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Previous mass media campaigns have aimed to influence how people manage back pain, with mixed success. Campaigns should target beliefs which are related to the behaviours they aim to change. This systematic review brings together research that has measured the prevalence of beliefs about back pain in the general population and factors associated with these beliefs, including future pain-related outcomes. Five databases were searched up until April 2017. Quantitative studies which reported a measure of agreement with a belief about back pain, cross-sectional associations, or associations between beliefs and future outcomes were eligible. Eligibility was assessed and data extracted independently by two authors. Results were tabulated and narratively synthesized. Nineteen studies from 10 countries were eligible (median study n [IQR] = 990.5 [524.75-2387.5]). Beliefs were measured using eight questionnaires and 57 stand-alone items. Beliefs about back pain's negative consequences were common across countries and populations, whereas most samples did not hold fear-avoidance beliefs. Beliefs about back pain's consequences were associated with pain and disability, but only one study investigated this specific relationship prospectively. No studies investigated whether beliefs are associated with future pain management behaviours. Agreement with certain beliefs (e.g. about negative consequences) was associated with sociodemographic characteristics (e.g. older age) and poorer self-rated health. Interventions may benefit from targeting beliefs about the perceived negative consequences of back pain in these populations. However, future research should explore how beliefs prospectively influence the management of back pain. SIGNIFICANCE: This review brings together studies which have assessed the prevalence of beliefs about back pain, and factors associated with holding them. It highlights that whether or not these beliefs represent important determinants of how people manage pain remains unknown., (© 2018 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC®.)

Background: Epidemiological studies on chronic pelvic pain (CPP) have focused on women of reproductive age. We aimed to determine the prevalence of chronic pelvic pain (CPP) in adult women and the differences in associated factors among women of reproductive age and older women. In addition, to determine whether distinct subgroups existed among CPP cases., Methods: A cross-sectional postal survey was conducted among 5300 randomly selected women aged ≥25 years resident in the Grampian region, UK. Multivariable logistic regression was used to determine pregnancy-related and psychosocial factors associated with CPP. To identify subgroups of CPP cases, we performed cluster analysis using variables of pain severity, psychosocial factors and pain coping strategies., Results: Of 2088 participants, 309 (14.8%) reported CPP. CPP was significantly associated with being of reproductive age (odds ratios (OR) 2.43, 95% CI 1.69-3.48), multiple non-pain somatic symptoms (OR 3.58 95% CI 2.23-5.75), having fatigue (OR mild 1.74 95% CI 1.24-2.44, moderate/severe 1.82, 95% CI 1.25-2.63) and having depression (OR 1.61, 95% CI 1.09-2.38). CPP was less associated with multiple non-pain somatic symptoms in women of reproductive age compared to older women (interaction OR 0.51, 95% CI 0.28-0.92). We identified two clusters of CPP cases; those having little/no psychosocial distress and those having high psychosocial distress., Conclusion: CPP is common in both age groups, though women of reproductive age are more likely to report it. Heightened somatic awareness may be more strongly associated with CPP in older women. There are distinct groups of CPP cases characterized by the absence/presence of psychosocial distress., Significance: Heightened somatic awareness may be more strongly associated with CPP in women of post-reproductive years compared to women of reproductive years. Two subgroups of CPP cases can be differentiated by the absence/presence of psychosocial distress suggesting that stratified management approach may be more efficient., (© 2016 European Pain Federation - EFIC®.)

Background: This study aims to determine whether older adults reporting back pain (BP) are at increased risk of premature mortality, specifically, to examine the association with disabling/non-disabling pain separately., Methods: Participants aged ≥75 years were recruited to the Cambridge City over-75s Cohort (CC75C) study. Participants answered interviewer-administered questions on BP and were followed up until death. The relationship between BP and mortality was examined using Cox regression, adjusted for potential confounding factors. Separate models were computed for men and women., Results: From 1174 individuals with BP data, the date of death was known for 1158 (99%). A significant association was found between disabling BP and mortality (hazard ratio: 1.4; 95% confidence interval: 1.1-1.8) and this remained, albeit of borderline significance, following adjustment for socio-demographic variables and potential disease markers (1.3; 0.99-1.7). Further, this association was found to vary with sex: women experienced a 40% increase in the risk of mortality associated with disabling BP (1.4; 1.1-1.9), whereas no such increase was observed for men (1.0; 0.5-1.9). Participants with non-disabling BP were not at increased risk of mortality., Conclusions: This study confirmed previous findings regarding the relationship between pain and excess mortality. Further, we have shown that, among older adults, this association is specific to disabling pain and to women. Clinicians should be aware not only of the short-term implications of disabling BP but also the longer-term effects. Future research should attempt to understand the mechanisms underpinning this relationship to avoid excess mortality and should aim to determine why the relationship differs in men and women., (© 2014 European Pain Federation - EFIC®)

Background: Previous studies have found an association between chronic pain and cardiovascular (CV) mortality., Objective: To explore the relationship between the severity of pain and non-fatal CV disease., Methods: A total of 45,994 adults randomly selected from general practice registers in Manchester and Aberdeen were posted a survey, which included a Chronic Pain Grade questionnaire, pain manikin and questions about lifestyle and medical history. A single component measuring pain severity was extracted using factor analysis. Logistic regression was used to test for an association between quintiles of pain severity and a history of CV disease, adjusting for confounders., Results: Of the 15,288 responders, 61% (n = 9357) reported pain for ≥ 1 day in the past month. Compared with the first (lowest) pain severity quintile, the fully adjusted odds ratio for heart attack in the second severity quintile was 1.25 (95% confidence interval 0.68, 2.30); third quintile: 1.65 (0.93, 2.94); fourth quintile: 1.76 (1.00, 3.11) and fifth (highest) quintile 2.47 (1.43, 4.28). Corresponding figures for angina (excluding heart attack) were: 1.79 (0.93, 3.45), 1.91 (1.00, 3.62), 1.03 (0.50, 2.11) and 3.17 (1.71, 5.85)., Conclusion: A history of CV disease is reported more often in those with severe pain than would be expected by chance, even when adjusting for shared risk factors., (© 2014 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFICC®.)

Background: The aim of the study was to test the hypothesis that associations with specific stress systems [hypothalamic-pituitary-adrenal (HPA) and growth hormone (GH) axes] would increase as the number of unexplained disorders increased while accounting for the possible confounding effects of psychosocial factors., Methods: A cross-sectional study identified those reporting chronic widespread pain, irritable bowel syndrome, chronic orofacial pain and chronic fatigue. Of the 1315 subjects, disorder status was available for 1180 (89.7%), of whom 766 (64.9%) reported no disorders, 277 (23.5%) reported one and 137 (11.6%) reported two or more. Eighty subjects were sought from each group for assessment of HPA (morning 8:00 a.m. and evening 10:00 p.m. saliva, and post-dexamethasone serum cortisol levels) and GH [serum insulin-like growth factor 1 (IGF-1) level] axis function. Validated questionnaires informed current psychological state., Results: Two hundred twenty-seven subjects participated [79 (35%) with no disorders, 78 (34%) with one disorder and 70 (31%) with two or more disorders]. There were no significant associations (p < 0.05) between individual disorders or an increasing disorder load with any of the neuroendocrine levels measured: saliva/serum cortisol, IGF-1 and dehydroepiandrosterone. Psychosocial factors were independently associated with disorders and with an increasing disorder load: health anxiety p < 0.01, anxiety p < 0.01, depression p < 0.01, life events p = 0.03., Conclusion: Although previous studies have shown that stress axis function acts to moderate the risk of onset of some of these disorders, the present study shows that the degree of dysfunction is not correlated with a corresponding increasing load of disorders. The uncertainty surrounding the role of these biomarkers in the aetiology of unexplained disorders needs further investigation., (© 2013 European Pain Federation ‐ EFIC®)

Aims: The aim of this study was to determine if genetic variation in the pain-modulating gene DREAM and its pathway genes influence susceptibility to reporting musculoskeletal pain in the population., Methods: Pairwise tag single nucleotide polymorphisms (SNPs) in DREAM, PDYN and OPRK1 were genotyped in a UK population-based discovery cohort in whom pain was assessed using blank body manikins at three time points. Depression and anxiety symptoms were assessed at the first time point. Zero-inflated negative binomial regression was used to test for association between SNPs and the maximum number of pain sites reported (0-29) across the three time points. Significantly associated SNPs (p < 0.05) were subsequently genotyped for validation in a cohort of European men with pain assessed at two time points., Results: Thirty-five SNPs were genotyped in 1055 subjects, of whom 83% reported pain, in the discovery cohort. SNPs in each gene were associated with the maximum number of pain sites reported, were independent of symptoms of anxiety and depression and had a significant cumulative effect (p = 7.0 × 10(-5) ). Significantly associated SNPs were successfully genotyped in 1733 men, 76% of whom reported pain, in the validation cohort, but did not show significant association with the number of pain sites., Conclusions: Genetic variation in the DREAM pathway genes was associated with the extent of pain reporting in a population-based cohort. These findings were not replicated in a single independent cohort; however, given the potential of this pathway as a therapeutic target, further investigation in additional cohorts is warranted., (© 2012 European Federation of International Association for the Study of Pain Chapters.)

Background/aims: To test whether mechanical hyperalgesia is associated with multiple idiopathic pain disorders (IPDs) and whether this relationship is independent of the confounding effects of psychosocial factors., Methods: One hundred eighteen subjects with chronic orofacial pain (COFP) were identified from their questionnaire responses to a population study in North West England. All subjects had a tender point examination according to the American College of Rheumatology classification. Validated tools on the questionnaire were used to identify presence of other IPDs (irritable bowel syndrome and chronic widespread pain) and psychosocial factors (anxiety, depression, health anxiety, sleep disturbance and reporting of somatic symptoms and adverse life events)., Results: Of the 118 subjects, 47.6% (n = 56) had COFP, 34.7% (n = 41) had COFP plus one IPD and 17.8% (n = 21) had all three IPDs. Univariate analysis revealed a dose-response relationship between number of tender points (TPs) and number of IPDs [2-6 TPs (OR 2.6, 95% CI 1.0-7.3), ≥ 7 TPs (OR 10.5, 95% CI 3.8-29.3)] and number of IPDs and psychological distress [anxiety (OR 2.8, 95% CI 1.2-6.4), depression (OR 4.3, 95% CI 1.7-10.6), sleep disturbance (OR 4.8, 95% CI 1.6-14.6)]. The relationship between IPDs and TPs persisted after adjusting for psychosocial factors in multivariate analyses [2-6 TPs (OR 2.5, 95% CI 0.8-7.8) ≥ 7 TPs (OR 10.7, 95% CI 3.4-33.7)]., Conclusion: The dose-response relationship between TPs and IPDs needs further investigation to determine the temporal nature of these relationships and to disentangle the complex gene-environment relationships that may influence the occurrence of multiple IPDs., (© 2012 European Federation of International Association for the Study of Pain Chapters.)

Objective: The aim was to examine the relationship between gestational age and birthweight and adult chronic widespread pain (CWP)., Design and Participants: A prospective cohort study of 18,558 participants recorded birthweight and gestation at birth., Exposure: Participants were categorised by gestation (fullterm ≥37 weeks; preterm <37 week) and birthweight (full birthweight (FBW) ≥2.5 kg; low birthweight (LBW) 1.5-2.5 kg; and very low birthweight (VLBW) <1.5 kg)., Outcome: The presence or absence of CWP was measured by self-completed questionnaire in 8572 participants at age 45 yrs. Risk ratios were calculated using Poisson regression. Adjustment was made for potential confounding factors., Results: Premature birth was associated with a 26% increase in the risk of CWP compared to fullterm birth, although this was not statistically significant (risk ratio 1.26, 95% confidence interval 0.95-1.67). This increased risk was robust to adjustment for sex, social class at birth and age 42 yrs, or birthweight, but was completely attenuated when adjusted for childhood behavioural problems and adult psychiatric disorder. LBW was not associated with an increased risk of CWP (RR 1.01, 95%CI 0.78-1.32). VLBW was associated with a non-significant increased risk (RR 1.48, 0.42-5.22) although there was insufficient study power to examine this relationship in the context of other factors., Conclusions: Premature birth and VLBW are associated with increased risk of adult CWP although these effects are modest, and not statistically significant. Although not conclusive in itself, this study lends support to the theory that adult chronic pain may have its origins - at least in part - in very early life., (© 2011 European Federation of International Association for the Study of Pain Chapters.)

The aetiology of ulcerative colitis (UC) is unknown, but there is evidence that bacteria are needed for initiation and maintenance of the disease. A number of organisms have been associated with UC, but evidence for a specific transmissible agent is weak. Despite this, there is a good case for mucosal bacterial involvement, either through pathogens colonizing the epithelial surface, by non-pathogenic commensal species occupying adhesion sites on the mucosa and preventing invasion by harmful bacteria, or by inappropriate host immune responses to members of the normal microflora. Since mucosal bacteria exist in close juxtaposition to host tissues, it might be expected that they interact to a greater extent with the immune and neuroendocrine systems than their luminal counterparts. For this reason, comparative bacteriological analyses were done on rectal biopsies from patients with active colitis, and individuals who had no inflammatory bowel disease. Complex bacterial communities colonized the rectal mucosa in all subjects and great interindividual variabilities in mucosal bacterial populations were observed in both groups. These organisms often occurred in microcolonies, which may have implications for UC, since it would result in higher localized concentrations of bacterial antigens, or toxins, than would be the case if the organisms were diffusely spread across the mucosa.

The relationship between the dose of tacrolimus, trough tacrolimus blood concentration, and selected clinical endpoints (acute rejection, nephrotoxicity, and other toxicities) were examined in a prospective, multicenter clinical trial to validate the use of an enzyme-linked immunosorbent assay (ELISA) for monitoring whole-blood concentrations of tacrolimus in liver transplant patients. A total of 111 subjects from six transplant centers were evaluated over 12 weeks posttransplantation. In addition to trough tacrolimus blood concentrations, hematocrit, ALT, AST, GGTP, alkaline phosphatase, total bilirubin, serum creatinine, BUN, serum potassium, serum magnesium, blood glucose, and serum albumin were also measured. The relationship between trough tacrolimus blood concentrations and clinical endpoints was analyzed using both a logistic regression model and a Cox proportional hazard model. By logistic regression analysis, a statistically significant (p = 0.0465) relationship between increasing trough tacrolimus blood concentrations and decreasing risk of acute rejection was demonstrated over a 7-day time window. Nephrotoxicity and other toxicities also demonstrated statistically significant relationships with trough tacrolimus blood concentrations. The results of the Cox analysis were consistent with the logistic regression analysis. Using receiver operator characteristic curves, trough tacrolimus concentrations as measured by the ELISA method were able to differentiate the occurrence of nephrotoxicity and toxicity from nonevents. To minimize nephrotoxicity of tacrolimus, it is necessary to maintain trough blood concentrations below 15 ng/ml. This study demonstrates that the ELISA method used to measure tacrolimus blood concentrations in this study provides information of predictive value for managing the risk of nephrotoxicity, other toxicity, and rejection in liver transplant patients.

The human large intestine contains a microbiota, the components of which are generically complex and metabolically diverse. Its primary function is to salvage energy from carbohydrate not digested in the upper gut. This is achieved through fermentation and absorption of the major products, short chain fatty acids (SCFA), which represent 40-50% of the available energy of the carbohydrate. The principal SCFA, acetate, propionate and butyrate, are metabolized by the colonic epithelium (butyrate), liver (propionate) and muscle (acetate). Intestinal bacteria also have a role in the synthesis of vitamins B and K and the metabolism of bile acids, other sterols and xenobiotics. The colonic microflora are also responsive to diet. In the presence of fermentable carbohydrate substrates such as non-starch polysaccharides, resistant starch and oligosaccharides, bacteria grow and actively synthesize protein. The amount of protein synthesis and turnover within the large intestine is difficult to determine, but around 15 g biomass is excreted in faeces each day containing 1 g bacterial-N. Whether bacterially synthesized amino acids are ever absorbed from the colon remains unclear. Finally, individual colonic micro-organisms such as sulphate-reducing bacteria, bifidobacteria and clostridia, respond selectively to specific dietary components in a way that may be important to health.