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The Epidemiology and Economic Consequences of Pain

      Abstract

      Pain is considered a major clinical, social, and economic problem in communities around the world. In this review, we describe the incidence, prevalence, and economic burden of pain conditions in children, adolescents, and adults based on an electronic search of the MEDLINE and EMBASE databases for articles published from January 1, 2000, through August 1, 2014, using the keywords pain, epidemiology, burden, prevalence, and incidence. The impact of pain on individuals and potential risk factors are also discussed. Differences in the methodology and conduct of epidemiological studies make it difficult to provide precise estimates of prevalence and incidence; however, the burden of pain is unquestionably large. Improved concepts and methods are needed in order to study pain from a population perspective and further the development of pain prevention and management strategies.

      Abbreviations and Acronyms:

      CLBP (chronic low back pain), DALY (disability adjusted life year), GDP (gross domestic product), PY (person-years), YLD (years lived with disability)
      CME Activity
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      Credit Statement: Mayo Clinic College of Medicine designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).™ Physicians should claim only the credit commensurate with the extent of their participation in the activity.
      Learning Objectives: On completion of this article, you should be able to (1) review and assess the epidemiology (prevalence, incidence and risk factors) for common pain conditions; (2) identify common methodological problems with epidemiological pain research; (3) describe the common drivers of the total economic burden of pain.
      Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Medicine (Mayo School of Continuous Professional Development) must ensure balance, independence, objectivity, and scientific rigor in its educational activities. Course Director(s), Planning Committee members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off-label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of this information will be published in course materials so that those participants in the activity may formulate their own judgments regarding the presentation.
      In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the content of this program but have no relevant financial relationship(s) with industry.
      The authors report no competing interests.
      Method of Participation: In order to claim credit, participants must complete the following:
      • 1.
        Read the activity.
      • 2.
        Complete the online CME Test and Evaluation. Participants must achieve a score of 80% on the CME Test. One retake is allowed.
      Visit www.mayoclinicproceedings.com, select CME, and then select CME articles to locate this article online to access the online process. On successful completion of the online test and evaluation, you can instantly download and print your certificate of credit.
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      Date of Release: 01/01/2015
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      Questions? Contact [email protected] .
      Pain is the defining feature for many disease diagnoses. It can serve as an index of the severity and activity of an underlying condition, a prognostic indicator, and a determinant of health service use.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      The International Association for the Study of Pain and the World Health Organization define pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

      International Association for the Study of Pain. IASP taxonomy. http://www.iasp-pain.org/Taxonomy?&navItemNumber=576. Updated October 20, 2014. Accessed November 5, 2014.

      In this article, we provide an overview of the epidemiology and economic burden of pain conditions in children, adolescents, and adults. Estimates of the incidence and prevalence of pain conditions, as well as risk factors and the impact of pain on individuals, are described. While recognizing the wide range of pain conditions that could be included, we have focused on areas that are common and contemporary in clinical and research practice: pain in children and adolescents, spinal pain, neuropathic pain, musculoskeletal pain, and fibromyalgia/chronic widespread pain. Factors that are associated with the prevalence of pain are also considered, as well as the individual, economic, and societal burden of pain conditions.
      In order to provide the most recent and highest-quality evidence on the epidemiology of pain, we performed an electronic search of the MEDLINE and EMBASE databases for articles published from January 1, 2000, through December 31, 2005, using the keywords pain, epidemiology, burden, prevalence, and incidence. Because there are a substantial number of large, well-conducted systematic reviews published on this topic, identifying these articles was the focus of the search, and their findings form the basis of the information presented in this review. The findings of systematic reviews also provide an insight into the methodological issues faced when performing studies on the epidemiology and economic consequences of pain. These issues are summarized briefly at the end of this article, and considerations for future studies are proposed.

      Defining the Incidence and Prevalence of Pain

      Describing the epidemiology of pain is challenging because of the subjective nature of the symptoms and a lack of consensus regarding specific diagnoses and definitions of conditions. Identifying true “incident” (or first-ever) episodes of pain, especially musculoskeletal pain, is problematic because of recall over a lifetime. Many pain conditions are episodic, with a large proportion of patients reporting symptoms that resolve and then recur with varying time periods in between. The true incidence for most pain conditions may thus remain unknown; however, from clinical and research perspectives, it is valuable to know the number of newly developing (or recurring) episodes within a given time frame. In light of this, the focus of this review was on incidence proportions over a period of 1 year. These proportions are calculated in longitudinal studies of pain-free (at baseline) populations, identifying the number of new or recurring episodes of pain that occur over 1 year.
      Similarly, the identification of prevalent cases of pain varies across studies because of differences in the definition of an “episode” or specific diagnosis. Case definitions may vary on the basis of duration, intensity, or burden on the patient, whereas diagnoses may be based to a greater or lesser extent on subjective patient experience, clinical tests, or results of imaging and pathologic studies. Comparability among studies is also hampered by the reporting of different prevalence periods (eg, point, weekly, monthly, lifetime). For the purpose of this review, we focus on the 1-month prevalence of pain. This parameter represents the proportion of a population who report having an episode of pain during the past month. Where a range of monthly prevalence estimates were reported in multiple studies, the median was calculated and reported.

      Incidence and Prevalence of Pain

      Pain in Children and Adolescents

      Pain conditions in children and adolescents have become the focus of an increasing amount of scientific literature in recent years.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      • Calvo-Muñoz I.
      • Gómez-Conesa A.
      • Sánchez-Meca J.
      Prevalence of low back pain in children and adolescents: a meta-analysis.
      The occurrence of pain in children takes on added importance in light of the growing evidence that implicates pain in childhood or adolescence as a predictive factor for pain in adulthood.
      • Fearon P.
      • Hotopf M.
      Relation between headache in childhood and physical and psychiatric symptoms in adulthood: national birth cohort study.
      • Gieteling M.J.
      • Bierma-Zeinstra S.M.
      • Passchier J.
      • Berger M.Y.
      Prognosis of chronic or recurrent abdominal pain in children.
      • Hestbaek L.
      • Leboeuf-Yde C.
      • Kyvik K.O.
      • Manniche C.
      The course of low back pain from adolescence to adulthood: eight-year follow-up of 9600 twins.
      Children experiencing pain may miss school and withdraw from social activities and are at risk for the development of negative health behaviors such as physical inactivity.
      • Walker L.S.
      • Sherman A.L.
      • Bruehl S.
      • Garber J.
      • Smith C.A.
      Functional abdominal pain patient subtypes in childhood predict functional gastrointestinal disorders with chronic pain and psychiatric comorbidities in adolescence and adulthood.
      • Palermo T.M.
      Impact of recurrent and chronic pain on child and family daily functioning: a critical review of the literature.
      The most commonly reported pains in children and adolescents are low back pain, headache, and abdominal pain.
      • Calvo-Muñoz I.
      • Gómez-Conesa A.
      • Sánchez-Meca J.
      Prevalence of low back pain in children and adolescents: a meta-analysis.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      In children and adolescents, the reported 1-year incidence of low back pain ranges from 11.8% to 33.0% (median, 22.4%), with the 1-month prevalence ranging from 9.8% to 36.0% (median, 22.9%) (Table 1).
      • Jeffries L.J.
      • Milanese S.F.
      • Grimmer-Somers K.A.
      Epidemiology of adolescent spinal pain: a systematic overview of the research literature.
      Because there are fewer studies on the prevalence of neck pain (49.0%) and upper back pain (30.0%), there is some doubt as to the precision of these estimates.
      • Jeffries L.J.
      • Milanese S.F.
      • Grimmer-Somers K.A.
      Epidemiology of adolescent spinal pain: a systematic overview of the research literature.
      A systematic review on the epidemiology of chronic pain (ie, pain lasting longer than 3 months) in children and adolescents reported that the 1-month prevalence of chronic back pain ranges from 18.0% to 24.0% (median, 21.0%).
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      In addition to these estimates from systematic reviews, a recently published survey of over 400,000 children and adolescents aged 11 to 15 years reported the 1-month prevalence of low back pain to be 37.0%.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      Table 1Characteristics of Selected Systematic Reviews of Pain Epidemiology in Children and Adolescents
      Reference, yearNo. of studies includedPain type1-Month prevalence (%)1-Year incidence (%)
      Jeffries et al,
      • Jeffries L.J.
      • Milanese S.F.
      • Grimmer-Somers K.A.
      Epidemiology of adolescent spinal pain: a systematic overview of the research literature.
      2007
      56Low back pain

      Neck pain

      Upper back pain
      9.8-36.0

      49.0

      30.0
      11.8-33.0

      28.4

      Not available
      Calvo-Muñoz et al,
      • Calvo-Muñoz I.
      • Gómez-Conesa A.
      • Sánchez-Meca J.
      Prevalence of low back pain in children and adolescents: a meta-analysis.
      2013
      14Low back pain18.3Not available
      King et al,
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      2011
      32Headache

      Recurrent abdominal pain

      Back pain

      Musculoskeletal/limb pain

      Multiple pains

      Other/general pain
      26.0-69.0

      3.8-41.2

      18.0-24.0

      38.9

      16.0

      60.0
      Not available

      Not available

      Not available

      Not available

      Not available

      Not available
      Abu-Arafeh et al,
      • Abu-Arafeh I.
      • Razak S.
      • Sivaraman B.
      • Graham C.
      Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies.
      2010
      50Headache58.0Not available
      Chitkara et al,
      • Chitkara D.K.
      • Rawat D.J.
      • Talley N.J.
      The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review.
      2005
      14Recurrent abdominal pain0.3-19.0Not available
      The estimated 1-month prevalence of headache in children and adolescents ranges from 26.0% to 69.0% (median, 47.5%) in systematic reviews
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      • Abu-Arafeh I.
      • Razak S.
      • Sivaraman B.
      • Graham C.
      Prevalence of headache and migraine in children and adolescents: a systematic review of population-based studies.
      and was reported to be 54.1% in a large school-based survey.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      The estimated monthly prevalence of stomachache was 49.8% in the study by Swain et al.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      Most studies in children and adolescents focus on recurrent abdominal pain, which is defined as 3 or more episodes of abdominal pain, severe enough to limit the child’s functioning, over 3 months or more.
      • Apley J.
      • Naish N.
      Recurrent abdominal pains: a field survey of 1,000 school children.
      The prevalence of recurrent abdominal pain ranged from 0.3% to 19.0% (median, 8.4%) in one review
      • Chitkara D.K.
      • Rawat D.J.
      • Talley N.J.
      The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review.
      and from 3.8% to 41.2% (median, 12.0%) in a more recent article.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      The monthly prevalence of multiple pains (ie, pain in more than one body location) in children and adolescents ranges from 12.1% to 35.7% (median, 23.9%).
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      Although the amount of research on pain epidemiology in children and adolescents is increasing, there is a need for future studies to consider the effect of age on pain prevalence. It is currently unclear which pains increase with age in childhood and adolescence and what the effect of the transition through puberty has on the incidence and prevalence of pain conditions.

      Spinal Pain

      Spinal pain, in particular low back pain, is a common problem that most people experience at some point in their lifetime. The lifetime prevalence of low back pain is reported to be in the range of 51.0% to 84.0%.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      • Manchikanti L.
      • Singh V.
      • Datta S.
      • Cohen S.P.
      • Hirsch J.A.
      Comprehensive review of epidemiology, scope, and impact of spinal pain.
      In comparison with other pain conditions, there is a large amount of research on the epidemiology of low back pain. This work, however, frequently suffers from a lack of clarity regarding the definition of episodes and heterogeneity with regard to sample populations and reporting time periods of incidence and prevalence.
      Estimates of the 1-year incidence of a first-ever episode of low back pain ranged from 6.3% to 15.4% (median, 10.9%) in one review
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      and from 13.5% to 26.2% (median, 19.9%) in another (Table 2).
      • Taylor J.B.
      • Goode A.P.
      • George S.Z.
      • Cook C.E.
      Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis.
      Estimates of the 1-year incidence of any low back pain (including patients who have had a previous episode) range between 1.5% and 38.9% (median, 20.2%).
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      • Taylor J.B.
      • Goode A.P.
      • George S.Z.
      • Cook C.E.
      Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis.
      Many people who experience activity-limiting low back pain recover quickly,
      • Henschke N.
      • Maher C.G.
      • Refshauge K.M.
      • et al.
      Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study.
      but some have recurrent episodes.
      • Pengel L.H.
      • Herbert R.D.
      • Maher C.G.
      • Refshauge K.M.
      Acute low back pain: systematic review of its prognosis.
      Estimates of recurrence at 1 year range from 24.0% to 80.0% (median, 52.0%).
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      Table 2Characteristics of Selected Systematic Reviews of Pain Epidemiology in Adults
      Reference, yearNo. of studies includedPain type1-Month prevalence (%)1-Year incidence (%)
      Hoy et al,
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      2010
      12



      Not stated
      Low back pain (first ever)

      Low back pain (from pain-free state)

      Low back pain
      Not available

      Not available

      24.0-49.5
      6.3-15.4

      1.5-36.0

      Not available
      Taylor et al,
      • Taylor J.B.
      • Goode A.P.
      • George S.Z.
      • Cook C.E.
      Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis.
      2014
      41Low back pain (first ever)

      Low back pain (from pain-free state)
      Not available

      Not available
      13.5-26.2

      5.0-38.9
      Briggs et al,
      • Briggs A.M.
      • Smith A.J.
      • Straker L.M.
      • Bragge P.
      Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults; a systematic review.
      2009
      33Thoracic spine pain1.4-34.83.8-35.3
      Hogg-Johnson et al,
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      The burden and determinants of neck pain in the general population.
      2008
      101Neck pain

      Cervicogenic headache
      15.4-45.3

      2.5
      Not available

      Not available
      Juniper et al,
      • Juniper M.
      • Le T.K.
      • Mladsi D.
      The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review.
      2009
      23Chronic low back pain5.9-11.1Not available
      Reid et al,
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      2011
      45Chronic low back pain

      Chronic neck pain

      Chronic upper back pain

      Moderate to severe chronic pain

      Chronic widespread pain

      Fibromyalgia
      9.0 (lifetime prevalence)

      5.0 (lifetime prevalence)

      6.0 (lifetime prevalence)

      19.0

      13.0 (point prevalence)

      2.9 (point prevalence)
      Not available

      Not available

      Not available

      Not available

      Not available

      Not available
      van Hecke et al,
      • van Hecke O.
      • Austin S.K.
      • Khan R.A.
      • Smith B.H.
      • Torrance N.
      Neuropathic pain in the general population: a systematic review of epidemiological studies.
      2014
      21Neuropathic pain0.9-17.9Not available
      Bennett et al,
      • Bennett M.I.
      • Rayment C.
      • Hjermstad M.
      • Aass N.
      • Caraceni A.
      • Kaasa S.
      Prevalence and aetiology of neuropathic pain in cancer patients: a systematic review.
      2012
      22Neuropathic pain in cancer patients19.0-39.1Not available
      Cook et al,
      • Cook C.E.
      • Taylor J.
      • Wright A.
      • Milosavljevic S.
      • Goode A.
      • Whitford M.
      Risk factors for first time incidence sciatica: a systematic review.
      2014
      8SciaticaNot available9.3
      Konstantinou & Dunn,
      • Konstantinou K.
      • Dunn K.M.
      Sciatica: review of epidemiological studies and prevalence estimates.
      2008
      23Sciatica0.4-16.4Not available
      Luime et al,
      • Luime J.J.
      • Koes B.W.
      • Hendriksen I.J.
      • et al.
      Prevalence and incidence of shoulder pain in the general population: a systematic review.
      2004
      19Shoulder pain18.6-31.0Not available
      Peat et al,
      • Peat G.
      • McCarney R.
      • Croft P.
      Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care.
      2001
      5Knee pain in older adults13.0-28.0Not available
      Thomas et al,
      • Thomas M.J.
      • Roddy E.
      • Zhang W.
      • Menz H.B.
      • Hannan M.T.
      • Peat G.M.
      The population prevalence of foot and ankle pain in middle and old age: a systematic review.
      2011
      31Foot pain

      Ankle pain

      Big toe pain
      28.0 (pooled prevalence)

      15.0 (pooled prevalence)

      14.0 (pooled prevalence)
      Not available

      Not available

      Not available
      There is considerable information on low back pain prevalence, and estimates of the 1-month prevalence range from 24.0% to 49.5% (median, 36.8%).
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      Thoracic spine pain prevalence ranges from 1.4% to 34.8% (median, 18.1%),
      • Briggs A.M.
      • Smith A.J.
      • Straker L.M.
      • Bragge P.
      Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults; a systematic review.
      while the 1-month prevalence of neck pain ranges from 15.4% to 45.3% (median, 30.4%).
      • Hogg-Johnson S.
      • van der Velde G.
      • Carroll L.J.
      • et al.
      The burden and determinants of neck pain in the general population.
      Chronic low back pain (CLBP) is commonly defined as low back pain that lasts longer than 12 weeks.
      • Furlan A.D.
      • Pennick V.
      • Bombardier C.
      • van Tulder M.
      Editorial Board, Cochrane Back Review Group
      2009 Updated method guidelines for systematic reviews in the Cochrane Back Review Group.
      Two reviews reported some variation in the prevalence estimates of CLBP in the general population in Europe, with a range between 5.9% and 11.1% (median, 8.5%).
      • Juniper M.
      • Le T.K.
      • Mladsi D.
      The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review.
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      A third review found that the median prevalence of CLBP was 18.1%.
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.

      Neuropathic Pain and Sciatica

      Neuropathic pain is defined by the International Association for the Study of Pain as “pain caused by a lesion or disease of the somatosensory nervous system.”

      International Association for the Study of Pain. IASP taxonomy. http://www.iasp-pain.org/Taxonomy?&navItemNumber=576. Updated October 20, 2014. Accessed November 5, 2014.

      It is distinguished from other pain conditions by its characteristic signs and symptoms, such as “burning” or “freezing” pain, as well as numbness, tingling, or “pins and needles” sensations.

      International Association for the Study of Pain. IASP taxonomy. http://www.iasp-pain.org/Taxonomy?&navItemNumber=576. Updated October 20, 2014. Accessed November 5, 2014.

      There are few high-quality studies that describe the incidence and prevalence of neuropathic pain in the population, as most studies focus on the presence of neuropathic pain within defined patient groups.
      Chronic pain with neuropathic characteristics has a reported prevalence ranging from 0.9% to 17.9% (median, 9.4%).
      • van Hecke O.
      • Austin S.K.
      • Khan R.A.
      • Smith B.H.
      • Torrance N.
      Neuropathic pain in the general population: a systematic review of epidemiological studies.
      The prevalence of neuropathic pain in patients with cancer varies from 19.0% to 39.1% (median, 29.1%).
      • Bennett M.I.
      • Rayment C.
      • Hjermstad M.
      • Aass N.
      • Caraceni A.
      • Kaasa S.
      Prevalence and aetiology of neuropathic pain in cancer patients: a systematic review.
      The incidence of neuropathic pain associated with postherpetic neuralgia ranges from 3.9 to 42.0 per 100,000 person-years (PY). The incidence range is 12.6 to 28.9 per 100,000 PY for trigeminal neuralgia, 15.3 to 72.3 per 100,000 PY for painful diabetic peripheral neuropathy, and 0.2 to 0.4 per 100,000 PY for glossopharyngeal neuralgia.
      • van Hecke O.
      • Austin S.K.
      • Khan R.A.
      • Smith B.H.
      • Torrance N.
      Neuropathic pain in the general population: a systematic review of epidemiological studies.
      Sciatica is described by a range of terms in the literature, such as lumbosacral radicular syndrome, radiculopathy, nerve root pain, and nerve root entrapment or irritation.
      • Cook C.E.
      • Taylor J.
      • Wright A.
      • Milosavljevic S.
      • Goode A.
      • Whitford M.
      Risk factors for first time incidence sciatica: a systematic review.
      The condition includes pain that is felt in the buttock or leg but is thought to originate in the lumbar spine. The incidence of sciatica over 1 year is reported to be 9.3%.
      • Cook C.E.
      • Taylor J.
      • Wright A.
      • Milosavljevic S.
      • Goode A.
      • Whitford M.
      Risk factors for first time incidence sciatica: a systematic review.
      The 1-month prevalence of sciatica ranges from 0.4% to 16.4% (median, 8.4%).
      • Konstantinou K.
      • Dunn K.M.
      Sciatica: review of epidemiological studies and prevalence estimates.

      Other Musculoskeletal Pain

      Musculoskeletal disorders are one of the most common causes of disability and work incapacity, especially in older people.
      • Coggon D.
      • Ntani G.
      • Palmer K.T.
      • et al.
      Disabling musculoskeletal pain in working populations: is it the job, the person, or the culture?.
      Apart from spinal pain, upper limb pain is one of the most common musculoskeletal symptoms—approximately 18.6% to 31.0% (median, 24.8%) of adults report shoulder pain every month.
      • Luime J.J.
      • Koes B.W.
      • Hendriksen I.J.
      • et al.
      Prevalence and incidence of shoulder pain in the general population: a systematic review.
      The prevalence of knee pain occurring at least monthly is reported to range from 13.0% to 28.0% (median, 20.5%) in older adults.
      • Peat G.
      • McCarney R.
      • Croft P.
      Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care.
      A systematic review of foot and ankle pain in adults reported pooled prevalence results incorporating a variety of case definitions.
      • Thomas M.J.
      • Roddy E.
      • Zhang W.
      • Menz H.B.
      • Hannan M.T.
      • Peat G.M.
      The population prevalence of foot and ankle pain in middle and old age: a systematic review.
      The pooled prevalence was 28.0% for foot pain, 15.0% for ankle pain, and 14.0% for big toe pain.
      • Thomas M.J.
      • Roddy E.
      • Zhang W.
      • Menz H.B.
      • Hannan M.T.
      • Peat G.M.
      The population prevalence of foot and ankle pain in middle and old age: a systematic review.

      Fibromyalgia and Chronic Widespread Pain

      The 3 cardinal features of chronic widespread pain are pain, chronicity, and widespread localization.
      • Cimmino M.A.
      • Ferrone C.
      • Cutolo M.
      Epidemiology of chronic musculoskeletal pain.
      According to the American College of Rheumatology 1990 criteria, chronic widespread pain is defined as pain that is bilateral (above and below the waist) in the axial skeleton and lasts for at least 3 months.
      • Wolfe F.
      • Smythe H.A.
      • Yunus M.B.
      • et al.
      The American College of Rheumatology 1990 criteria for the classification of fibromyalgia.
      This definition has also been used to develop the diagnostic criteria for fibromyalgia.
      • Wolfe F.
      • Clauw D.J.
      • Fitzcharles M.A.
      • et al.
      The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.
      Estimates of the prevalence of fibromyalgia range from 0.7% in Denmark, 2.0% to 5.0% in the United States, and up to 10.5% in Norwegian women.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      • Arnold L.M.
      • Clauw D.J.
      • McCarberg B.H.
      FibroCollaborative
      Improving the recognition and diagnosis of fibromyalgia.
      Reports of chronic widespread pain are remarkably consistent among populations, with prevalence rates between 10.6% and 13.5%.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      Similar to other chronic pain states, fibromyalgia is a clinical diagnosis, so the lack of a clear case definition restricts comparison of prevalence estimates. The American College of Rheumatology 2010 diagnostic criteria for fibromyalgia include an assessment of widespread pain in combination with other symptoms (such as fatigue and cognitive symptoms) to create a more specific case definition.
      • Wolfe F.
      • Clauw D.J.
      • Fitzcharles M.A.
      • et al.
      The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.
      Future studies on the epidemiology of fibromyalgia using this definition are likely to improve the accuracy of current prevalence estimates.

      Trends in Prevalence Over Time

      Studies that have examined changes in the prevalence of pain conditions over time are limited in number, and most have focused on low back pain prevalence. Palmer et al
      • Palmer K.T.
      • Walsh K.
      • Bendall H.
      • Cooper C.
      • Coggon D.
      Back pain in Britain: comparison of two prevalence surveys at an interval of 10 years.
      reported that over a 10-year period from 1987 to 1997, the 1-year prevalence of low back pain increased by 12.7%, and this increase was consistent across sex, age groups, social class, and area of residence. In contrast, another study reported that the 1-month prevalence had declined from 26.1% to 22.6% over a 7-year period.
      • Macfarlane G.J.
      • McBeth J.
      • Garrow A.
      • Silman A.J.
      Life is as much a pain as it ever was.
      In the United States, the prevalence of chronic, impairing low back pain appears to have increased significantly, from 3.9% in 1992 to 10.2% in 2006.
      • Freburger J.K.
      • Holmes G.M.
      • Agans R.P.
      • et al.
      The rising prevalence of chronic low back pain.

      Health Impacts of Pain

      Pain conditions, especially chronic pain, place a substantial burden on patients and their families. In most patients, it negatively affects overall perceptions of general health, interferes considerably with everyday activities, is associated with depressive symptoms, and dramatically and negatively affects relationships and interactions with others.
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      • Froud R.
      • Patterson S.
      • Eldridge S.
      • et al.
      A systematic review and meta-synthesis of the impact of low back pain on people’s lives.
      Interference with functioning and well-being appears to be significantly associated with increasing pain severity.
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      • Doth A.H.
      • Hansson P.T.
      • Jensen M.P.
      • Taylor R.S.
      The burden of neuropathic pain: a systematic review and meta-analysis of health utilities.
      For the purposes of assessing nonmortality-related disease burden, the World Health Organization–sponsored Global Burden of Disease Study uses the construct of disability. They define disability as “any short term or long term health loss”
      • Vos T.
      • Flaxman A.D.
      • Naghavi M.
      • et al.
      Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
      and calculate time-based metrics called disability-adjusted life years (DALYs) and years lived with disability (YLD) to quantify and compare the worldwide burden of various diseases. Conditions characterized or defined by the presence of pain (low back pain, neck pain, other musculoskeletal disorders, migraine, and falls) accounted for 5 of the top 10 conditions responsible for the most YLD globally.
      • Vos T.
      • Flaxman A.D.
      • Naghavi M.
      • et al.
      Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.
      Low back pain was responsible for 83 million DALYs and was the greatest contributor of YLD of all conditions, accounting for 10.7% of all YLD.
      • Buchbinder R.
      • Blyth F.M.
      • March L.M.
      • Brooks P.
      • Woolf A.D.
      • Hoy D.G.
      Placing the global burden of low back pain in context.
      Neck pain and migraine/headache were each responsible for approximately 24 million DALYs, other musculoskeletal disorders for 28 million DALYs, and falls for 19 million DALYs. Other major contributors included osteoarthritis (17 million DALYs) and road injuries (13 million DALYs).
      • Murray C.J.
      • Vos T.
      • Lozano R.
      • et al.
      Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010.

      Risk Factors for Pain

      Identifying factors that are related to the onset of pain conditions in the population is difficult because differences in study methodology and reporting markedly impact the estimates of incidence. For this review, we focus on the main categories of risk factors: age, sex, social (group) factors, and individual factors. In general, there is a lack of available evidence on risk factors for pain. Future studies are required that consider all aspects of the pain experience from both an individual and population perspective.

      Age and Sex

      Studies of pain in children and adolescents have found that girls generally experience more pain than boys.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      In adults, the relationship of pain with sex is clear—in most studies, women report more severe levels of pain, more frequent pain, and pain of longer duration than men.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      • Thomas M.J.
      • Roddy E.
      • Zhang W.
      • Menz H.B.
      • Hannan M.T.
      • Peat G.M.
      The population prevalence of foot and ankle pain in middle and old age: a systematic review.
      • Macfarlane T.V.
      • Glenny A.M.
      • Worthington H.V.
      Systematic review of population-based epidemiological studies of oro-facial pain.
      • Unruh A.M.
      Gender variations in clinical pain experience.
      However, there is still debate as to whether this sex difference is due to the underlying biological mechanisms of pain or the contribution of psychological and social factors.
      • Unruh A.M.
      Gender variations in clinical pain experience.
      With regard to age, it appears that the prevalence of some pain conditions such as low back pain increases from childhood into adolescence to approach the prevalence in adults.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      • Swain M.S.
      • Henschke N.
      • Kamper S.J.
      • Gobina I.
      • Ottová-Jordan V.
      • Maher C.G.
      An international survey of pain in adolescents.
      The reported effect of age on pain prevalence in older people is inconsistent, with some studies reporting an increase in prevalence with age and others reporting a decrease in prevalence with age. The effect also varies by sex and site of pain.
      • Abdulla A.
      • Adams N.
      • Bone M.
      • et al.
      British Geriatric Society
      Guidance on the management of pain in older people.
      It was widely believed that adults of working age are the most likely to experience musculoskeletal pain and hence that the prevalence of pain decreases from around the middle of the sixth decade of life.
      • Dionne C.E.
      • Dunn K.M.
      • Croft P.R.
      Does back pain prevalence really decrease with increasing age? a systematic review.
      However, recent studies have found that pain remains a prevalent and serious problem in older age. The prevalence of chronic pain in older people (>65 years) living in the community ranges from 25.0% to 76.0%, while the prevalence of chronic pain in older people living in residential care is much higher and ranges from 83.0% to 93.0%.
      • Abdulla A.
      • Adams N.
      • Bone M.
      • et al.
      British Geriatric Society
      Guidance on the management of pain in older people.

      Social (Group) Factors

      There is increasing recognition of the role that social factors have on health throughout the life course.
      • Viner R.M.
      • Ozer E.M.
      • Denny S.
      • et al.
      Adolescence and the social determinants of health.
      Socioeconomic status is usually measured by determining education, income, occupation, or a composite of these dimensions. Few studies of pain in children and adolescents have examined the association with socioeconomic status. In those studies that have, there is conflicting evidence of a relationship.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      In adults, there is an inverse relationship between socioeconomic status and the prevalence of pain. Data suggest that lower levels of education, lower income, and being unemployed are all associated with an increased prevalence of pain.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      More recently, studies of pain prevalence in populations of varying cultures, ethnicity, and socioeconomic status have been performed. A review of pain in American Indians, Alaska Natives, and Aboriginal Canadians revealed a higher pain prevalence in these groups than in the general population of the United States.
      • Jimenez N.
      • Garroutte E.
      • Kundu A.
      • Morales L.
      • Buchwald D.
      A review of the experience, epidemiology, and management of pain among American Indian, Alaska Native, and Aboriginal Canadian peoples.
      Studies conducted in Africa have found a mean 1-year prevalence of low back pain of 33.0% in adolescents and 50.0% in adults.
      • Louw Q.A.
      • Morris L.D.
      • Grimmer-Somers K.
      The prevalence of low back pain in Africa: a systematic review.
      This appears to be slightly higher than the 1-year prevalence for adults in studies conducted in mostly Western countries (mean 1-year prevalence of 38.1%).
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      However, because of differences in methodology, this comparison should be interpreted with caution. Another review of the prevalence of chronic pain reported an estimate of 24.8% in less developed countries compared with 28.1% in more developed countries, based on the Human Development Index of the World Bank.
      • Elzahaf R.A.
      • Tashani O.A.
      • Unsworth B.A.
      • Johnson M.I.
      The prevalence of chronic pain with an analysis of countries with a Human Development Index less than 0.9: a systematic review without meta-analysis.

      Individual Factors

      An assortment of individual risk factors have been associated with the occurrence of pain conditions. Unfortunately, these risk factors are commonly explored in single studies, and most systematic reviews find synthesis difficult because of the lack of consistency across studies.
      • McBeth J.
      • Jones K.
      Epidemiology of chronic musculoskeletal pain.
      • Taylor J.B.
      • Goode A.P.
      • George S.Z.
      • Cook C.E.
      Incidence and risk factors for first-time incident low back pain: a systematic review and meta-analysis.
      The most consistent risk factor for the development of pain conditions is a previous episode of pain.
      Various occupational factors have been associated with the onset of musculoskeletal pain, such as high job demands, job insecurity, sedentary work position, job dissatisfaction, low levels of social support in the workplace, and whole-body vibration.
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      • Côté P.
      • van der Velde G.
      • Cassidy J.D.
      • et al.
      Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders
      The burden and determinants of neck pain in workers: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders.
      Individual lifestyle factors such as smoking, obesity, and poor health status may also play a role in the development of pain conditions.
      • Peat G.
      • McCarney R.
      • Croft P.
      Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care.
      Psychosocial variables thought to have impact on pain prevalence include stress, anxiety, depression, low self-esteem, and the presence of chronic health problems.
      • King S.
      • Chambers C.T.
      • Huguet A.
      • et al.
      The epidemiology of chronic pain in children and adolescents revisited: a systematic review.
      • Hoy D.
      • Brooks P.
      • Blyth F.
      • Buchbinder R.
      The epidemiology of low back pain.
      Genetic research on pain is becoming more common, with chronic pain increasingly conceptualized as a classic example of gene-environment interaction.
      • Mogil J.S.
      Pain genetics: past, present and future.
      Inflammatory processes or nerve injuries are often suspected to be the initial trigger of chronic pain syndromes, but only a small minority of people actually have subsequent development of chronic pain. Once chronic pain has developed, pain severity and analgesic response are also highly variable among individuals. To date, however, there is a lack of evidence about the strength of genetic influence on the development of pain conditions as well as their interaction with psychosocial and environmental factors.

      Economic Impacts of Pain

      Individual Economic Burden

      Chronic pain has an undeniable impact on a patient’s quality of life; however, there are also financial consequences. Caring for those with chronic pain can also lead to financial costs, with the mean cost per adolescent experiencing chronic pain in the United Kingdom being approximately £8000 per year, including direct and indirect costs.
      • Sleed M.
      • Eccleston C.
      • Beecham J.
      • Knapp M.
      • Jordan A.
      The economic impact of chronic pain in adolescence: methodological considerations and a preliminary costs-of-illness study.
      Patients may also find themselves needing to pay for activities that they can no longer perform, such as housekeeping.
      • Kronborg C.
      • Handberg G.
      • Axelsen F.
      Health care costs, work productivity and activity impairment in non-malignant chronic pain patients.
      It has been estimated that individuals with moderate to severe chronic pain lose an average of 8 days of work every 6 months, and 22% lose at least 10 workdays.
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      Just over 50% of European patients undergoing rehabilitation for CLBP are working full- or part-time.
      • Engbers L.H.
      • Vollenbroek-Hutten M.M.
      • van Harten W.H.
      A comparison of patient characteristics and rehabilitation treatment content of chronic low back pain (CLBP) and stroke patients across six European countries.
      Indirect costs resulting from lost work productivity represent the majority of overall costs associated with low back pain; these costs may be borne by the individual, by employers, or both.
      • Dagenais S.
      • Caro J.
      • Haldeman S.
      A systematic review of low back pain cost of illness studies in the United States and internationally.
      In Australia, arthritis and back pain are reported to triple the odds of people aged 45 to 64 years being out of the workforce. It is estimated that older Australians not working because of poor health reduces the gross domestic product (GDP) by $14.7 billion per annum. Back pain and arthritis compose almost half of this burden. With an aging workforce in many countries, the social and economic impact of older workers having to retire because of painful health conditions is enormous and potentially increasing.
      • Schofield D.J.
      • Shrestha R.N.
      • Passey M.E.
      • Earnest A.
      • Fletcher S.L.
      Chronic disease and labour force participation among older Australians.

      Health Care Utilization

      Patients with pain conditions consume close to twice as much health care resources as the general population. The management of pain requires a range of services, for which the costs are substantial. In the United States, the largest proportion of direct medical costs for low back pain are spent on physical therapy (17.0%) and inpatient services (17.0%), followed by pharmacy (13.0%) and primary care (13.0%).
      • Dagenais S.
      • Caro J.
      • Haldeman S.
      A systematic review of low back pain cost of illness studies in the United States and internationally.
      Data from a European study of patients with chronic pain revealed that 93.0% visited their physician in the past 6 months. In contrast, 84.0% of the general European adult population visited their physician in the same period.
      • Reid K.J.
      • Harker J.
      • Bala M.M.
      • et al.
      Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact.
      The proportion of individuals with chronic pain who sought care from a physician in the past year also appears to be increasing, with one study reporting an increase from 73.1% to 84.0% in the period from 1992 to 2006.
      • Freburger J.K.
      • Holmes G.M.
      • Agans R.P.
      • et al.
      The rising prevalence of chronic low back pain.
      In an Australian study of 65,279 general practitioner encounters with children and adolescents, 4.9% were attributable to musculoskeletal problems.
      • Henschke N.
      • Harrison C.
      • McKay D.
      • et al.
      Musculoskeletal conditions in children and adolescents managed in Australian primary care.
      The estimated cost to the health care system differs depending on the country and the condition. In Belgium, for instance, the cost to the health care system for low back pain ranges from €83.8 billion to €164.7 billion per year (2004 values).
      • Phillips C.J.
      Economic burden of chronic pain.
      In the United Kingdom, the total cost of low back pain to the National Health Service was estimated at £1 billion (1998 values), and in Germany, the corresponding value was €5.11 billion.
      • Phillips C.J.
      Economic burden of chronic pain.

      Total Cost

      The cumulative burden of chronic pain, including the cost to patients, those who care for them, the health care system, and the economy, is considerable. In Australia, a country of 22.7 million people, the total annual cost of chronic pain was estimated in 2007 to be $34.3 billion or $10,847 per person with chronic pain.
      Access Economics Pty Limited
      The High Price of Pain: The Economic Impact of Persistent Pain in Australia.
      The total cost across Europe has been estimated to be in the region of 1.5% to 3.0% of the European GDP.
      • Phillips C.J.
      Economic burden of chronic pain.
      In 2008, about 100 million adults in the United States were affected by chronic pain, including joint pain or arthritis.
      Access Economics Pty Limited
      The High Price of Pain: The Economic Impact of Persistent Pain in Australia.
      The total costs ranged from $560 billion to $635 billion in 2010. The annual cost of pain is greater than the annual costs of heart disease ($309 billion), cancer ($243 billion), and diabetes ($188 billion).
      • Gaskin D.J.
      • Richard P.
      The economic costs of pain in the United States.

      The Challenges of Pain Epidemiology Research

      Despite restricting the focus of this review to 1-year incidence and 1-month prevalence periods, the range of incidence and prevalence estimates for pain conditions reported in the literature is still large. These differences in estimates, often for the same condition, could be due to a variety of methodological issues inherent to pain epidemiology research. As discussed previously, the lack of a case definition or diagnosis makes identifying cases difficult, especially in population-based studies. Consensus documents for a number of conditions have been developed to define clinical diagnoses of chronic pain conditions
      • Apley J.
      • Naish N.
      Recurrent abdominal pains: a field survey of 1,000 school children.
      • Wolfe F.
      • Clauw D.J.
      • Fitzcharles M.A.
      • et al.
      The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity.
      or episodes of pain for research purposes.
      • de Vet H.C.
      • Heymans M.W.
      • Dunn K.M.
      • et al.
      Episodes of low back pain: a proposal for uniform definitions to be used in research.
      Capturing the multidimensional nature of pain conditions through assessment of subjective, functional, and psychological impacts is challenging.
      Our understanding of the epidemiology of pain is also limited by the small number of studies providing general population prevalence estimates. These studies are often difficult to implement, are costly, and involve very large sample sizes. The manner in which data are collected and reported can also have an effect on estimates, with differences arising from studies using surveys, interviews, or clinical examinations.
      • Cimmino M.A.
      • Ferrone C.
      • Cutolo M.
      Epidemiology of chronic musculoskeletal pain.
      Large-scale population-based studies can provide richer data on the age and sex distributions of pain, and when assessments are performed in a longitudinal manner, insights into incidence and risk factors should be possible. Performing epidemiological studies in a variety of cultural, social, and ethnic groups can further our understanding of the influence of and interactions between individual and societal risk factors.

      Conclusion

      Pain represents a major clinical, social, and economic problem across all ages, with estimates of the monthly prevalence ranging from 1.0% to over 60.0%. In addition, pain conditions appear to have the greatest negative impact on quality of life compared with other health problems, and they contribute the most to disability around the world. The impact of pain on economies is enormous, with the total cost of pain estimated to be up to 3.0% of the GDP. The annual cost of pain is greater than the cost of heart disease or cancer. Improvements in the methodology and conduct of epidemiological research are needed to fully understand this complex problem and develop effective strategies to manage it.

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