Spine (Phila Pa 1976). 2004 (Mar 1); 29 (5): 576–580 ~ FULL TEXT
Jan Hartvigsen, DC, PhD, Kaare Christensen, MD, PhD, and Henrik Frederiksen, MD, PhD
Nordic Institute of Chiropractic and Clinical Biomechanics,
Institute of Public Health,
University of Southern Denmark,
Odense C, Denmark.
STUDY DESIGN: Cross-sectional and longitudinal analysis of data comprising 4,486 Danish twins 70-102 years of age.
OBJECTIVES: To describe the 1-month prevalence of back pain, neck pain, and concurrent back and neck pain and the development of these over time, associations with other health problems, education, smoking, and physical, and mental functioning.
SUMMARY OF BACKGROUND DATA: Back pain and neck pain are prevalent symptoms in the population; however, there is little research addressing these conditions in older age groups.
METHODS: Extensive interview data on health, lifestyle, social, and educational factors were collected in a nationwide cohort-sequential study of 70+ year-old Danish twins. Data for back pain, neck pain, lifetime prevalence of a comprehensive list of diseases, education, and self-rated health were based on self-report. Physical and mental functioning were measured using validated performance tests. Data including associated factors were analyzed in a cross-sectional analysis for answers given at entry into the study, and longitudinal analysis was performed for participants in all four surveys.
RESULTS: The overall 1-month prevalence for back pain only was 15%, for neck pain only 11%, and for concurrent back and neck pain 11%. The prevalence varied negligibly over time and between the age groups, and 63% of participants in all surveys had no episodes or only one episode of back or neck pain. Back pain and neck pain were associated with a number of other diseases and with poorer self-rated health. Back and neck pain sufferers had significantly lower scores on physical but not cognitive functioning.
CONCLUSIONS: Back pain and neck pain are common, intermittent symptoms in old age. Back pain and neck pain are associated with general poor physical health in old age.
KEYWORDS: back pain, comorbidity, education,
geriatrics, neck pain, old age, prevalence, self-rated
From the FULL TEXT Article:
Back pain and neck pain are common complaints in the
population both with lifetime prevalence rates of roughly
70%. [1, 2] Specific knowledge about back pain and neck
pain in seniors is, however, limited, and there is an underrepresentation
of older age groups in the back pain
literature.  Furthermore, it is unknown how back pain
and neck pain develop over time in older individuals
since no longitudinal studies with repeated identical
prevalence measurements in the same cohort have been
There is some evidence that back pain and neck pain
may commonly occur together in both younger and older
persons. For instance, Cote et al  found odds ratios (OR)
>20 for severe low back pain in a Canadian population
with concurrent severe neck pain, and Isacsson et al
found that 23% of retired men in Sweden experienced
both back pain and neck pain on a daily basis.  In contrast,
Brochet et al, in a sample of elderly Frenchmen,
found back pain to be almost three times as prevalent as
neck pain with very little co-occurrence.  It is thus unclear
to what extent back pain and neck pain in old age
do occur together, and whether they might share common
determinants and risk factors or merely occur together
occasionally as two common, randomly associated
We present data from a large population-based prospective
cohort study of Danish twins 70 to 102 years of
age. We report data describing the 1-month prevalence
of back pain, neck pain, and concurrent back pain and
neck pain and associations with other health problems,
smoking, education, self-rated health, and decreased
physical and mental functioning. Further, we describe
the development of back pain and neck pain over time
both at the group and individual level.
Study Population and Data Collection.
The Danish Twin
Registry contains information on Danish twins born since
1870.  The twin registry is the basis for the Longitudinal Study
of Aging Danish Twins (LSADT), which has previously been
described in detail.  In brief, data were collected using face-to-face
interviews on four occasions starting in 1995 for Danish
twins 75 years of age or older (regardless of whether the co-twin
was alive). In 1997, intact Danish twin pairs 73 years of
age and older were invited to participate, and in 1999 and 2001
age groups of 70+ years were included regardless of whether
the co-twin was alive. A total of 4,731 twins participated, resulting
in an overall participation rate of 80.4%; however, 245
provided answers by proxy (most often because the participant
had dementia), and these answers were subsequently excluded
from the analysis. Participation rates were significantly higher
in men than in women, but the responders and non-responders
were similar in terms of age.  The survey was conducted by
trained interviewers with substantial experience in interviewing
the elderly, was home based and consisted of an extensive
battery of questions, and tests of cognitive and physical
Back pain was assessed in all four data collection waves
using the same questions: “Have you during the past month
suffered from back pain, acute low back pain or lumbago?”
Neck pain was assessed in all waves using the question: “Have
you during the past month suffered from pain or stiffness in the
neck or shoulders?”
In all surveys, the participants were asked whether a physician
had ever told them that they suffered from various diseases.
Participants who answered “yes, previously” or “yes,
currently” were subsequently asked to confirm that the diagnosis
had been made by a physician before the answer was
accepted as valid. Further, participants were asked about current
or past smoking habits, years of school, and education
after school (i.e., no further education, skilled worker, college,
university), and self-rated health.
Assessment of functional abilities was based on self-report,
which has generally been found to be reliable and valid.  The
instrument used has previously been validated in Denmark and
has been shown to discriminate levels of functional abilities
among community-dwelling elderly persons.  All items were
rated on a 1 to 4 scale and, after a factor analysis, averaged into
a strength score, which was subsequently adjusted for age and
Cognitive state and function was measured using the Mini-
Mental State Examination. 
Prevalence of Back and Neck Pain.
In the cross-sectional
analysis, results from the four LSADT surveys were combined
and answers given at entry into the study, i.e., the first time a
person participated in a survey, were used. Sex-specific prevalence
estimates with 95% confidence intervals (CI) were calculated
for 5-year age groups for back pain alone, neck pain
alone, and back pain and neck pain together.
In the longitudinal analysis, prevalence of back pain alone,
neck pain alone, and back pain and neck pain together for
subjects 75 to 84 years of age in 1995 and participating again in
the 1997, 1999, and 2001 waves were calculated to investigate
whether the prevalences tended to change over time among the
survivors. Further, the number of times each individual survivor
reported back pain alone, neck pain alone, or back pain
and neck pain together were tabulated to study if back pain and
neck pain were most often persistent or a passing symptom.
Comorbidity and Factors Associated With Back and Neck Pain.
Co-morbidity and factors associated with back pain and
neck pain were assessed using the cross-sectional sample, i.e.,
answers at intake into any of the four waves.
We compared co-occurring health indicators among participants
with back pain and neck pain with participants without
back pain and neck pain. The associations between cooccurring
health indicators and back pain and neck pain were
estimated using logistic regression models for categorical indicators
(self-reported diseases, self-rated health, education, and
smoking), and a multivariate linear regression model for the
continuous indicators (strength score, Mini-Mental State Examination
score) controlling for age and sex.
To account for the non-independence of twins (i.e., bias arising
from twin pair similarities due to genetic or environmental
factors), twins from complete pairs (both twins in a pair participating)
were analyzed in clusters of two in all regression
For all analyses, the Stata statistical software package version 6.0 was used.12
A total of 4,484 of 4,486 participants included in the
analysis answered the questions regarding back and neck
pain within the past month. For back pain alone, the
overall 1-month prevalence was 15% (95% CI 14–16%), for neck pain it was 11% (95% CI 10–12%), and
for concurrent back and neck pain it was 11% (95% CI 10–12%). Thus, the total 1-month prevalence of back
pain and neck pain was 26% and 22%, respectively. For
neck pain, the prevalences did not differ between men
and women (10%, 95% CI 7–15% versus 11%, 95% CI 8–14%).
For back pain and concurrent back pain and
neck pain, the prevalences were significantly higher in
women than in men (back pain: 17%, 95% CI 15–18% versus 12%, 95% CI 10–13%; back and neck pain:
13%, 95% CI 11–14% versus 8%, 95% CI 6–9%) (Figure 1). No significant differences or consistently increasing
or decreasing trends were found between the 5-year
age groups in the cross-sectional analysis for any of the
outcomes (Figure 1).
Results of the longitudinal analysis revealed that prevalence
varied negligibly over time both for men and
women among survivors from the initial 1995 wave (Figure 2). At the individual level, the vast majority of participants in all four LSADT waves had either not experienced back pain, neck pain, or both during the month before any of the interviews or one occasion only (Figure 3).
Lower levels of self-rated health were associated with
back pain, neck pain, and concurrent back and neck pain
prevalence in statistically significant dose-response-like
relationships. The association was strongest for concurrent
back and neck pain (Table 1) and strongest among
women (data not shown).
Back pain alone was associated with bone and joint
diseases (osteoarthritis, disc prolapse, osteoporosis), migraine
headaches, chronic bronchitis, heart attack, and
gastric ulcer (Table 2).
Neck pain alone was associated
with osteoarthritis, rheumatoid arthritis, migraine headache,
cardiovascular disorders (hypertension, heart attack),
and gastric ulcer (Table 2).
Concurrent back and
neck pain was associated with a long list of co-occurring
diseases: bone and joint disorders (osteoarthritis, disc
prolapse, osteoporosis, rheumatoid arthritis), migraine
headaches, chronic bronchitis, cardiovascular disorders
(hypertension, coronary attack), and gastric ulcer (Table
Neurologic disorders (Parkinson’s disease, epilepsy)
and endocrinological disorders (diabetes, Graves’ disease,
Hashimoto’s disease) were not associated with
back pain or neck pain (data not shown).
Living alone, past or present smoking, higher body
mass index, and years of school and education after
school were not associated with back pain, neck pain, or
concurrent back and neck pain (data not shown).
Poorer physical functioning was significantly associated
with back pain alone (OR 1.42, 95% CI 1.28–1.58), neck pain alone (OR 1.17, 95% CI 1.04–1.32),
and concurrent back and neck pain (OR 1.19, 95% CI 1.06–1.35). No associations were found between back
pain, neck pain, or the two together and Mini-Mental State Examination scores.
The results of this study add new information to the
scant body of knowledge regarding back pain and neck
pain in old age. First, we conclude that back pain and
neck pain remain common symptoms both in the old and
in the very old with 1-month prevalence rates of 15% for
back pain alone and 11% for both neck pain and concurrent
back and neck pain (Figure 1). The prevalence
rates for back pain and concurrent back and neck pain
(but not for neck pain alone) are consistently higher for
women than for men. We did not find evidence for either
significantly increasing or decreasing prevalence rates
with increasing age after using both a cross-sectional and
longitudinal analysis with identical measurements at
four different time points. However, despite both back
and neck pain being prevalent symptoms, the vast majority
of participants had not experienced any or only
one episode of back pain and/or neck pain during the
month before any of the interviews (Figure 2). Thus,
both back pain and neck pain appear to be common but
intermittent symptoms in both men and women 70 years
of age and older.
Second, we conclude that back pain and neck pain
commonly occur together in old age (OR > 4 for having
back pain if neck pain is also present and vice versa) and
that concurrent back and neck pain is associated with
extensive comorbidity (Table 2) and significantly poorer
self-rated health than back pain or neck pain alone (Table 1). Previous studies support this, having found widespread
musculoskeletal pain to be associated with depression,  low quality of life scores,  greater frequency
of care seeking,  and in a recent study was shown to
predict long-term work disability in younger persons
while low back pain alone did not.  According to the
results of the present study, spinal pain in more than one
area also associated with poorer overall general health in
the older population. This information may help to clinically
categorize an otherwise heterogeneous patient
Back pain and neck pain share many determinants
and risk factors, including co-occurring diseases, education,
smoking, and increased odds for lower level of
physical function. This appears to be true in middle and
old age but not in childhood. Cote et al found a similar
pattern of co-occurrence in Saskatchewan adults, 
whereas Wedderkopp et al, after interviewing more than
800 Danish children and adolescents, concluded that
neck pain and back pain should be regarded as specific
and distinct entities early in life. 
Twins have to be representative of the normal singleton
population for these results to be valid on a larger
scale. Indeed, the representativeness of twin studies has
been questionned.  However, twins, despite an average
lower birth weight, have the same prevalence of many
adult diseases, including diabetes mellitus  and thyroid
disease,  and they have the same fecund ability as ordinary
siblings,  the same ischemic heart disease mortality,  and general mortality rate as the general population. 
Furthermore, the 1-year period prevalence (46%)
of back pain in younger Danish twins is comparable with
the 1-year period prevalence (44–54%) found in other
studies from the Nordic countries using population-based
samples. [25, 26] Therefore, twins are considered to be
representative of the general population,  and we found
no reason to challenge this assumption.
The results of the current study have to be interpreted
in light of several potential limitations. Most importantly,
very simple outcome measures were used, namely,
self-report of back pain and/or neck pain within the past
month. No information regarding the duration, intensity
or impact, and consequences of this pain were recorded.
In spite of this, we think that these results are important
for both clinicians and researchers. Clinicians should be
aware of co-occurring health problems in older patients
with back pain and neck pain and ensure that adequate
medical attention is paid to these.
Further, older patients
with both back pain and neck pain may require more
extensive treatment approaches than patients suffering
from only one or the other. Finally, they should inform
older patients that back and neck complaints are common
but intermittent complaints.
For researchers, the
challenge is to further describe patterns of back pain and
neck pain in old age and to address the impact and consequences
of these. Such research is needed to disentangle
the relationships between back pain, neck pain, and
other health problems and to rationally address the issues
of prevention and treatment in the older segments of
the population. Further, twin samples, such as used in
this study, can be used to determine genetic contributions
to various back and neck pain patterns as well as
interactions between genetic and environmental factors
in the causality of these complaints. The authors of this
paper are currently addressing these issues based on this
sample, and future waves of LSADT will have expanded
sections on back pain and neck pain.
Observational studies nested in large general health
surveys, such as the present study, have several advantages.
The investigation of back pain and neck pain specifically
was not singled out to the participants as the aim
of the interview, and bias arising from excessive attention
to these conditions was likely avoided. In addition,
the high response rate ensures representativeness of the
study sample. Finally, longitudinal data covering a wide
range of lifestyle and health conditions can potentially
contribute to a better understanding of conditions with
presumed multifactorial origins.
More research is needed to provide a better understanding
of the possible interplay between spinal pain in
different body regions (i.e., back or neck) and other
health problems. Nevertheless, based on these results, we
propose that back pain and neck pain are not independent
health problems in old age but rather may be part of
an overall pattern of poor health.
Back pain and neck pain are common symptoms in old
age. In the 70+ year age group, back pain alone affects
roughly 15%, neck pain alone affects approximately
10%, and both back pain and neck pain affect about
10% on a monthly basis. The majority (>70%), however,
experienced only one episode or none at all before
any of the four interviews. Prevalence estimates for back
pain, neck pain, and concurrent back and neck pain remain
constant with increasing age both in a cross-sectional
analysis and a longitudinal analysis. Back pain
and neck pain are associated with many co-occurring
health problems and with poorer self-rated health. Both
back pain and neck pain sufferers had significantly lower
scores on physical functioning tests, whereas cognitive
scores were unaffected.
Back pain affects 15%, neck pain affects 11%, and concurrent back and neck pain
affects 11% of persons aged 70+ years.
Prevalences of both back and neck pain change very little with increasing age
and appear to be intermittent symptoms.
Back and neck pain in old age is associated with other health problems, poorer
self-rated health, and decreased physical functioning.
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