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Original Investigation |

The Rising Prevalence of Chronic Low Back Pain FREE

Janet K. Freburger, PT, PhD; George M. Holmes, PhD; Robert P. Agans, PhD; Anne M. Jackman, MSW; Jane D. Darter, BA; Andrea S. Wallace, RN, PhD; Liana D. Castel, PhD; William D. Kalsbeek, PhD; Timothy S. Carey, MD, MPH
[+] Author Affiliations

Author Affiliations: Cecil G. Sheps Center for Health Services Research (Drs Freburger, Holmes, and Carey and Mss Jackman and Darter), Division of Physical Therapy (Dr Freburger), Survey Research Unit (Drs Agans and Kalsbeek), Department of Biostatistics (Drs Agans and Kalsbeek), and Department of Medicine (Dr Carey), University of North Carolina at Chapel Hill; College of Nursing, University of New Mexico, Albuquerque (Dr Wallace); and Department of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (Dr Castel).


Arch Intern Med. 2009;169(3):251-258. doi:10.1001/archinternmed.2008.543.
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Background  National or state-level estimates on trends in the prevalence of chronic low back pain (LBP) are lacking. The objective of this study was to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care–seeking characteristics of individuals with the condition have changed over the last 14 years.

Methods  A cross-sectional, telephone survey of a representative sample of North Carolina households was conducted in 1992 and repeated in 2006. A total of 4437 households were contacted in 1992 and 5357 households in 2006 to identify noninstitutionalized adults 21 years or older with chronic (>3 months), impairing LBP or neck pain that limits daily activities. These individuals were interviewed in more detail about their health and health care seeking.

Results  The prevalence of chronic, impairing LBP rose significantly over the 14-year interval, from 3.9% (95% confidence interval [CI], 3.4%-4.4%) in 1992 to 10.2% (95% CI, 9.3%-11.0%) in 2006. Increases were seen for all adult age strata, in men and women, and in white and black races. Symptom severity and general health were similar for both years. The proportion of individuals who sought care from a health care provider in the past year increased from 73.1% (95% CI, 65.2%-79.8%) to 84.0% (95% CI, 80.8%-86.8%), while the mean number of visits to all health care providers were similar (19.5 [1992] vs 19.4 [2006]).

Conclusions  The prevalence of chronic, impairing LBP has risen significantly in North Carolina, with continuing high levels of disability and health care use. A substantial portion of the rise in LBP care costs over the past 2 decades may be related to this rising prevalence.

Figures in this Article

Low back pain (LBP) is the second most common cause of disability in US adults1 and a common reason for lost work days.2,3 An estimated 149 million days of work per year are lost because of LBP.4 The condition is also costly, with total costs estimated to be between $100 and $200 billion annually, two-thirds of which are due to decreased wages and productivity.5

More than 80% of the population will experience an episode of LBP at some time during their lives.6 For most, the clinical course is benign, with 95% of those afflicted recovering within a few months of onset.7 Some, however, will not recover and will develop chronic LBP (ie, pain that lasts for 3 months or longer). Recurrences of LBP are also common, with the percentage of subsequent LBP episodes ranging from 20% to 44% within 1 year for working populations to lifetime recurrences of up to 85%.8

The use of health care services for chronic LBP has increased substantially over the past 2 decades. Multiple studies using national and insurance claims data have identified greater use of spinal injections,911 surgery,1216 and opioid medications17—treatments most likely to be used by individuals with chronic LBP. Studies have also documented increases in medication prescription and visits to physicians, physical therapists, and chiropractors.1821 Because individuals with chronic LBP are more likely to seek care2224 and to use more health care services,2527 relative to individuals with acute LBP, increases in health care use are likely driven more by chronic than acute cases.

Increased health care use for chronic LBP could be a function of (1) increased prevalence of chronic LBP; (2) increased proportion of those with chronic LBP who seek care; (3) increased use by those who seek care, or (4) some combination of these factors.28 The documented increase in use of services is often assumed to be due to increased health care seeking or use by those who seek care. A less investigated contributing factor is increased prevalence of chronic LBP.

National and state estimates on trends in the prevalence of LBP have been hampered by the lack of consistent data over time.29,30 Previous studies have used inconsistent definitions of LBP, preventing cross-study comparisons, or do not use the same definition over time, leading to varying conclusions on trends in prevalence.29,31,32 Data from England suggest that the prevalence of LBP has increased substantially over the past several decades,31,33 while data from the United States, Finland, and Germany indicate little change over the past 2 decades.29,32,3436 Studies specifically focusing on trends over time in the prevalence of chronic LBP in the United States, using consistent definitions from one time point to the next, are severely lacking. Discerning whether the prevalence of chronic LBP is increasing and contributing to the increase in the use of health services is vital to the development of strategies to contain costs and improve care for this condition.

We repeated a population-based telephone survey, originally conducted in 1992 in North Carolina, to determine whether the prevalence of chronic LBP and the demographic, health-related, and health care–seeking characteristics of those so afflicted have changed in the state. For both surveys, we used identical definitions of chronic LBP.

The present study builds on a computer-assisted telephone survey of LBP prevalence and health care use conducted in 1992.25,26 The 1992 survey addressed acute and chronic LBP. The current survey, fielded in 2006, addressed chronic LBP and chronic neck pain. Low back pain was defined as pain at the level of the waist or below, with or without buttock and/or leg pain.25 An individual was considered to have chronic LBP if she or he reported (1) pain and activity limitations nearly every day for the past 3 months or (2) more than 24 episodes of pain that limited activity for 1 day or more in the past year.25 This study was approved by the institutional review board of the University of North Carolina at Chapel Hill.

2006 SURVEY INSTRUMENT

The 2006 survey instrument was an expansion of the 1992 instrument. Questions were added to identify individuals with neck pain and to gather more detailed information about the health and health care use of individuals with chronic pain. We also created a Spanish version, since the Hispanic population of North Carolina had increased substantially in the interval. Prior to data collection, the University of North Carolina at Chapel Hill Survey Research Unit (UNC-SRU) piloted the instrument, using computer-assisted telephone interviewing, on a random sample of North Carolina residents or known cases of chronic LBP (n = 84). Instrument revisions were made based on the results of the pilot study.

The final instrument had 4 sections: household roster, acute/chronic screener, back pain module, and neck pain module. The household roster, to be completed by an adult member of the household, included questions on the demographic characteristics of each household member 21 years or older and a screener for LBP and neck pain (ie, “As far as you know, did [adult 1] have any kind of back or neck problem in the past few years?”). The acute/chronic screener, to be completed by a household member with a history of back or neck pain, included questions on pain severity and duration in the past year. The back pain module, to be completed by individuals with chronic LBP, included a series of questions on symptoms (eg, pain intensity, presence of leg pain), general health status (Medical Outcomes Study Short Form 12, presence of comorbidities), functional status (Roland-Morris Disability Questionnaire), and use of health care providers and treatments in the past year. The neck pain module had a similar design.

Both the back and neck pain modules ended with more detailed questions on employment and demographic characteristics. Two questions were used for individuals to self-identify their race/ethnicity. These were (1) “How would you describe your race/ethnicity?” and (2) “Do you consider yourself Hispanic or Latino?”

SAMPLE SELECTION

At each contacted household, an adult gave verbal consent and completed the household roster. If 1 or more adults in the household had a history of back problems (1992 survey) or back or neck problems (2006 survey) in the past few years, one individual was randomly selected to be interviewed in more detail. The selected individual gave verbal consent and completed the survey. Individuals who reported both chronic back and neck pain in the 2006 survey completed the questions on back pain in order to emulate the 1992 survey procedures.

2006 SAMPLE

A stratified probability sample of North Carolina telephone numbers was obtained from GENESYS Sampling Systems (Marketing Systems Group, Fort Washington, Pennsylvania).37 Numbers were chosen from 6 sampling strata, defined by the cross-classification of region of the state (mountains, piedmont, coastal) and concentration of African Americans (high, ≥15.5% of population; low, <15.5% of population). The latter variable was chosen to ensure adequate representation of African Americans so we could more accurately determine whether the prevalence of chronic LBP varied by race/ethnicity.

The Figure details the sample selection strategy. A total of 5357 households with 1 or more adults 21 years or older were contacted and 9924 adults were rostered. The household response rate was 66%, computed as the sum of households interviewed divided by the sum of eligible households plus an estimate of the proportion of households with unknown eligibility.38

Place holder to copy figure label and caption
Figure.

2006 Sample selection. LBP indicates low back pain.

Graphic Jump Location

Of the 5357 households contacted, 3276 households (61%) had 1 or more adults with a history of back and/or neck pain in the past few years. Of the adults randomly selected from these households (n = 3276), 2723 were interviewed for an individual response rate of 86% and an overall response rate (household response rate × individual response rates) of 57%. Adults randomly selected to be interviewed were similar in age, sex, and race to those not selected. Adults who refused to be interviewed or who could not be reached were similar in age and race to responders but were more likely to be male (χ2 test, P < .001).

1992 SAMPLE SELECTION

Details of the sample selection in 1992 are described elsewhere.25 Briefly, a 2-stage proportionate stratified sample (based on region of state and urban/rural status) of residential North Carolina telephone numbers was generated using a modified version of the Waksberg random digit dialing sampling design.39 A total of 4437 households with 1 or more adults 21 years or older were contacted. The household response rate, computed as the number of completed interviews divided by a prorated estimate of the number of eligible households,40 was 79%. Of the 4437 households contacted, 2053 households had 1 or more adults with a history of back pain. One adult with back pain was randomly selected from each of these households and interviewed.

INTERVIEWING PROCEDURES

Both surveys were conducted by trained personnel in the UNC-SRU. Interviews for the 2006 survey were conducted from April to November. A call scheduling system was used to ensure that repeated calls were conducted at different times of the day and week. Telephone numbers were withdrawn after a minimum of 10 unsuccessful call attempts with at least 1 day, 1 weekend, and 1 evening call. The 1992 methods were identical with the exception of using more current software in 2006.

WEIGHTING OF THE DATA

Sample weights and prevalence weights were created for both the 2006 and 1992 data.

2006 Data

The sample weights provided by GENESYS Sampling Systems were first adjusted to account for the differential probability of selection into our sample due to the use of only a proportion of the vendor-provided numbers, the number of household landlines, and stratum-specific household nonresponse. To reduce bias resulting from differences in response rates among demographic subgroups, a poststratification adjustment was made by calibrating the weighted sample to the distribution of the North Carolina population with respect to age, race/ethnicity, and sex. Data from the 2005 American Community Survey (conducted by the US Census Bureau to gather demographic, economic, social, and housing information) were used for the calibration.41 Weights used for prevalence estimation also took into account the number of nominated back and neck pain cases in the respondent's household as well as nonresponse among nominated back and neck pain cases.

1992 Data

Sample weights were created for the 1992 data to account for the differential probability of selection, telephone coverage, and survey nonresponse. A poststratification adjustment was then made to ensure the survey data were representative in terms of age, race, and sex, using data from the 1990 census. Prevalence weights were calculated using a method identical to that used for the 2006 data.

DATA ANALYSIS

All analyses were conducted using the survey commands in Stata statistical software (version 9.2; StataCorp, College Station, Texas). Prevalence estimates, 95% confidence intervals (CIs), and descriptive statistics on the chronic LBP respondents were generated for the 1992 and 2006 data. Two-sample t tests and χ2 tests of proportions were conducted to determine differences in the demographic, health-related, and health care–seeking characteristics of the 2 groups. Missing data ranged from 0% to 9% for the variables examined in this study and were treated as such (ie, no imputation or use of dummy variables).

The prevalence of chronic LBP more than doubled in the 14-year interval from 3.9% to 10.2%. This marked increase occurred among all sex, age, and race/ethnic subgroups (Tables 1, 2, and 3). In both years, the prevalence of chronic LBP was greater in women.

Table Graphic Jump LocationTable 1. Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006
Table Graphic Jump LocationTable 2. Prevalence of Chronic Low Back Pain by Age and Sex
Table Graphic Jump LocationTable 3. Prevalence of Chronic Low Back Pain by Race and Sex

Table 4 presents demographic, health-related, and health care–seeking characteristics of the 1992 and 2006 chronic back pain respondents. The groups were similar in regard to demographic characteristics, with the exception of the 2006 respondents being more educated, with a greater percentage of individuals who were 45 to 54 years old, and Hispanic. North Carolina has undergone a marked increase in its Hispanic population, particularly in the 0- to 44-year age group, over the past decade.42 In the 1992 survey, few respondents claimed Hispanic ethnicity. There were also some differences in the insurance and employment status of the 1992 and 2006 groups. Most notably, the proportion of individuals receiving Medicare who were younger than 62 years (ie, receiving Social Security Disability Insurance) more than doubled from 1992 to 2006 and parallels the increase in chronic LBP prevalence. A considerable proportion of individuals in both groups had a low household income. In 2006, 40% of the subjects reported a household income of $20 000 or less. In 1992, 55% reported a household income of $20 000 ($29 000 in 2006 dollars) or less.

Table Graphic Jump LocationTable 4. Demographic and Clinical Characteristics of 1992 and 2006 Chronic Low Back Pain (LBP) Samples

Health-related characteristics of the 2 groups were also similar in regard to onset of LBP, pain intensity, and health status. For individuals who reported continuous chronic pain, those in the 2006 group reported a longer duration of pain. Condition-specific functional data were only collected in 2006 using the Roland-Morris Disability Questionnaire, which measures degree of functional limitation on a scale from 0 to 23. The mean Roland score for the 2006 group was 14.9 (95% CI, 14.3-15.5), indicating substantial functional impairment, similar to scores for patients considering surgery for their LBP.43,44 Health care seeking had significantly increased for the 2006 group, from 73.1% to 84.0%; the percentage seeking care from a physician increased from 66.5% to 78.1%. Among those who sought care, there was little change in the number who had surgery or in the number of provider visits.

To our knowledge, this is the first population-based study in the United States that has examined trends in the prevalence of chronic LBP using similar survey methods and identical definitions of chronic LBP. We found an alarming increase in the prevalence of chronic LBP from 1992 to 2006 in North Carolina, which occurred across all demographic subgroups. We also found that episodes of acute LBP (defined as pain that limited usual activities for at least 1 day but less than 3 months; or less than 25 episodes of LBP that limited activities) in the past year increased from 7.3% (95% CI, 6.6%-8.1%) to 10.5% (95% CI, 9.5%-11.4%). Although the cross-sectional nature of our data prevents any firm conclusions, the smaller increase in prevalence of acute vs chronic LBP is consistent with a greater percentage of acute cases transitioning to chronic cases.

Reasons for the increase in chronic LBP are unclear. Changes in the age composition of the state do not explain the increase since the rise in prevalence was similar across all age strata. Ethnic differences also do not explain the increase. As our data indicate, the Hispanic population has a lower prevalence of chronic LBP, which is likely because of their younger age. More than 50% of the Hispanic individuals surveyed in our study were 21 to 34 years old. Individuals in this age group, relative to older groups, have a lower prevalence of LBP. An increase in the rate of smoking, a potential risk factor for LBP,45,46 is also not a likely explanation for the increase in chronic LBP because rates of smoking in North Carolina adults have decreased slightly over the past decade (26% in 1995 to 22% in 2006).47

One potential reason for the increase may be increasing rates of obesity. North Carolinians have grown considerably more obese (body mass index ≥30 [calculated as weight in kilograms divided by height in meters squared]) over the period we examined (13.4% in 1992 to 26.6% in 2006).47 Whether obesity is a risk factor for LBP, however, is still unclear.4850 Changes in psychosocial and physical work demands, risk factors for LBP,51 may have also contributed to the increase in prevalence. The workforce in North Carolina has changed over the past 15 years, with decreases in the percentage of manufacturing jobs and increases in the percentage of construction and service industry jobs.52

Increases in back pain prevalence may also be due to increases in depression prevalence. Rates of major depression in the United States more than doubled from 3.33% in 1991-1992 to 7.06% in 2001-200253; and longitudinal studies suggest that major depression increases the risk of developing future chronic pain.5456 Individuals with major depression are almost 3 times more likely to develop incident chronic back pain within 2 years relative to nondepressed individuals.56

Others have speculated that increases in back pain prevalence may be due to increased symptom awareness and reporting.33,57 Increasing public knowledge of LBP via medicalization, the media, and the Internet have likely made back pain a more prominent part of life over the past 2 decades. Current care for chronic LBP often includes the use of multiple health care professionals which, some argue, encourages the further medicalization and persistence of chronic LBP.57,58 Recent analyses of data from several German health surveys indicate that immediately after reunification, rates of back pain prevalence were roughly 10 percentage points less in East Germany relative to West Germany, but they were essentially the same 10 years later.59 While selective migration and differences in rates of unemployment may have contributed to rising prevalence rates in East Germany, the authors hypothesized that much of the increase in prevalence was due to dissemination of back-related attitudes and beliefs from the more “medicalized” West Germany to East Germany. When we tried to assess whether our respondents were simply labeling ongoing back symptoms as functionally impairing, we found that those with back pain in 2006 were functioning either similarly or worse than in 1992, with decreased employment, greater use of disability insurance, and continued high pain scores.

Although we attempted to apply identical methods for the 2 surveys, it remains possible that minor sampling or measurement issues may have accounted for some of the difference in prevalence between the 2 years. Differences in survey methods, however, would likely not explain all of the increase in prevalence. While direct comparisons are not possible, our estimates and trends are similar to data from the National Health Interview Survey. In 2006, 8.3% (95% CI, 7.8%-8.7%) of adults 21 years or older reported difficulty with 1 or more of 12 functional activities (ie, walking a one-quarter mile [400 meters]; climbing 10 steps; standing for 2 hours; sitting for 2 hours; stooping, bending, kneeling; reaching overhead; grasping small objects; lifting/carrying 4.5 kg; pushing/pulling large objects; going out to events, participating in social activities; relaxing at home) because of chronic back or neck problems. In 1997, 3.2% of adults reported difficulty with these activities because of chronic back or neck problems.60 National data indicate that the proportion of Social Security Disability Income awardees claiming “musculoskeletal disease” as their cause of disability has also increased markedly, from 15.2% in 1992 to 28.2% in 2006.61 In 1983 musculoskeletal disorders were the fourth leading diagnostic group in disability awards; in 2003, they were the leading diagnostic group.62 While the musculoskeletal disease classification includes conditions other than back pain, this national trend is consistent with our data on Medicare recipients with chronic LBP younger than 62 years.

Some authors have hypothesized that the increases in the use of health care services for chronic LBP are due to increased health care seeking by those with the condition.11,12,29,63 Our data, however, suggest that increased prevalence may be the primary factor contributing to this phenomenon. In fact, as we illustrated, there was only a moderate increase in health care seeking from 1992 to 2006, with little change in the total number of visits to physicians, physical therapists, and chiropractors, conditional on 1 visit. The proportion of individuals who had surgery was also similar across the 2 years.

To further explore the relationship between prevalence and use of surgery, we conducted an age-adjusted analysis of change in lumbar spine surgery rates in North Carolina, using state inpatient and ambulatory surgery data housed at our center. From 1997 to 2005, surgical procedures per person among the North Carolina population increased 157%. This increase parallels the increase we saw in prevalence. Others have also reported increasing surgery rates using state and national data.12,14,63,64 The rates of surgery among our survey respondents—individuals with chronic LBP—were similar in 1992 and 2006. These findings suggest that increasing prevalence of chronic LBP may be the contributing factor to increased surgery rates rather than increased use of surgery by those with chronic LBP, at least in the state of North Carolina.

This study has limitations. The cross-sectional nature of the analysis prevents us from making firm conclusions regarding causality. In addition, because we did not collect data on risk factors, our hypotheses regarding the causes for the increase in prevalence are speculative. It is also possible that there was some underreporting of pain in the surveys, since a household member was asked to identify all household members with a history of back or neck problems. Finally, the study was conducted in only 1 state.

The major strength of this study is that we used similar methods and identical definitions of chronic LBP to examine trends in prevalence over time. Although our data come from only 1 state, the lack of comparable national or other state data on trends in the prevalence of chronic LBP elevate their significance. This study provides valuable and timely information on a common, disabling, and increasingly costly condition.

We found an alarming increase in the prevalence of chronic LBP in North Carolina, with moderate increases in already high use of health care. These findings suggest that increases in health care costs on a population basis may be due to the increased prevalence of this condition, more so than increased use by those afflicted. Efforts to improve function and constrain costs of back pain will need to address issues of causality and self-management if we are to adequately address this health and health care challenge.

Correspondence: Timothy Carey, MD, MPH, The Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, 725 Martin Luther King, Jr Blvd, Chapel Hill, NC 27599-7590 (carey@schsr.unc.edu).

Accepted for Publication: August 13, 2008.

Author Contributions: Dr Freburger had access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Freburger, Agans, Jackman, Castel, Kalsbeek, and Carey. Acquisition of data: Agans, Jackman, and Kalsbeek. Analysis and interpretation of data: Freburger, Holmes, Agans, Darter, Wallace, and Carey. Drafting of the manuscript: Freburger and Agans. Critical revision of the manuscript for important intellectual content: Freburger, Holmes, Jackman, Darter, Wallace, Castel, Kalsbeek, and Carey. Statistical analysis: Freburger, Holmes, Agans, and Kalsbeek. Obtained funding: Freburger and Carey. Administrative, technical, and material support: Agans, Jackman, Darter, Castel, and Carey. Study supervision: Agans and Carey.

Financial Disclosure: None reported.

Funding/Support: This study was supported by grant R01 AR051970 from the National Institute of Arthritis and Musculoskeletal and Skin Diseases; National Research Service Award Institutional Training Grant T32 HS000032 from the Agency for Healthcare Research and Quality; and National Research Service Award Institutional Training Grant T32 NR08856 from the National Institute of Nursing Research.

Role of the Sponsor: The funding agencies did not have any role in the design and conduct of the study; collection, management, analysis, and interpretation of data; and preparation, review, or approval of the manuscript.

Previous Presentation: This work was presented as a platform presentation, “The Rising Prevalence of Chronic, Disabling Low Back Pain,” at the Society of General Internal Medicine's annual meeting; April 11, 2008; Pittsburgh, Pennsylvania.

Additional Contributions: Stefanie Knauer assisted in editing of the manuscript.

From the Centers for Disease Control and Prevention, Prevalence of disabilities and associated health conditions among adults—United States, 1999. JAMA 2001;285 (12) 1571- 1572
PubMed
Stewart  WFRicci  JAChee  EMorganstein  DLipton  R Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290 (18) 2443- 2454
PubMed
Ricci  JAStewart  WFChee  ELeotta  CFoley  KHochberg  MC Back pain exacerbations and lost productive time costs in United States workers. Spine 2006;31 (26) 3052- 3060
PubMed
Guo  HRTanaka  SHalperin  WECameron  LL Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health 1999;89 (7) 1029- 1035
PubMed
Katz  JN Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006;88 ((suppl 2)) 21- 24
PubMed
Rubin  DI Epidemiology and risk factors for spine pain. Neurol Clin 2007;25 (2) 353- 371
PubMed
Carey  TSGarrett  JJackman  AMcLaughlin  CFryer  JSmucker  DR The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons: the North Carolina Back Pain Project. N Engl J Med 1995;333 (14) 913- 917
PubMed
van Tulder  MKoes  BBombardier  C Low back pain. Best Pract Res Clin Rheumatol 2002;16 (5) 761- 775
PubMed
Weiner  DKKim  YSBonino  PWang  T Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med 2006;7 (2) 143- 150
PubMed
Carrino  JAMorrison  WBParker  LSchweitzer  MELevin  DCSunshine  JH Spinal injection procedures: volume, provider distribution, and reimbursement in the US Medicare population from 1993 to 1999. Radiology 2002;225 (3) 723- 729
PubMed
Friedly  JChan  LDeyo  R Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine 2007;32 (16) 1754- 1760
PubMed
Deyo  RAGray  DTKreuter  WMirza  SMartin  BI United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30 (12) 1441- 1445
PubMed
Deyo  RAMirza  SK Trends and variations in the use of spine surgery. Clin Orthop Relat Res February 2006;443139- 146
PubMed
Gray  DTDeyo  RAKreuter  W  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine 2006;31 (17) 1957- 1963
PubMed
Deyo  RANachemson  AMirza  SK Spinal-fusion surgery—the case for restraint. N Engl J Med 2004;350 (7) 722- 726
PubMed
Ciol  MADeyo  RAHowell  EKreif  S An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 1996;44 (3) 285- 290
PubMed
Luo  XPietrobon  RHey  L Patterns and trends in opioid use among individuals with back pain in the United States. Spine 2004;29 (8) 884- 890
PubMed
Feuerstein  MMarcus  SCHuang  GD National trends in nonoperative care for nonspecific back pain. Spine J 2004;4 (1) 56- 63
PubMed
Hurwitz  ELCoulter  IDAdams  AHGenovese  BJShekelle  PG Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88 (5) 771- 776
PubMed
Kessler  RCDavis  RBFoster  DF  et al.  Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001;135 (4) 262- 268
PubMed
Martin  BIDeyo  RAMirza  SK  et al.  Expenditures and health status among adults with back and neck problems. JAMA 2008;299 (6) 656- 664
PubMed
IJzelenberg  WBurdorf  A Patterns of care for low back pain in a working population. Spine 2004;29 (12) 1362- 1368
PubMed
Molano  SMBurdorf  AElders  LA Factors associated with medical care-seeking due to low-back pain in scaffolders. Am J Ind Med 2001;40 (3) 275- 281
PubMed
Mortimer  MAhlberg  G To seek or not to seek? care-seeking behaviour among people with low-back pain. Scand J Public Health 2003;31 (3) 194- 203
PubMed
Carey  TSEvans  AHadler  NKalsbeek  WMcLaughlin  CFryer  J Care-seeking among individuals with chronic low back pain. Spine 1995;20 (3) 312- 317
PubMed
Carey  TSEvans  ATHadler  NM  et al.  Acute severe low back pain: a population-based study of prevalence and care-seeking. Spine 1996;21 (3) 339- 344
PubMed
Von Korff  MLin  EHFenton  JJSaunders  K Frequency and priority of pain patients' health care use. Clin J Pain 2007;23 (5) 400- 408
PubMed
Thorpe  KEFlorence  CSJoski  P Which medical conditions account for the rise in health care spending? Health Aff (Millwood) 2004; ((suppl web exclusives)) W4-437- W4-445
PubMed
Deyo  RAMirza  SKMartin  BI Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 2006;31 (23) 2724- 2727
PubMed
Walker  BF The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 2000;13 (3) 205- 217
PubMed
Harkness  EFMacfarlane  GJSilman  AJMcBeth  J Is musculoskeletal pain more common now than 40 years ago? two population-based cross-sectional studies. Rheumatology (Oxford) 2005;44 (7) 890- 895
PubMed
Heistaro  SVartiainen  EHeliovaara  MPuska  P Trends of back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors. Am J Epidemiol 1998;148 (7) 671- 682
PubMed
Palmer  KTWalsh  KBendall  HCooper  CCoggon  D Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years. BMJ 2000;320 (7249) 1577- 1578
PubMed
Leino  PIBerg  MAPuska  P Is back pain increasing? results from national surveys in Finland during 1978/9-1992. Scand J Rheumatol 1994;23 (5) 269- 276
PubMed
Pitkala  KHStrandberg  TETilvis  RS Management of nonmalignant pain in home-dwelling older people: a population-based survey. J Am Geriatr Soc 2002;50 (11) 1861- 1865
PubMed
Hüppe  AMuller  KRaspe  H Is the occurrence of back pain in Germany decreasing? two regional postal surveys a decade apart. Eur J Public Health 2007;17 (3) 318- 322
PubMed
GENESYS Sampling Services, GENESYS-IDplus. http://www.genesys-sampling.com/GENESYS-IDplus.aspx. Accessed January 2, 2008
American Association for Public Opinion Research (APOR),  Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys.  4th ed. Lenexa, Kansas APOR2006;
Waksberg  J Sampling methods for random digit dialing. J Am Stat Assoc 1978;73 (361) 40- 46
Task Force on Completion Rates, Council of American Survey Research (CASRO),  On the Definition of Response Rates: Special Report.   New York, NY CASRO1982;
US Census Bureau, American community survey 2005—public use file. http://www.census.gov/acs/www/Products/users_guide/2005/index.htm. Accessed January 2, 2008
US Census Bureau, State and County Quick Facts 2006. http://quickfacts.census.gov/gfd/. Accessed January 2, 2008
Deyo  RA Comparative validity of the sickness impact profile and shorter scales for functional assessment in low-back pain. Spine 1986;11 (9) 951- 954
PubMed
Chang  YSinger  DEWu  YAKeller  RBAtlas  SJ The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years. J Am Geriatr Soc 2005;53 (5) 785- 792
PubMed
Goldberg  MSScott  SCMayo  NE A review of the association between cigarette smoking and the development of nonspecific back pain and related outcomes. Spine 2000;25 (8) 995- 1014
PubMed
Leboeuf-Yde  C Smoking and low back pain: a systematic literature review of 41 journal articles reporting 47 epidemiologic studies. Spine 1999;24 (14) 1463- 1470
PubMed
Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System: Centers for Disease Control, 2008. Atlanta, GA: US Dept of Health and Human Services. http://www.cdc.gov/brfss/index.htm. Accessed January 2, 2008
Janke  EACollins  AKozak  AT Overview of the relationship between pain and obesity: what do we know? where do we go next? J Rehabil Res Dev 2007;44 (2) 245- 262
PubMed
Lake  JKPower  CCole  TJ Back pain and obesity in the 1958 British birth cohort. cause or effect? J Clin Epidemiol 2000;53 (3) 245- 250
PubMed
Leboeuf-Yde  C Body weight and low back pain: a systematic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine 2000;25 (2) 226- 237
PubMed
Kerr  MSFrank  JWShannon  HS  et al.  Biomechanical and psychosocial risk factors for low back pain at work. Am J Public Health 2001;91 (7) 1069- 1075
PubMed
Herrin  KB  Occupational Health Trends in North Carolina.   Raleigh, NC NC Department of Health and Human Services, Occupational and Environmental Epidemiology Branch2006;
Compton  WMConway  KPStinson  FSGrant  BF Changes in the prevalence of major depression and comorbid substance use disorders in the United States between 1991-1992 and 2001-2002. Am J Psychiatry 2006;163 (12) 2141- 2147
PubMed
Croft  PRPapageorgiou  ACFerry  SThomas  EJayson  MISilman  AJ Psychologic distress and low back pain: evidence from a prospective study in the general population. Spine 1995;20 (24) 2731- 2737
PubMed
Larson  SLClark  MREaton  WW Depressive disorder as a long-term antecedent risk factor for incident back pain: a 13-year follow-up study from the Baltimore Epidemiological Catchment Area sample. Psychol Med 2004;34 (2) 211- 219
PubMed
Currie  SRWang  J More data on major depression as an antecedent risk factor for first onset of chronic back pain. Psychol Med 2005;35 (9) 1275- 1282
PubMed
Croft  P Is life becoming more of a pain? BMJ 2000;320 (7249) 1552- 1553
PubMed
Weiner  BK Spine update: the biopsychosocial model and spine care. Spine 2008;33 (2) 219- 223
PubMed
Raspe  HHueppe  ANeuhauser  H Back pain, a communicable disease? Int J Epidemiol 2008;37 (1) 69- 74
PubMed
Lawrence  RCFelson  DTHelmick  CG  et al.  Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: part II. Arthritis Rheum 2008;58 (1) 26- 35
PubMed
Social Security Administration,  Annual Statistical Report on the Social Security Disability Insurance Program.   Baltimore, MD Office of Research Evaluation and Statistics2006;
Autor  DHDuggan  MG The growth in the Social Security Disability rolls: a fiscal crisis unfolding. J Econ Perspect 2006;20 (3) 71- 96
PubMed
Cowan  JA  JrDimick  JBWainess  RUpchurch  GR  JrChandler  WFLa Marca  F Changes in the utilization of spinal fusion in the United States. Neurosurgery 2006;59 (1) 15- 20
PubMed
Weinstein  JNLurie  JDOlson  PRBronner  KKFisher  ES United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine 2006;31 (23) 2707- 2714
PubMed

Figures

Place holder to copy figure label and caption
Figure.

2006 Sample selection. LBP indicates low back pain.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Prevalence of Chronic Low Back Pain in North Carolina, 1992 and 2006
Table Graphic Jump LocationTable 2. Prevalence of Chronic Low Back Pain by Age and Sex
Table Graphic Jump LocationTable 3. Prevalence of Chronic Low Back Pain by Race and Sex
Table Graphic Jump LocationTable 4. Demographic and Clinical Characteristics of 1992 and 2006 Chronic Low Back Pain (LBP) Samples

References

From the Centers for Disease Control and Prevention, Prevalence of disabilities and associated health conditions among adults—United States, 1999. JAMA 2001;285 (12) 1571- 1572
PubMed
Stewart  WFRicci  JAChee  EMorganstein  DLipton  R Lost productive time and cost due to common pain conditions in the US workforce. JAMA 2003;290 (18) 2443- 2454
PubMed
Ricci  JAStewart  WFChee  ELeotta  CFoley  KHochberg  MC Back pain exacerbations and lost productive time costs in United States workers. Spine 2006;31 (26) 3052- 3060
PubMed
Guo  HRTanaka  SHalperin  WECameron  LL Back pain prevalence in US industry and estimates of lost workdays. Am J Public Health 1999;89 (7) 1029- 1035
PubMed
Katz  JN Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am 2006;88 ((suppl 2)) 21- 24
PubMed
Rubin  DI Epidemiology and risk factors for spine pain. Neurol Clin 2007;25 (2) 353- 371
PubMed
Carey  TSGarrett  JJackman  AMcLaughlin  CFryer  JSmucker  DR The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons: the North Carolina Back Pain Project. N Engl J Med 1995;333 (14) 913- 917
PubMed
van Tulder  MKoes  BBombardier  C Low back pain. Best Pract Res Clin Rheumatol 2002;16 (5) 761- 775
PubMed
Weiner  DKKim  YSBonino  PWang  T Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med 2006;7 (2) 143- 150
PubMed
Carrino  JAMorrison  WBParker  LSchweitzer  MELevin  DCSunshine  JH Spinal injection procedures: volume, provider distribution, and reimbursement in the US Medicare population from 1993 to 1999. Radiology 2002;225 (3) 723- 729
PubMed
Friedly  JChan  LDeyo  R Increases in lumbosacral injections in the Medicare population: 1994 to 2001. Spine 2007;32 (16) 1754- 1760
PubMed
Deyo  RAGray  DTKreuter  WMirza  SMartin  BI United States trends in lumbar fusion surgery for degenerative conditions. Spine 2005;30 (12) 1441- 1445
PubMed
Deyo  RAMirza  SK Trends and variations in the use of spine surgery. Clin Orthop Relat Res February 2006;443139- 146
PubMed
Gray  DTDeyo  RAKreuter  W  et al.  Population-based trends in volumes and rates of ambulatory lumbar spine surgery. Spine 2006;31 (17) 1957- 1963
PubMed
Deyo  RANachemson  AMirza  SK Spinal-fusion surgery—the case for restraint. N Engl J Med 2004;350 (7) 722- 726
PubMed
Ciol  MADeyo  RAHowell  EKreif  S An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. J Am Geriatr Soc 1996;44 (3) 285- 290
PubMed
Luo  XPietrobon  RHey  L Patterns and trends in opioid use among individuals with back pain in the United States. Spine 2004;29 (8) 884- 890
PubMed
Feuerstein  MMarcus  SCHuang  GD National trends in nonoperative care for nonspecific back pain. Spine J 2004;4 (1) 56- 63
PubMed
Hurwitz  ELCoulter  IDAdams  AHGenovese  BJShekelle  PG Use of chiropractic services from 1985 through 1991 in the United States and Canada. Am J Public Health 1998;88 (5) 771- 776
PubMed
Kessler  RCDavis  RBFoster  DF  et al.  Long-term trends in the use of complementary and alternative medical therapies in the United States. Ann Intern Med 2001;135 (4) 262- 268
PubMed
Martin  BIDeyo  RAMirza  SK  et al.  Expenditures and health status among adults with back and neck problems. JAMA 2008;299 (6) 656- 664
PubMed
IJzelenberg  WBurdorf  A Patterns of care for low back pain in a working population. Spine 2004;29 (12) 1362- 1368
PubMed
Molano  SMBurdorf  AElders  LA Factors associated with medical care-seeking due to low-back pain in scaffolders. Am J Ind Med 2001;40 (3) 275- 281
PubMed
Mortimer  MAhlberg  G To seek or not to seek? care-seeking behaviour among people with low-back pain. Scand J Public Health 2003;31 (3) 194- 203
PubMed
Carey  TSEvans  AHadler  NKalsbeek  WMcLaughlin  CFryer  J Care-seeking among individuals with chronic low back pain. Spine 1995;20 (3) 312- 317
PubMed
Carey  TSEvans  ATHadler  NM  et al.  Acute severe low back pain: a population-based study of prevalence and care-seeking. Spine 1996;21 (3) 339- 344
PubMed
Von Korff  MLin  EHFenton  JJSaunders  K Frequency and priority of pain patients' health care use. Clin J Pain 2007;23 (5) 400- 408
PubMed
Thorpe  KEFlorence  CSJoski  P Which medical conditions account for the rise in health care spending? Health Aff (Millwood) 2004; ((suppl web exclusives)) W4-437- W4-445
PubMed
Deyo  RAMirza  SKMartin  BI Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine 2006;31 (23) 2724- 2727
PubMed
Walker  BF The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord 2000;13 (3) 205- 217
PubMed
Harkness  EFMacfarlane  GJSilman  AJMcBeth  J Is musculoskeletal pain more common now than 40 years ago? two population-based cross-sectional studies. Rheumatology (Oxford) 2005;44 (7) 890- 895
PubMed
Heistaro  SVartiainen  EHeliovaara  MPuska  P Trends of back pain in eastern Finland, 1972-1992, in relation to socioeconomic status and behavioral risk factors. Am J Epidemiol 1998;148 (7) 671- 682
PubMed
Palmer  KTWalsh  KBendall  HCooper  CCoggon  D Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years. BMJ 2000;320 (7249) 1577- 1578
PubMed
Leino  PIBerg  MAPuska  P Is back pain increasing? results from national surveys in Finland during 1978/9-1992. Scand J Rheumatol 1994;23 (5) 269- 276
PubMed
Pitkala  KHStrandberg  TETilvis  RS Management of nonmalignant pain in home-dwelling older people: a population-based survey. J Am Geriatr Soc 2002;50 (11) 1861- 1865
PubMed
Hüppe  AMuller  KRaspe  H Is the occurrence of back pain in Germany decreasing? two regional postal surveys a decade apart. Eur J Public Health 2007;17 (3) 318- 322
PubMed
GENESYS Sampling Services, GENESYS-IDplus. http://www.genesys-sampling.com/GENESYS-IDplus.aspx. Accessed January 2, 2008
American Association for Public Opinion Research (APOR),  Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys.  4th ed. Lenexa, Kansas APOR2006;
Waksberg  J Sampling methods for random digit dialing. J Am Stat Assoc 1978;73 (361) 40- 46
Task Force on Completion Rates, Council of American Survey Research (CASRO),  On the Definition of Response Rates: Special Report.   New York, NY CASRO1982;
US Census Bureau, American community survey 2005—public use file. http://www.census.gov/acs/www/Products/users_guide/2005/index.htm. Accessed January 2, 2008
US Census Bureau, State and County Quick Facts 2006. http://quickfacts.census.gov/gfd/. Accessed January 2, 2008
Deyo  RA Comparative validity of the sickness impact profile and shorter scales for functional assessment in low-back pain. Spine 1986;11 (9) 951- 954
PubMed
Chang  YSinger  DEWu  YAKeller  RBAtlas  SJ The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years. J Am Geriatr Soc 2005;53 (5) 785- 792
PubMed
Goldberg  MSScott  SCMayo  NE A review of the association between cigarette smoking and the development of nonspecific back pain and related outcomes. Spine 2000;25 (8) 995- 1014
PubMed
Leboeuf-Yde  C Smoking and low back pain: a systematic literature review of 41 journal articles reporting 47 epidemiologic studies. Spine 1999;24 (14) 1463- 1470
PubMed
Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System: Centers for Disease Control, 2008. Atlanta, GA: US Dept of Health and Human Services. http://www.cdc.gov/brfss/index.htm. Accessed January 2, 2008
Janke  EACollins  AKozak  AT Overview of the relationship between pain and obesity: what do we know? where do we go next? J Rehabil Res Dev 2007;44 (2) 245- 262
PubMed
Lake  JKPower  CCole  TJ Back pain and obesity in the 1958 British birth cohort. cause or effect? J Clin Epidemiol 2000;53 (3) 245- 250
PubMed
Leboeuf-Yde  C Body weight and low back pain: a systematic literature review of 56 journal articles reporting on 65 epidemiologic studies. Spine 2000;25 (2) 226- 237
PubMed
Kerr  MSFrank  JWShannon  HS  et al.  Biomechanical and psychosocial risk factors for low back pain at work. Am J Public Health 2001;91 (7) 1069- 1075
PubMed
Herrin  KB  Occupational Health Trends in North Carolina.   Raleigh, NC NC Department of Health and Human Services, Occupational and Environmental Epidemiology Branch2006;
Compton  WMConway  KPStinson  FSGrant  BF Changes in the prevalence of major depression and comorbid substance use disorders in the United States between 1991-1992 and 2001-2002. Am J Psychiatry 2006;163 (12) 2141- 2147
PubMed
Croft  PRPapageorgiou  ACFerry  SThomas  EJayson  MISilman  AJ Psychologic distress and low back pain: evidence from a prospective study in the general population. Spine 1995;20 (24) 2731- 2737
PubMed
Larson  SLClark  MREaton  WW Depressive disorder as a long-term antecedent risk factor for incident back pain: a 13-year follow-up study from the Baltimore Epidemiological Catchment Area sample. Psychol Med 2004;34 (2) 211- 219
PubMed
Currie  SRWang  J More data on major depression as an antecedent risk factor for first onset of chronic back pain. Psychol Med 2005;35 (9) 1275- 1282
PubMed
Croft  P Is life becoming more of a pain? BMJ 2000;320 (7249) 1552- 1553
PubMed
Weiner  BK Spine update: the biopsychosocial model and spine care. Spine 2008;33 (2) 219- 223
PubMed
Raspe  HHueppe  ANeuhauser  H Back pain, a communicable disease? Int J Epidemiol 2008;37 (1) 69- 74
PubMed
Lawrence  RCFelson  DTHelmick  CG  et al.  Estimates of the prevalence of arthritis and other rheumatic conditions in the United States: part II. Arthritis Rheum 2008;58 (1) 26- 35
PubMed
Social Security Administration,  Annual Statistical Report on the Social Security Disability Insurance Program.   Baltimore, MD Office of Research Evaluation and Statistics2006;
Autor  DHDuggan  MG The growth in the Social Security Disability rolls: a fiscal crisis unfolding. J Econ Perspect 2006;20 (3) 71- 96
PubMed
Cowan  JA  JrDimick  JBWainess  RUpchurch  GR  JrChandler  WFLa Marca  F Changes in the utilization of spinal fusion in the United States. Neurosurgery 2006;59 (1) 15- 20
PubMed
Weinstein  JNLurie  JDOlson  PRBronner  KKFisher  ES United States' trends and regional variations in lumbar spine surgery: 1992-2003. Spine 2006;31 (23) 2707- 2714
PubMed

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