Musculoskeletal pain and its associated risk factors in residents of National Capital Region.

BACKGROUND: Musculoskeletal (MS) pain is responsible for poor quality of life and decreased productivity. Objective information about the burden of musculoskeletal disorders among the general community in India is scanty, and the few reports that exist are based on a small sample size.
MATERIALS AND METHODS: This paper examines the issue of MS pain and its associated risk factors in a cross-sectional study of 2086 subjects from National Capital Region (NCR).
RESULTS: Overall prevalence of MS pain was found to be 25.9%. Pain was found to be more frequent among females (31.3%) as compared with males (20.9%). Significant association of pain in joints/limbs/knee/lower legs with obesity (OR = 2.1, P < 0.001) and high body fat (OR = 2.2, P < 0.001) was established. More than 50% of the subjects complained of backache.
CONCLUSIONS: Our findings confirm that MS pain is a significant burden of disease among the residents of NCR. Women and subjects doing heavy work load, like agriculture and dairy farming, constitute the chief demographic groups. It is high time that a policy is framed to reduce this load of sickness.

INTRODUCTION

The prevalence of musculoskeletal disorders (MSD) among the general population in India is not well documented. A cross-sectional study of MSD in slums of Mumbai by Pingle et al.[1] and a study by Mahajan et al.[2] on the prevalence of rheumatic disorders in Jammu are the only studies reported in the general population. However, few studies from different occupational settings[3-7] are available.

Complaints of musculoskeletal (MS) pain/discomfort are associated with physical disability, and affect the health-related quality of life.[89] MS impairment is the most common chronic impairment in developed as well as in developing countries, as nearly 25% of the adult subjects suffer from chronic MS pain.[10] In spite of the enormous global impact, these disorders do not receive the attention they deserve by the medical profession, policy makers or the media and are not considered national health priorities.[10] This is because MS diseases are perceived to be less serious than cardiovascular diseases, diabetes, AIDS and cancer, while MSD are largely chronic, non-fatal conditions and are perceived to be a consequence of aging. The United Nations and World Health Organization (WHO) declared the decade 2000–2010 as a bone and joint decade with the aim of increasing the understanding of the burden posed by MSD and improving the health-related quality of life.[11]

This paper reports the findings of a community-based cross-sectional study of more than 2000 subjects living in Gurgaon and NOIDA, which are part of National Capital Region (NCR), India. The aim of the study was to determine the prevalence of the MS pain and the associated risk factors in the NCR.

MATERIALS AND METHODS

Study Sample and Selection Process

Two thousand and eighty-six subjects of all age groups and both sexes from Gurgaon (1060) and NOIDA (1026) in the NCR were studied. The details of sample size from each village of NOIDA and Gurgaon represented in Figure 1. The sample size was calculated to be 1418 considering an expected prevalence rate of 18% in the general population,[1-7] with precision of 2% and confidence limit of 95%. Households were selected using a systematic random sample using the list of households of these areas as the sampling frame.

Figure 1

Sample size of the studied population in different villages of Gurgaon and NOIDA Source: http://www.mapsofindia.com

All the identified residents were approached through household visits by social workers and requested to participate in the study on the basis of voluntary informed consent. The participation of the study subjects was ensured by motivating the community leaders, teachers, doctors, etc. through social workers. Ninety percent of the registered population turned up for the study.

Survey areas and number of subjects studied in each area are shown in Figure 1. Subjects of both sexes in the age range of 10–70 years were included in the study.

Ethical Clearance

Clearance was obtained from the Institutional Human Ethical Committee before starting the study.

Study Parameters

(a) Detailed History: Personal, social and occupational details of each subject were collected through a structured interview method and all information was noted on a pre-tested questionnaire.

The personal details comprised information regarding age, occupation, dietary practices, smoking, addictions, education and income.

(b) Clinical Examination: Information regarding location and degree of pain, medications, etc. was collected through a structured interview. A questionnaire was developed to include the above information and was pre-tested in the field before usage. The investigation depended on self-reported symptoms along with their location. A pain diagram was prepared showing a sketch of the human body in a standing posture (rear view) along with body locations marked with arrows. During the interview, each subject was asked to pinpoint the body location(s) where pain was felt at the time of interview or the preceding 24 h. Information about pain in the neck, shoulders, upper back, upper arms, lower back, forearms, wrists, hip/buttocks, thighs, knees, lower legs and ankles was recorded in separate datasheets for each individual.

A general clinical examination of each subject was done to rule out chronic morbidities and to make a probable diagnosis where possible.

Body Composition Measurements

Body fat percentage and body mass Index (BMI) were measured using the bioelectric impedance analysis-based body fat monitor (Model: Omron HBF-352; Omron Healthcare Co. Ltd., 24 Yamanoshita-cho Yamanouchi Ukyo-ku Kyoto-shi, Kyoto 615-0084, Japan). Height was measured using a stadiometer and weight was measured using a manual personal scale.

The subjects’ BMI were classified into normal, overweight and obese based on the WHO classification. Body fat percentage was graded for low, normal and high based on the earlier report.[12]

(c) Data Processing and Analysis

Data collected was transferred to the personal computer and subjected to statistical analysis to determine the various associated risk factors vis-a-vis disease outcome by computing prevalence rates and odds ratio. The statistical significance was computed using the Chi square test using Systat 9.0 software.

RESULTS

Age and Sex-Wise Prevalence

One thousand seventy-seven males and 1009 females subjects were studied. Sex-wise distribution was similar [Table 1] in all the age groups. Prevalence of overall MSD symptoms was 25.9%, and it was significantly more common (P < 0.001) in females (31.3%) as compared [Table 2] with males (20.9%). MSD symptoms showed a significantly higher (P < 0.001) prevalence with increase in age, both for males and females. Pain in back (14.0%), limbs (5.5%) and knees (3.1%) were found to be the most common.

Table 1

Overweight, obesity and musculoskeletal pain in the study subjects

Table 2

Sex-wise prevalence of musculoskeletal disorders symptoms in the study population

Backache (lower/upper) was responsible for more than 50% of the total morbidity [Table 2] in both the sexes, and was more common among females (17.0%) as compared with (P < 0.001) males (11.1%). Pain in limbs was also more common (P < 0.05) in females than in males (males = 4.4%, females = 6.6%), whereas no significant sex-wise differences were observed for the rest of the symptoms.

Lifestyle Factors

No association with smoking and MS pain could be established (smokers = 25.9%; non-smokers = 26.2%). Overall prevalence of MS pain among vegetarians and non-vegetarians [Table 3] was also found to be statistically similar (vegetarians = 26.6%; non-vegetarians = 23.3%).

Table 3

Body fat % and musculoskeletal pain in the study subjects

Body Composition Factors

Prevalence of overweight and obese subjects (as per BMI classification of WHO) with MS pain was 25.4% as compared with 20.4% with no MS pain [Table 1]. This difference was found to be statistically significant (OR = 1.67, P < 0.001).

Pain in joints, limbs, knee and lower leg was found to be significantly associated with overweight and obesity (OR = 2.1, P < 0.001). However, no association of obesity and overweight with backache could be established (OR = 1.28, P > 0.05).

Subjects with higher body fat were more prone to MS pain. Prevalence of MS symptoms was significantly higher (61.3%) in subjects with high fat as compared with normal subjects (50.5%, OR = 1.55, P < 0.0061). Pain in joints, limbs, knee and lower leg was also found to be significantly associated [Table 3] with overweight and obesity (OR = 2.2, P = 0.00).

Occupational Factors

Highest prevalence of MS pain (31.4%) among males was in agricultural/dairy workers followed by laborers (21.9%), while the lowest prevalence was observed among students (15.9%) and desk job workers (16.7%).

A similar pattern was observed in females, and the highest prevalence of MS pain (44.7%) was reported by agriculture/dairy workers. This was followed by housewives (35.9%) and laborers (32.3%).

Treatment history of the subjects with MS pain revealed that 7.8% (42%) and 7.02% (38%) were taking regular treatment for arthritis and back pain, respectively.

DISCUSSION

The prevalence of MS pain in our study was observed to be 25.9%, which is much higher as compared with the studies by Pingle et al.,[1] Chopra et al.,[13] Faroqui and Gibson[14] and Lawarence et al.[15] In all these studies, the prevalence ranged between 15 and 18.2%. However, a study done in the general community in Cuba by Llerena et al.[16] reported a much higher prevalence of (43.9%) MS symptoms. Mahajan et al.[2] reported a prevalence of 24.2% MS symptoms, which is quite close to the present study.

Females are more affected than males. Similar findings have been reported by Pingle et al.,[1] Mahajan et al.,[2] and Chopra et al.[13] The study by Woolf and Pfleger[17] also revealed that females had a high prevalence of MSD complaints than males. The back pain (lower or upper) accounts for more than 50% of the total complaints, and it was more common in females than in males.

Age was seen to be an important factor in MS pain. Prevalence of pain increased with age till 50, but later a fall was seen in the prevalence [Table 3]. Similar findings are reported by Pingle et al.[1] and Chopra et al.[13] However, in a study by Woolf and Pfleger,[17] the prevalence of MSD complaints increased markedly with age.

Overweight and obesity (BMI ≥ 24.9) were found to be important risk factors of MS pain. The risk among overweight/obese was 1.7-times more as compared with subjects with a BMI ≤ 24.9. Similarly, the subject with high body fat percentage had 1.5-times more risk of MSD compared with normal subjects. Grotle et al.[18] have also reported a similar association with obesity and development of osteoarthritis.

Statistically significant association between pain in joints, knees, limbs and lower leg was high body fat percent and high BMI. These subjects had twice the risk of pain in joints, knees, limbs and lower leg compared with normal subjects. Our result supports the studies of Rogger et al.[19] and Coggen et al.[20]

Subjects engaged in heavy work, like agriculture and dairy farming, had more complaints, i.e. 31.4% in males and 44.7% in females. Coggon et al.[20] and Kar et al.[3] also reported that MSD problems were be more common in subjects who performed heavy physical work and, particularly, in those in jobs that involve kneeling and squatting.

MS pain is very common and every fourth person suffers from it. Subjects in productive age groups, women and those who are overweight/obese are at special risk. Widespread MS pain represents a mixed category of pathologies that include single-site and polyarticular osteoarthritis, other arthritic conditions, spine diseases and chronic pain syndromes.[21]

The baseline health and behavioral characteristics associated with pain indicate issues for further study. Several other studies[1819] have also shown that obesity is a risk factor for the onset and progression of osteoarthritis.

Globally, people suffering from MS problems increased by 25% over the past decade. MS conditions are currently the most common cause of chronic disability. Although the evidence needed to determine the most cost-effective interventions is scant, affordable measures to prevent and treat MS conditions are available in the public domain.[21]

The primary MS dysfunctions include:

Osteoarthritis

Inflammatory arthritis (principally, rheumatoid arthritis)

Back pain

MS injuries (such as sports injuries)

Crystal arthritis (such as gout)

Metabolic bone disease (principally osteoporosis)

MS conditions make up 2% of the global disease burden. Osteoarthritis accounts for the largest portion – 52% of the total burden of MS conditions in developing countries and 61% of the total burden of MS conditions in industrialized countries.

Osteoarthritis is increasing as the world's elderly population grows, and is the sixth leading cause of years lost to disability.[17] Although MS conditions are the most common cause of chronic disability worldwide, little information is available on approaches to addressing these conditions. It is therefore difficult to estimate the most cost-effective interventions for developing countries. Nevertheless, affordable strategies like good nutrition and exercise are the sheet anchor of many of the preventive and treatment strategies for MS conditions. Some facts are mentioned below:

Weight reduction reduces pain and disability from osteoarthritis of the knee.

Obesity is associated with back pain.

Poor diet contributes to gout.

Smoking and excessive alcohol use is linked to osteoporosis.

Adequate calcium intake helps to maintain bone density and reduce the risk of fractures.

The best way to prevent these conditions is the following:[21]

Engage in adequate physical activity for fitness

Maintain ideal body weight.

Follow a balanced diet that meets the requirements for calcium and vitamin D.

Avoid smoking.

Use only moderate amounts of alcohol, if any

Put in place accident prevention programs related to road traffic crashes, leisure activities and workplaces.

The study highlights the need to formulate a policy and device specific intervention to alleviate suffering and reduce health care costs and lost productivity due to MS problems.