David Coggon, Georgia Ntani, Keith T Palmer, Vanda E Felli, Raul Harari, Lope H Barrero, Sarah A. Felknor, David Gimeno, Anna Cattrell, Sergio Vargas-Prada, Matteo Bonzini, Eleni Solidaki, Eda Merisalu, Rima R. Habib, Farideh Sadeghian, M Masood Kadir, Sudath SP Warnakulasuriya, Ko Matsudaira, Busisiwe Nyantumbu, Malcolm R Sim, Helen Harcombe, Ken Cox, Maria H Marziale, Leila M Sarquis, Florencia Harari, Rocio Freire, Natalia Harari, Magda V Monroy, Leonardo A Quintana, Marianela Rojas, Eduardo J. Salazar Vega, E Clare Harris, Consol Serra, J Miguel Martinez, George Delclos, Fernando G Benavides, Michele Carugno, Marco M Ferrario, Angela C Pesatori, Leda Chatzi, Panos Bitsios, Manolis Kogevinas, Kristel Oha, Tuuli Sirk, Ali Sadeghian, Roshini J Peiris-John, Nalini Sathiakumar, A Rajitha Wickremasinghe, Noriko Yoshimura, Helen L Kelsall, Victor C W Hoe, Donna M Urquhart, Sarah Derrett, David McBride, Peter Herbison, Andrew Gray

To explore definitions for multisite pain, and compare associations with risk factors for different patterns of musculoskeletal pain, we analysed cross-sectional data from the Cultural and Psychosocial Influences on Disability (CUPID) study. The study sample comprised 12,410 adults aged 20-59 years from 47 occupational groups in 18 countries. A standardised questionnaire was used to collect information about pain in the past month at each of 10 anatomical sites, and about potential risk factors. Associations with pain outcomes were assessed by Poisson regression, and characterised by prevalence rate ratios (PRRs). Extensive pain, affecting 6-10 anatomical sites, was reported much more frequently than would be expected if the occurrence of pain at each site were independent (674 participants vs 41.9 expected). In comparison with pain involving only 1-3 sites, it showed much stronger associations (relative to no pain) with risk factors such as female sex (PRR 1.6 vs 1.1), older age (PRR 2.6 vs 1.1), somatising tendency (PRR 4.6 vs 1.3), and exposure to multiple physically stressing occupational activities (PRR 5.0 vs 1.4). After adjustment for number of sites with pain, these risk factors showed no additional association with a distribution of pain that was widespread according to the frequently used American College of Rheumatology criteria. Our analysis supports the classification of pain at multiple anatomical sites simply by the number of sites affected, and suggests that extensive pain differs importantly in its associations with risk factors from pain that is limited to only a small number of anatomical sites.