Mary Ellen Rousseau, CNM, MS; Sarabeth F. Gottlieb, CNM, MSN

Disclosures

J Midwifery Womens Health. 2004;49(6) 

In This Article

Musculoskeletal Pain

The most common musculoskeletal diagnoses include osteoarthritis (19.6%), soft tissue rheumatism (6.1%), low back pain (5.7%), rheumatoid arthritis (2.7%), fibromyalgia (0.7%), and systemic lupus erythematosus (0.7%).[10] Musculoskeletal disorders are the fourth most common cause of disability following neuropsychiatric disorders, neoplasms, and cardiovascular disease.[11] Women suffer disproportionately from clinical pain conditions such as fibromyalgia and rheumatoid arthritis.[12] Although sex-related factors, including gonadal hormones, influence pain and analgesic response, these represent only one set of variables that affect the occurrence of pain in women; others include age, level of physical activity, body mass index (BMI), smoking, parity, vertebral fractures, diabetes, arthritis, and psychosocial status.

Muscle and joint pain are common complaints throughout life. Low back pain in particular is associated with a large proportion of annual health care expenditures for both men and women. Back and spine impairments are more common in women than men (73.3 versus 57.7 per 1000 population) and are most common between the ages of 45 and 64.[13] Lifetime prevalence of back pain exceeds 70%,[14] with an annual cost in the United States estimated to be from $38 billion to more than $50 billion.[15] Age, smoking, parity, and occupation are also associated with back pain in women. Female sex hormones, such as high levels of estrogen, may promote joint laxity, thereby increasing the risk of back pain.[16] Although there is no difference in reported back pain between women taking oral contraceptives (OCs) and those who do not, a longitudinal study of back pain and radiological changes in the lumbar spines of middle-aged women reported that postmenopausal women who have a history of OC use were at increased risk for back pain compared with those who had no history of OC use.[17]

Although back pain occurs in both younger and older women, some women experience an increase in back pain during the menopausal transition, and women often attribute the complaints to menopause. Women using HT have a slightly increased risk of back problems compared with non-users, but the difference between the two groups is small and probably of minimal clinical significance.[18] It should be noted that African-American women traditionally have been excluded from most studies of back pain because of the known lower incidence of osteoporotic fractures in this population.

Back exercise, general exercise, stretching, and heat and cold therapy have been effective for relief of back pain. Weight reduction is essential in the obese woman with back pain.[19] However, the more disabling the pain, the more difficult it is for women to move. Individuals may then be caught in a vicious cycle: without movement, the ability to burn calories sufficient for weight loss is impeded, and both weight and pain will increase.

Osteoarthritis (OA) is a degenerative process involving all of the major joint tissues. It is not solely a women's issue, because the condition ultimately affects 8 of 10 elderly individuals of both sexes. Before the age of 50, OA of the knee is more frequent in men, but later in life, the incidence increases more rapidly in women. This finding suggests a relationship with menopause. However, there are no prospective studies that have specifically assessed the effect of natural menopause on OA, and no randomized controlled trials have been designed to examine whether HT has an impact on the disease incidence or progression.[20] Risk factors for OA include aging, obesity, previous injury, repetitive trauma, and congenital anomalies. The increasing epidemic of obesity in the developed world makes obesity one of the most important preventable risk factors for OA in the hips and knees and consequent disability.

Women with OA have varying levels of endogenous estrone and estradiol. The concentration of sex hormone-binding globulin (SHBG) has been reported to be lower in women with generalized OA than in women without OA, which suggests that the levels of "free" circulating estrogen may be higher in affected women.[21] Some studies have found no relationship between estrogen concentrations and OA; other reports suggest an association between OA and higher than average testosterone concentrations.[21] In contrast, some investigators suggest that premenopausal free estrogen levels offer a protective effect. This is based on observations that OA often first appears during the menopause transition when estradiol levels are reduced. Both in vivo and in vitro studies suggest that estrogen may be chondro-destructive through the up-regulation of estrogen receptors.[22] Studies of OA involving women undergoing surgical menopause and using HT are for the most part contradictory in conclusions.

Part of the problem may be that OA itself is not well defined. In addition, the literature on the relationship between OA and hormones is confounded by lack of specificity of the hormonal milieu itself. Time of cycle, years from menopause, type of menopause, use of HT and the duration, type, and route of HT have not been sufficiently well defined in studies to provide information about the association between OA pain and menopause. A more complete understanding of this problem is of great importance. By age 60, the female population is significantly affected by OA; this has a major impact on the quality of life for older women.

In general, women continue to increase their body mass until age 60 to 70; after this age, body mass tends to decrease.[23] With more than 50% of the US population overweight and 20% considered obese, the most important clinical intervention with regard to OA is to educate women about maintaining their recommended weight or setting realistic goals for weight loss. BMI is positively associated with increased pain in the joints of the leg, foot, ankle, and knee.[24] Clinicians should advise life style changes, which include both reaching ideal BMI as well as exercising to keep joints moving. Instructions in joint protection, exercise to improve fitness, and recommendations for weight loss are the mainstays for nonpharmacologic treatment of OA. Small steps in the direction of weight loss and exercise are recommended so that the patient does not get discouraged. Clinicians can offer frequent follow-up visits to review progress and offer encouragement. For some populations of women, referrals to nutrition and exercise programs are possible. Participation in community-based education programs for only a few hours a week has proven successful in decreasing pain, disability, and depression.[25] Brandt suggests that if knowledge alone were sufficient, few individuals would be obese; good patient education combines the provision of knowledge with the development of skills in problem solving and with motivational activities.[25] In the busy clinic, too often these principles and the opportunities to put them into practice are overlooked.

Over the past 30 years, NSAIDs have been used for OA pain relief with only modest improvement over placebos and about as effective as acetaminophen.[25] Cox-1-sparing NSAIDs (COXIBS) were developed to avoid the gastrointestinal problems seen with NSAIDs. Although the gastrointestinal symptoms are seen less often, many people taking COXIBS are also taking aspirin for cardiac disease protection. This mitigates the gastrointestinal advantage of the COXIB over nonselective NSAIDs such as ibuprofen. Furthermore, COXIBS can lead to retention of salt and water, which may contribute to edema, congestive heart failure, and hypertension.[25] Glucosamine and chondroitin sulfate are popular options for treating the pain of OA. Widely available in grocery stores and pharmacies, neither is approved for treatment of OA by the US Food and Drug Administration (FDA). Although several studies suggest efficacy, there are no large well-designed, placebo-controlled trials.[26] A multicenter study is currently underway to compare the efficacy of glucosamine, chondroitin sulfate, the combination of glucosamine and chondroitin, or celecoxib (Celebrex) with placebo in patients with OA of the knee.[25]

Other nonpharmacologic interventions for women suffering from joint and muscle pain include instruction in principles of joint protection, weight loss, exercise to improve fitness, proprioception, and thermal modalities. Referral to a podiatrist for orthotics or to a physical therapist for exercises to strengthen periarticular muscles are important options to consider. Coupled with NSAIDs and/or glucosamine and chondroitin as first-line pharmacologic interventions, a comprehensive management program can improve health and quality of life for many women with back pain and osteoarthritis.

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