scholarly journals Frequency of Impaired Spinal Mobility in Patients with Chronic Back Pain Compared to Patients with Early Axial Spondyloarthritis

2018 ◽  
Vol 45 (12) ◽  
pp. 1643-1650 ◽  
Author(s):  
Camilla Fongen ◽  
Hanne Dagfinrud ◽  
Inger Jorid Berg ◽  
Sofia Ramiro ◽  
Floris van Gaalen ◽  
...  
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Spinal Mobility ◽  
Chest Expansion ◽  
Wall Distance ◽  
Intermalleolar Distance ◽  
Cervical Rotation ◽  
Mobility Measure ◽  
Spinal Flexion

Objective.To examine the frequency of impaired spinal mobility in patients with chronic back pain of short duration and to compare it with the frequency of impaired spinal mobility in patients with axial spondyloarthritis (axSpA), possible SpA, and no SpA.Methods.The SpondyloArthritis Caught Early (SPACE) cohort includes patients with chronic back pain (≥ 3 mos, ≤ 2 yrs, onset < 45 yrs). Spinal mobility was assessed with lateral spinal flexion, chest expansion, cervical rotation, occiput-to-wall distance, and lumbar flexion. Hip mobility was assessed with intermalleolar distance. Mobility measures were defined as impaired if below the 5th percentile reference curve from general population, adjusted for age and height when appropriate. Proportions of patients categorized with impaired mobility were examined with chi square.Results.In total, 393 patients with chronic back pain were included: 142 axSpA, 140 possible SpA, and 111 no SpA. Impairment in ≥ 1 mobility measure was present in 66% of all patients. The most frequently impaired mobility measure was lateral spinal flexion (40%), followed by chest expansion (22%), cervical rotation (18%), intermalleolar distance (17%), lumbar flexion (15%), and occiput-to-wall distance (11%). No statistically significant differences in proportion of patients with impaired spinal mobility were found between patients with axSpA and the other subgroups in any of the tests.Conclusion.Two out of 3 patients with chronic back pain of short duration had impaired spinal mobility compared to the general population. Impaired spinal mobility occurs as often in patients with early axSpA as in other forms of chronic back pain.

scholarly journals OP0076 CLINICAL DISEASE ACTIVITY, MRI SPINAL INFLAMMATION AND ENTHESITIS ARE KEY DETERMINANTS OF IMPAIRMENT OF SPINAL MOBILITY IN EARLY AXIAL SPONDYLOARTHRITIS – DATA FROM THE DESIR COHORT

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 51-52
Author(s):  
P. Carvalho ◽  
A. Marreiros ◽  
J. E. Fonseca ◽  
A. Ruyssen-Witrand ◽  
P. M. Machado
Keyword(s):  
Ankylosing Spondylitis ◽  
Disease Activity ◽  
Spinal Mobility ◽  
Mobility Impairment ◽  
Intermalleolar Distance ◽  
The Individual ◽  
Spinal Damage ◽  
Cervical Rotation ◽  
Spinal Inflammation ◽  
Spinal Flexion

Background:It has been shown that spinal mobility impairment in axial spondyloarthritis (axSpA) is independently determined both by irreversible spinal damage and by reversible spinal inflammation. However, these relationships have only been investigated in patients with longstanding disease (ankylosing spondylitis). Moreover, only the composite score Bath Ankylosing Spondylitis Metrology Index (BASMI) has been evaluated rather than individual mobility assessments.Objectives:Our aim was to investigate the determinants of spinal mobility in patients with early axSpA.Methods:We analysed longitudinal data from the DEvenir des Spondyloarthrites Indifférenciées Récentes (DESIR) cohort, collected during the first five years of follow-up. We selected patients with a definite diagnosis of axSpA according to the treating rheumatologist, at the end of follow-up (month 60). Associations were tested using generalised estimating equations (GEE), a multilevel approach that adjusts for within-patient correlation. The Bath Ankylosing Spondylitis Metrology Index (BASMI) or the individual components of BASMI (lateral spinal flexion, tragus-to-wall distance, cervical rotation, anterior lumbar flexion, maximal intermalleolar distance) were used as dependent variables, and clinical and demographic variables were used as independent variables in univariable models. Spinal MRI inflammation was assessed using the Berlin scoring system and radiographic structural damage was assessed using the modified Stoke ankylosing spondylitis spinal score (mSASSS)]. As physical function and quality of life are considered to be hierarchically superior to spinal mobility, they were not included in the analysis. Multivariable models were built, adjusting for potential confounding. Variables with a p-value <0.10 were re-tested in the multivariable models. Six models were built, one regarding the BASMI total score and five regarding the individual components of BASMI.Results:Data from 644 patients and 5152 visits were analysed. In the multivariable analyses (table), we found an independent association between higher BASMI values and age [adjusted B (aB)=1.02, confidence interval (CI)=1.01-1.03], Ankylosing Spondylitis Disease Activity Score-C Reactive Protein (ASDAS-CRP) (aB=1.23, CI=1.15-1.32), enthesitis score (aB=1.02, CI=1.01-1.04) and MRI inflammation score (aB=1.13, CI=1.05-1.23). All individual BASMI components were independently associated with ASDAS-CRP. Apart from maximal intermalleolar distance, all other mobility measures were associated with MRI spinal inflammation. Lateral spinal flexion, cervical rotation and maximal intermalleolar distance were associated with the enthesitis score. mSASSS was associated with lateral spinal flexion and a contributory factor to tragus-to-wall distance and cervical rotation.Conclusion:In early axSpA, spinal mobility impairment is independently determined by clinical disease activity, MRI spinal inflammation and the severity of enthesitis. Maximal intermalleolar distance (which is not a true measure of spinal mobility) was the only measure not associated with MRI spinal inflammation. The influence of spinal inflammation prevails in the early phase of axSpA while spinal damage becomes more relevant in later disease stages.References:None.Disclosure of Interests:Pedro Carvalho: None declared, Ana Marreiros: None declared, Joao Eurico Fonseca: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Pedro M Machado Consultant of: PMM: Abbvie, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Roche and UCB, Speakers bureau: PMM: Abbvie, BMS, Lilly, MSD, Novartis, Pfizer, Roche and UCB

scholarly journals SAT0380 ENHANCING RHEUMATOLOGY REFERRALS AMONG INFLAMMATORY BOWEL DISEASE PATIENTS WITH SUSPECTED AXIAL SPONDYLOARTHRITIS

2020 ◽  
Vol 79 (Suppl 1) ◽  
pp. 1138.2-1138
Author(s):  
C. S. E. Lim ◽  
M. Tremelling ◽  
L. Hamilton ◽  
A. Macgregor ◽  
K. Gaffney
Keyword(s):  
Back Pain ◽  
Musculoskeletal Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Inflammatory Back Pain ◽  
Aminosalicylic Acid ◽  
Research Support ◽  
Clinical Probability ◽  
Asas Criteria ◽  
History Of

Background:Axial spondyloarthritis (axSpA) is associated with inflammatory bowel disease (IBD). In IBD patients, the clinical probability of axSpA increases in those with chronic back pain (CBP) whose symptoms started before the age of forty-five years old. In practice, this should trigger a rheumatology review especially if accompanied by other symptoms suspicious of inflammatory disease. However, in any health system, the goal of identifying all possible cases need to be balanced with the practical realisation of the finite resources available.Objectives:The study aimed to define the clinical characteristics of a subgroup of IBD patients who are routinely managed in secondary care who have an increased clinical probability for axSpA. Identification of these characteristics may help improve the quality and specificity of referrals to Rheumatology from Gastroenterology clinics.Methods:An analytical cross-sectional study was undertaken. Consecutive IBD patients attending routine Gastroenterology clinics were sent a modified validated back pain questionnaire. The questionnaire included the presence or absence of a previous diagnosis of axSpA; components of validated inflammatory back pain criteria; diagrams to indicate the location of back pain and other musculoskeletal pain; personal and family history of known axSpA manifestations; and details of their IBD course, activity and treatment.IBD patients, with back pain duration > 3 months with onset before 45 years were considered to have a medium diagnostic probability (MDP) for axSpA. MDP-positive IBD patients were compared with MDP-negative IBD patients and logistic regression was used to model the association with clinical features.Results:Four hundred and seventy consecutive IBD patients (mean age 54 years; 46% male) were surveyed. Two hundred and nine patients (59%) replied, of whom 191 patients (69%) consented to participate. One hundred and seventy-three (91%) of those who consented had a valid completed questionnaire and were included for data analysis. Of these, 74% had Ulcerative Colitis and 26% had Crohn’s disease. Their mean age was 58 years, 39% male. Mean age at IBD diagnosis was 39 years, mean IBD disease duration 19 yrs. CBP (back pain greater than three months) was reported by 76%. Inflammatory back pain fulfilling Calin, Berlin, ASAS criteria was seen in 23%, 29%, and 15% respectively. In addition, 80% reported peripheral musculoskeletal pain. Self-reported personal history of enthesitis, reactive arthritis (ReA), acute anterior uveitis (AAU), skin psoriasis (PSO) and dactylitis were 50%, 30%, 24%, 15% and 0% respectively. Self-reported family history of IBD, ReA, PSO, axSpA and AAU were 60%, 36%, 22%, 11%, and 1% respectively.Ninety-one (53%) patients were MDP-positive and 82 (47%) patients were MDP-negative. The clinical characteristics associated with MDP (adjusted for age at invitation) were: the presence of inflammatory back pain using ASAS criteria [OR 8.84 (1.61,48.67); p=0.01], longer interval between symptom onset and gastroenterologist diagnosis of IBD [OR 1.09 (1.03,1.16); p=0.005], and use of rectal topical 5-aminosalicylic acid [OR 3.27 (1.11,9.68); p=0.03].Conclusion:Chronic back pain and peripheral musculoskeletal pain are common in a secondary care IBD population. In IBD patients, with back pain duration > 3 months and onset before 45 years, the presence of inflammatory back pain, longer diagnostic delay of IBD and the use of rectal topical 5-aminosalicylic acid were associated with a higher clinical probability of axSpA. The identification of these clinical features may not only improve the quality and specificity of Rheumatology referrals from Gastroenterology in this subgroup of patients but also lends real world evidence to current ASAS-endorsed recommendations for early referral of patients with a suspicion of axial spondyloarthritis.Disclosure of Interests:Chong Seng Edwin Lim Grant/research support from: AbbVie - Research support/grant but NOT for this study., Mark Tremelling: None declared, Louise Hamilton: None declared, Alexander Macgregor: None declared, Karl Gaffney Grant/research support from: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Consultant of: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma, Speakers bureau: AbbVie, Celgene, MSD, Novartis, Pfizer, and UCB Pharma

Reference intervals of spinal mobility measures in normal individuals: the mobility study

2014 ◽  
Vol 74 (6) ◽  
pp. 1218-1224 ◽  
Author(s):  
Sofia Ramiro ◽  
Astrid van Tubergen ◽  
Carmen Stolwijk ◽  
Désirée van der Heijde ◽  
Patrick Royston ◽  
...  
Keyword(s):  
Axial Spondyloarthritis ◽  
Cross Sectional Study ◽  
Reference Intervals ◽  
Spinal Mobility ◽  
Cross Sectional ◽  
Percentile Curves ◽  
Normal Individuals ◽  
And Gender ◽  
Gender Specific ◽  
Spinal Flexion

ObjectivesTo establish reference intervals (RIs) for spinal mobility measures as recommended for patients with axial spondyloarthritis, and to determine the effect of age, height and gender on spinal mobility, in normal individuals.MethodsA cross-sectional study (MOBILITY) was conducted among normal individuals aged 20–69 years. Recruitment was stratified by gender, age (10-year categories) and height (10 cm categories). Eleven spinal mobility measures were assessed. Age specific RIs and percentiles were derived for each measure.Results393 volunteers were included. All spinal mobility measures decreased with increasing age. Therefore, age specific RIs were developed. The 95% RIs (2.5th and 97.5th percentiles), as well as the 5th, 10th, 25th, 50th, 75th and 90th percentiles for each spinal mobility measure and different ages are presented. Mobility percentile curves were also plotted for each of the measures. For instance, the 95% RI for lateral spinal flexion was 16.2–28.0 cm for a 25-year-old subject, 13.2–25.0 cm for a 45-year-old subject and 10.1–21.9 cm for a 65-year-old subject. After adjustment for age, there was no need for gender specific RIs, while RIs of some measures are height-adjusted.ConclusionsAge specific RIs and percentiles were derived for each of the spinal mobility measures for normal individuals. These may guide clinicians when assessing the mobility of patients with axial spondyloarthritis. The RIs may serve as cut-off levels for ‘normal’ versus ‘abnormal’, whereas the mobility percentile curves may be used to assess the level of mobility of patients with axial spondyloarthritis.

Alternative diagnoses in patients with chronic back pain not diagnosed with axial spondyloarthritis: data from the SPACE cohort

2017 ◽  
pp. annrheumdis-2017-212175
Author(s):  
Zineb Ez-Zaitouni ◽  
Robert B M Landewé ◽  
Désirée van der Heijde ◽  
Floris A van Gaalen
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis

scholarly journals Is a positive family history of spondyloarthritis relevant for diagnosing axial spondyloarthritis once HLA-B27 status is known?

Rheumatology ◽  
2019 ◽  
Vol 58 (9) ◽  
pp. 1649-1654 ◽  
Author(s):  
Miranda van Lunteren ◽  
Désirée van der Heijde ◽  
Alexandre Sepriano ◽  
Inger J Berg ◽  
Maxime Dougados ◽  
...  
Keyword(s):  
Back Pain ◽  
Family History ◽  
Anterior Uveitis ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Positive Family History ◽  
Hla B27 ◽  
Acute Anterior Uveitis ◽  
Negative Results ◽  
History Of

Abstract Objectives A positive family history (PFH) of spondyloarthritis, in particular a PFH of AS or acute anterior uveitis, is associated with HLA-B27 carriership in chronic back pain patients. As it is unknown, the study aimed to investigate if a PFH contributes to diagnosing axial spondyloarthritis (axSpA) once HLA-B27 status is known. Methods In axSpA-suspected patients from the Assessment of SpondyloArthritis international Society (ASAS), DEvenir des Spondyloarthropathies Indifférenciéés Récentes (DESIR) and SPondyloArthritis Caught Early (SPACE) cohorts, logistic regression analyses were performed with HLA-B27 status and PFH according to the ASAS definition (ASAS-PFH) as determinants and clinical axSpA diagnosis as outcome at baseline. Analyses were repeated with a PFH of AS or acute anterior uveitis. Results In total, 1818 patients suspected of axSpA were analysed (ASAS n = 594, DESIR n = 647, and SPACE n = 577). In patients from the ASAS, DESIR and SPACE cohorts, respectively 23%, 39% and 38% had an ASAS-PFH, 52%, 58% and 43% were HLA-B27 positive, and 62%, 47% and 54% were diagnosed with axSpA. HLA-B27 was independently associated with an axSpA diagnosis in each cohort but an ASAS-PFH was not [ASAS cohort: HLA-B27 odds ratio (OR): 6.9 (95% CI: 4.7, 10.2), ASAS-PFH OR: 0.9 (95% CI: 0.6, 1.4); DESIR: HLA-B27 OR: 2.1 (95% CI: 1.5, 2.9), ASAS-PFH OR: 1.0 (95% CI 0.7, 1.3); SPACE: HLA-B27 OR: 10.4 (95% CI: 6.9, 15.7), ASAS-PFH OR: 1.0 (95% CI: 0.7, 1.5)]. Similar negative results were found for PFH of AS and acute anterior uveitis. Conclusion In three independent cohorts with different ethnical backgrounds, ASAS, DESIR and SPACE, a PFH was not associated independently of HLA-B27 with a diagnosis of axSpA. This indicates that in the vast majority of patients presenting with back pain, a PFH does not contribute to the likelihood of an axSpA diagnosis if HLA-B27 status is known.

scholarly journals Identifying patients with axial spondyloarthritis in primary care: how useful are items indicative of inflammatory back pain?

2011 ◽  
Vol 70 (10) ◽  
pp. 1782-1787 ◽  
Author(s):  
A Braun ◽  
E Saracbasi ◽  
J Grifka ◽  
J Schnitker ◽  
J Braun
Keyword(s):  
Primary Care ◽  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age At Onset ◽  
Inflammatory Back Pain ◽  
Single Item ◽  
Inflammatory Drugs ◽  
Waking Up ◽  
Key Questions

BackgroundThe value of clinical items defining inflammatory back pain to identify patients with axial spondyloarthritis (SpA) in primary care is unclear.ObjectiveTo identify predictive clinical parameters for a diagnosis of axial SpA in patients with chronic back pain presenting in primary care.MethodsConsecutive patients aged <45 years (n=950) with back pain for >2 months who presented to orthopaedic surgeons (n=143) were randomised based on four key questions for referral to rheumatologists (n=36) for diagnosis.ResultsThe rheumatologists saw 322 representative patients (mean age 36 years, 50% female, median duration of back pain 30 months). 113 patients (35%) were diagnosed as axial SpA (62% HLA B27+), 47 (15%) as ankylosing spondylitis (AS) and 66 (21%) as axial non-radiographic SpA (nrSpA). Age at onset ≤35 years, improvement by exercise, improvement with non-steroidal anti-inflammatory drugs, waking up in the second half of the night and alternating buttock pain were identified as most relevant for diagnosing axial SpA by multiple regression analysis. Differences between AS and nrSpA were detected. No single item was predictive, but ≥3 items proved useful for good sensitivity and specificity by receiver operating characteristic modelling.ConclusionThis study shows that a preselection in primary care of patients with back pain based on a combination of clinical items is useful to facilitate the diagnosis of axial SpA.

General Practitioners’ Perceptions of Their Ability to Identify and Refer Patients with Suspected Axial Spondyloarthritis: A Qualitative Study

2014 ◽  
Vol 41 (5) ◽  
pp. 897-901 ◽  
Author(s):  
Marloes van Onna ◽  
Simone Gorter ◽  
Aniek van Meerendonk ◽  
Astrid van Tubergen
Keyword(s):  
Back Pain ◽  
Qualitative Study ◽  
General Practitioners ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Inflammatory Back Pain ◽  
Coding System ◽  
Disease Spectrum ◽  
Insidious Onset ◽  
Mechanical Back Pain

Objective.To explore the knowledge, beliefs, and experiences of general practitioners (GP) about inflammatory back pain (IBP) and axial spondyloarthritis (axSpA) and potential barriers for referral of patients suspected of having axSpA.Methods.A qualitative study involving semistructured interviews with GP was conducted. Transcripts of the interviews were independently read and annotated by 2 readers. Illustrative themes were identified and a coding system to categorize the data was developed.Results.Ten GP (all men; mean age 49 yrs) were interviewed. All could adequately describe “classic” ankylosing spondylitis (AS) and mentioned chronic back pain and/or stiffness as key features. All GP thought that AS is almost exclusively diagnosed in men. Six GP knew that there is a difference between mechanical back pain and IBP, but could recall only a limited number of variables indicative of IBP, such as awakening night pain (4 GP), insidious onset of back pain (1 GP), improvement with movement (1 GP), and (morning) stiffness (2 GP). Two GP mentioned peripheral arthritis as other SpA features, none mentioned dactylitis or enthesitis. GP awareness of associated extraarticular manifestations was low. Most GP expressed that (practical) referral measures would be useful.Conclusion.GP are aware of “classic”, but longterm features of axSpA. Knowledge about the disease spectrum and early detection is, however, limited. Addressing these issues in training programs may improve recognition of axSpA in primary care. This may ultimately contribute to earlier referral, diagnosis, and initiation of effective treatment in patients with axSpA.

Advancing Early Identification of Axial Spondyloarthritis: An Interobserver Comparison of Extended Role Practitioners and Rheumatologists

2019 ◽  
Vol 47 (4) ◽  
pp. 524-530 ◽  
Author(s):  
Laura Passalent ◽  
Christopher Hawke ◽  
Daeria O. Lawson ◽  
Ahmed Omar ◽  
Khalid A. Alnaqbi ◽  
...  
Keyword(s):  
Back Pain ◽  
Chronic Back Pain ◽  
Axial Spondyloarthritis ◽  
Age Of Onset ◽  
Clinical Information ◽  
Models Of Care ◽  
Clinical Impression ◽  
Written Form ◽  
Mechanical Back Pain ◽  
Magnetic Resonance Imaging Mri

Objective.To compare clinical impression and confidence of extended role practitioners (ERP) with those of rheumatologists experienced in axial spondyloarthritis (axSpA) according to (1) evaluation of patients with chronic back pain assessed for axSpA; and (2) magnetic resonance imaging (MRI) recommendation for further investigation of these patients.Methods.Patients with ≥ 3 months of back pain and age of onset < 45 years were referred for axSpA evaluation. An ERP assessed consecutive patients and recorded standardized clinical information in written form. Three rheumatologists subsequently evaluated each patient based on the recorded information. Patients were classified as having axSpA or mechanical back pain based on clinical and investigative findings. Level of confidence was noted for classification and MRI indication. Agreement between assessors was evaluated using percentage agreement and κ coefficient.Results.Fifty-seven patients were assessed. Interobserver agreement of clinical impression for all raters was moderate (κ = 0.52). Agreement of clinical impression between ERP and rheumatologists ranged between 71.2% (κ = 0.41) and 79.7% (κ = 0.57). Agreement of clinical impression among rheumatologists ranged from 74.1% (κ = 0.49) to 79.7% (κ = 0.58). All rater agreement for MRI indication was fair (κ = 0.37). ERP agreement with rheumatologist for MRI recommendation ranged from 64.2% (κ = 0.32) to 75% (κ = 0.48). Agreement for MRI indication among rheumatologists ranged from 62.9% (κ = 0.27) to 74% (κ = 0.47). Confidence in clinical impression was similar among all practitioners.Conclusion.ERP with specialty training in inflammatory arthritis demonstrate clinical impressions comparable with those of rheumatologists in the assessment of axSpA. Incorporation of such roles into existing models of care may assist in early detection of axSpA.

scholarly journals Determinants of the patient global assessment of well-being in early axial spondyloarthritis: 5-year longitudinal data from the DESIR cohort

Rheumatology ◽  
2020 ◽  
Vol 60 (1) ◽  
pp. 316-321
Author(s):  
Fumio Hirano ◽  
Désirée van der Heijde ◽  
Floris A van Gaalen ◽  
Robert B M Landewé ◽  
Cécile Gaujoux-Viala ◽  
...  
Keyword(s):  
Back Pain ◽  
Educational Level ◽  
Joint Pain ◽  
Structural Damage ◽  
Axial Spondyloarthritis ◽  
Morning Stiffness ◽  
Well Being ◽  
Spinal Mobility ◽  
Explanatory Variables ◽  
Over Time

Abstract Objectives To investigate the determinants of patient well-being over time, and the influence of age, gender and education in patients with early axial spondyloarthritis (axSpA). Methods Five-year data from DESIR, a cohort of early axSpA, were analysed. The outcome was the BAS-G over 5 years. Generalized estimating equations (GEE) were used to test the relationship between potential explanatory variables from five outcome domains (disease activity, physical function, spinal mobility, structural damage and axial inflammation) and BAS-G over time. Longitudinal relationships were analysed using an autoregressive GEE model. Age, gender and educational level were tested as effect modifiers or confounders. Results A total of 708 patients were included. Higher BASDAI questions on fatigue [β (95% CI): 0.17 (0.13, 0.22)], back pain [0.51 (0.46, 0.56)], peripheral joint pain [0.08 (0.04, 0.12)] and severity of morning stiffness [0.08 (0.03–0.13)], and higher BASFI [0.14 (0.08, 0.19)] were associated with a higher BAS-G. In the autoregressive model, the same variables except for morning stiffness were associated with a worsening in BAS-G. Age, gender and educational level were neither effect modifiers nor confounders. Conclusion A higher level of back pain is associated with a worsening of patient well-being, as are, though to a lesser extent, higher levels of fatigue, peripheral joint pain and physical disability. Age, gender and educational level do not have an impact on these relationships.

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