Pictured
The epidemiology of chronic pain
Gary J. Macfarlanea,b
1. Descriptive epidemiology of chronic pain
Epidemiological studies have demonstrated that, within the
past month, around half us will have experienced an episode
of pain which has lasted at least 1 day, with the most common
sites reported, in a United Kingdom population study, being
the low back (30%), hip (25%), neck and shoulder (25%) and
knee (24%).9 Using a more stringent definition (suffered pain
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for 6 months, experienced pain in the last month and several
times during the last week), a pan-European study reported a
prevalence of 19%.1
Prevalence of chronic pain increases through adult life, reach-
ing a peak around the seventh decade (eg, Ref. 5). Pain at some
regional sites, particularly in the lower limb, increase in preva-
lence across the age range (eg, Ref. 12), whereas some such
as low back pain decrease at older ages.3 Such a decrease has
been hypothesised to be related to changes in pain perception,
expectation of pain at older ages and comorbidities. Chronic
pain may be related to premature mortality; a review of studies
showed a relationship with cancer and cardiovascular death11
which may partly be related to lifestyle factors such as low levels
of physical activity and poor quality diet.14
2. Early life factors in the aetiology of chronic pain
Early life factors have been linked to chronic pain in adult-
hood. Although retrospective studies are subject to recall bias,
which has been shown to occur, long-term prospective studies
demonstrate an increased risk of chronic pain in adulthood relat-
ed to social environment in childhood (raised in care, death of a
parent) as well as physically traumatic events such as premature
birth, very low birth weight,8 and hospitalisation for a motor vehi-
cle accident at young ages.6
3. Mechanisms mediating the relationship between
early life factors and adult chronic pain
Clinical studies have demonstrated that physical stresses (eg,
preterm birth) result in altered function of the stress-response
axis and such perturbations are still present at age 18 months.4
Amongst preterm infants, neonatal procedure-related stress
predicted cortisol levels at age 7 years.2 This gave rise to the
hypothesis that among persons experiencing “stressful” early
life events, altered function of the Hypothalamic–Pituitary–Adre-
nal axis may be an important mediator of pain onset, and this
has been confirmed in a prospective population-based study.10
The author has no conflicts of interest to declare.
a
Epidemiology Group, School of Medicine, Medical Sciences and Nutrition,
University of Aberdeen, United Kingdom bAberdeen Centre for Arthritis and
Musculoskeletal Health, University of Aberdeen, United Kingdom
*Corresponding author. Address: University of Aberdeen, United Kingdom.
E-mail address: g.j.macfarlane@abdn.ac.uk (G. J. Macfarlane).
http://dx.doi.org/10.1097/j.pain.0000000000000676
2158 G.J. Macfarlane • 157 (2016) 2158–2159
Risk is likely to involve both genetic and environmental effects
although it is likely that many genes, all with small effects, will
be involved.15
4. Predicting outcome of an episode pain
A key issue for epidemiologists is identifying, amongst those with
a new episode of pain, in whom the pain is likely to become
chronic. Focussing early management on these people is likely
to optimise cost effectiveness of management approaches. A
review of factors preceding transition from acute to chronic pain
identified clinical factors, older age, and mood as the factors with
strongest evidence for long-term disability or work absence,13
and tools such as the Orebro Screening Questionnaire seek to
capture such factors (and wider psychosocial factors) in terms of
predicting risk of poor outcome.7
References
[1] Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of
chronic pain in Europe: prevalence, impact on daily life, and treatment.
Eur J Pain 2006;10:287–333.
[2] Brummelte S, Chau CM, Cepeda IL, Degenhardt A, Weinberg J, Synnes
AR, Grunau RE. Cortisol levels in former preterm children at school age
are predicted by neonatal procedural pain-related stress. Psychoneuro-
endocrinology 2015;51:151–63.
[3] Dionne CE, Dunn KM, Croft PR. Does back pain prevalence really decrease
with increasing age? A systematic review. Age Ageing 2006;35:229–34.
[4] Grunau RE, Haley DW, Whitfield MF, Weinberg J, Yu W, Thiessen P. Al-
tered basal cortisol levels at 3, 6, 8 and 18 months in infants born at
extremely low gestational age. J Pediatr 2007;150:151–6.
[5] Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence
of chronic pain in United States adults: results of an Internet-based sur-
vey. J Pain 2010;11:1230–9.
[6] Jones GT, Power C, Macfarlane GJ. Adverse events in childhood and
chronic widespread pain in adult life: results from the 1958 British Birth
Cohort Study. PAIN 2009;143:92–6.
[7] Linton SJ, Boersma K. Early identification of patients at risk of developing
a persistent back problem: the predictive validity of the Orebro Musculo-
skeletal Pain Questionnaire. Clin J Pain 2003;19:80–6.
[8] Littlejohn C, Pang D, Power C, Macfarlane GJ, Jones GT. Is there an
association between preterm birth or low birthweight and chronic wide-
spread pain? Results from the 1958 Birth Cohort Study. Eur J Pain
2012;16:134–9.
[9] Macfarlane GJ, Beasley M, Smith BH, Jones GT, Macfarlane TV. Can
large surveys conducted on highly selected populations provide valid in-
formation on the epidemiology of common health conditions? an analysis
of UK Biobank data on musculoskeletal pain. Br J Pain 2015;9:203–12.
[10] McBeth J, Silman AJ, Gupta A, Chiu YH, Ray D, Morriss R, Dickens C,
King Y, Macfarlane GJ. Moderation of psychosocial risk factors through
dysfunction of the hypothalamic-pituitary-adrenal stress axis in the on-
set of chronic widespread musculoskeletal pain: findings of a popula-
tion-based prospective cohort study. Arthritis Rheum 2007;56:360–71.
[11] Smith D, Wilkie R, Uthman O, Jordan JL, McBeth J. Chronic pain and
mortality: a systematic review. PLoS One 2014;9:e99048.
[12] Urwin M, Symmons D, Allison T, Brammah T, Busby H, Roxby M, Sim-
mons A, Williams G. Estimating the burden of musculoskeletal disorders
in the community: the comparative prevalence of symptoms at different
anatomical sites, and the relation to social deprivation. Ann Rheum Dis
1998;57:649–55.
[13] Valentin GH, Pilegaard MS, Vaegter HB, Rosendal M, Ørtenblad L, Væg-
gemose U, Christensen R. Prognostic factors for disability and sick leave
in patients with subacute non-malignant pain: a systematic review of co-
hort studies. BMJ Open 2016;6:e007616.
[14] Vandenkerkhof EG, Macdonald HM, Jones GT, Power C, Macfarlane GJ.
Diet, lifestyle and chronic widespread pain: results from the 1958 British
Birth Cohort Study. Pain Res Manag 2011;16:87–92.
[15] Zorina-Lichtenwalter K, Meloto CB, Khoury S, Diatchenko LB. Genet-
ic predictors of human chronic pain conditions. Neuroscience 2016. pii:
S0306-4522(16)30126-9.
PAIN®
 Childhood Chronic pain in adulthood
Adverse family and social environment

Neck and

Prevalence
shoulder 25%

Age

Lower back 30%

Hip 25% Risk markers and factors

Knee 24% • Injury
• Altered mood
Physical trauma • Poor sleep
• Psychosocial environment
• Female gender

One month period prevalence

Predictors of pain episode

long-term disability
• Clinical factors (severe and
multi-site pain, longer pain duration)
• Older age
• Depression and anxiety
• Occupational factors
Biological mediators of pain onset • Female gender

Genetics axis Stress response

M.
D.
Salivary cortisol

am pm
Day

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