Weather Does Not Affect Back Pain

Everyone has a story about their back pain and one story you often hear is that the weather makes the person’s back pain worse. Topical now in Sydney as it is quite cold. We had an open mind on the issue because we had heard the story so many times but we also know that as a research question it was wide open as no-one had rigorously evaluated this belief.

We had just finished a case-crossover study investigating whether exposure to factors such as being fatigued/tired or distracted during an activity or task increased the risk of an episode of sudden onset, acute low back pain. We had devoted quite a bit of time and resources to this study as we needed to recruit 1,000 patients from primary care. We then had to promptly interview them about what they were doing for the four days preceding the onset of the acute low back pain. It was a huge undertaking.

After we finished that study we realised that we were in a perfect position to evaluate the story about weather influencing back pain as we could link our back pain data to weather data from the Bureau of Meteorology. Because we conceived the weather study after the first study the weather and back pain data were independent and participants and staff were blinded to the study hypotheses during data collection.
So our data would be unbiased by preconceptions about the influence of weather on back pain. And because data collection took 14 months we had data for weather experienced across four seasons in Sydney.

So what did we do? We used a case-crossover analysis to compare the weather at the time patients first noticed back pain (case window) with weather conditions one week and one month before the onset of pain (control windows). Results showed no association between back pain and temperature, humidity, air pressure, wind direction or precipitation. However, higher wind speed and wind gusts did slightly increase the chances of lower back pain, but the amount of increase was not clinically important. If you are interested the full citation to the article is below.

Subsequent to publishing the paper there has been huge media interest. We had expected some interest but not this much. Along with the media interest there have been lots of people with back pain saying we got it wrong (and mostly in more colourful language than this!).

Have we got it wrong? Well our results came from temperate Sydney and perhaps things are different in other parts of the world with more cold/wet weather. We also only looked at a new episode of back pain and again perhaps things are different for conditions such as long term back pain, fibromyalgia, rheumatoid arthritis, and osteoarthritis. Our results also describe what happens typically and it does not preclude the possibility that there are outliers whose experiences may be different to the average. But as I noted earlier there are lots of things about the study that suggests we probably haven’t got it wrong. It is the context that is key here.

Why would people have such strong views about the weather and their back pain? Well they are no different to the rest of us. We are all fallible and tend to pay more attention to information that confirms our view of the world than information that challenges it. I suspect that people may preferentially recall the occasions when their new episode of back pain lined up with poor weather and tend to forget the other times when this was not the case. This trait of humans is particularly a problem for scientists who have to work really hard to make sure that we base our opinions on a balanced overview of all the research in an area. Scientists were notoriously bad at this and that was one of the reasons why systematic reviews have been promoted in contrast to the earlier (biased) narrative reviews.

About Chris Maher

Chris Maher George Institute

Chris is Professor of Physiotherapy in Sydney Medical School, The University of Sydney and Director of the Musculoskeletal Division at The George Institute for Global Health. He leads a research division focusing on the management of musculoskeletal conditions in primary care and community settings. Prof Maher’s research evaluates the primary care management of back pain and he holds an honorary NHMRC Senior Research Fellowship and an ARC Future Fellowship.
Link to Chris’ published research here

Reference

Steffens, D., Maher, C., Li, Q., Ferreira, M., Pereira, L., Koes, B., & Latimer, J. (2014). Weather does not affect back pain: Results from a case-crossover study Arthritis Care & Research DOI: 10.1002/acr.22378

Comments

  1. John Ware, PT says:

    I recall Adriaan Louw mentioning at a CRPS/GMI course this past spring the relatively recent discovery of ion channels along nerve cell membranes that are sensitive to changes in barometric pressure. I’ll see if I can track down the reference.

  2. Hi, thanks Chris for your study. In these times, significant weather changes can evoke an emotionally aversive response. There has been great work done by AD (Bud) Craig on the thermosensory activation of insular cortex in which a proposal was made that ‘central pain’ results from loss of the normal inhibition of pain by cold. It went on to highlight that thermal distress is selectively associated with activation of the anterior cingulate. Vague autonomic disturbances are repeatedly noted with ‘central pain’ – some experience relief simply by going into a warm room, exercising lightly or a spa . Thanks for the great start in the discussion but I agree with many responders in that you have just scratched the surface with acute LBP in terms of understanding the influence of weather on the many facets of pain.

  3. I think it’s utterly fantastic that you weighing in to such a contentious area Chris. Physiotherapy needs studies, studies and more studies ~ both clinical trials and basic science. I salute you for publishing your findings because yes, it is daunting and physiotherapists are a vociferous lot!

  4. André Manso says:

    Good evening everyone,

    I think this is a complex matter, because , as it has already been told above, there are many possibilities to explain the relation between weather and LBP, assuming there’s one (direct effect in the inflammation mechanism, influence in the muscle tension, psychological effect, central sensitization mechanisms that may predispose the pain onset, etc).

    I’d just like to add one characteristic I’ve noticed in many chronic LBP patients that is the factor humidity. Some patients who say that their pain aggravates with cold weather, feel better when they go on vacation to the interior regions of the country (Portugal, by the way), in which the temperature is lower and sometimes negative (ºC). They refer to it as a “dry cold” instead of a “wet cold” like there is near the coast, and they say that this difference is responsible for the difference in the perceived pain.

    I know the study is about acute LBP, but once we are discussing future possible steps of research, I thought I should share my experience. I think the chronic conditions are more likely to be influenced in some way by weather.

  5. Chris Maher says:

    Dear Frederic

    Thank you for your positive comment.

    I really enjoyed that many people offered an opinion even if some disagreed. Putting your work up for public scrutiny can be daunting but if you are willing to listen to people I find you can learn a lot. Thank you to everyone for your contribution.

  6. Frédéric Wellens, pht says:

    Thanks for the study Chris,

    I really liked that such as study was carried out. To me, it’s intuitive that there is no real correlation. But that is my bias. I too would like to see a similar study with chronic conditions to ascertain the conclusions and allow the result to be more generalizable.

  7. Megan Willing says:

    Hello everyone,
    I agree that weather is more relevant to persistent pain.
    I seem to remember a rheumatologist at the Australian Pain Society Annual Meeting quoting a study that showed weather did have an impact on pain associated with osteoarthritis.
    I live in Hobart and work at the Persistent Pain Service – it has been a cold week, snow on the mountain, and the majority of my patients have had a flare up (and ask me if they are mad to think the cold has anything to do with this). I agree that psychological etc factors could play a role. Tensing up, shivering, being less active, wearing heavier, more restrictive clothing might as well – can often tell people with neuropathic pain here because they persist in wearing shorts even in winter. What about cold allodynia ‘tho – that is usually my explanation?

  8. Additional questions about the study:

    It was pulled from chiropractors, GPs, PTs and pharmacists and leg pain was included while serious spinal pathology being excluded. It seems there can be quite a large difference in these healthcare providers to pull information from. Do pharmacists screen for red flags when people have back pain

    Also the reoccurrence of episodes of back pain was around 5, could this be saying that it was an acute episode over a chronic problem?

    Chris Maher Reply:

    Yes pharmacists screen for red flags. And you are correct most participants had experienced an episode of LBP in past.

  9. Bamboo Ilana says:

    It is not acute back pain that would be affected directly and quantitatively by weather. It is the chronic pain, post surgical and traumatic pain conditions that will respond.

    I think this is an interesting and good idea to study. Hopefully it won’t be taken out of context. Since we know of so many people who are able to predict the weather changes after experiencing traumas, it would be a great shame to hear them being told its all in your head or that’s just not true. Here’s the evidence. It would be comparing apples to pineapples.

  10. I wonder . . . the weather may not have a tangible effect on ‘sudden onset, acute low back pain’ but in my experience it is the chronic, low-grade grumbling old-fashioned ‘lumbago’ type back pain that is more influenced by the weather. This is what the patients say.

    Chris Maher Reply:

    Sarah that is a good point. We are trying to chase down a suitable data set to look at the issue. Thanks for the suggestion.

  11. I like the large number and the number looked at through the various seasons
    Questions:

    1. What percentage of acute back pain gets better on its own so is it a good generalization to the patients PTs see versus general practitioners
    2. Does weather have an impact on certain diagnoses such as arthritis. Are there studies correlating certain barometric pressures with particular diagnoses

    The diagnoses of acute back pain is too broad for me to correlate to weather. So, don’t know if out of > 900 patients that it mainly involved those back patients that were going to get better anyway? So, maybe categorizing pain patients and then assessing if there is a correlation may be helpful?

    I couldn’t pull up the whole article. Any help would be great!

  12. Peter vonLossnitzer says:

    This is ridiculous. The study did not show that weather does not affect back pain.
    The study compared “the weather at the time patients first noticed back pain with weather conditions one week and one month before the onset of pain.”
    I don’t think anyone has ever claimed that weather causes back pain.

    Most people say that the weather aggravates joint pain. I hear it from patient after patient. I think a better study should be: “Do high & low pressure systems effect perception of pain.”
    The low-pressure systems (which brings rainy weather) allows joint and tissue inflammation to expand further and thus cause greater symptoms if pain. High-pressure systems put greater pressure on the body thus making it feel better. The same way a compression brace works on knee & ankle pain
    I live in New England at the convergence of three different prevailing weather streams. We get high and low variances every couple of days. I see the differences in many of my patients. It’s so commonplace that I don’t even think of it as anecdotal evidence anymore. It’s as common as not seeing the sun on rainy days.
    Thumbs up to Salina who sees the same discrepancy.
    Thank you for the stud Chris

    Selena Horner Reply:

    Thanks, Peter. From a clinical perspective, the study wasn’t horribly relevant. In my 20 years as a clinician, I have yet to have a patient walk in my doors seeking services because they stated the weather caused their complaint of low back pain. (Unless it was due to a weather related event actually causing definitive trauma i.e. slip & fall on ice, shoveling too long, motor vehicle accident, snowmobile accident)

    Frédéric Wellens, pht Reply:

    I agree with you the relation is more often braught up by folfs with chronic pain conditions. And that is why I think the comment I put above in reply to Mary-Anne applies.

  13. Mary-Anne Therrien says:

    Working in a UK chronic pain service I find that patients often talk about the impact of weather on their pain severity. This is more common for peripheral joints, fibromyalgia and CRPS than for non-specific LBP. What people report they respond to varies from cold and damp to extremes of hot or cold or sudden changes in weather. For CRPS windy weather is often cited as an aggravator.
    I agree that this could in part be due to expectations but have always been intrigued by the ‘weather.co.uk’ aches and pains forecast map!

    Frédéric Wellens, pht Reply:

    I think people with the aforementionned chronic conditions tend to present with very fluctuant pain intensities and very variable symptoms. It seems to be the normal presentation of their condition. It then seem very likely that, at numerous times, their pain presentation will match the weather by pure chance. Given the folkloric association between pain and the weather, I think it make sense they wrongfully associate their pain fluctuation with the weather not really noticing that it turns out to be the opposite the other half of the time.

  14. I remember some studies done on folk with RA where they were put in a chamber and had the temperature, humidity and pressure varied and found no correlation to reported symptoms.

    Great that we can nail this to attribution error, folk associating and finding cause and effect where none exists because of the power of the story to make sense of a senseless, purposeless existance.

    Any chance of this data set being used to look at physical activity prior to pain onset. It would be my opinion that most folk more strongly associate prior physical activity with pain onset and this drives risk aversion, fear avoidance behaviours. If it were possible to challenge the belief that physical activity prior to onset of pain flare is a majorly significant factor that would be clinically helpful. Or at least relegating its prominance to co-incidence rather than cause?
    Kind thoughts,
    Steve

  15. Eric Kruger says:

    It seems to me the association between weather and pain is mostly attribution error. However I do wonder if someone is in a state of chronic central sensitivity if their pain changes may be associated with changes in the environment, especially barometric pressure and humidity. I wonder if we could classify subpopulations of responders to weathe. I am only half joking about that last part 🙂

    Chris Maher Reply:

    It is a good point that in other conditions, particularly established chronic pain, the weather may have an influence. Having completed this study we are sourcing other data sets to see what we can discover.

    The interesting thing for me as a scientist was that there had been so little research in this area.

  16. Schagné Venter says:

    Congratulations on your excellent idea to conduct this piece of research. While I don’t doubt the veracity of your findings for Sydney I would like to suggest you complete another study in Canberra where the fluctuations in temperature are a bit more dramatic. I loved winter and snow, until my nervous system became sensitised. Now I dread those really cold days because I’m either in a hot bath or in bed wrapped in heat because temp ⬇️ = pain ⬆️

    Schagné Venter Reply:

    PS: I have no culture of cold = pain or unhappiness. I lived in a snowy area for very long and love snowy weather. Even now it makes me happy, but the pain ruins it

  17. Jukka Aho says:

    I like this study and it makes sense to me as well as it will help me with my clinical practice. It’s true that the weather in Sydney is very different from eg. Northern Europe or Canada and therefore this can be speculated as well as people could argue about the acute onset of pain versus chronic one. So maybe these can be looked into in the future…

    One idea that I have been speculating over as a possible explanation is that since patients with chronic pain also might present with anxiety, depression and other such issues could just as easily feel more blue on days of bad weather (or just the kind of weather he/she doesn’t enjoy all that much). Also, how many of us “know” that chronic pain gets or should get worse with bad weather? So, besides what the author wrote about remembering the times our pain has gotten worse compared to when it has not, could the mood swings and expectations explain the alleged pain fluctuations during days of bad weather in (some) chronic pain patients who might have the tendency of believing in this phenomena?

    Christine Phillips Reply:

    Yes of course, we know many factors influence pain perception; mood, memory, beliefs, thinking, affect, Temperature, humidity, pressure etc etc

  18. Nice report. Funny that you say “Topical now in Sydney as it is quite cold” I see that the lowest average Temp is 8C
    maybe chilly but cold?

    Chris Maher Reply:

    Yes in Sydney we do think 8C is cold. My new PhD students from Brazil think 8C is freezing! My ex-PhD student from New Foundland found Sydney winters toasty warm.

    Christine phillips Reply:

    Another factor to consider with this research, definitions of “cold” – perhaps a broader IV is needed e.g. “Weather changes” to encompass temperature, pressure, humidity factors?

    Chris Maher Reply:

    Dear Christine,

    Good point. We included temperature, humidity, air pressure, wind direction, precipitation, wind speed and wind gusts.

  19. Rolf-inge Nodberg says:

    Agree Christine! 😉

  20. One swallow doesn’t make a Spring? More studies needed?
    Also, your remark regarding the nature of the pain studied i.e. acute pain episodes is very relevant here. Perhaps similar studies should be carried out in chronic pain conditions where central sensitisation of sensory inputs is highly relevant to the pain experience.

  21. Selena Horner says:

    Living in the United States in Michigan which has extremes of temperatures, I can’t say I’ve ever had a patient ever say the weather was the reason for some new source of back pain.

    What I do know though… for folks who have chronic problems – think arthritis, healing fractures and even post-op situations, they are actually sometimes better weather forecasters than the professionals. They don’t term their sensations as “pain.” They mention they feel an ache sensation. They do not seek out treatment for the sensation they experience. A significant change in weather has a mild effect and alters how their body feels. The time window of the feeling they report is not consistent with everyone – seems to be some time the day before, the day of or day after. In other words, the window of time is quite short.

    As an n =1, after my horse busted my clavicle in 2 places, for about 1 year after, even I became a weather forecaster. I wouldn’t call what I felt pain either… not even necessarily an ache – I would describe what I felt more as an increased awareness that I actually had a clavicle (vs not really noticing my body part).

    As a geriatric clinical specialist, I can also say many older adults can tell me if we’re going to have a storm. They say they feel it in their bones. FYI, in MI it’s not the temperature that is key as much as a rapid change in temperature (typically a drop in temperature) combined with a significant change in pressure. It’s the change that seems to be the component, not the actual weather value. Of course, that’s just my own unscientific observations and experience.

    The weather may actually have an effect – the level or intensity of the effect may not really be at the level the person would actually seek services though.