Ó The Author 2007. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

doi:10.1093/fampra/cmm012

Family Practice Advance Access published on 15 May 2007

Patterns of pain and consulting behaviour in
patients with musculoskeletal disorders
in rural Crete, Greece
Maria Antonopouloua,b, N Antonakisa,c, A Hadjipavloud and C Lionisa
Antonopoulou M, Antonakis N, Hadjipavlou A and Lionis C. Patterns of pain and consulting behaviour in patients with musculoskeletal disorders in rural Crete, Greece. Family Practice 2007;
24: 209–216.
Background. Musculoskeletal disorders (MSDs) account as a reason for frequent consultations
in primary care. However, the magnitude of the problem at the GP’s clinic, the patterns of pain
and the consulting behaviour has not been sufﬁciently explored.
Objectives. The aim of this study was to report on patterns of pain relevant to MSDs and explore the co-morbidities and consulting behaviour in rural primary care settings in Crete.
Methods. Three primary care centres (PCCs) of Crete were selected for a study period of 2
weeks. Every visitor, aged 20–75 years, regardless of the reason for visiting the facility was invited to participate. The Greek version of the general Nordic questionnaire for the analysis of
musculoskeletal disorders (NMQ) was used for data collection.
Results. A total of 455 subjects answered the NMQ. Three hundred and seventy-six (82.6%) of
the study population reported having one or more symptoms during the previous year. Low back
(56.9%), neck (34.1%), shoulder (29.9%) and knee (27.9%) were the commonest sites of pain. In
almost half cases (48.6%), the complaints about pain were accompanied by activity restrictions.
Multivariate statistical analysis showed signiﬁcant correlations with increasing age and female
gender (P < 0.05). Common chronic conditions were associated with co-morbidities from the
musculoskeletal system. Only one-third of those who reported MSDs had consulted their GPs
for the same problems within the previous year.
Conclusions. MSDs are highly prevalent among rural population in Crete but fewer patients
seek care than those who report symptoms.
Keywords. Greece, musculoskeletal disorders, pain patterns, primary care, rural.

a heavy community burden.5 Furthermore, working
conditions correlate well with MSDs.6 In family practice settings, MSDs often co-exist with multiple medical conditions, addressing special care needs.7
In Greece, although MSDs have been considered as
common reasons for patients’ visits to GPs in rural
areas,8,9 issues of pain patterns and consulting behaviour are still unexplored. This paper reports on the
magnitude of musculoskeletal problems within the primary care setting with emphasis on co-morbidities and
consulting behaviour and intends to discuss its implications for GPs in a southern European country.

Introduction
Musculoskeletal disorders (MSDs) comprise a major
health problem for the general population, affecting
their quality of life, demanding increased health care
and organization.1 According to reports from Canada
and the Netherlands,2,3 the prevalence of musculoskeletal problems range from 29% to 74.5%, respectively.
However, the annual consultation rate by health care
professionals of musculoskeletal problems is about
20%.4 MSDs often cause pain and signiﬁcant disability, especially in the elderly population, signifying

Received 3 June 2006; Revised 3 February 2007; Accepted 18 March 2007.
a
Clinic of Social and Family Medicine, Department of Social Medicine, School of Medicine, University of Crete, Crete, Greece,
b
Spili Health Centre and cAnogeia Health Centre, Regional Health and Welfare System of Crete, Crete, Greece and dDepartment
of Orthopaedics and Traumatology, School of Medicine, University of Crete, Crete, Greece. Correspondence to: Maria
Antonopoulou, Clinic of Social and Family Medicine, University of Crete, PO Box 2208, Heraklion 71003, Crete, Greece; Email:
antonopm@uoc.gr

209

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Family Practice—an international journal

Methods
Setting
Data were gathered from three PCCs in rural Crete.
These PCCs provide around the clock outpatient care
for a rural district, serving a population of approximately 37 000 inhabitants10 with most of them being
farmers [International Standard Classiﬁcation of Occupations, 88 (ISCO-COM 6) and craft and related
trades sectors (ISCO-COM 7)]. People are also employed in restaurant services and travel-related services (ISCO-COM 5), since a lot of tourists are visiting
these areas. The unemployment rate is nearly 12%,
slightly higher, as compared to 10% in the rest of the
country. The educational status is low with more than
50% of the general population being either illiterate
or with primary education only [International Standard Classiﬁcation of Education 1997 (ISCED 0 + 1)].
Sampling
All consecutive visitors (20–75 years of age) in the
three PCCs during a period of 10 working days in
November 2002 participated in the study. A written
consent was obtained and the study protocol was applied by health professionals. The month of November
was selected because most agricultural tasks in the ﬁelds
take place during this period throughout the catchment area of the PCCs. During that period, farmers
are engaged in intensive harvesting of grapes and
olives, demanding hard manual work with the spine in
a bend over position for a prolonged period of time.
Other awkward positions during farming can also extract musculoskeletal strain. Moreover, at this time
there are no tourists visiting the PCCs, so the study
population comes from the permanent inhabitants
served by these PCCs. The sample collected was further scrutinized for clinical co-morbidities and the
consulting behaviour, using the medical records of
one PCC.
Methods
The Greek version of the general form of the standardized Nordic questionnaire for the analysis of musculoskeletal symptoms (NMQ) was used for data
collection. NMQ had been previously translated and
validated in the Greek language.11 Apart from a few
general demographic questions, it contains a picture
of the back aspect of the human body divided in nine
anatomical areas (neck, shoulders, elbows, wrists/
hands, upper back, low back, hips/thighs, knees and
ankles/feet) (Fig. 1). The rest of the questions are distributed in three columns. There are nine screening
questions in the ﬁrst column. For example, ‘have you
at any time during the last 12 months had trouble i.e.
ache, pain or discomfort in this area?’. In case of a positive answer, the respondents answer whether or not
they had been prevented from doing their normal

FIGURE 1 The back aspect of the human body as it appears
in the NMQ

work at home or away from home, during the same
period because of that ailment. They are also asked if
they had experienced that symptom during the previous 7 days (questions in the second and the third
column). Therefore, the questionnaire’s structure investigates the prevalence of different MSDs and examines which of the particular problems are the more
debilitating (i.e. prohibited patients from engaging in
their normal work routine within the previous 12
months). Even though, NMQ is self-administered, because of the special features of the study population
(mean age of 51.9 years and education level between
0 and 6 years), trained health professionals assisted
the subjects with the completion of the questionnaire.
Additional data concerning age, sex, body mass index (BMI) and working records were extracted by the
NMQ. BMI was classiﬁed into four categories: underweight (BMI < 20 kg/m2), normal (BMI > 20 and <
25 kg/m2), overweight (BMI > 25 and < 30 kg/m2)
and obese (BMI > 30 kg/m2).12 To determine the extent to which NMQ identiﬁed musculoskeletal symptoms during primary care visits, we carried out
a medical audit in one of the participating PCCs and
all medical records of the subjects were reviewed. Comorbidities (according to International Classiﬁcation
for Primary Care 2), education level (according to
ISCED 1997), type of occupation (according to ISCOCOM 88), cohabitation status (any kind of cohabitation

211

Patterns of pain and consulting behaviour in patients

or living alone) and consultation patterns were also
collected using a pre-tested questionnaire.

TABLE 1

Sample characteristics
n = 455, %

Statistical analyses
Statistical analyses were performed using SPSS version
12.0. A P-value of P < 0.05 was accepted as signiﬁcant.
For the nine anatomical areas, the 1-year period prevalence, the prevalence of daily limitations due to
reported symptoms and the point prevalence (musculoskeletal symptoms during last week) were calculated.
Those were the dependent variables. Independent variables were age, gender, BMI, working time at present
work and working hours per week. Adjusted odds
ratios (ORs) were calculated. Multiple logistic regression analysis was performed to evaluate the association
between each exposure variable and musculoskeletal
symptoms. This method was applied stepwise in an
enter approach. The association between education
level, type of occupation, cohabitation status, comorbidities and the patterns of pain was also measured. To study the effects of different occupations to
limitations in daily activities, the total score of positive
answers for each patient and for each question was
calculated. Wilcoxon paired and unpaired (Mann–
Whitney) tests were used to compare these scores into
the same and among different occupational groups.
Chi-square test was used to compare those who had
consulted their physicians for MSDs with those who
did not.

Results
Sample characteristics
Overall, 455 subjects completed the questionnaire at the
three PCCs with participation rate at 95.2%. Table 1
shows the general demographic characteristics. Two
hundred and sixty (57.2%) of the respondents were
females and the mean age was 51.9 [95% conﬁdence
interval (CI): 50.3–53.7] years.
Patterns of pain
Three hundred and seventy-six subjects (82.6%) reported at least one musculoskeletal problem during
the previous year, while 219 (48.1%) subjects reported
limitations of activities due to their symptoms during
the same period of time. Low back pain was the commonest complaint (56.9%), followed by neck (34.1%),
shoulder (29.9%) and knee (27.9%) problems. Two
musculoskeletal co-morbidities were present in 24%
of patients (n = 109); one in 23.3% (n = 105), while
3.3% (n = 15) reported widespread pain in all nine regions of the body. Low back pain was also the most
debilitating symptom reported (28.6%), causing limitations in daily activities. Low back and neck pain was
the commonest combination reported (n = 124,
27.5%), resulting in the higher disability rate (11.0%).

Gender
Age group

BMI

Residence area

Years at present work

Weekly working hours

Men
Women
20–39
40–59
60–75
Underweight (BMI < 20)
Acceptable (20 < BMI < 25)
Overweight (25 < BMI < 30)
Obese (BMI > 30)
No records available
Anogeia
Perama
Spili
<1–4
5–14
15–24
25–34
35–44
45+
No records available
5–14
15–24
25–34
35–44
45–54
55+
No records available

42.8
57.2
29.3
28.2
42.5
0.8
20.2
55.4
21.1
2.4
15.4
45.9
38.7
12.1
20.4
13.0
12.3
11.6
4.8
25.7
4.2
5.3
2.9
17.1
25.1
17.1
28.3

Although the co-existence of more than two symptoms
was not frequent, this seemed to be associated with
more disability but without statistical signiﬁcance. The
reported patterns of pain by age groups and gender
are presented in Table 2.
The prevalence of the reported symptoms was statistically related to increasing age (P < 0.05) for neck,
elbow, low back, hip and knee pain. Multiple musculoskeletal symptoms were also related to aging. Patients
with shoulder and low back pain reported also more
disability in terms of limitation in their daily activities.
Morbidity patterns also differed between women
and men. While low back pain was the commonest
symptom in both genders, female patients reported
higher prevalence for every symptom (P < 0.05) except for elbow and foot (Table 2). Women reported
more pain conditions than men 11.9/10.7 (P < 0.05)
and more disability.
In the questions about working schedules, the majority of the sample reported 20 (95% CI: 18.6–21.8)
years of work for 45.6 (95% CI: 43.6–47.6) hours per
week. Men worked longer hours but this tended to decrease, as they grew older. Women worked mainly at
home or at the farms, fewer hours per week than men
(men/women ratio: 1.1). Working for a period of more
that 15 years was related to higher morbidity mainly
from shoulder and elbow pain (Table 3). Limitations
in daily activities due to neck, shoulder, low back
and foot complaints were related to longer working

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TABLE 2

Patterns of pain by age and gender

Pain patterns/age groups

Prevalence of pain during the last year/gender
Males

Level of signiﬁcancea

Females

n
Neck
20–39 years
40–64 years
65+ years
Shoulder
20–39 years
40–64 years
65+ years
Elbow
20–39 years
40–64 years
65+ years
Wrist/hand
20–39 years
40–64 years
65+ years
Upper back
20–39 years
40–64 years
65+ years
Low back
20–39 years
40–64 years
65+ years
Hip
20–39 years
40–64 years
65+ years
Knees
20–39 years
40–64 years
65+ years
Foot/ankle
20–39 years
40–64 years
65+ years
a

%

n

%

41
3
15
22
45
7
15
22
18
0
7
10
21
3
6
12
20
3
6
11
86
24
29
32
20
2
4
13
43
6
11
27
33
4
8
20

21.0
1.5
7.7
11.3
23.1
3.6
7.7
11.3
9.2
0.0
3.6
5.1
10.8
1.5
3.1
6.2
10.3
1.5
3.1
5.6
44.1
12.3
14.9
16.4
10.3
1.0
2.1
6.7
22.1
3.1
5.6
13.8
16.9
2.1
4.1
10.3

114
16
49
48
91
19
34
37
39
3
19
17
67
9
35
23
77
11
18
29
173
35
73
63
77
8
32
36
84
11
27
36
52
9
22
21

43.8
6.2
18.8
18.5
35.0
7.3
13.1
14.2
15.0
1.2
7.3
6.5
25.8
3.5
13.5
8.8
29.6
4.2
6.9
11.2
66.5
13.5
28.1
24.2
29.6
3.1
12.3
13.8
32.3
4.2
10.4
13.8
20.0
3.5
8.5
8.1

<0.0001
0.025
0.001
0.048
0.008
0.139
0.092
0.441
0.087
0.336
0.139
0.670
<0.0001
0.307
0.0002
0.393
<0.0001
0.166
0.113
0.054
<0.0001
0.813
0.001
0.056
<0.0001
0.234
0.0001
0.023
0.024
0.716
0.096
0.890
0.926
0.549
0.093
0.519

Statistical signiﬁcant values are printed in italic.

schedule per week. Multiple regression analysis for
the most frequent patterns of pain is presented in
Table 3.
Further analysis from the sample in one PCC
showed that occupation did not constitute a statistically
signiﬁcant risk factor for the presence of MSDs.
Thirty-one per cent of the sample were farmers
(ISCO-COM 6), 11% were employed in restaurant
services and travel-related services (ISCO-COM 5)
and 27%—almost half of all the women—were housewives. Comparing the total scores in the three questions of the NMQ among various occupational
groups, it came out that the majority kept their usual
everyday activities during the previous year, even
though they reported a great number of musculoskeletal symptoms (P < 0.001). Different occupations did
not statistically affect this result.

Cohabitation and educational status did not signiﬁcantly differ in the patterns of reported symptoms.
Co-morbidities
Half of the study population (55.4%) for both sexes
were overweight (BMI > 25 kg/m2) with mean BMI =
29.0 (95% CI: 28.6–29.9), especially women in advanced
age (BMI > 30 kg/m2 in 24.6% of females) (Pearson R
correlation, Rp = 0.328, P < 0.001 of correlation
between overweight women and age). Overweight
(BMI > 25) and obese (BMI > 30) patients had a
tendency to report more musculoskeletal symptoms
but not of statistical signiﬁcance. However, they reported more activity limitations as a result of shoulder,
elbow, wrist and foot pain.
Review of medical records in one PCC revealed that
the most common diagnoses co-existing with MSDs

213

Patterns of pain and consulting behaviour in patients
TABLE 3 Logistic regression analysis of most frequent patterns of pain by age, gender, BMI and working time
Variable
Low back pain
Age
Gender
BMI
Years in the present work
Hours per week
Neck pain
Age
Gender
BMI
Years in the present work
Hours per week
Shoulder pain
Age
Gender
BMI
Years in the present work
Hours per week
Knee pain
Age
Gender
BMI
Years in the present work
Hours per week

B

SE

0.023
0.858
0.033
0.001
0.005

0.012
0.239
0.031
0.012
0.984

0.054
1.323
0.009
0.007
0.010

Exp. B

95% CI

0.046
0.0003
0.294
0.956
0.458

1.024
2.359
1.033
1.001
0.995

1.000–1.047
1.477–3.768
0.972–1.098
0.977–1.025
0.981–1.009

0.013
0.274
0.033
0.013
0.008

0.00003
0.000001
0.792
0.582
0.191

1.056
3.756
0.991
0.993
0.990

1.029–1.083
2.193–6.431
0.930–1.057
0.968–1.018
0.975–1.005

0.014
0.631
0.029
0.028
0.004

0.013
0.267
0.032
0.013
0.008

0.285
0.018
0.373
0.031
0.596

1.014
1.879
1.029
1.028
1.004

0.989–1.040
1.114–3.171
0.966–1.096
1.033–1.055
0.989–1.019

0.033
1.006
0.033
0.015
0.007

0.013
0.280
0.033
0.013
0.008

0.011
0.003
0.321
0.258
0.396

1.034
2.735
1.033
1.015
1.007

1.008–1.061
1.578–4.738
0.969–1.102
0.989–1.041
0.991–1.022

were hypertension (64/176, 36%), osteoarthritis (OA)
of hip and/or knee (56/176, 32%), coronary artery disease (CAD) (21/176, 12%) and mental disorders (20/
176, 11%). The number of co-morbidities was increasing with age without statistical signiﬁcance. Mental
disorders, mainly depression, ranked as the medical
conditions with the highest proportion of musculoskeletal symptoms (95.0%), followed by chronic obstructive pulmonary disease (COPD) (92.8%), CAD
(90.4%), OA (84.0%), diabetes (83.3%) and hypertension (82.8%). The multiple logistic regression analysis
of the most common co-morbidities in correlation to
the reported symptoms highlighted strong correlations, especially with arthritic conditions. Shoulder
pain was statistically associated with COPD (adjusted
OR = 8.94, 95% CI 1.47–54.17, P = 0.017) and OA
(adjusted OR = 4.25, 95% CI 1.67–10.81, P = 0.002),
whereas wrist pain was more frequent in subjects with
diabetes (adjusted OR = 3.87, 95% CI 1.09–13.68, P =
0.035). The prevalence of elbow pain was correlated
to CAD (adjusted OR =5.01, 95% CI 1.01–24.87, P =
0.048). Patients with OA also reported statistically signiﬁcant activity restriction (P < 0.05) due to neck,
shoulder, upper back, hip, knee and foot symptoms,
unlike diabetic patients who did not complain for
many daily restrictions. Cancer of any form, mental
disorders or stomach problems were not statistically
correlated to MSDs.
Consulting behaviour
Data from one PCC showed that although the prevalence of reported MSD was measured at 71.4% (125

P-value

out of 176), only 56 subjects (32%) had reported the
same symptoms to their GP during previous consultations. These symptoms originated mainly from low
back, neck, knee and hip areas. Patients with multiple
co-morbidities were more likely to have previously consulted their GPs for those problems (adjusted OR =
2.21, 95% CI 1.6–2.9, P < 0.0001). Seventy-four of the
participants (41.7%) reported symptoms during the
last week (question in the third column of the NMQ),
but only 13 (17.5%) visited their GP complaining for
musculoskeletal symptoms. When comparing those
visiting GPs with those who did not (chi-square test)
during the previous year, we found that younger patients of both genders with limited education did not
consult their physician due to MSDs. A patient with
knee or shoulder pain was seeking care more often regardless of age. Older patients and patients suffering
from OA or hypertension reported signiﬁcantly more
consultations. Other factors like gender, BMI, working
time or occupation were not found to have statistical
signiﬁcance.

Discussion
Summary of results
There are several interesting points revealed by this
study such as the patterns and distribution of pain, the
differences between genders and the consulting behaviour. Low back pain was the commonest reported site
among all age groups. Low back pain, followed by neck
and shoulder pain, was also the main symptom for
daily living limitations. This ﬁnding is in accordance

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Family Practice—an international journal

with the results of a recent systematic review in general
practice of work-related diseases.13 Age was found to
be a risk factor for many musculoskeletal symptoms.
Younger patients (20–39 years) reported fewer symptoms and less frequently, as compared with older
patients (66.2% prevalence of any MSDs versus 90%
for the older group over 60 years of age, P < 0.05).
Pain patterns also differed between genders. In our
study, women reported on average more symptoms
and more disability. Women to a greater extent than
men blamed musculoskeletal pain in neck, wrist, low
back, hip or knee for restrictions in daily activities.
The tendency for MSDs to affect more women than
men has been shown in other epidemiological studies.3,14 Reasons for gender differences, apart from the
apparent biological differences (genetics, physiology,
hormones, etc.), include different psychosocial aspects
of symptoms and care. Women also seem to visit more
promptly health care facilities and recall health problems to a greater extent than men.15 However, in our
study, such gender preference was not revealed.
In our study, overweight or obesity, a common public
health problem in contemporary Crete,16 showed signiﬁcant correlations only with the reported disabilities
due to pain of upper limb and foot. According to other
studies, obesity has been related to hip and low back
pain in middle-aged men,17 whereas in rural communities, it causes more disability to patients with knee OA.18
Working for many years was correlated to shoulder
and elbow pain. More comprehensive surveys that included physical and psychosocial work factors, such as
work intensity or working postures, have previously
shown associations with MSDs,6 but these were not
explored in our study.
Unlike other epidemiological evidence which relates
MSDs to physically demanding professions like farming,19 occupation did not statistically relate to any
MSD. However, analysing the positive answers for all
occupational groups, we found that the majority of
participants carried on with their daily functions, independently of their job, despite the occurrence of multiple musculoskeletal problems. Cultural or local social
network variables, not included in this study, could
play a role in the perceived limitations of activity for
this population.20
Other social factors, such as living alone or low education, were not found to affect the reported patterns
of pain, which comes in agreement with other studies.21
The clinical co-morbidity rate was high. Patients
with OA, COPD, diabetes, hypertension or CAD
tended to report more musculoskeletal symptoms. Comorbidities with MSDs were also shown to prevent
their daily activities. Co-morbidity for OA in general
practice has also been found to be extensive with musculoskeletal as well as non-musculoskeletal conditions
in the UK.22 Patterns of co-morbidity in the Dutch
population have shown that MSDs were most likely to

coincide with lung and heart diseases, neurological disorders, diabetes and cancer.23 The explanation for the
perceived co-morbidity lies beyond the present study
in shared pathology of diseases or the impact which
one condition might have in the occurrence of another. However, the recognition of this large extent of
co-morbidity has implications for the way in which primary care should be organized. The burden is on primary care physicians to provide the majority of care,
not only for the target condition but also for all comorbid conditions.
Another interesting point was that only 13 out of 74
who reported musculoskeletal symptoms were actually
seeking care at the time of the study. On an annual
basis, 32% of this sample had contacted a primary care
physician because of musculoskeletal pain which can
be considered high in comparison with other studies,4
although it corresponds to less than half of the same
population reporting MSDs in the NMQ. The more
concurrent chronic conditions they had, the more
likely they were to have consulted their GP and complain for MSDs, too. Those were mainly older patients
with higher education suffering from OA and hypertension that came complaining for knee or shoulder
pain. Similarly, another study in a rural Swedish population showed that only one-ﬁfth of those reporting
current neck and/or low back pain had a primary care
consultation.24 Possible explanations could be either
the poor registration rates of primary care physicians
who underestimate the symptoms or that symptoms
are not severe enough to be reported. A recent report
on primary care consultations due to indigestion problems in the same district showed under diagnosis of
functional gastrointestinal disorders by physicians.25
However, a recent European study involving eight
countries regarding musculoskeletal pain showed that
up to 27% of people with pain do not seek medical
care in spite of constant or daily pain.26 The disbelief
or ignorance of effective treatments for MSDs could
prevent patients from consulting a health professional.23 Even when they do seek help, this is often limited to prescription for non-steroidal anti-inﬂammatory
drugs (NSAIDS), which result in non-compliance to
their treatment.26 In fact, according to a previous study
conducted in the same district, prescriptions for painkillers and NSAIDS ranked second accounting for
19% of prescriptions during 1-year period.27 To overcome the doctors’ difﬁculty in identifying those diseases, a change in doctor–patient communication with
an emphasis on patients’ perceptions and needs seems
as a promising option.26
Strengths and weakness
Several concerns should be raised when discussing
study ﬁndings. Overestimating prevalence due to sampling method is one issue: our sample was probably
overrepresented by patients with multiple morbidities

Patterns of pain and consulting behaviour in patients

waiting to see their physicians. High prevalence of
MSDs has been documented in many studies, especially when self-administered questionnaires are being
used for data collection.28 People tend to recall the
most recent or most debilitating painful conditions
when asked to complete questionnaires. Whether or
not the reported symptoms were major or minor cannot be explored through the NMQ.
Although the NMQ has been used in a great number of studies in different countries,29 it still has several limitations. Since NMQ is counting symptoms
throughout the human body, the estimated prevalence
is expected to be high. Most general population studies focus on special anatomic sites, while others deal
with speciﬁc occupational groups.30,31 The used questionnaire seems to be appropriate for general screening in occupational groups, without permitting further
discrimination. For example, the pain in the hips, considering the area marked as ‘hip/thighs’ in the picture
of NMQ is unclear if it is actually a hip problem or
originates from the low back area and reﬂects at the
hips. Moreover, the use of a picture of the back aspect
of the body may not allow problems in the frontal aspect to be revealed.
The timing of data collection did not seem to have
an effect on the measured prevalence. Data from one
PCC that was collected during 10 working days in
spring did not show a seasonal variation for the reported MSDs.
Although the sample size reﬂected the underlying
population i.e. the general population of rural primary
care in Crete (95% conﬁdence level and 95% CI 7%),
limitations should be taken into account interpreting
the results for co-morbidities and consulting behaviour
since the data came only from one PCC (n = 175).
Conclusions
In conclusion, this study showed that musculoskeletal
pain is very common in the rural population of Crete.
GPs need to be alert and well skilled in order to prevent or identify early the musculoskeletal problems.
The observed patterns of co-morbidity highlight the
need for primary care oriented towards patients’ overall health care. Patients, especially women and elderly,
who suffer from hypertension or diabetes, could also
suffer from musculoskeletal problems, even if this
does not come up as their major complain, and they
should be treated accordingly. Further evaluation of
the consequences of MSDs to this population in terms
of disability or effect in the quality of life should contribute towards that effort.

Ethical approval: Approval of a speciﬁc scientiﬁc
committee of the University of Crete.
Conﬂicts of interest: None.

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Declaration
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Funding: None.

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