. We used linear mixed models for continuous outcomes and logistic generalized estimating equation for binary outcomes. Analyses were stratified to assess effect modification, whereas control ( n  = 229) and intervention ( n  = 232) groups were pooled in analyses of outcome trajectories. Results Baseline multimorbidity and co-occurring musculoskeletal pain sites did not modify the effect of the self BACK app. The effect was somewhat stronger in people with multimorbidity than among those with LBP only (difference in RMDQ due to interaction, − 0.9[95 % CI − 2.5 to 0.6]). Participants with a greater number of long-term conditions and more co-occurring musculoskeletal pain had higher levels of baseline disability (RMDQ 11.3 for ≥ 2 long-term conditions vs 9.5 for LBP only; 11.3 for ≥ 4 musculoskeletal pain sites vs 10.2 for ≤ 1 additional musculoskeletal pain site); along with higher baseline scores for stress/depression/illness perception and poorer pain self-efficacy/general health ratings. In the pooled sample, LBP-related disability improved slightly less over time for people with ≥ 2 long-term conditions additional to LBP compared to no multimorbidity and for those with ≥4 co-occurring musculoskeletal pain sites compared to ≤ 1 additional musculoskeletal pain site (difference in mean change at 9 months = 1.5 and 2.2, respectively). All groups reported little improvement in secondary outcomes over time. Conclusions Multimorbidity or co-occurring musculoskeletal pain does not modify the effect of the selfBACK app on LBP-related disability or other secondary outcomes. Although people with these health problems have worse scores both at baseline and 9 months, the AI-based selfBACK app appears to be helpful for those with multimorbidity or co-occurring musculoskeletal pain. Trial registration NCT03798288 . Date of registration: 9 January 2019

Background The severity and course of spinal pain is poorly understood in adolescents. The study aimed to determine the prevalence and two-year incidence, as well as the course, frequency, and intensity of pain in the neck, mid back, and low back (spinal pain). Methods This study was a school-based prospective cohort study. All 5th and 6th grade students (11–13 years) at 14 schools in the Region of Southern Denmark were invited to participate (N = 1,348). Data were collected in 2010 and again two years later, using an e-survey completed during school time. Results The lifetime prevalence of spinal pain was 86% and 89% at baseline and follow-up, respectively. A group of 13.6% (95% CI: 11.8, 15.6) at baseline and 19.5% (95% CI: 17.1, 22.0) at follow-up reported that they had pain frequently. The frequency of pain was strongly associated with the intensity of pain, i.e., the majority of the participants reported their pain as relatively infrequent and of low intensity, whereas the participants with frequent pain also experienced pain of higher intensity. The two-year incidence of spinal pain varied between 40% and 60% across the physical locations. Progression of pain from one to more locations and from infrequent to more frequent was common over the two-year period. Conclusions Spinal pain is common at the age of 11–15 years, but some have more pain than others. The pain is likely to progress, i.e., to more locations, higher frequency, and higher pain intensity over a two-year period.