The lifetime prevalence of low back pain is reported to be more than 70% in industrialized countries (1-year prevalence, 15% to 45%; adult incidence, 5% per year) with varying degrees of symptom severity.1 The prevalence of low back pain during school age approaches that seen in adults,2,3 increases from childhood to adolescence,4 and peaks between ages 35 and 55 years.5
Few studies specifically examine sciatica, but some low back pain studies include data on sciatica prevalence, risk factors, and natural history. Low back-related leg pain, or sciatica, is one of the most common variations of low back pain.6 Sciatica is known by a range of terms in the literature, such as lumbosacral radicular syndrome, radiculopathy, nerve root pain, and nerve root entrapment or irritation. Controversy exists in clinical and research circles about the use of sciatica as a term.5,6 Although definitions of sciatica used in epidemiological surveys vary, sciatic pain is generally defined as pain radiating to the leg, normally below the knee and into the foot and toes. As with low back pain, sciatica is a symptom rather than a specific diagnosis, but lumbar disk herniation and lumbar canal or foraminal stenosis are typical pathologies that may cause sciatic pain.
Patients with sciatica usually have a more persistent and severe type of pain than patients with low back pain, have a less favorable outcome, consume more health resources, and have more prolonged disability and absence from work.5,7–12
Low back pain was long considered a mainly mechanical problem. However, in the past decade, several authors13–15 reported that sociocultural, socioeconomic, and work-related factors (eg, poor job satisfaction and psychological stress at work) not previously investigated may contribute to low back pain prevalence and intensity.16–22 A patient’s culture may also affect not only the likelihood of reporting low back pain, but also the perception and intensity of low back pain.23,24
It is well known among researchers that significant cultural, social, economic, and mentality differences exist between the people living in northern and southern Europe. The objective of this retrospective cross-sectional study was to estimate the 6-month prevalence and severity of low back pain and sciatica in a representative sample of a general adult Mediterranean population.
Materials and Methods
This study was conducted between October 2005 and May 2006 in a prefecture (ie, second-level administrative division) located in the southwestern region of a Mediterranean country with a mainly urban population of approximately 350,000 people. It included a sample of 674 randomly selected people, aged 20 years or older, stratified on sex, age, socioeconomic status, and employment. Information was collected by means of structured personal interviews conducted by 2 of the authors (P.K., T.R.) after written consent was obtained from all participants. The interview was based on a questionnaire that included 26 questions that elicited the following information: demographics (ie, age, sex, nationality), socioeconomic parameters, employment variables (ie, work status and type of work), health-related parameters (ie, smoking and depression), reported individual history of low back pain and sciatica in the past 6 months, and medical sequences (Tables 1, 2).
Table 1: Anthropometric and General Data Affecting LBP and Sciatica (N=674)
Table 2: LBP and Sciatica Data and Medical Sequences (N=674)
The section of the questionnaire referring to low back pain and sciatica pain intensity (using the visual analog scale [VAS]) was validated by the authors during a 2-week interval using 50 people who consented to participate in this evaluation. To compare with other variables, pain intensity was categorized into 4 categories: VAS score of 0=no pain; VAS score of 1 to 3=mild pain; VAS score of 4 to 7=moderate pain; and VAS score of 8 to 10=se-vere pain (Tables 3, 4). No clinical evaluation for sciatica and low back pain was performed because physical examinations were not in the scope of this study.
Table 3: Parameters Affecting Low Back Pain Intensity (N=674)
Table 4: Parameters Affecting Sciatica Pain Intensity (N=674)
Low back pain was considered pain and discomfort localized below the costal margin and above the inferior gluteal folds, and sciatica considered pain, numbness, or tingling radiating in the posterior surface of the leg.
Analysis was performed using Stata/SE version 11.0 software (StataCorp LP, College Station, Texas).
Frequency distributions of responses and cross-tabulations of demographic, socioeconomic, and employment analysis with reported history of low back pain and sciatica were examined. For each question specified, associations of demographic, socioeconomic, and employment variables with low back pain and sciatica intensity were tested by univariate and multivariate logistic regression. Odds ratios (ORs) and 95% confidence intervals were estimated.
The association of VAS scores with pain duration, days in bed, and duration of work absenteeism were tested using Pearson’s correlation coefficient (giving numerical values as follows: age 20–40 years=1; age 46–65 years=2; age older than 65 years=3). The association of the pain intensity (VAS score 1–10) of low back pain (first dependent variable) and sciatica (second dependent variable) with several socioeconomic and demographic parameters (independent variables) was tested with ordinal logistic regression analysis using the whole cohort. Results of ordered adjusted (multivariate) and unadjusted (univariate) logistic regression for low back pain and sciatica are shown in Tables 5–8.
Table 5: Ordered Multivariate Logistic Regression for LBP Intensity
Table 6: Ordered Univariate Logistic Regression for LBP Intensity
Table 7: Ordered Multivariate Logistic Regression for Sciatica Intensity
Table 8: Univariate (Unadjusted) Logistic Regression for Sciatica Intensity
In the ordered logistic regression, the modeling strategy was to chunkwise delete nonsignificant predictors (deletion of nonsignificant terms at 1 time) using the likelihood ratio test. Although most researchers use stepwise procedures, these are not optimal. Then postestimation was performed as appropriate (linear model, residuals, multicollinearity, heteroskedasticity). Ordered logistic regression included the proportional odds assumption. Categorical predictors of all demographics were entered into the model. In regression models, Stata software takes the first category as the reference group by default and compares the other groups with this reference group. For example, no smoking=0, smoking=1: the model provides a relative risk of smokers compared with nonsmokers.
The validation of the questionnaire showed high Kappa values (0.90–0.95). Women composed 62.3% of participants. The majority (60.5%) of participants were younger than 46 years; 8.5% were older than 65 years (Table 1).
Almost all (98.7%) participants were citizens of Greece. The majority (74.8%) of participants lived in an urban area; 25.2% lived in a rural area. Approximately 42% of the participants reported their work status as “employee,” whereas the rest reported that they did not do manual work. Concerning educational level, the majority (42.9%) of participants had completed high school. The majority of participants (56.5%) were married (Table 1).
A total of 39.5% and 24.6% of participants reported low back pain and sciatica, respectively, in the past 6 months (Table 2). Moreover, 21.4% of participants consulted a physician because of low back pain or sciatica during the past 6 months. Plain radiographs were most often (12.5%) ordered by the treating physician, followed by magnetic resonance imaging (6.8%) and computed tomography (5%) (Table 2). Also, 14.7% of participants reporting low back pain and sciatica received medication during the past 6 months, and 9.7% of participants abstained from work during the same period. Tables 3 and 4 demonstrate pain severity prevalence plotted vs different parameters.
Low Back Pain
Participants older than 65 years reported 2.4 times more severe low back pain than participants aged 20 to 45 years (OR, 2.4; P=.006). Men reported 0.6 times less severe low back pain than women (OR, 0.6; P=.005). Housewives reported 3.5 times more severe low back pain than participants who worked outside the home (OR, 3.5; P=.001). Married participants reported 2.0 times more severe low back pain than unmarried participants (OR, 2.0; P=.001). Smokers reported 1.7 times higher low back pain intensity than non-smokers (OR, 1.7; P=.002). Participants diagnosed and treated for depression reported 2.3 times more severe low back pain than those without depression (OR, 2.3; P=.040.).
Participants aged older than 65 years reported 2.9 times more severe sciatic pain than participants aged 20 to 45 years (OR, 2.9; P=.004). Men reported 0.6 times less severe sciatic pain than women (OR, 0.6; P=.020). Increased sciatic pain intensity was 2.4 times more frequently reported by self-employed participants than by employees (OR, 2.4; P=.021).
Married participants reported 2.3 times higher sciatic pain intensity than unmarried participants (OR, 2.3; P=.001). Smokers reported 2.1 times higher sciatica intensity than nonsmokers (OR, 2.1; P=.000).
Generally, the prevalence of chronic pain in the general population ranges from 10% to more than 40%, depending on the definition and the population studied. Low back pain and associated sciatica are considered major health problems in modern societies because they may cause significant disability and frequent use of health services. The reported prevalence of low back pain varies between 50% and 85%, with an annual prevalence of approximately 50%.25–32 Sciatica prevalence rates vary between 1.6% and 43%,33,34 likely because of the variable definitions of sciatica and differences between self-reported and clinically assessed symptoms.15
Because the prevalence of low back pain among the working population is high, several epidemiological studies have been conducted to assess different risk factors that may increase the risk of low back disorders.35–38 In addition, it has been suggested that individual characteristics (eg. height and weight), habits (eg, smoking), and psychosocial factors (eg, mental stress and poor job satisfaction) are plausible risk factors, but the evidence is less consistent.
The perception of low back pain and sciatica intensity is a matter of the mentality of each individual living in a given community.25–32 Most epidemiological studies of low back pain come from North America, Great Britain, and other countries in central or northern Europe; little information concerning low back pain prevalence and intensity comes from countries in southern Europe.39 Moreover, few studies report on sciatica, although some low back pain studies have included data on the prevalence, risk factors, and natural history of sciatica.
The current study, which focuses on low back pain and sciatica in a Mediterranean population, had some drawbacks. First, the sample population was neither random nor selected. The study was open to all adult inhabitants of a specific area, but the final sample comprised only those who responded. This is likely the reason for the slightly increased percentage of women (62.3%) in the final sample. It was assumed that women tend to respond more eagerly to medical surveys. Moreover, concern exists about the meaning and validity of retrospective recall ratings. Although the accuracy of pain memory has been investigated, most studies have failed to use appropriate statistical analyses for validity.40 Few studies support the single rating of pain “on average” as a valid and practical measure of a patient’s pain intensity over a period of time.41
In the current study, 24.6% of the participants reported sciatica according to the definition used in this study for sciatic pain. Comparing this result with other studies was not an easy task. Data collection methods, definitions of sciatica, population studies, and differing time frames of reported prevalence figures contribute to a wide range of reported sciatica prevalence. Deyo and Tsui-Wu34 considered sciatica present only if patients reported pain radiating to the leg lasting more than 2 weeks and made worse by coughing, sneezing, or taking a deep breath. Using these criteria, they reported a 1.6% point prevalence of sciatica.34 Thus, it is difficult to compare the current study’s data with those of other studies because only 2 other studies used symptom duration as a criterion for a positive case of sciatica using self-reported methods.42,43 Hofmann et al44 estimated the point prevalence of sciatica to be 4.6% in clerks and 13.4% in nurses using a self-reported questionnaire. Working populations, especially those in more manual jobs, report higher rates of sciatica prevalence.33,45,46 Few previously published studies used clinical examination to investigate sciatica and reported a low prevalence of sciatica, ranging between 4.8%47 and 1.2%.48 The prevalence of sciatica in the current study that was within the previously reported prevalence range was not assessed by means of physical examination, and the pain severity was objectively evaluated using the VAS. The age of the study population may have also contributed to the variability in prevalence. Age-specific data within a single study is required to investigate the relationship between sciatica and age; such data were not available from the studies in a previous review.49
Several previous studies reported controversial results suggesting an association between social and demographic characteristics and a prevalence of low back pain ranging between 12% and 33%, a 1-year prevalence between 22% and 65%, and a lifetime prevalence between 11% and 84%.26,31,50–53 In comparing low back pain prevalence derived from countries with similar sociocultural habits, the 6-month low back pain prevalence in Israel was 32%,54 similar to the prevalence in the current study. This similarity should theoretically exist due to the similarities in culture and mentality among Mediterranean countries.
Differences in low back pain prevalence were shown not only between different populations (northern vs southern countries), but also between studies derived from the same country.24,55 Possible explanations for these differences may be methodological differences among studies and different population ages, sampling methods, study periods, and definitions of low back pain and methods of collecting information. However, the prevalence of low back pain in the current study appears to be within the limits of other general population surveys.27,50,52,56–60
The Mediterranean population presents several social, economic, and mentality differences compared with other populations studied (eg, Nordic and North American populations). However, on the basis of the results of this study and those derived from the available literature, it is difficult to say how a higher prevalence of self-reported low back pain corresponds with a higher morbidity or reflects culturally different perceptions of pain.
Approximately half (55%) of the working population in the current study had nonmanual jobs. However, the previously reported prevalence of low back pain in workers does not differ dramatically from that of nonworkers. 61
Diversity exists in the literature regarding sex-related low back pain prevalence. In previously published series, men and women reported approximately the same prevalence of low back pain, although some large surveys in the United Kingdom62 and Sweden63 showed a higher prevalence in women. The current findings agree with these studies: women showed a higher prevalence of low back pain than men. The theoretical explanation for this difference is that women have a weaker muscle system and married women work hard at home, thus making them more prone to pain than men.15,29,31,64–69 Another interesting finding derived from the current study is that although low back pain was sex dependent, sciatica prevalence did not significantly differ between women (27.1%) and men (20.5%). The authors found no clear explanation for this finding.
In the current study, the prevalence and severity of low back pain were correlated with parameters such as work status, marital status, residence, smoking status, and antidepressive medication status. People who live in rural regions in the studied country are usually hard working. Manual work is also related to the risk of low back pain and sciatica in the studied population.
Clinical trials have shown that psychosocial factors have an important influence on the prognosis of low back pain, and a psychotherapeutic element in the treatment of low back pain is beneficial when conducted at the early stage of chronification.5 Psychosocial risk factors include stress, distress, anxiety, depression, cognitive functioning, pain behavior, job dissatisfaction, and mental stress at work.5
According to a recent systematic review that evaluated prospective studies of the psychological risk factors for back pain, mental stress plays an important role in the onset and development of neck and back disorders.70,71 However, results derived from a study by Miranda et al11 suggest that mental stress is an independent risk factor for sciatic pain, which agrees with the current study’s findings. Because studies of sciatic pain are lacking, no comparisons can be made.
In the current study, individuals older than 65 years reported 2.4 times more severe low back pain (P=.006). The previously reported prevalence of low back pain was highest between ages 55 and 64 years.67 The increased risk of sciatic pain with increased age derived from the current study is biologically plausible because age-related degeneration causes morphologic and functional changes in the intervertebral disks and the spinal canal.72,73
In the current study, individuals with low back pain often experienced a more physically heavy workload at work associated with low education (41.3% university vs 58.9% primary school). This is in accordance with previously published data.63,67,74 Authors have previously reported that severe low back pain is less prevalent among adults of higher socioeconomic status75; no differences were found in the current study.
Other socioeconomic influences on low back pain prevalence include social class and habitat.15 In a recent study, living in a major urban center was significantly associated with an increased risk for low back pain.15 This was not reflected in the current study for low back pain or sciatica because people who lived in rural areas reported more low back pain and sciatica than those living in urban areas.
Some authors reported that severe pain was associated with female sex (P<.0001), being divorced, being widowed or separated (P<.05), and having a lower education level (P<.0001).54 In the current study, unmarried women reported significantly less low back pain and sciatica than their married, divorced, and widowed counterparts. Unmarried women usually have no children and a small house; thus, they have less work at home and are less prone to low back pain and sciatica.
This 6-month cross-sectional observation of a sample of Mediterranean adults from a mainly urban population shows that low back pain affects married housewives, people older than 65 years, smokers, and people in treatment for depression with increased severity. A working married woman older than 65 years who smokes was more prone to severe sciatica.
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Anthropometric and General Data Affecting LBP and Sciatica (N=674)
|Parameter||No. (%)||Parameter||No. (%)|
| Sex|| Residence|
| Female||420 (62.3)|| Rural||170 (25.2)|
| Male||254 (37.7)|| Urban||504 (74.8)|
| Age, y|| Marital status|
| 20–45||408 (60.5)|| Unmarried||251 (37.2)|
| 46–65||209 (31.0)|| Married||381 (56.5)|
| >65||57 (8.5)|| Divorced/widowed||42 (6.3)|
| Nationality|| Education|
| Greek||665 (98.7)|| Primary school||112 (16.6)|
| Other||9 (1.3)|| Junior high school||46 (6.8)|
|Employment|| High school||289 (42.9)|
| Work status|| College||67 (9.9)|
| Employee||286 (42.4)|| University||160 (23.7)|
| Self-employed||71 (10.5)|| Annual income, €|
| Housewife||61 (9.1)|| <7000||201 (29.8)|
| Agricultural worker||28 (4.2)|| 7000–14,000||209 (31.0)|
| Retired||45 (6.7)|| >14,000||264 (39.2)|
| Student||162 (24.0)||Health related|
| Multiple jobs||21 (3.1)|| Smoking|
| Work type|| No||444 (65.9)|
| Not manual||371 (55.0)|| Yes||230 (34.1)|
| Manual||158 (23.5)|| Antidepressive medication|
| Combination||145 (21.5)|| No||648 (96.1)|
| Yes||26 (3.9)|
LBP and Sciatica Data and Medical Sequences (N=674)
|Parameter||No. (%)||Parameter||No. (%)|
|Reported LBP in past 6 mo||Examination|
| None||510 (75.7)|
| No||408 (60.5)|| Plain radiographs||84 (12.5)|
| Yes||266 (39.5)|| CT scan||34 (5.0)|
|Reported sciatica in past 6 mo|| MRI||46 (6.8)|
| No||508 (75.4)|| No||575 (85.3)|
| Yes||166 (24.6)|| Yes||99 (14.7)|
|LBP intensity, VAS|| Medication duration, d|
| No pain||408 (60.5)|| 1–10||56 (56.6)|
| 1||15 (2.2)|| 11–30||34 (34.3)|
| 2||20 (3.0)|| 45–180||9 (9.1)|
| 3||34 (5.0)||Physical therapy|
| 4||27 (4.0)|| No||632 (93.8)|
| 5||40 (5.9)|| Yes||42 (6.2)|
| 6||35 (5.2)||Bed rest in past 6 mo|
| 7||26 (3.9)|| No||597 (88.6)|
| 8||27 (4.0)|| Yes||77 (11.4)|
| 9||20 (3.0)|| Time in bed, d|
| 10||22 (3.3)|| 1–7||46 (59.7)|
|Sciatica intensity, VAS|| 8–30||28 (36.4)|
| No pain||508 (75.4)|| 31–60||3 (3.9)|
| 1||20 (3.0)||Abstain from work|
| 2||19 (2.8)|| No||609 (90.3)|
| 3||16 (2.4)|| Yes||65 (9.7)|
| 4||21 (3.1)|| Time abstained from work, d|
| 5||16 (2.4)|| 1–30||56 (86.2)|
| 6||19 (2.8)|| 31–60||8 (12.3)|
| 7||13 (1.9)|| 61–120||1 (1.5)|
| 8||19 (2.8)||Hospital admission in past y|
| 9||9 (1.3)|| No||656 (97.4)|
| 10||14 (2.1)|| Yes||18 (2.6)|
|Medical help requested||Surgery for LBP or sciatica|
| No||530 (78.6)|| No||661 (98.1)|
| Yes||144 (21.4)|| Yes||13 (1.9)|
Parameters Affecting Low Back Pain Intensity (N=674)
|Parameter||VAS Pain Score, n||Average LBP Prevalence, %|
| Agricultural work||6||7||11||4||78.6a|
| Multiple jobs||6||4||7||4||71.4a|
| Primary school||46||15||31||20||58.9|
| Junior high school||21||5||12||8||54.3a|
| High school||209||29||42||9||27.7|
|Annual income, €|
Parameters Affecting Sciatica Pain Intensity (N=674)
|Parameter||VAS Pain Score, n||Average Sciatica Prevalence, %|
| Agricultural work||10||7||9||2||64.3a|
| Multiple jobs||13||4||2||2||38.1a|
| Primary school||66||9||18||19||41.1|
| Junior high school||35||2||5||4||23.9|
| High school||230||22||26||11||20.4|
|Annual income, €|
Ordered Multivariate Logistic Regression for LBP Intensity
|Antidepressive medication, yes||2.3||0.9||2.04||.040||1.0–5.0|
Ordered Univariate Logistic Regression for LBP Intensity
|Antidepressive medication, yes||3.2||1.3||2.95||.003||1.5–6.9|
Ordered Multivariate Logistic Regression for Sciatica Intensity
Univariate (Unadjusted) Logistic Regression for Sciatica Intensity