Increased serum uric acid--a marker of non-gouty widespread pain? A study of female patients with inflammatory and non-inflammatory pain.

OBJECTIVE: To study the relationship between reported chronic pain and the level of serum urate (SU) among women with various diagnoses of the musculoskeletal system. METHODS: Consecutive female patients (aged 20-70 years, n = 124), at rheumatology and rehabilitation practices, with chronic musculoskeletal pain of different origins were followed for 1 year after an initial survey of pain, lifestyle, quality of life, and disability. Repeated blood samples (including urate, creatinine, cholesterol, and glucose) were analysed. Multiple regression analysis was performed to explain initial variations in SU level in relation to pain and confounding factors. RESULTS: The level of SU was increased among individuals with widespread pain (>5 locations) independent of underlying diagnoses compared to those with fewer pain sites (270.5 vs. 241.2 micromol/L). Serum creatinine, body mass index (BMI), the number of pain locations, and sleep disturbances independently contributed to the SU level and explained 43% of the variation in SU. Individual variation in SU during 4 months was low. CONCLUSIONS: Epidemiological data on the relationship between the extent of body pain and SU were confirmed in a clinical setting. Besides known factors such as impaired renal function and obesity, widespread pain and sleep disturbances were related to an increase in SU. Medication and alcohol intake could not explain the findings. Longitudinal studies are necessary to elucidate whether the level of SU has any implications for the prognosis of chronic pain.

Impact of chronic pain on health care seeking, self care, and medication. Results from a population-based Swedish study.

STUDY OBJECTIVE: To explore individual and social factors that could predict health care utilisation and medication among people with chronic pain in an unselected population. DESIGN: A mailed survey with questions about pain and mental symptoms, disability, self care action, visits to health care providers, and medication. SETTING: General populations in two Swedish primary health care (PHC) districts. Medical care was given in a state health system. PARTICIPANTS: A random sample (from the population register) of 15% of the population aged 25-74 (n = 1806). MAIN RESULTS: Among people reporting chronic pain 45.7% (compared with 29.8 of non-chronic pain persons, p < 0.05) consulted a physician and 7.2% (compared with 1.2%, p < 0.05) a physiotherapist during three months. Primary health care was the most frequent care provider. High pain intensity, aging, depression, ethnicity, and socioeconomic level had the greatest impact on physician consultations. Alternative care, used by 5.9%, was associated with high pain intensity and self care. Use of self care was influenced by high pain intensity, regular physical activity, and ethnicity. Alternative care and self care did not imply lower use of conventional health care. Women reporting chronic pain consumed more analgesics and sedatives than corresponding men. Besides female gender, high pain intensity, insomnia, physician consultation, social network, and self care action helped to explain medication with analgesics. Use of herbal remedies and ointments correlated to self care action, visit to an alternative therapist, high pain intensity, and socioeconomic level. CONCLUSIONS: The presence of chronic pain has an impressive impact on primary health care and medication. Various therapeutic actions are common and are partly overlapping. The use of health care among people with chronic pain depends above all on pain perception and intensity of pain but is also affected by ethnicity, age, socioeconomic level, and depressive symptoms. Among people with chronic pain use of analgesics is common in contrast with other types of pain relief (acupuncture, physiotherapy) suitable for treating chronic pain symptoms.

Musculoskeletal chronic pain in general practice. Studies of health care utilisation in comparison with pain prevalence.

OBJECTIVE: To study the relations between population prevalence of chronic pain and pain-related diagnoses (musculoskeletal and headaches) in primary health care (PHC) and to examine longitudinal variations in these diagnoses. DESIGN: A population-based mailed survey to catch prevalence data and continuous computerised diagnosis registration in PHC. SETTING: General population in a well-defined Swedish PHC district. SUBJECTS: A random sample of 15% of the population aged 25-74, n = 1101. Annual visitors to district physicians at the health centre. MAIN OUTCOME MEASURES: Rates of pain-related diagnoses in PHC in relation to population prevalence of chronic pain. Comparisons of the number of individuals (annual visiting rates) with pain-related diagnoses 1987-1996. RESULTS: Population pain prevalence and pain-related diagnoses in PHC corresponded as regards the magnitude and distribution of chronic pain by age and partly by pain location. Compared to low-back and widespread pain, neck-shoulder pain and headaches were less frequent in PHC in relation to reported prevalence. From 1987 to 1996 we found an increasing number of individuals seeking primary care with pain-related diagnoses. The increase was mainly assigned to the groups of fibrositis/myalgia and headache. CONCLUSION: Pain-related diagnoses in PHC reflect partly the occurrence of self-reported chronic pain symptoms in the population. The observed increase in visits with pain-related diagnoses in the last 10 years is due to an increased number of individuals with soft-tissue rheumatism and headaches. Future studies will have to elucidate whether these findings are due to an increase in morbidity or changes in care-seeking and social conditions.

Widespread musculoskeletal chronic pain associated with smoking. An epidemiological study in a general rural population.

Data on smoking and pain symptoms from a random sample (n = 1806) of a general population were used to evaluate the association between chronic pain at various locations and smoking. In both genders current smoking was associated with reports of increased pain in low back, neck and with multiple locations. In a multiple logistic regression analysis current smoking was associated with an increase in widespread chronic musculoskeletal pain (OR 1.60, CI 1.04-2.46, in relation to non-smokers) and chronic low back pain (OR 1.58, CI 1.13-2.20, in relation to non-smokers). A dose-response relationship was found between the daily cigarette consumption and the prevalence of chronic low back pain. Smoking is associated not only with low back pain but also with chronic widespread musculoskeletal pain. No conclusive decrease in pain prevalence was found after quitting smoking. Further studies are necessary to elucidate an aetiologic relationship between smoking and chronic pain.

Characteristics of subjects with chronic pain, in relation to local and widespread pain report. A prospective study of symptoms, clinical findings and blood tests in subgroups of a geographically defined population.

The relation between reported chronic pain and clinical findings was studied by comparing survey data six months before and eighteen months after a clinical examination. Studied individuals (n = 165) were randomly selected from subsamples of an initial survey (n = 1806) to a general population. Among individuals reporting chronic pain 85% were assessed to have chronic pain at the examination. Diagnoses were found in 22% of examined pain individuals. Myofascial pain syndrome and myalgia were the most common findings. Compared with located neck-shoulder pain, widespread pain had a greater impact on the individual, a worse prognosis regarding pain duration and working capacity, and revealed a raised serum urate level of unclear significance. Although no specific cause of pain is found in individuals with widespread pain it is important to identify and treat this group due to the great effects on functional capacity and the worse prognosis.

Health and health care utilization among early retirement pensioners with musculoskeletal disorders.

OBJECTIVE: To estimate subjective health status among early retired individuals pensioned due to disorders of the musculoskeletal system. DESIGN: A survey of self-reported health status and health care utilization by means of a mailed questionnaire. SETTING: Early retirees (cases) and a random sample (controls) of individuals from the municipality of Kristianstad, Sweden. CASES: all individuals aged 25-59 years granted a full-time early retirement pension during the period 1986-1990 due to disorders of the musculoskeletal system (n = 450). The response rate was 83.6%. CONTROLS: An age- and sex-matched sample (n = 450). The response rate was 82.7%. MAIN OUTCOME MEASURES: Self-reported health status and health care utilization. RESULTS: Early retirement entailed a deterioration in self-reported health status among men, all ages, and women aged 25-54 years. Female retirees aged 55-64 reported an improvement in health status since retirement. Early retired female immigrants were less satisfied with their health status than the Swedish ones. Early retirees reported higher health care utilization than controls, but with a reduction since retirement. Drug consumption was high. CONCLUSION: The beneficial effects of early retirement were evident among old women. Men and young and middle-aged women may need support to adjust to life as a retiree. Special attention should be given to the female immigrant retiree.

Immigration and socio-economy as predictors of early retirement pensions.

The purpose of this study, performed in a Swedish municipality, was to obtain a view of early retirement pensioners, focusing on immigration and socio-economy as predictors of early retirement pensions. A questionnaire was sent to 453 early retirement pensioners with disorders of the musculoskeletal system. A corresponding questionnaire was sent to a randomly selected, age- and sex-matched control group of the same size. The response rate was 83%. The study concludes that immigration and low socio-economy are predictors of early retirement pension (ERP). The rate of immigrants was 19% among the ERPs compared to 5% among the controls. The early retired immigrants were comparatively young, and some of them were overqualified for their previous jobs. Of the ERPs 74% were blue-collar workers compared to 39% of the controls. Neither work satisfaction nor unemployment was found to predict ERP.

Did Bechterew describe the disease which is named after him? A question raised due to the centennial of his primary report.

From paleopathological studies of egyptian mummies it is known that pelvospondylitis existed in ancient times. In spite of that a disease entity has not been clearly defined until recent years. The discovery of the rheumatoid factor, 1940 by Waaler and 1948 by Rose, allowed differentiation from RA. The first criteria for pelvospondylitis were proposed at a symposium in Rome 1961. Another important step in the history of pelvospondylitis occurred in 1973 when the connection to the HLA-B27 was discovered. Initial clinical descriptions appeared in the last decade of the 18th century. One of the contributors was the Russian Wladimir Bechterew (Fig. 1) whose name thereafter has been linked to the disease. Since it is the centennial of Bechterew's original report it seems appropriate to review that publication.

Chronic pain in a geographically defined general population: studies of differences in age, gender, social class, and pain localization.

OBJECTIVE: To establish basic epidemiological data on chronic pain (duration > 3 months) in a defined population. Relationships between age, gender, and social class were tested. DESIGN: A survey of pain symptoms, including location, intensity, duration, and functional capacity, was conducted by means of a mail questionnaire. SETTING: General populations in two Swedish primary health care districts. Medical care was provided in a state health system. SUBJECTS: A random sample (from the population register) of 15% of the population aged 25-74 (n = 1,806). The response rate was 90%. OUTCOME MEASURES: Descriptive epidemiologic data in relation to objectives of the study. RESULTS: Without sex differences, 55% (95% confidence interval, 53-58%) of the population had perceived persistent pain for 3 months and 49% for 6 months. Among individuals with chronic pain, 90% localized their pain to the musculoskeletal system to a variable extent. Women experienced more multiple localizations of pain and had pain in the neck, shoulder, arm, and thigh to a greater extent than men. Prevalence of pain increased by age up to 50-59 years for both genders and then slowly decreased. The neck-shoulder area was the most common site of pain (30.2%), followed by the lower back (23.2%). Even in the youngest age groups more than one of four reported chronic pain. Blue-collar workers and employers (including farmers) reported chronic pain to a greater extent than other groups. In 13% of the population, manifest pain problems were associated with reduced functional capacity. CONCLUSION: Chronic pain symptoms are common but unevenly distributed in a general population. The results may influence planning and consultation in primary health care as well as warranting selective prevention activities.

A double-blind comparison of oral ketoprofen 'controlled release' and indomethacin suppository in the treatment of rheumatoid arthritis with special regard to morning stiffness and pain on awakening.

A double-blind, double-dummy, crossover study was carried out in 8 centres to compare the efficacy and tolerability of 'controlled-release' ketoprofen tablets (200 mg) with that of indomethacin suppositories (100 mg) in out-patients with definite or classical rheumatoid arthritis. Patients were allocated at random to receive a daily bedtime dose of either 1 ketoprofen tablet or 1 indomethacin suppository plus the dummy of the other formulation for a period of 3 weeks. They were then crossed over to the alternative treatment for a further 3 weeks. Daily diary records were kept by patients of the number of night-time awakenings due to pain, pain severity at awakening in the morning and the duration of early morning stiffness. Treatment efficacy was also assessed at the end of each trial period by means of an articular index and by physician's and patient's overall evaluation of response. Adverse effects spontaneously mentioned by the patients or elicited by direct questioning using a symptom check-list were recorded. Statistical analysis of the results from 83 evaluable patients showed that the 'controlled-release' tablet formulation of 200 mg ketoprofen was equally as effective as the 100 mg indomethacin suppository in the treatment of rheumatoid arthritis, especially with regard to pain at awakening and morning stiffness. Side-effects in both groups were those commonly seen with non-steroidal anti-inflammatory drugs and, as expected, gastro-intestinal and CNS disturbances predominated. Overall, side-effects were fewer with ketoprofen than with indomethacin.