Prevalence and characteristics of chronic musculoskeletal pain in Japan: A second survey of people with or without chronic pain

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1 J Orthop Sci (2014) 19: DOI /s ORIGINAL ARTICLE Prevlence nd chrcteristics of chronic musculoskeletl pin in Jpn: A second survey of people with or without chronic pin Msy Nkmur Yuji Nishiwki Tkhiro Ushid Yoshiki Toym Received: 7 April 2013 / Accepted: 16 Decemer 2013 / Pulished online: 7 Ferury 2014 Ó The Author(s) This rticle is pulished with open ccess t Springerlink.com Astrct Bckground An epidemiologicl survey conducted in Jpn in fiscl yer 2010 reveled high prevlence of chronic musculoskeletl pin, low ptient stisfction with tretment, high incidence of protrcted tretment lsting yer or more, nd reduced qulity of life. To improve the current system for treting chronic musculoskeletl pin, it is importnt to identify risk fctors, including ptient chrcteristics, for developing chronic pin. Thus, we sought to determine the incidence of new chronic pin in the Jpnese popultion, s well s the persistence rte, ssocited fctors, nd current stte of tretment of chronic pin, y repeting postl survey in ntionwide representtive smple group first surveyed in Methods Among 11,507 prticipnts in the 2010 epidemiologicl survey, 1,717 reported chronic pin nd 6,283 reported no chronic pin. A repet questionnire, miled to sujects in these 2 groups in fiscl yer 2011, received replies from 85 % of those who reported pin nd 76 % of those without pin in Results The incidence of new chronic pin ws 11.1 %. Risk fctors for developing chronic pin included working in professionl, mngeril, or clericl/specilist M. Nkmur (&) Y. Toym Deprtment of Orthopedic Surgery, School of Medicine, Keio University, 35 Shinnomchi, Shinjuku, Tokyo , Jpn e-mil: ms@8.keio.jp Y. Nishiwki Deprtment of Environmentl nd Occuptionl Helth, School of Medicine, Toho University, Ot, Tokyo, Jpn T. Ushid Multidisciplinry Pin Center, Aichi Medicl University, Ngkute, Aichi, Jpn occuption, eing femle, hving BMI C25; currently using lcohol or cigrettes; nd hving completed n eduction level of voctionl school or higher. Persistent chronic pin ws reported y 45.2 % of respondents. Those with severe (VAS score C7) nd constnt lower-ck pin lsting more thn 5 yers hd the highest risk of the pin persisting. More thn 80 % respondents with persistent chronic pin hd history of tretment, nd while out 30 % were still receiving tretment t the time of the survey, the other 50 % hd discontinued tretment despite the persistence of pin ecuse of low degree of stisfction with tretment. Discussion We identified risk fctors relted to the development of new chronic pin nd the persistence of chronic pin. Countermesures to prevent chronic pin could e especilly importnt for the high-risk popultions for understnding the pthology of chronic pin. Introduction The Ntionl Livelihood Survey found motor-orgn pin in the form of low ck pin, stiff shoulders, nd rthrlgi to e the most common symptoms [1] suffered y the Jpnese pulic. However, we do not know enough out these symptoms, even t sic level, to crete effective strtegies to counterct chronic pin in our country. The Survey Study on Chronic Musculoskeletl Pin, conducted in Jpn in 2010, found tht chronic musculoskeletl pin hd symptom prevlence of 15.4 % nd tht 42 % of people reporting chronic musculoskeletl pin hd received tretment. The tretment period ecme protrcted, lsting yer or more, in 70 % of those who were treted, nd ptient stisfction with tretment ws low. We lso found tht chronic musculoskeletl pin strongly impcted the

2 340 M. Nkmur et l. sufferer s life through oth loss of socil ctivity nd long-term increse in the degree of ssistnce needed in dily life nd lso strongly ffected the lives of people round the one suffering pin in Jpn [2]. This emphsizes the importnce of identifying the chrcteristics nd risk fctors of ptients whose pin ecomes chronic, nd estlishing preventive mesures. In the present study, we repeted postl survey of representtive ntionwide smple to exmine the incidence of new chronic pin, the chronic pin persistence rte, fctors ssocited with chronic pin, nd the ctul stte of tretment for those with persistent, chronic pin in Jpn. Methods The originl survey group, ntionwide, rndomly selected smple, ws chosen in 2010 through the Mil-in Survey Pnel mintined y the Nippon Reserch Center [2]. The Pnel is sed on rndomly selected ddresssed smple with gender nd ge distriutions similr to those in the ntionl popultion census. To crete miling ddress smple tht reflected the demogrphic composition of the Jpnese popultion, sujects were specified s eing residents of Jpn who were 18 or more yers of ge, nd quots were set for gender, ge, nd regionl distriution to correspond to the popultion s whole. The 2010 survey included 11,507 sujects, of which 1,770 reported chronic pin nd the others reported no chronic pin. We miled repet questionnire to these 2 groups in 2011, nd otined replies from 1,460 of those who hd reported chronic pin (reply rte 82.5 %) nd 4,797 of those who did not hve chronic pin (reply rte 76 %) t the time of the 2010 survey. Besides such sic informtion s gender, ge, loction of residence, nd occuption, our questionnire sked out the severity, loction, nd durtion of chronic musculoskeletl pin, whether the pin ws treted, nd out the fcility where tretment ws received, the nture of the tretment, the tretment period nd effectiveness, nd the ptient s degree of stisfction. In oth the 2010 nd 2011 surveys, musculoskeletl pin ws defined s pin ssocited with one, muscle, joints, or nerves t ech of 11 ntomicl sites (neck, ck, low ck, shoulder, elow, wrist/hnd, rm, hip, knee, nkle/foot nd leg) (Fig. 1), nd chronic pin ws lso defined s pin experienced t lest once in the pst 30 dys, with severity score of 5 or more on visul nlogue scle (VAS), nd persisting for 6 months or more. We clculted the incidence rte of new chronic pin sed on the 4,797 persons who did not hve chronic pin in fiscl 2010, nd the chronic pin persistence rte sed on the 1,460 persons who hd reported chronic pin in fiscl Incidence rtes nd persistence rtes were Fig. 1 The full-ody mnikin used in the pin-ssocited epidemiologicl survey. 1 neck, 2 shoulder, 3 elow, 4 wrist/hnd, 5 rm, 6 ck, 7 low ck, 8 hip, 9 knee, 10 nkle/foot, 11 leg clculted ccording to the individul fctors such s gender, re of residence, nd urn size, nd occurrence rtes were compred y the v 2 test. In ddition to gender nd ge, significntly ssocited fctors identified y the crude odds rtio (p \ 0.1) were ultimtely included in multivrite nlysis (logistic regression nlysis), nd djusted odds rtios were clculted. Fctors for which the crude odds rtio did not find n ssocition were lso incorported into the finl model, one y one, to check their effect. We evluted the tretment circumstnces in detil for respondents who reported persistent chronic pin, including whether the pin ws treted, the type of treting fcility, the nture nd effectiveness of the tretment, the suject s degree of stisfction, nd whether the ptient chnged tretment fcilities. This study ws pproved y the IRB of Keio University.

3 Chronic musculoskeletl pin in Jpn 341 Tle 1 Incidence of chronic pin y fctors Numer Incidence (%) Crude OR Multivrite-djusted OR All 531/ Gender Men 220/ Women 311/ ( ) ( ) Age / / ( ) ( ) / ( ) ( ) / ( ) ( ) / ( ) ( ) / ( ) ( ) / ( ) ( ) Are Hokkido 27/ Touhoku 32/ ( ) ( ) Knto 204/ ( ) ( ) Chuu 55/ ( ) ( ) Hokuriku 17/ ( ) ( ) Kinki 101/ ( ) ( ) Chugoku 38/ ( ) ( ) Shikoku 8/ ( ) ( ) Kyushu 49/ ( ) ( ) City size 500,000^ 180/ ,000^ 163/ ( ) ( ) \150, / ( ) ( ) County 39/ ( ) ( ) No nswer 7/ ( ) ( ) Occuption Others 346/ Professionl, mnger, clericl, nd skill 183/ ( ) \ ( ) Mritl sttus Divorced/widowed/single 100/ Mrried 427/ ( ) ( ) Living condition Alone 28/ Not lone 497/ ( ) BMI ctegory / ( ) ( ) / / ( ) ( ) Alcohol drinking c Never 197/ Ex-drinker 49/ ( ) ( ) Current drinker 282/ ( ) ( ) Smoking c Never 335/ Ex-drinker 74/ ( ) ( ) 0.567

4 342 M. Nkmur et l. Tle 1 continued Numer Incidence (%) Crude OR Multivrite-djusted OR Current drinker 119/ ( ) ( ) Eduction High school or lower 241/ Technicl or higher 287/ ( ) ( ) Income -3,990, / ,000,000 7,990, / ( ) ,000,000 9,990,000 60/ ( ) ,000,000 48/ ( ) c dding to ge ctegory nd sex, vriles which hd sttisticlly significnt influence on odds rtio were included in the model griculture, forestry, nd fisheries/independent usiness/prt-time worker/full-time homemker/student/inoccuption lcohol drinking nd smoking were ctegorized into three ctegories [never, ex (used to), nd currently smoking] sed on the questionnire Results Incidence rte nd risk fctors for new chronic pin Among the 4,797 people who did not hve chronic pin in 2010, 531 reported newly developed chronic pin in the 2011 survey; the incidence rte ws 11.1 %. Tle 1 shows the incidence rtes ccording to individul fctors. Crude nlysis suggested ssocitions etween the development of chronic pin nd ge, re, city size, occuption, mritl sttus, BMI ctegory, lcohol use, smoking, nd eduction history. Multivrite nlysis identified sttisticlly significnt ssocitions with gender (femle), occuption (professionl, mngeril, clericl/specilist), BMI C25, current lcohol or cigrette use, nd highest-completed eduction level of voctionl school or higher (Tle 1). Persistence rte for chronic pin, nd risk fctors for persistence Of the 1,460 persons who reported chronic pin in 2010, 660 reported its persistence in the 2011 survey (45.2 %). Tle 2 shows persistence rtes ccording to individul fctors. Crude nlysis suggested ssocitions etween pin persistence nd ge, re, occuption, mritl sttus, nd household income, nd the pin site, severity, frequency nd durtion nd chnge of prctice s reported on the 2010 survey. Multivrite nlysis identified sttisticlly significnt ssocitions with the following fctors in the 2010 survey: pin VAS score of 7 8, constnt pin, pin persistence for 5 yers or more, nd pin site in the lower ck (Tle 2). Although the for the crude nlysis of chnge of prctice ws 0.082, it is not included in the multivrite nlysis ecuse this gretly reduced the smple size. Even if we forcily included this vrile of the model, it did not show sttisticlly significnt result (p = 0.299). The stte of tretment for persistent chronic pin Chrcteristics of initil tretment Although 31.7 % of the people with persistent chronic pin reported ongoing tretment for pin, 50.6 % hd received tretment in the pst ut were no longer eing treted, nd 15.3 % hd never received tretment (Fig. 2). Approximtely 60 % of those with persistent chronic pin nd history of tretment were initilly treted t medicl fcility such s n orthopedic surgery deprtment or surgery deprtment, nd the others were initilly treted with folk medicines such s chiroprctic, osteopthy, mssge, or cupuncture/moxiustion (Fig. 2). The most common type of initil tretment ws physicl therpy (28 %), followed y mssge (26 %), mediction (22 %), nd orthotic tretment (8 %) (Fig. 2c). The most common tretment frequencies were once nd severl times weekly (pproximtely 30 % ech), followed y once every 2 weeks or less, nd dily (Fig. 3). The most common tretment durtion, reported y 40 %, ws yer or longer (Fig. 3). Effectiveness of initil tretment nd degree of ptient stisfction Of the respondents who were initilly treted t medicl fcility, the pin ws improved in 7 %, somewht improved in 54 %, unchnged in 33 %, somewht ggrvted in 2 %, nd ggrvted in 1 % y the tretment received (Fig. 4). Only 6 % reported tht they were very stisfied with the tretment received; 28 % were somewht stisfied, 35 % were neither stisfied nor disstisfied, 20 %

5 Chronic musculoskeletl pin in Jpn 343 Tle 2 Continunce rte of pin y fctors Numer Continunce rte for v 2 test Crude OR Multivrite-djusted OR All 660/ % Gender Men 248/ % p = Women 412/ % 1.08 ( ) ( ) Age / % p \ / % 0.66 ( ) ( ) / % 0.82 ( ) ( ) / % 0.63 ( ) ( ) / % 0.5 ( ) ( ) / % 0.45 ( ) ( ) / % 0.15 ( ) ( ) Are Hokkido 32/ % p = Touhoku 41/ % 0.94 ( ) ( ) Knto 264/ % 0.84 ( ) ( ) Chuu 85/ % 0.92 ( ) ( ) Hokuriku 28/ % 1.16 ( ) ( ) Kinki 101/ % 0.80 ( ) ( ) Chugoku 33/ % 0.68 ( ) ( ) Shikoku 12/ % 0.46 ( ) ( ) Kyushu 64/ % 0.96 ( ) ( ) City size 500,000^ 220/ % p = ,000^ 206/ % 0.84 ( ) \150, / % 0.89 ( ) County 52/ % 0.91 ( ) Occuption Others 491/ % p = Professionl, mnger, 169/ % 1.49 ( ) ( ) clericl, nd skill Mritl sttus Divorced/widowed/single 156/ % p = Mrried 503/ % 0.64 ( ) ( ) Living condition Alone 36/ % p = Not lone 622/ % 0.77 ( ) BMI ctegory / % p = ( ) / % / % 1.08 ( ) Alcohol drinking c Never 253/ % p = Ex-drinker 83/ % 1.29 ( ) Current drinker 322/ % 1.16 ( ) Smoking c Never 413/ % p = Ex-drinker 101/ % 0.98 ( ) 0.893

6 344 M. Nkmur et l. Tle 2 continued Numer Continunce rte for v 2 test Crude OR Multivrite-djusted OR Current drinker 145/ % 1.12 ( ) Eduction High school or lower 317/ % p = Technicl or higher 339/ % 1.07 ( ) Income of fmily -3,990, / % p = ,000,000 7,990, / % 1.1 ( ) ( ) ,000,000 9,990,000 63/ % 0.97 ( ) ( ) ,000,000 80/ % 1.47 ( ) ( ) Strength of pin (VAS) / % p = / % 1.54 ( ) \ ( ) / % 1.21 ( ) ( ) Frequency of pin 2 3 times/week 141/ % p \ Once/dy 100/ % 1.1 ( ) ( ) Alwys 419/ % 2.13 ( ) \ ( ) \0.001 Durtion of pin \3 yers 152/ % p \ yers 89/ % 1.31 ( ) ( ) yers 145/ % 2.14 ( ) \ ( ) \ yers 274/ % 1.87 ( ) \ ( ) \0.001 Site of pin Others 81/ % p = Neck 131/ % 1.6 ( ) ( ) Shoulder 115/ % 1.2 ( ) ( ) Low ck 207/ % 1.65 ( ) ( ) Knee 32/ % 0.78 ( ) ( ) Tretment None 342/ % p = At hospitl/clinic 134/ % 1.11 ( ) At folk remedy 139/ % 1.14 ( ) Both 26/ % 1.39 ( ) Chnge of prctice No 126/ % p = Yes 144/ % 1.34 ( ) d c d dding to ge ctegory nd sex, vriles which hd sttisticlly significnt influence on odds rtio were included in the model griculture, forestry, nd fisheries/independent usiness/prt-time worker/full-time homemker/student/inoccuption lcohol drinking nd smoking were ctegorized into three ctegories (never, ex (used to), nd currently smoking) sed on the questionnire p for crude nlysis of chnge of prctice ws 0.082, ut not included in the multivrite nlysis ecuse this reduced smple size were somewht disstisfied, nd 10 % were very disstisfied (Fig. 4). When compred y the type of tretment provider, 20 % of those treted t medicl fcilities such s n orthopedics or surgery deprtment reported eing very or somewht stisfied; however, 50 % of those who used folk medicine such s chiroprctic, osteopthy, mssge, or cupuncture/moxiustion, reported eing very or somewht stisfied (Fig. 5). Thus, the degree of stisfction with folk medicine tretments ws higher thn with tretments received t medicl fcilities.

7 Chronic musculoskeletl pin in Jpn 345 Fig. 2 Tretments received for persistent, chronic pin: tretment circumstnces, initil tretment fcility, nd c nture of the initil tretment c Circumstnces regrding chnges in tretment fcility Approximtely 60 % of the persons who hd een treted for pin hd chnged tretment fcilities. Of these, 31 % hd chnged once, 28 % hd chnged twice, 22 % hd chnged 3 times, nd, of prticulr note, high proportion, 15 %, hd chnged 5 or more times. The most common reson for chnging, given y 40 %, ws disstisfction with the previous tretment, which is consistent with the low degree of stisfction reported (Fig. 6). A review of the dt of the initil nd most-recent tretment fcilities showed tht the use of conventionl medicl fcilities decresed to less thn hlf of the initil frequency, wheres hrdly ny decrese in folk medicine tretment ws oserved (Fig. 7). Reflecting these results, the most common most-recent tretments reported were mssge for 34 %, physicl therpy for 21 %, nd cupuncture/moxiustion for 8 %, therey ccounting for out 60 % of the ptients who received tretment. Mediction ws the most recent tretment for 18 %, nerve lock therpy for 4 %, nd orthotic tretment for 6 % (Fig. 7). The most common reson given for discontinuing tretment ws, ecuse it wsn t effective (30 %), followed y, I didn t hve the time, I couldn t fford it, nd, I thought I could tke cre of it myself (Fig. 7c). Actul sttus of persons with persistent, untreted chronic pin Approximtely 15 % of the respondents reporting persistent chronic pin hd never received tretment (Fig. 2). The most common resons given for not seeking tretment

8 346 M. Nkmur et l. Fig. 3 Frequency nd durtion of tretment for persistent chronic pin: tretment frequency nd durtion were, I thought I could tke cre of it myself (24 %) nd, I didn t think tretment ws necessry (16 %), indicting indequte recognition or knowledge of chronic pin. Another 24 % chose, I didn t expect tretment to e effective, indicting low expecttion for successful tretment for chronic pin (Fig. 8). Approximtely 40 % of the respondents with untreted chronic pin coped y using non-prescription drugs, helth foods, or supplements, or tried to improve their diet or lifestyle. Discussion New development of chronic musculoskeletl pin The incidence rte of new chronic musculoskeletl pin mong those who did not hve chronic pin the previous yer ws 11.1 %, nd in ctulity, 1 in 10 persons met the criteri for newly developed chronic pin. On the other hnd, the prevlence rte of chronic pin clculted the previous fiscl yer ws 15.4 %, indicting tht much of Fig. 4 Initil tretment t medicl fcility for chronic pin: effectiveness nd ptients degree of stisfction the chronic pin tht met the criteri t tht time resolved reltively quickly. Prevlence is generlly clculted s prevlence rte = incidence rte 9 durtion of illness; when the corresponding figures were inserted into the eqution, the durtion of chronic pin ws 1.4 yers. In other words, ccording to this clcultion, chronic pin resolves in out yer nd hlf on verge. However, this should e interpreted with cution, since it mens tht the pin no longer meets the criterion for chronic pin fter out yer nd hlf, not tht the pin hs completely resolved. In ddition, cution is required ecuse 48 % of

9 Chronic musculoskeletl pin in Jpn 347 Fig. 5 Ptient stisfction with initil tretment, y type of tretment fcility those reporting pin in the 2010 survey sid tht the pin hd persisted for 3 yers or longer. This study identified the following risk fctors for the new development of chronic pin: femle gender, occuption (professionl, mngeril, clericl/specilist), BMI C25, current use of lcohol, current use of cigrettes, nd completing n eduction level of voctionl school or higher. As mny diseses re ssocited with low socioeconomic sttus [3], it is very interesting tht chronic pin ws insted ssocited with high socioeconomic sttus, including professionl occuptions, nd higher levels of eduction. By occuption, mngeril, professionl, nd technicl work ctegories hd the highest incidence. The lower ck ws the most frequently reported site of pin. Previous studies demonstrted tht occuptionl fctors, such s long periods of sedentry posture nd psychologicl fctors due to disstisfction with work sitution, supervisor, or ded-end jo nd oredom, pper to promote the development of new chronic pin [4, 5]. Furthermore, the recent studies demonstrted tht the psychosocil fctors ply importnt roles in chronic musculoskeletl pin [6 8]. Becuse the limittion of the present study ws tht the psychosocil fctors were not exmined, further study should e performed to clrify the Fig. 6 Circumstnces of chnges in tretment fcility: whether chnged, numer of chnges, nd c reson for chnging c

10 348 M. Nkmur et l. c Fig. 7 Detils of chnges in tretment fcility: initil nd most-recent tretment fcility, type of most recent tretment, nd c reson for discontinuing tretment effects of these fctors on the chronic musculoskeletl pin in the future. Tken together, consistent with the previous studies [9 12], the reltionship etween musculoskeletl pin nd the identified fctors such s femle gender, high BMI nd smoking my e explined in prt y shred risk fctors, oth physicl nd psychosocil [13, 14]. The mechnism involved in the current identifiction of lcohol use s risk fctor for new development of chronic pin is unknown. Persistence of chronic musculoskeletl pin The results showed tht 45 % of the respondents who reported chronic pin in 2010 lso reported chronic pin in It is possile tht people who suffered from chronic pin through the entire period were more inclined to reply to the second questionnire; thus, we cnnot rule out the possiility tht 45 % is n overestimtion, even though the reply rte ws 85 %. Multivrite nlysis did not find ny

11 Chronic musculoskeletl pin in Jpn 349 Fig. 8 Resons given for not seeking tretment for persistent chronic pin ssocitions etween the persistence of chronic pin nd sic ttriutes such s ge nd gender; the only ssocited fctors were relted to the pin itself. A pin severity VAS score of 7 8 ws sttisticlly significnt. Although the odds rtio incresed to 1.30 with the more severe pin reflected in VAS scores of 9 10, it did not rech sttisticl significnce, perhps ecuse the smple size for this group ws so smll. The risk of chronic pin persisting yer lter ws twice s high mong persons who hd complined of constnt pin compred to those who hd reported frequency of 2 3 times week. The odds rtio for pin persistence ws significntly higher for those who reported pin lsting 5 yers or more. Bsed on these findings, those with constnt, severe pin persisting 5 yers or more ppered to e t the highest risk for the persistence of chronic pin 1 yer lter. These findings suggested tht once the pthologicl condition of chronic musculoskeletl pin hs een estlished, it could e quite difficult to relieve the chronic musculoskeletl pin. The risk of pin persisting ws prticulrly high for those whose chief complint ws low ck pin, compred to pin t other sites. Countermesures to prevent chronic pin pper to e especilly importnt for these high-risk popultions. Prolems in treting persons with persistent chronic pin nd countermesures More thn 8 out of 10 people with persistent chronic pin hd history of tretment, nd while 3 of the 8 were still receiving tretment t the time of the survey, the other 5 hd discontinued tretment despite the persistence of pin. Of those who hd een treted for pin, 60 % were initilly treted t medicl fcility; these respondents reported low degree of stisfction even though 75 % hd received frequent (dily or severl times week) tretment, nd 40 % hd een treted long-term ( yer or more). Of prticulr note, results y type of tretment provider showed tht respondents were less stisfied with tretment received t medicl fcilities thn with folk medicine tretment. We thought tht differences in pin severity might e responsile for this finding, ut the verge VAS scores of those treted t medicl fcilities nd those treted with folk medicine were 6.0 nd 5.7, respectively, nd this difference ws not sttisticlly significnt. Other fctors might include tendency towrd unrelisticlly high expecttions of medicl fcilities, nd less communiction nd physicl contct in comprison with folk medicine methods. Additionl surveys will e necessry in order to verify these fctors. More thn 60 % of the respondents with persistent chronic pin hd chnged their tretment fcility; of these, pproximtely 60 % hd chnged once or twice. Surprisingly, 15 % of the respondents with persistent chronic pin chnged 5 or more times, engging in so-clled doctor shopping. A review of the initil nd most-recent tretment fcilities showed tht pproximtely hlf of those initilly exmined in n orthopedics deprtment chnged tretment fcilities, ut no mjor chnge ws seen in those initilly exmined for folk medicine tretment. The results y type of tretment lso showed tht the use of mssge nd cupuncture/moxiustion incresed, ccounting for 42 % of the most-recent tretment types reported. This is consistent with the finding of low degree of stisfction with tretment t medicl fcilities. The recent ntionwide survey of chronic pin sufferers in Jpn lso demonstrted they did not hve high degree of stisfction with medicl tretment [15]. The most common reson given for chnging tretment providers or discontinuing tretment ws, ecuse the tretment ws ineffective, which reflects the indequte effectiveness of the current tretments for chronic musculoskeletl pin. Nociceptive pin, neuropthic pin, nd psychogenic pin re intermingled in chronic musculoskeletl system pin, nd neuropthic pin is involved in chronic low ck pin in prticulr [16]. Without n dequte grsp of the roles these fctors ply in the pthology of pin, tretment my fil ecuse it is not pproprite for the ptient. Furthermore, the recent studies demonstrted tht the psychosocil fctors ply importnt roles in chronic musculoskeletl pin [13, 14]. Becuse the limittion of the present study ws tht the psychosocil fctors were not exmined, further study should e performed to clrify the effects of these fctors on the chronic musculoskeletl pin in the future. Mny people with persistent chronic pin discontinued tretment. Others did not seek tretment, giving resons

12 350 M. Nkmur et l. such s not hving time, thinking they could tke cre of it themselves, not thinking they needed tretment, nd so on. The mjority of the respondents who were not treted for pin reported using non-prescription drugs to cope with the pin. Thus, poor recognition of the seriousness of chronic pin ppers to e prolem. It is reported tht chronic musculoskeletl pin tkes toll on oth mentl nd physicl helth, nd strongly impcts dily nd socil life [2]. However, it cnnot e sid tht this stte of ffirs hs een dequtely conveyed to the Jpnese pulic. We orthopedists, who specilize in treting the musculoskeletl system, hve efore us the importnt tsk of finding wys to relily convey the importnce of treting chronic pin, to oth ptients nd the generl pulic, through pulic wreness cmpigns. Acknowledgments This study ws conducted s 2011 Ministry of Helth, Lour nd Welfre Helth Lour Sciences Reserch Grnt for Comprehensive Reserch on Disility Helth nd Welfre (Survey study of chronic musculoskeletl pin). Conflict of interest of interest. The uthors declre tht they hve no conflict Open Access This rticle is distriuted under the terms of the Cretive Commons Attriution License which permits ny use, distriution, nd reproduction in ny medium, provided the originl uthor(s) nd the source re credited. References 1. Annul Sttisticl Report of Ntionl Helth Conditions. 2010/ 2011, Helth nd welfre sttistics ssocition, pp 72 3 (in Jpnese). 2. Nkmur M, Nishiwki Y, Ushid T, Toym Y. Prevlence nd chrcteristics of chronic musculoskeletl pin in Jpn. J Orthop Sci. 2011;16: Mrmot MG. Understnding socil inequlities in helth. Perspect Biol Med. 2003;46:S Ehrlich GE. Low ck pin. Bull World Helth Orgn. 2003;81: Kopec JA, Syre EC. Work-relted psychosocil fctors nd chronic pin: prospective cohort study in Cndin workers. J Occup Environ Med. 2004;46: Mtsudir K, Plmer KT, Reding I, Hiri M, Yoshimur N, Coggon D. Prevlence nd correltes of regionl pin nd ssocited disility in Jpnese workers. Occup Environ Med. 2011;68: Plmer KT, Reding I, Clnn M, Linker C, Coggon D. Does knee pin in the community ehve like regionl pin syndrome? Prospective cohort study of incidence nd persistence. Ann Rheum Dis. 2007;66: Plmer KT, Reding I, Linker C, Clnn M, Coggon D. Popultion sed cohort study of incident nd persistent rm pin: role of mentl helth, self-rted helth nd helth eliefs. Pin. 2008;136: Dodet P, Perrot S, Auvergne L, Hjj A, Simoneu G, Decleves X, Poitou C, Oppert JM, Peoc h K, Mouly S, Bergmnn JF, Lloret- Linres C. Sensory impirment in oese ptients? Sensitivity nd pin detection thresholds for electricl stimultion fter surgeryinduced weight loss, nd comprison with nonoese popultion. Clin J Pin. 2013;29: Shiri R, Soloviev S, Husgfvel-Pursiinen K, Timel S, Srikoski LA, Huupponen R, Viikri J, Ritkri OT, Viikri- Juntur E. The ssocition etween oesity nd the prevlence of low ck pin in young dults: The Crdiovsculr Risk in Young Finns Study. Am J Epidemiol. 2008;167: Admson J, Erhim S, Dieppe P, Hunt K. Prevlence nd risk fctors for joint pin mong men nd women in the West of Scotlnd Twenty-07 study. Ann Rheum Dis. 2006;65: Hkim AJ, Cherks LF, Grhme R, Spector TD, McGregor AJ. The genetic epidemiology of joint hypermoility: popultion study of femle twins. Arthritis Rheum. 2004;50: Mtsudir K, Konishi H, Miyoshi K, Isomur T, Tkeshit K, Hr N, Ymd K, Mchid H. Potentil risk fctors for new onset of ck pin disility in Jpnese workers: findings from the Jpn epidemiologicl reserch of occuption-relted ck pin study. Spine. 2012;37: Coggon D, Ntni G, Plmer KT, Felli VE, Hrri R, Brrero LH, Felknor SA, Gimeno D, Cttrell A, Vrgs-Prd S, Bonzini M, Solidki E, Merislu E, Hi RR, Sdeghin F, Msood Kdir M, Wrnkulsuriy SS, Mtsudir K, Nyntumu B, Sim MR, Hrcome H, Cox K, Mrzile MH, Srquis LM, Hrri F, Freire R, Hrri N, Monroy MV, Quintn LA, Rojs M, Slzr Veg EJ, Hrris EC, Serr C, Mrtinez JM, Delclos G, Benvides FG, Crugno M, Ferrrio MM, Pestori AC, Chtzi L, Bitsios P, Kogevins M, Oh K, Sirk T, Sdeghin A, Peiris-John RJ, Sthikumr N, Wickremsinghe AR, Yoshimur N, Kelsll HL, Hoe VC, Urquhrt DM, Derrett S, McBride D, Herison P, Gry A. Ptterns of multisite pin nd ssocitions with risk fctors. Pin. 2013;154: Yuki S, Ushid T, Tkeshit K, Sur R, Ogw S, Ktsumt A, Htnk S. A ntionwide survey of chronic pin sufferers in Jpn. Clin Orthop. 2012;47: (in Jpnese). 16. Freynhgen R, Bron R, Tölle T, Stemmler E, Gockel U, Stevens M, Mier C. Screening of neuropthic pin components in ptients with chronic ck pin ssocited with nerve root compression: prospective oservtionl pilot study (MIPORT). Curr Med Res Opin. 2006;22: