Prevalence and Impact of Comorbid Widespread Pain in Adults With Chronic Low Back Pain

A Registry-Based Study

John C. Licciardone, DO, MS, MBA; Vishruti Pandya, MBBS, MHA


J Am Board Fam Med. 2020;33(4):541-548. 

In This Article


Nonpersistent or persistent WP was observed in 84% of patients with CLBP over 12 months of followup and was associated with adverse clinical consequences. These findings support the NIH-RTF stance that WP is a key comorbid condition in patients with CLBP, and suggest that WP may be identified with a simple patient self-report item from the NIH-RTF minimum dataset.[4] Epidemiologic studies involving large populations have reported prevalence rates of 5% to 14% for chronic WP and 1% to 3% for fibromyalgia.[13] Among patients with CLBP, 25% met the American College of Rheumatology criteria for chronic WP.[14] Such patients with WP in the latter study were more likely to be female, have longer CLBP duration, and more often report comorbidities such as osteoarthritis and depression than patients without WP. The NIH-RTF item used in our study appears to identify patients at an earlier stage in the WP spectrum because significant associations with sex, CLBP duration, and medical comorbidities were not observed (Table 2).

The gradient in each clinical measure with increasing WP persistence generally remained constant over 12 months, despite ongoing active treatment for CLBP (Figure 2). A possible explanation for this phenomenon is that physicians may not routinely assess the presence and impact of WP when treating patients for localized pain. Consequently, pain management may not adequately address remote pain sites, physical functioning, and other quality-of-life issues relating to such factors as sleep disturbance, anxiety, and depression. However, simply providing a visual display of PROMIS symptom scores to primary care physicians in a busy clinical setting did not improve patient quality-of-life outcomes over 3 months.[15] It remains to be seen if the simpler WP bothersomeness item from the NIH-RTF minimum dataset could be more efficiently and effectively implemented in clinical practice.

Limitations of our study include self-report measures and computation of WP period prevalence rates rather than incidence rates because there were too few patients who were WP-free at baseline to assemble a suitable prospective cohort. Nevertheless, disease registries such as ours may increasingly exploit the historic (ie, retrospective) cohort design to conduct pragmatic studies that assess health care outcomes in real-world settings.[16] Low patient attrition was also a strength of our study.

In summary, annual period prevalence rates of 76% for nonpersistent WP and 8% for persistent WP were observed in patients with CLBP using the NIH-RTF minimum dataset bothersomeness item. Being non-White and having moderate or high levels of pain catastrophizing were significant independent predictors of WP. Generally stable gradients involving greater low back pain intensity and back-related disability and poorer quality of life were observed over 12 months in patients with increasing levels of WP persistence. Greater efforts are needed in primary care to help close these gaps in clinical measures associated with WP.