Comorbidities of Long Term Back Pain

By: Erin Ritterbusch, MS CPT

Weight 

Zingg and Kendall: Low back pain may have multiple obesity-related contributions. Considerations include but are not limited to abnormal biomechanical loading, loss of trunk and lower extremity muscle mass, increased levels of systemic inflammation, increased levels of arthritis, and dysregulated blood supply [18,26,27]. Research suggests that obesity additionally impacts duration of recovery and resources required (such as PT) in treating low back pain [28]. Furthermore, overweight and obesity have been found to have associations with higher levels of disability before treatment of low back pain, higher levels of kinesiophobia, and decreased meaningfully important change with treatment (most significant with class II-III obesity) [29].

Cardiovascular & Aortic Atherosclerotic Diseases: 

Zingg and Kendall: ​​In light of the prevalence and mortality associated with cardiovascular disease, aortic atherosclerotic disease should be considered in a broader assessment of low back pain. This attention is both reflective of poor perfusion to lumbar structures, as well as of overall mortality risk; based on Framingham data, aortic calcifications are associated with a twofold increased risk of cardiac death in men and women <65 years of age [15,16].

Ramanathan et al.: Hypertension and hyperlipidaemia were also consistent with more than 23 other studies that clearly illustrate that Low Back Pain is associated with cardiovascular disease and poor health overall.

Anxiety/Depression

Ciaramella and Poli: Studies that have been conducted via diagnostic interviews show a consistently high prevalence of psychiatric comorbidities in Chronic LBP, ranging from 41% to 99% (Atkinson et al., 1991; Dersh et al., 2006; Kinney et al., 1993; Polatin et al., 1993; Reich et al., 1983). The most common comorbid conditions are somatoform disorders, affective disorders, and substance abuse disorders, with major depression being the most common single diagnosis (Kinney et al., 1993; Polatin et al., 1993). There is also a significantly greater prevalence of psychiatric disorders in those reporting Chronic LBP compared with those without CLBP in the general population, as seen across 17 countries in global mental health surveys (Demyttenaere et al., 2007).

Ramanathan et al.: A Norwegian study found that LBP patients were significantly more likely to suffer from neck pain, upper back pain, pain in feet during exercise, headache, migraine, sleep problems, heat sensations, anxiety, and depression than patients without LBP [9]. In addition to physical disorders, both episodic and chronic LBP have also been shown to be significantly associated with mental illnesses such as depression, GI disease and anxiety [6, 19, 20] and increased healthcare utilization and costs [21].

Heart disease

Fernandez et al.: Chronic LBP is associated with a higher prevalence of myocardial infarction and coronary heart disease. It is possible that this association remains even when controlling for genetics and early shared environment, although this should be investigated with larger samples of twins discordant for LBP.

Chronic diseases/conditions

Ramanathan et al.: National Health Survey (ANHS), LBP is featured in the second and third most common comorbidities in Australian adults, based on eight selected chronic diseases (i.e. arthritis, asthma, LBP, cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, and mental health conditions) [10].

Strine and Hootman: After adjusting for sociodemographic characteristics, with the exception of diabetes, which was equally prevalent in persons with NPO and those with neither condition, we found the remaining respiratory, cardiovascular, gastrointestinal, chronic pain and musculoskeletal conditions, and other chronic conditions to be significantly more prevalent among those with LBPO, NPO, and LBPNP than those with neither condition (Table 2). The prevalence of individual comorbid conditions was consistently highest among individuals with LBPNP.

low back pain only (LBPO); persons who reported neck pain without low back pain were considered to have neck pain only (NPO); persons reporting both low back and neck pain were considered to have both conditions (LBPNP).

Hypertension & osteoarthritis

Ramanathan et al.: The top ten specific comorbid conditions reported by LBP patients are presented in Table 2 with hypertension and hyperlipidaemia being the two most frequently reported (approximately two out of every five LBP patients reported having at least one of these conditions). Osteoarthritis and dyspepsia were the next most frequently reported conditions, with at least one in four LBP patients reporting that they had been treated for these conditions. The two most common comorbidities found in the medical records were hypertension (a condition for which approximately 29% of LBP patients had received treatment) and osteoarthritis (one in four LBP patients).

Divorce

Feuerstein, Michael, et al.: An epidemiological study of back pain (type and duration unspecified) indicated a higher prevalence in those who have lost a spouse through death, divorce, or separation within the previous year than those who have not been exposed to such stressors [26].

Asthma and headaches

Hestbaek et al.: There is strong evidence that young people (12 to 22 years of age) with low back pain are considerably more likely to have asthma and headache/migraine than their contemporaries without low back pain.

Beeckmans et al.: A significant correlation between the presence of LBP and the presence of Respiratory Disease such as dyspnea, asthma, different forms of allergy, and respiratory infections was found.

1. Beeckmans, Nele, et al. “The presence of respiratory disorders in individuals with low back pain: A systematic review.” Manual Therapy, vol. 26, 2016, pp. 77-86. doi: 10.1016/j.math.2016.07.011.
2. Ciaramella, Antonella, and Paolo Poli. “Chronic Low Back Pain: Perception and Coping With Pain in the Presence of Psychiatric Comorbidity.” The Journal of Nervous And Mental Disease, vol. 203, no. 8, 2015, pp. 632-640. doi:10.1097/NMD.0000000000000340.
3. Fernandez, Matt, et al. “Is Chronic Low Back Pain Associated with the Prevalence of Coronary Heart Disease when Genetic Susceptibility Is Considered? A Co-Twin Control Study of Spanish Twins.” PLOS ONE, vol. 11, no. 5, 2016, p. e0155194. doi:10.1371/journal.pone.0155194.
4. Feuerstein, Michael, et al. “Environmental Stressors and Chronic Low Back Pain: Life Events, Family and Work Environment.” Pain, vol. 22, no. 3, 1985, pp. 295-307. doi:10.1016/0304-3959(85)90030-2.
5. Gore, Mugdha, et al. “The Burden of Chronic Low Back Pain: Clinical Comorbidities, Treatment Patterns, and Health Care Costs in Usual Care Settings.” Spine, vol. 37, no. 11, 2012, pp. E668-E677. doi:10.1097/BRS.0b013e318241e5de
6. Hestbaek, Lise, et al. “Comorbidity With Low Back Pain: A Cross-sectional Population-Based Survey of 12- to 22-Year-Olds.” Spine, vol. 29, no. 13, 2004, pp. 1483-1491. doi:10.1097/01.BRS.0000129230.52977.86.
7. Jiménez-Sánchez, Silvia, et al. “Prevalence of chronic head, neck and low back pain and associated factors in women residing in the Autonomous Region of Madrid (Spain).” Gaceta Sanitaria, vol. 26, no. 6, 2012, pp. 534-540. doi:10.1016/j.gaceta.2011.10.012.
8. Ramanathan, Shanthi, et al. “What is the association between the presence of comorbidities and the appropriateness of care for low back pain? A population-based medical record review study.” BMC Musculoskeletal Disorders, vol. 19, no. 1, 2018. doi:10.1186/s12891-018-2316-z.
9. Strine, Tara W., and Jennifer M. Hootman. “US National Prevalence and Correlates of Low Back and Neck Pain Among Adults.” Arthritis and Rheumatism, vol. 57, no. 4, 2007, pp. 656-665. doi:10.1002/art.22684.
10. Zingg, Rebecca Wilson, and Richard Kendall. “Obesity, Vascular Disease, and Lumbar Disk Degeneration: Associations of Comorbidities in Low Back Pain.” PM&R, vol. 9, no. 4, 2017, pp. 398-402. doi:10.1016/j.pmrj.2016.09.011.