Arthritis & Rheumatism (Arthritis Care & Research)

Vol. 57, No. 4, May 15, 2007, pp 656 665

DOI 10.1002/art.22684
2007, American College of Rheumatology
ORIGINAL ARTICLE

US National Prevalence and Correlates of Low

Back and Neck Pain Among Adults
TARA W. STRINE AND JENNIFER M. HOOTMAN

Objective. To estimate the US prevalence and psychological and health behavior correlates of low back pain and/or neck
pain. No current US national prevalence estimates of low back and neck pain exist and few studies have investigated the
associations between low back and neck pain, psychological factors, and health behaviors in a representative sample of
US community dwellers.
Methods. We analyzed data obtained from adults ages 18 years or older (n 29,828) who participated in the 2002
National Health Interview Survey, a cross-sectional, population-based survey of US adults.
Results. The 3-month US prevalence of back and/or neck pain was 31% (low back pain: 34 million, neck pain: 9 million,
both back and neck pain: 19 million). Generally, adults with low back and/or neck pain reported more comorbid
conditions, exhibited more psychological distress (including serious mental illness), and engaged in more risky health
behaviors than adults without either condition.
Conclusion. Low back and neck pain are critical public health problems. Our study supports the idea of a multidimen-
sional approach to examining low back and neck problems and suggests the need for further research to address
potentially modiable psychological factors and health behaviors in these populations.

KEY WORDS. Back pain; Neck pain; Health behaviors; Psychological distress.

INTRODUCTION directional association between psychological factors and

Seventy percent of all adults experience back or neck pain
at some point in their lives, resulting in more than 15
million outpatient physician visits for back pain alone in a
given year (1,2). In the US, back and neck problems are the
second leading cause of disability (3) and the leading
cause of job-related disability, costing Americans more
than $50 billion each year (4). Despite the known clinical
burden, costs, and disability associated with back and
neck pain in the US, no recent nationally representative
prevalence estimates are available for these conditions.
These estimates are critical to demonstrate the public
health importance of these conditions and for informing
prevention initiatives.
Research using clinical samples has examined the bi-
The ndings and conclusions in this article are those of
the authors and do not necessarily represent the views of the
Centers for Disease Control and Prevention.
Tara W. Strine, MPH, Jennifer M. Hootman, PhD, ATC,
FACSM: Centers for Disease Control and Prevention, At-
lanta, Georgia.
Address correspondence to Tara W. Strine, MPH, Division
of Adult and Community Health, Centers for Disease Control
and Prevention, 4770 Buford Highway NE, Mailstop K-66,
Atlanta, GA 30341. E-mail: tws2@cdc.gov.
Submitted for publication June 19, 2006; accepted in re-
vised form October 2, 2006.
low back and neck pain; however, no recent epidemiologic
studies have investigated the associations between low
back and neck pain, health behaviors, and psychological
factors in a representative sample of US community dwell-
ers, particularly after adjusting for sociodemographic char-
acteristics and comorbid conditions. To estimate the prev-
alence and examine psychological and health behavior
correlates of these conditions, we analyzed data from the
2002 National Health Interview Survey (NHIS).
SUBJECTS AND METHODS
Subjects. The NHIS is an ongoing, computer-assisted
personal interview examining a nationwide representative
sample of the civilian noninstitutionalized population of
the US. The NHIS is conducted by the Centers for Disease
Control and Prevention, the National Center for Health
Statistics in cooperation with the US Census Bureau (5,6).
Each year, a representative sample of households across
the US is selected using a multistage cluster sample de-
sign. All US counties, as reported in the 1990 Decennial
Census (available at http://www.census.gov/main/www/
cen1990.html), representing all 50 states and the District of
Columbia are eligible for sampling. Counties with similar
characteristics (e.g., size, rate of growth, industry) are

656
Back and Neck Pain, Mental Distress, and Behaviors
grouped together. From each group, 1 counties are se-
lected (called the primary sampling unit [PSU]). Within
each PSU a sample of small land areas or groups of ad-
dresses are selected (called segments). From each segment
a random sample of household addresses are obtained and
assigned to an interviewer in 1 quarterly samples (7).
Each selected household is contacted via an advance letter
describing the survey. Trained interviewers from the US
Census Bureau visit each selected household, obtain per-
mission, and administer the NHIS in person. The inter-
view consists of 3 core components: the Family Core, the
Sample Adult Core, and the Sample Child Core, in addi-
tion to supplemental modules.
Our study used data obtained from the Sample Adult
Core, which collects information from a randomly selected
adult per family on health conditions, activity limitations,
health behaviors, and access to and use of health care
services. In 2002, 31,044 adults were interviewed, with a
response rate of 74.4%. Data were weighted to reect the
probability of selection, along with adjustments for nonre-
sponse and poststratication to produce national estimates
(8). NHIS methods, including details on the weighting
procedure, were described in detail elsewhere (6,8).
Back and neck pain status. Back or neck pain was de-
ned as a yes response to the following 2 questions: The
following questions are about pain you may have experi-
enced in the past 3 months. Please refer to pain that lasted
a whole day or more. Do not report aches and pain that are
eeting or minor. During the past 3 months did you have
low back pain? and During the past 3 months did you
have neck pain? Persons who reported low back pain
without neck pain were considered to have low back pain
only (LBPO); persons who reported neck pain without low
back pain were considered to have neck pain only (NPO);
persons reporting both low back and neck pain were con-
sidered to have both conditions (LBPNP). The comparison
group comprised persons with neither condition.
Comorbid conditions and sociodemographic character-
istics. Data on 17 individual, dichotomous (yes/no) self-
reported conditions were categorized into 5 mutually ex-
clusive groups. The respondent had a respiratory
condition if he or she had ever had an allergic reaction to
food, odor, or medication; asthma; or emphysema or re-
ported chronic bronchitis or sinusitis in the previous 12
months. The respondent had a cardiovascular abnormality
if he or she had ever had coronary heart disease, angina,
heart attack, stroke, hypertension, hypercholesterolemia,
or other heart disease. Gastrointestinal conditions in-
cluded a report of ever having stomach, duodenal, or pep-
tic ulcer, or inammatory bowel disease, irritable bowel,
or severe constipation. Chronic pain and musculoskeletal
conditions included ever having arthritis, reported facial
ache or pain in the jaw muscles or the joint in front of the
ear, or migraines or severe headaches in the previous 3
months. Other chronic conditions included cancer, diabe-
tes, hypothyroidism or hyperthyroidism, neuropathy, or
seizures. A separate variable represented the total number
of conditions (range 0 17) reported across these 5 catego-
ries. Therefore, comorbidity status was represented in 2
657
domains: type of comorbidity (5 groups) and quantity (to-
tal number). Sociodemographic characteristics included
age, sex, race/ethnicity, education level, marital status,
and employment status.
Assessment of psychological factors. The NHIS mea-
sures nonspecic psychological distress over a 30-day re-
call period with the Kessler 6 (K6) scale (9 11). The K6
scale queries respondents in 6 domains: During the past
30 days, how often did you feel: a) So sad that nothing
could cheer you up? b) Nervous? c) Restless or dgety? d)
Hopeless? e) That everything was an effort? and f) Worth-
less? Possible responses are none of the time, a little of
the time, some of the time, most of the time, and all of the
time, with points 0, 1, 2, 3, and 4 assigned to each category,
respectively. Item scores are summed for a total score of
0 24 (12). According to scoring criteria established by
Kessler et al, persons with a score 13 are considered
likely to have serious mental illness (11,12). Clinically,
serious mental illness is dened as any one 12-month
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition disorder from the Structured Clinical Inter-
view (other than a substance use disorder) and a clinically
rated Global Assessment of Functioning score 60 (11). A
K6 score 13 equalizes false positives and false negatives,
thus creating a total classication accuracy of 0.92 (11). A
separate, dichotomous variable (all/most of the time ver-
sus some/little/none of the time) was also created for each
K6 item. Additionally, we examined responses to the fol-
lowing 4 yes/no questions about the prior 12 months that
are asked independent of the K6 scale: Have you been
frequently depressed or anxious?; Have you regularly
had insomnia or trouble sleeping?; Have you had exces-
sive sleepiness during the day?; and Have you had re-
curring pain?
Assessment of health behaviors. Current smokers were
dened as persons who reported having smoked at least
100 cigarettes during their lifetime and who reported pres-
ently smoking every day or some days. Heavy drinkers
were dened as men who reported drinking 2 drinks per
day and women who reported drinking 1 drink per day
(13). Persons were considered to be inactive if they never
participated in light or moderate activities (exercise for at
least 10 minutes that causes light sweating or a slight to
moderate increase in breathing or heart rate) or vigorous
activity (exercise for at least 10 minutes that causes heavy
sweating or large increases in breathing or heart rate) dur-
ing their leisure time. Body mass index (BMI) was calcu-
lated as weight in kilograms divided by the square of the
height in meters. Consistent with the National Heart, Lung,
and Blood Institute, persons were considered overweight/
obese if their BMI was 25 kg/m2 (14).
Statistical analysis. SUDAAN software, version 9 (Re-
search Triangle Institute, Research Triangle Park, NC) was
used in the analyses to account for the complex sample
design and to calculate prevalence estimates, 95% con-
dence intervals, unadjusted odds ratios (ORs), and ad-
justed ORs. In all analyses the alpha level for statistical
658 Strine and Hootman

Table 1. Prevalence of low back pain, neck pain, and both conditions in the previous 3 months among US adults ages >18
years, by selected sociodemographic characteristics: National Health Interview Survey, 2002*

Low back pain only Neck pain only Both neck and low back pain
Characteristic (n 34 million) (n 9 million) (n 19 million)

Total, % 17.0 (16.617.5) 4.4 (4.14.7) 9.3 (8.99.7)

Age group, years
1824 15.0 (13.616.4) 1.8 (1.42.4) 5.8 (4.96.8)
2534 15.9 (14.917.1) 3.7 (3.14.3) 7.2 (6.58.0)
3544 16.2 (15.217.3) 5.4 (4.76.2) 9.9 (9.110.7)
4554 17.3 (16.218.6) 5.2 (4.55.9) 11.7 (10.712.8)
5564 18.6 (17.120.1) 4.6 (3.95.4) 11.7 (10.512.9)
65 19.7 (18.420.9) 4.8 (4.25.5) 9.0 (8.110.0)
Sex
Male 16.5 (15.817.2) 3.9 (3.54.3) 7.7 (7.28.3)
Female 17.6 (16.918.2) 4.8 (4.45.2) 10.7 (10.211.3)
Race/ethnicity
White, non-Hispanic 17.9 (17.318.5) 4.8 (4.45.2) 9.6 (9.110.1)
Black, non-Hispanic 15.6 (14.416.9) 3.1 (2.53.7) 8.1 (7.19.2)
Other, non-Hispanic 14.2 (12.116.7) 2.5 (1.73.6) 7.1 (5.78.9)
Hispanic 14.1 (12.915.3) 3.4 (2.94.1) 9.2 (8.110.3)
Education
Less than high school 18.5 (17.319.7) 3.5 (3.04.1) 11.3 (10.312.4)
High school graduate or GED 17.8 (16.918.7) 4.4 (3.95.0) 9.7 (9.010.5)
Some college 17.5 (16.518.6) 4.4 (3.95.0) 9.6 (8.710.5)
Bachelors degree/associates degree 15.9 (15.016.8) 4.9 (4.35.6) 7.9 (7.28.7)
More than bachelors degree 14.0 (12.615.5) 4.3 (3.55.2) 7.1 (6.08.3)
Marital status
Married 17.3 (16.618.0) 4.7 (4.35.2) 9.0 (8.49.5)
Previously married 18.7 (17.819.8) 5.1 (4.65.7) 12.0 (11.212.9)
Never married 14.3 (13.215.4) 2.8 (2.43.3) 6.7 (6.07.5)
Member of an unmarried couple 19.3 (17.021.8) 4.0 (3.05.2) 13.0 (11.315.0)
Employment status
Currently working 15.9 (15.416.5) 4.5 (4.14.9) 8.0 (7.58.5)
Retired 19.9 (18.621.4) 4.6 (3.95.4) 8.3 (7.59.3)
Formerly worked 20.0 (18.821.4) 4.0 (3.54.7) 15.9 (14.717.1)
Never worked 12.9 (10.915.2) 2.6 (1.93.7) 6.6 (5.38.2)

* Values are the 90% and 95% condence interval. GED general equivalency diploma.
Number is weighted to the US population using standardized statistical weights from the National Center for Health Statistics.
Signicant pairwise t-tests as compared with the rst level of each variable.

signicance was set at P less than 0.05. Respondents with-
out complete information on low back and neck pain (n
78) and those without complete information about socio-
demographic characteristics (sex, age, race/ethnicity, edu-
cation, marital status, and employment status; n 548)
and comorbid conditions (n 590) were excluded from
the analysis, yielding a total of 29,828 respondents avail-
able for analysis.
First, we calculated the unadjusted prevalence of LBPO,
NPO, and LBPNP overall and by sociodemographic char-
acteristics and tested for signicant sociodemographic dif-
ferences among those with LBPO, NPO, and LBPNP using
pairwise t-tests (Table 1). Second, we calculated percent-
ages and odds, unadjusted and adjusted, of comorbid con-
ditions (Table 2), psychological factors (Table 3), and
health behaviors (Table 4) among persons with LBPO,
NPO, LBPNP, and neither condition using logistic regres-
sion modeling. To examine the association between co-
morbid condition and low back and neck pain, we ad-
justed for potential confounding sociodemographic
characteristics. To examine the association between psy-
chological factors, health behaviors, and low back and
neck pain, we adjusted for sociodemographic characteris-
tics and number and type of comorbidity.
RESULTS
Prevalence estimates and sociodemographic character-
istics. Approximately 17.0% of adults ages 18 years re-
ported LBPO in the previous 3 months, 4.4% reported
NPO, and 9.3% reported LBPNP (Table 1). In general,
LBPO, NPO, and LBPNP were more common among the
older age groups, women, and white non-Hispanics. As
educational attainment increased, the prevalence of LBPO
and LBPNP decreased; however, the opposite was true for
persons with NPO. Persons never married were signi-
cantly less likely to report LBPO, NPO, and LBPNP than
those married, and those previously married were signi-
cantly more likely than those married to report LBPNP and
LBPO, although the difference between those currently
married and previously married with regard to LBPO was
negligible. Finally, persons who formerly worked were
signicantly more likely to report LBPO and LBPNP than
those who were currently working, whereas persons who
Back and Neck Pain, Mental Distress, and Behaviors 659

Table 2. Percentages and adjusted odds of comorbid conditions among US adults ages >18 years by reported lower back or
neck pain status: National Health Interview Survey, 2002*

Neither low back Low back pain Both lower back

Comorbid condition nor neck pain only Neck pain only and neck pain

Respiratory conditions
Allergy to food, odors, or medication (ever)
% (95% CI) 13.7 (13.214.3) 22.7 (21.424.1) 25.2 (22.428.2) 32.5 (30.534.5)
OR (95% CI) Referent 1.9 (1.72.0) 2.1 (1.82.5) 3.0 (2.73.3)
Adjusted OR (95% CI) Referent 1.8 (1.61.9) 1.9 (1.62.3) 2.7 (2.53.0)
Asthma (ever)
% (95% CI) 8.6 (8.19.2) 13.6 (12.514.8) 13.0 (11.115.2) 19.3 (17.821.0)
OR (95% CI) Referent 1.7 (1.51.9) 1.6 (1.31.9) 2.5 (2.22.9)
Adjusted OR (95% CI) Referent 1.7 (1.51.9) 1.6 (1.42.0) 2.5 (2.22.8)
Chronic bronchitis (previous 12 months) or
emphysema (ever)
% (95% CI) 3.6 (3.33.9) 8.3 (7.49.2) 6.9 (5.58.7) 13.3 (11.914.8)
OR (95% CI) Referent 2.4 (2.12.8) 2.0 (1.52.6) 4.1 (3.54.7)
Adjusted OR (95% CI) Referent 2.1 (1.82.4) 1.8 (1.42.3) 3.2 (2.83.7)
Sinusitis (previous 12 months)
% (95% CI) 10.5 (10.011.0) 18.9 (17.620.2) 23.6 (20.926.4) 30.0 (28.132.0)
OR (95% CI) Referent 2.0 (1.82.2) 2.6 (2.33.1) 3.7 (3.34.1)
Adjusted OR (95% CI) Referent 1.9 (1.72.1) 2.3 (2.02.8) 3.4 (3.03.7)
Cardiovascular abnormalities
Coronary heart disease, angina, heart attack,
stroke, other heart disease (ever)
% (95% CI) 9.5 (9.110.0) 16.3 (15.217.5) 18.0 (15.920.3) 20.6 (19.022.2)
OR (95% CI) Referent 1.9 (1.72.1) 2.1 (1.82.4) 2.5 (2.22.7)
Adjusted OR (95% CI) Referent 1.7 (1.51.9) 2.0 (1.72.3) 2.2 (2.02.5)
Hypertension (ever)
% (95% CI) 20.7 (20.021.3) 30.0 (28.531.5) 30.8 (27.933.8) 35.1 (33.137.2)
R (95% CI) Referent 1.7 (1.51.8) 1.7 (1.52.0) 2.1 (1.92.3)
Adjusted OR (95% CI) Referent 1.5 (1.41.7) 1.6 (1.31.9) 1.9 (1.72.1)
Hypercholesterolemia (ever)
% (95% CI) 17.7 (17.018.3) 25.2 (23.726.7) 27.8 (25.130.7) 30.8 (29.032.7)
OR (95% CI) Referent 1.6 (1.41.7) 1.8 (1.62.1) 2.1 (1.92.3)
Adjusted OR (95% CI) Referent 1.5 (1.31.6) 1.6 (1.41.9) 1.9 (1.82.1)
Gastrointestinal conditions
Stomach, duodenal, or peptic ulcer (ever)
% (95% CI) 5.1 (4.75.4) 11.3 (10.412.4) 11.2 (9.413.3) 18.0 (16.319.8)
OR (95% CI) Referent 2.4 (2.12.7) 2.4 (1.92.9) 4.1 (3.64.7)
Adjusted OR (95% CI) Referent 2.2 (1.92.4) 2.1 (1.72.7) 3.5 (3.14.0)
Inammatory bowel disease, irritable bowel, or
constipation severe enough to require
medication (ever)
% (95% CI) 3.4 (3.13.7) 7.3 (6.58.1) 11.2 (9.413.2) 14.6 (13.216.1)
OR (95% CI) Referent 2.2 (1.92.6) 3.6 (2.94.4) 4.8 (4.25.6)
Adjusted OR (95% CI) Referent 2.0 (1.72.3) 3.1 (2.53.8) 4.1 (3.54.8)
Chronic pain and musculoskeletal conditions
Facial ache or pain in jaw muscles or the joint
in front of the ear (previous 3 months)
% (95% CI) 1.9 (1.72.1) 5.6 (4.96.5) 11.8 (10.013.9) 19.4 (17.721.3)
OR (95% CI) Referent 3.1 (2.53.8) 7.0 (5.68.7) 12.6 (10.614.9)
Adjusted OR (95% CI) Referent 3.0 (2.43.7) 6.9 (5.58.7) 11.3 (9.413.5)
Migraine or severe headache (previous 3
months)
% (95% CI) 8.6 (8.19.0) 21.9 (20.623.3) 29.7 (27.032.6) 44.1 (42.046.2)
OR (95% CI) Referent 3.0 (2.73.3) 4.5 (3.95.2) 8.4 (7.69.3)
Adjusted OR (95% CI) Referent 3.1 (2.83.4) 4.8 (4.15.6) 8.6 (7.89.6)
Arthritis (ever)
% (95% CI) 13.8 (13.214.4) 31.2 (29.832.6) 35.1 (32.238.0) 46.2 (44.048.5)
OR (95% CI) Referent 2.8 (2.63.1) 3.4 (3.03.8) 5.4 (4.95.9)
Adjusted OR (95% CI) Referent 2.8 (2.63.1) 3.4 (2.93.9) 5.7 (5.16.4)

(continued)
660 Strine and Hootman

Table 2. Percentages and adjusted odds of comorbid conditions among US adults ages >18 years by reported lower back or
neck pain status: National Health Interview Survey, 2002* (Continued)

Neither low back Low back pain Both lower back

Comorbid condition nor neck pain only Neck pain only and neck pain

Other chronic conditions

Cancer (ever)
% (95% CI) 5.8 (5.56.2) 8.6 (7.89.5) 9.3 (7.811.0) 11.1 (9.912.5)
OR (95% CI) Referent 1.5 (1.31.7) 1.7 (1.42.0) 2.0 (1.72.4)
Adjusted OR (95% CI) Referent 1.3 (1.11.5) 1.4 (1.11.7) 1.8 (1.52.1)
Diabetes (ever)
% (95% CI) 5.5 (5.15.9) 8.0 (7.28.8) 6.4 (5.18.0) 10.2 (8.911.6)
OR (95% CI) Referent 1.5 (1.31.7) 1.2 (0.91.5) 2.0 (1.72.3)
Adjusted OR (95% CI) Referent 1.3 (1.11.5) 1.1 (0.81.4) 1.6 (1.31.9)
Hypothyroidism or hyperthyroidism (ever)
% (95% CI) 5.5 (5.15.8) 8.6 (7.89.5) 9.7 (8.011.6) 13.3 (11.814.9)
OR (95% CI) Referent 1.6 (1.41.9) 1.9 (1.52.3) 2.7 (2.33.1)
Adjusted OR (95% CI) Referent 1.4 (1.21.6) 1.5 (1.21.8) 2.1 (1.82.5)
Neuropathy (ever)
% (95% CI) 0.6 (0.50.7) 1.4 (1.11.8) 2.1 (1.43.2) 2.7 (2.23.5)
OR (95% CI) Referent 2.5 (1.83.5) 3.8 (2.46.2) 5.1 (3.76.9)
Adjusted OR (95% CI) Referent 2.1 (1.52.9) 3.1 (1.95.0) 3.7 (2.75.2)
Seizures (ever)
% (95% CI) 1.0 (0.81.2) 2.0 (1.62.6) 1.8 (1.22.8) 3.1 (2.54.0)
OR (95% CI) Referent 2.1 (1.62.8) 1.8 (1.22.9) 3.2 (2.44.4)
Adjusted OR (95% CI) Referent 1.9 (1.42.5) 1.9 (1.23.0) 2.6 (1.93.5)

* 95% CI 95% condence interval; OR odds ratio.

Adjusted by age, sex, race/ethnicity, education, marital status, and employment status.

never worked were signicantly less likely than those who
were currently working to report LBPO and NPO.
Comorbidities. After adjusting for sociodemographic
characteristics, with the exception of diabetes, which was
equally prevalent in persons with NPO and those with
neither condition, we found the remaining respiratory,
cardiovascular, gastrointestinal, chronic pain and muscu-
loskeletal conditions, and other chronic conditions to be
signicantly more prevalent among those with LBPO,
NPO, and LBPNP than those with neither condition (Table
2). The prevalence of individual comorbid conditions was
consistently highest among individuals with LBPNP. No-
tably, adults with NPO were signicantly more likely than
those with LBPO to report sinusitis in the previous 12
months; inammatory bowel disease, irritable bowel, or
constipation severe enough to require medication; facial
ache or pain in the jaw muscles or the joint in front of the
ear in the previous 3 months; and migraines or severe
headaches in the previous 3 months.
Psychological factors. After adjusting for sociodemo-
graphic characteristics and number and type of comorbid
conditions, we found that persons with LBPO, NPO, and
LBPNP were signicantly more likely than those with
neither condition to report frequent depressive or anxiety
symptoms, insomnia or trouble falling asleep, excessive
sleeplessness during the day, and recurrent pain during
the previous 12 months (Table 3). These conditions were
more prevalent among individuals with LBPNP than those
with LBPO or NPO.
Among the K6 domains, after adjusting for sociodemo-
graphic characteristics and number and type of comorbid
conditions, adults with LBPO, NPO, and LBPNP were
signicantly more likely than adults with neither condi-
tion to report nervousness, restlessness, and a feeling that
everything required effort all or most of the time in the past
30 days (Table 3). However, adults with NPO were no
more likely to report sadness, hopelessness, or worthless-
ness than were adults with neither condition. These con-
ditions were most prevalent among persons with LBPNP.
Overall, persons with LBPO were 1.8 times more likely
than those with neither low back pain nor neck pain to
have potential serious mental illness, those with NPO
were 1.7 times more likely, and those with LBPNP were
3.4 times more likely.
Health behaviors. After adjusting for sociodemographic
characteristics and number and type of comorbid condi-
tions, individuals with LBPO were signicantly more
likely to smoke (adjusted OR 1.3), to be overweight or obese
(OR 1.2), and to drink heavily (OR 1.3) than those with
neither low back pain nor neck pain. Moreover, those with
NPO were signicantly more likely than those with neither
condition to drink heavily (OR 1.5); however, persons with
NPO were signicantly less likely than those with neither
low back or neck pain to be physically inactive (OR 0.8).
Finally, individuals with LBPNP were signicantly more
likely than those with neither condition to smoke (OR 1.5).
DISCUSSION
To our knowledge, these are the rst national prevalence
estimates of low back and neck pain in the US adult
Back and Neck Pain, Mental Distress, and Behaviors 661

Table 3. Percentages and odds of selected psychological factors among US adults ages >18 years by reported lower back or
neck pain status: National Health Interview Survey, 2002*

Neither low back Low back pain Both lower back

Characteristic pain nor neck pain only Neck pain only pain and neck pain

Reported conditions during the

previous 12 months
Frequently depressed or anxious
% (95% CI) 9.8 (9.310.3) 23.1 (21.724.6) 23.9 (21.326.7) 40.1 (38.142.2)
OR (95% CI) Referent 2.8 (2.53.1) 2.9 (2.53.4) 6.2 (5.66.9)
Adjusted OR (95% CI) Referent 1.9 (1.72.1) 1.8 (1.52.1) 2.9 (2.63.2)
Insomnia or trouble falling asleep
% (95% CI) 11.0 (10.511.6) 24.7 (23.326.0) 30.1 (27.233.3) 44.2 (42.146.4)
OR (95% CI) Referent 2.6 (2.42.9) 3.5 (3.04.0) 6.4 (5.77.1)
Adjusted OR (95% CI) Referent 1.7 (1.61.9) 2.0 (1.72.4) 2.9 (2.53.2)
Excessive sleepiness during the day
% (95% CI) 5.8 (5.46.3) 14.2 (13.015.4) 16.5 (14.518.9) 26.5 (24.828.3)
OR (95% CI) Referent 2.7 (2.43.0) 3.2 (2.73.8) 5.8 (5.26.6)
Adjusted OR (95% CI) Referent 1.7 (1.51.9) 1.9 (1.62.4) 2.6 (2.23.0)
Recurring pain
% (95% CI) 8.3 (7.88.8) 33.5 (32.135.0) 34.0 (31.236.9) 53.4 (51.055.7)
OR (95% CI) Referent 5.6 (5.26.1) 5.7 (5.06.5) 12.7 (11.414.2)
Adjusted OR (95% CI) Referent 3.7 (3.44.1) 3.2 (2.73.7) 5.6 (4.96.4)
Kessler 6: reported condition all of the
time or most of the time in the
previous 30 days
So sad nothing could cheer you up
% (95% CI) 1.8 (1.62.0) 3.9 (3.24.6) 2.8 (2.03.9) 8.2 (7.29.4)
OR (95% CI) Referent 2.2 (1.72.8) 1.6 (1.12.2) 4.9 (4.05.9)
Adjusted OR (95% CI) Referent 1.5 (1.22.0) 1.1 (0.81.6) 2.4 (1.93.0)
Nervous
% (95% CI) 2.1 (1.92.4) 5.8 (5.06.6) 6.4 (5.18.0) 13.3 (12.014.9)
OR (95% CI) Referent 2.8 (2.33.4) 3.1 (2.44.1) 7.0 (5.98.4)
Adjusted OR (95% CI) Referent 1.9 (1.52.2) 2.0 (1.52.7) 3.2 (2.63.8)
Restless and dgety
% (95% CI) 2.8 (2.53.1) 6.7 (5.97.6) 7.5 (6.09.3) 15.2 (13.716.8)
OR (95% CI) Referent 2.6 (2.23.0) 2.9 (2.23.7) 6.3 (5.47.4)
Adjusted OR (95% CI) Referent 1.7 (1.52.0) 1.9 (1.52.5) 3.0 (2.53.5)
Hopeless
% (95% CI) 1.3 (1.21.5) 2.9 (2.43.5) 1.9 (1.22.8) 6.2 (5.37.2)
OR (95% CI) Referent 2.2 (1.72.8) 1.4 (0.92.2) 4.9 (4.06.1)
Adjusted OR (95% CI) Referent 1.5 (1.11.9) 0.9 (0.61.5) 2.1 (1.72.7)
Everything is an effort
% (95% CI) 2.7 (2.43.0) 6.7 (5.97.7) 8.4 (6.810.3) 14.0 (12.615.7)
OR (95% CI) Referent 2.6 (2.23.1) 3.3 (2.64.2) 5.9 (5.07.0)
Adjusted OR (95% CI) Referent 1.8 (1.52.2) 2.4 (1.93.1) 2.9 (2.43.4)
Worthless
% (95% CI) 1.1 (1.01.3) 2.9 (2.43.5) 2.3 (1.63.3) 6.0 (5.17.1)
OR (95% CI) Referent 2.7 (2.13.5) 2.1 (1.43.1) 5.7 (4.57.2)
Adjusted OR (95% CI) Referent 1.7 (1.32.2) 1.3 (0.92.0) 2.2 (1.72.9)
Kessler 6 scale
Likely cases of serious mental illness
% (95% CI) 1.5 (1.41.7) 4.3 (3.65.0) 4.0 (3.05.4) 11.4 (10.112.9)
OR (95% CI) Referent 2.9 (2.33.6) 2.7 (1.93.8) 8.3 (6.910.1)
Adjusted OR (95% CI) Referent 1.8 (1.52.3) 1.7 (1.22.4) 3.4 (2.84.2)

* 95% CI 95% condence interval; OR odds ratio.

Adjusted by age, sex, race/ethnicity, education, marital status, employment status, and number and type of comorbid condition.
A measure of psychological distress over a 30-day recall period developed by Ronald C. Kessler (9 11). Scoring of the scale ranges from 0 to 4 points
for each of the 6 questions in accordance with the reported frequency of the problem (e.g., none of the time 0, a little of the time 1, some of the
time 2, most of the time 3, and all of the time 4), yielding a total score on a scale from 0 to 24.
A total score on the Kessler scale of 13 to 24.
662 Strine and Hootman

Table 4. Percentages and adjusted odds of selected health behaviors among US adults ages >18 years by reported lower back
or neck pain status: National Health Interview Survey, 2002*

Neither low back nor Low back pain Both lower back
Characteristic neck pain only Neck pain only and neck pain

Current smoker (100 cigarettes during lifetime

and currently smoke every day or some
days)
% (95% CI) 20.3 (19.621.1) 26.3 (24.727.9) 22.7 (20.225.3) 31.5 (29.433.6)
OR (95% CI) Referent 1.4 (1.31.5) 1.2 (1.01.3) 1.8 (1.62.0)
Adjusted OR (95% CI) Referent 1.3 (1.21.4) 1.1 (1.01.3) 1.5 (1.41.7)
Overweight/obese (BMI 25 kg/m2)
% (95% CI) 56.5 (55.657.3) 64.3 (62.665.9) 57.7 (54.560.9) 62.7 (60.664.7)
OR (95% CI) Referent 1.4 (1.31.5) 1.1 (0.91.2) 1.3 (1.21.4)
Adjusted OR (95% CI) Referent 1.2 (1.11.3) 0.8 (0.71.0) 1.0 (0.91.1)
Heavy drinker (1 drink per day for women,
2 drinks per day for men)
% (95% CI) 4.7 (4.45.1) 6.1 (5.36.9) 6.6 (5.28.3) 5.3 (4.46.5)
OR (5% CI) Referent 1.3 (1.11.5) 1.4 (1.11.9) 1.1 (0.91.4)
Adjusted OR (95% CI) Referent 1.3 (1.11.6) 1.5 (1.12.0) 1.2 (0.91.6)
No leisure-time physical activity (never
participate in light, moderate, or vigorous
activities)
% (95% CI) 37.1 (36.038.3) 36.9 (35.238.6) 31.8 (28.834.9) 43.9 (41.546.3)
OR (95% CI) Referent 1.0 (0.91.1) 0.8 (0.70.9) 1.3 (1.21.5)
Adjusted OR (95% CI) Referent 0.9 (0.81.0) 0.8 (0.70.9) 1.2 (1.01.3)

* 95% CI 95% condence interval; OR odds ratio; BMI body mass index.
Adjusted by age, sex, race/ethnicity, education, marital status, employment status, and number and type of comorbid condition.

population. Our results indicate that low back and neck
pain are major public health problems in the US because
more than 34 million (17%) adults reported LBPO, 9 mil-
lion (4%) reported NPO, and 19 million (9%) reported
LBPNP in the previous 3 months. Not only does our study
corroborate previous research suggesting an association
between low back and neck pain, depressive and anxiety
symptoms (1530), fatigue (31), and sleep impairments
(32,33), it also suggests that persons with LBPO, NPO, and
LBPNP are signicantly more likely than those without
either condition to have potential serious mental illness,
even after adjustment for number and type of comorbid
conditions and sociodemographic characteristics.
As much as 16% of low back pain in the general popu-
lation may be attributable to psychological distress (23).
Notably, a recent review article suggested that psycholog-
ical factors are more important than most biomedical or
biomechanical factors in the development of pain and
disability (18). Depression, which is highly prevalent
among persons with chronic pain (24,25), is a strong inde-
pendent risk factor for the onset of disabling neck and low
back pain (23,26 30). Additionally, persons with depres-
sive symptoms often have a lower threshold for pain and
report greater functional impairment than those without
depressive symptoms (34). In fact, the combination of
chronic back pain and major depression is associated with
greater disability than is either condition alone (24).
Our research also indicates that persons with LBPO and
LBPNP are signicantly more likely than persons with
neither condition to smoke. It is surmised that smoking
may be used as a coping mechanism by alleviating anxiety,
inducing relaxation, and distracting attention away from
pain (35,36). However, the current literature suggests that
smoking is potentially associated with the incidence and
prevalence of nonspecic back pain (3739), intervertebral
disc disorders (40), and neck pain (17), as well as chronic
widespread musculoskeletal pain (41). In fact, a clear
dose-response effect has been reported between the num-
ber of cigarettes smoked daily and prevalence of low back
pain (41). Additionally, in a study of identical twins, ana-
lysis revealed 18% higher disc degeneration scores in the
lumbar spines of smokers as compared with nonsmokers
(42). Other reports (37,39,41) have postulated additional
explanations for the association between smoking and
LBPO, NPO, and LBPNP such as physiologic and meta-
bolic processes and the presence of other behavioral con-
ditions.
We also found that persons with LBPO and NPO were
signicantly more likely than those with neither condition
to drink heavily (i.e., 2 drinks per day for men and 1
drink per day for women; ORs 1.3 and 1.5, respectively).
Very little research has examined these associations, and
the research that has been conducted has produced incon-
sistent results. Leboeuf-Yde suggests that alcohol con-
sumption is not associated with low back pain (43); how-
ever, other research has found an association between pain
and drinking in older adults (44). Notably, similarly to
patterns of tobacco use, a signicant proportion of patients
with chronic pain have a history of alcohol abuse before
the onset of pain (45).
Our results are strikingly similar to results reported by
Webb et al in a similar cross-sectional population-based
study in the UK (46). They reported a 1-month prevalence
of 29% for a combination of back and neck pain, whereas
Back and Neck Pain, Mental Distress, and Behaviors
we reported a 3-month prevalence of 31% (LBPO, NPO,
and LBPNP). However, the range of prevalence estimates
for similar conditions reported in other community-based
and clinical population studies varies considerably. In a
systematic review (47), the point prevalence of low back
pain ranged from 12% to 33%, 1-year prevalence ranged
from 22% to 65%, and lifetime prevalence ranged from
11% to 84%. This nding is likely due to many factors
including varying case denitions of back and neck pain,
different referent populations, study designs and data col-
lection methods, and the use of various referent time pe-
riods (point in time, 1 year, lifetime, etc.) for prevalence
estimation (47). The eld would benet tremendously by
the development and validation of a consistent surveil-
lance case denition for monitoring population burden
and evaluating prevention effectiveness as has been done
for self-reported doctor-diagnosed arthritis (48).
Both our study and the study by Webb et al (46) found
that overweight/obesity was associated with back pain and
not neck pain after adjusting for sociodemographics and
comorbid conditions. While comorbidity may play a large
role in the associations between LBPO, LBPNP, and over-
weight/obesity, weight loss is an important back pain in-
tervention. Notably, studies of bariatric surgery patients
with low back pain have reported vast improvements in
pain and disability, and in some cases low back pain has
completely resolved with weight loss (49,50). As obesity
rates continue to increase in the US, it is reasonable to
assume that the prevalence of back pain and its associated
comorbidity in the population will continue to increase.
Our study has several limitations. First, NHIS is unable
to identify sites of pain, or pain patterns (e.g., radiating),
with the specicity of clinical samples. For example, it is
unclear how a respondent with pain in the thoracic region
would respond to the 2 case denition questions regarding
site of pain used in this study. Additionally, there is no
information about the severity or duration of the subjects
low back or neck pain. Second, the data were based on self
reports and were not validated by physical or psychiatric
examination. However, pain and psychological distress
are subjective experiences and can only be gathered by self
report. Third, the time references for variables of interest
are different. Psychological and physical distress are ref-
erenced to the previous 12 months, K6 is referenced to the
previous 30 days, and the low back and neck pain ques-
tions are referenced to the previous 3 months. Fourth, we
have no information on the nonresponders and therefore
cannot examine potential differences between them and
the responders. Fifth, Table 1 includes 57 pairwise com-
parisons, which inates the Type I error. We were unable
to control for the multiple comparisons because doing so
would cause unacceptably low power. In light of this, the
reader should interpret statistically signicant differences
with caution; 95% condence intervals are provided to aid
in interpretation. Finally, because the study was cross-
sectional, we could not determine time course or infer
causality between low back or neck pain, psychological
factors, health behaviors, and comorbidities.
Despite these limitations, the NHIS sampling plan fol-
lows a multistage area probability design that permits the
representative sampling of households in the US. The
663
adult respondents included in this report are therefore a
valid, representative sample of the US population ages 18
years and older. Sampling and interviewing are continu-
ous throughout each year and the annual response rate of
the NHIS is 90% of the eligible households in the sam-
ple. The survey instrument is standardized, cognitively
tested, and administered according to strict protocol. Data
collectors are extensively trained and monitored for qual-
ity control. Few clinical and community-based studies
have these strengths; subsequently, these data are an im-
portant contribution to the literature on the epidemiology
of low back and neck pain in the US.
Back and neck pain are complex conditions that involve
an interaction of biologic, social (interpersonal, economic,
occupational, etc.) (34), and psychological (depression,
anxiety disorders, somatization, personality disorders,
etc.) factors (1530), as well as coping skills (51). Impair-
ments in any of these domains likely contribute to the
onset and chronicity of back and neck pain. Our study
identied some modiable psychological factors and
health behaviors associated with back and neck pain and
our results suggest that further research should be multi-
dimensional and aim to reduce mental distress and rein-
force benecial health behaviors in this population. Vari-
ous interventions that address physical and psychological
factors have been shown to be effective for low back and
neck pain as well as general pain syndromes and include
exercise therapy, spinal manipulation and mobilization,
back schools, mind-body therapies, and multidisciplinary
treatments (5255). Moreover, expanded assessment of
low back pain and neck pain in the general population
may provide a better understanding of both the prevalence
of these conditions and the extent of their implications.
AUTHOR CONTRIBUTIONS
Ms Strine had full access to all of the data in the study and takes
responsibility for the integrity of the data and the accuracy of the
data analysis.
Study design. Strine, Hootman.
Acquisition of data. Strine.
Analysis and interpretation of data. Strine, Hootman.
Manuscript preparation. Strine, Hootman.
Statistical analysis. Strine.
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