Low Back Pain in the Older Adult Gregory E. Hicks, PT, PhD University of Delaware

Low Back Pain in the Older Adult

Gregory E. Hicks, PT, PhD University of Delaware

Epidemiology of LBP Among Older Adults

Epidemiology• Low back pain (LBP) is the most frequently

reported musculoskeletal problem and third most reported symptom of any kind in people over 75 (Bressler, 1999)

• Evidence that older people experience more disabling LBP than younger people.

• Between 1991 & 2002, Medicare data shows a 132% increase in LBP patients and a 387% increase in related costs for LBP (Weiner, 2006)

• As the older population grows, it is important to pursue methods of delaying the natural history of the development of LBP.

LBP in Older Adults

• Little research has been done in the area of LBP among the older population (>65yrs).

• Reasons for lack of research interest in older adults with LBP?– Younger, working population– Less serious than other conditions/diseases– Societal attitudes

Epidemiology

• Prevalence of LBP is uncertain in 65yo+– 6.8% to 49%

• Factors influencing prevalence reports– cognitive impairment, decreased pain

perception, co-morbidities, resignation to perceived effects of aging, depression

What do we know so far?• Back Pain is associated with impaired function

(ADL’s and mobility)– SOF (women)

– Iowa 65+ Rural Health Study

– WHAS (women)

– Framingham

– Health ABC

*primarily measure self-reported function

• Very little research done in the areas of underlying mechanisms or interventions in this age group

1.67

1.77

1.87

1.97

2.07

2.17

2.27

Year 1 Year 4

No/Mild Back Pain Mod/Extreme Back PainHea

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Back Pain and Function

Hicks et al, J Gerontol Med Sci, Nov 2005

https://209.213.209.137/ucsf_cc/version1.5/habc/welcome.asp?studyname=HABC&servername=Medusa&databasename=HABCEdits

Associations of back and leg pain with health status and functional capacity of older adultsFindings from the Retirement Community Back Pain Study

Gregory E. Hicks, PhD, PTUniversity of Delaware, Department of Physical Therapy

Jean M. Gaines, RN, PhDThe Erickson Foundation, Geriatric Medicine and Gerontology

Eleanor M. Simonsick, PhDNational Institute on Aging, Clinical Research Branch

• Population-based survey study

• 522 men (32%) and women

• Aged 60 and above

• Independently living resident in one of four CCRCs in MD and Northern VA

Retirement Community Back Pain Study

• To examine cross-sectional associations between back pain status (LBP alone or LBP with leg pain) and general health status, as well as functional capacity, in older adults living in a continuing care retirement community (CCRC) setting

• To examine care-seeking behaviors related to back pain status in this population with high access to health care

Objectives

Participant Characteristics

LBP statusNo pain LBP only LBP + LP P-value

for trendN=271 N=140 N=111

AgeMean (SD)

81.7 (5.36) 81.0 (5.48) 19.8 (6.27) .061

% Female 63.1 71.0 65.5 .305% White 98.6 97.8 99.1 .617% College grad 42.5 48.2 38.7 .406% Married 50.2 47.9 55.9 .438

30

35

40

45

50

55

60

65

70

PCS MCS

No pain LBP only LBP + leg pain

PCS and MCS Subscale Scores by LBP status

Good Health

Poor Health

Norm

P<.0001 P<.0001

LBP Status and Functional Limitations

Odds Ratio (95% CI)Any LBP vs. No pain LBP+LP vs. No pain

Difficulty with…

Lifting or carrying grocery bags

1.16 (0.93, 1.46) 4.60 (2.51, 8.43)

Climbing a flight of stairs

2.03 (1.29, 3.17) 4.69 (2.31, 9.51)

Bending, kneeling or stooping

1.68 (1.10, 2.57) 3.68 (1.82, 7.42)

Adjusted for age, sex, race, marital status, education, BMI and chronic conditions



Difficulty with…

Walking several blocks

1.18 (0.95, 1.46) 3.97 (2.19, 7.20)

Walking one block 1.00 (0.80, 1.25) 3.79 (2.05, 6.99)

Bathing and dressing

1.08 (0.83, 1.39) 3.53 (1.54, 8.09)




Fallen in past year 1.10 (0.90, 1.34) 2.05 (1.11, 3.78)

Assistive device for walking

1.02 (0.82, 1.27) 2.81 (1.45, 5.46)

Fair/poor self-rated health

1.09 (0.87, 1.38) 2.64 (1.34, 5.31)

Social interference due to physical problems

1.08 (0.80, 1.46) 8.94 (2.73, 29.26)


• Less than half (45.2%) with LBP sought care– LBP only: 30% sought care– LBP + leg pain: 65% sought care

• All sought care with a physician, but no other healthcare practitioners (i.e. PT, DC, CMT)

• Only 37.7% took prescription meds for LBP

Care-seeking and LBP

Characteristics of Care-Seekers

Sought care for LBP?No Yes P-value

AgeMean (SD)

81.0 (5.67) 79.6 (5.88) >.05

% Female 64.2 74.7 >.05% College grad 45.2 42.9 >.05% Married 47.8 55.4 >.05% Osteoarthritis 31.1 69.7 <.0001

Characteristics of Care-Seekers

Sought care for LBP?No Yes P-value

PCSMean (SD)

44.3 (12.4) 37.3 (13.2) .0003

MCSMean (SD)

50.1 (11.4) 44.1 (13.4) .0016

Avg. LBP IntensityMean (SD)

3.9 (1.7) 5.3 (1.9) <.0001

Consecutive wks of LBPMean (SD)

10.6 (19.9) 26.4 (23.6) <.0001

• Two mainstays in conservative management of LBP are active rehabilitation and medication use – Interestingly, no one received PT services and <40% were

prescribed medicine

• Why do so few older adults seek care?• The combination of high prevalence and low care-

seeking suggests that clinicians who see older adults should routinely:– Ask targeted questions about LBP and leg pain

– Make appropriate referrals prn to prevent decline

Summary

Epidemiology• Depression and Back Pain in the Elderly

– Depressive symptoms are common in older adults

– Depressive symptoms and LBP are strongly associated in cross-sectional studies

– Chronic pain can increase risk for depressive symptoms

– Depressive symptoms are a strong, independent risk factor for onset of disabling back pain 1 year later (Reid, 2003)

– Disabling LBP increases odds of depressive symptoms 2 years later (Meyer, 2007)

– Relationship may be bi-directional

Classification and Staging of Older Patients with LBP

First-Level Classification

Physical Therapy Only Consultation Referral

Stage 1 Stage 2Stage 3

Inflammatory Process(Medical)

Psychological

Medical Psychological

Surgical


Serious Pathology

• Sleep disturbances

• Bowel/Bladder Dysfunction

• Unexplained Weight Loss

• Recent Episodes of Fever Related to LBP

• Trauma


Serious Pathology

• Abdominal Aortic Aneurysm (AAA)– Ballooning of the aorta

• Risk factors- HTN and atherosclerosis

• Most often seen in older, Caucasian men

• Medical emergency when rupture occurs

First-Level ClassificationAbdominal Aortic Aneurysm (AAA)

– Symptoms• Back pain—severe, sudden, persistent• Pulsating sensation in abdomen• Pain in abdomen• Nausea and vomiting• Light-headedness and fainting with upright posture

– Signs• Bruit on auscultation “Whooshing sound”• Pulsatile mass sensitive to palpation around umbilicus• Rapid Pulse

Second-Level Classification

Third-Level Classification

• Immobilization

• Mobilization– Sacroiliac

Mobilization– Lumbar

Mobilization

• Specific Exercise– Extension Syndrome– Flexion Syndrome*– Lateral Shift (able

to centralize)

• Traction

Differential Diagnosis: LBP vs. Hip Pain

LBP vs. Hip Pain

• Source = Lumbar spine– Provocation and amelioration of symptoms with

spinal movement

• Source = Hip– Hip Osteoarthritis (OA)– Hip fracture– Trochanteric bursitis

Ben-Galim et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine 2007

Hip OA(Altman et al, 1991)

Presence of all 5 findings• Hip Pain• Hip IR > 15 degrees• Pain with Hip IR• Morning Stiffness

< 60 minutes• >50 years of age

Presence of all 3 findings• Hip Pain• Hip IR < 15 degrees• Hip Flexion < 115

degrees

Undiagnosed hip OA is one of the leading causes of failedback surgery syndrome

Management of the Patient in Stage I

Stabilization/Immobilization Category

Do we need to address the core muscles to reduce pain and improve function in older adults with LBP?

Kirkaldy-Willis Model of LBP

DysfunctionDysfunctionDegenerative changes begin

InstabilityInstabilityAbnormal movement due to degenerative changes

StabilizationStabilizationSevere degenerative changesDevelopment of osteophytesMotion limitations

Spinal Stabilizing System

The spinal stabilizing system consists of three inter-related subsystems:

Neuromuscular Control

Passive Subsystem

Active Subsystem

No hypermobility with lumbar spring testing

Age (<40 years old)

FABQ – physical activity subscale (<9)

Average straight leg raise (>910)

Aberrant movement absentAberrant movement present

Negative prone instability testPositive prone instability test

Prediction of FailurePrediction of Success

Immobilization: Key Examination Findings

Active Subsystem:Aging Factors

• Decreased muscle strength and mass associated with aging (Sarcopenia)– May be due to a decrease in number of muscle fibers, size of

individual fibers or both

• Type II (fast-twitch) fiber atrophy associated with aging– Results in slower muscle contractile properties

– Can be reversed with training

• Decreased muscle attenuation (increased intramuscular fat infiltration) is associated with aging muscle

• Longitudinal cohort study• 3075 black (42%) and white, men (48%) and women• Aged 70-79 years between 4/97 – 6/98• Community-resident in Memphis or Pittsburgh• Well-functioning

- no reported difficulty walking ¼ mile, up 10 steps, or performing basic ADL- no need for a walking aid or proxy respondent

• Present analysis—Pittsburgh site only•1527 black (44%) and white, men (48%) and women•CT scans of paraspinous muscles only done in Pittsburgh

Health, Aging and Body Composition Study


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Baseline

No LBP Mild LBP Mod LBP Severe/Extreme LBP

Tru

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Back Pain & Trunk Muscle Composition

Hicks et al, J Gerontol Med Sci, Jul 2005

p-value for trend <.0001


1.67

1.77

1.87

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2.17

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No/Mild Back Pain Mod/Extreme Back PainHea

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Back Pain and Function

Hicks et al, J Gerontol Med Sci, Nov 2005


Variable Parameter Estimate

Standard Error

Partial R2

Intercept 2.585 .590

Trunk Muscle Attenuation .006* .002 .123

Thigh Muscle Attenuation -.002 .003 .024

Back Pain Severity -.088* .029 .003

Covariates .369

Model R2=.519† Dependent Variable=Health ABC PPB

Muscle attenuation, HU, at Year 1Hea

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Mod/Extreme Back Pain

Variable Parameter Estimate

Standard Error

Partial R2

No/Mild Back Pain

Intercept 2.500 .667

Trunk Muscle Attenuation .005* .002 .087


Covariates .372

Model R2=.484‡ Dependent Variable=Health ABC PPB

Moderate/Extreme Back Pain

Intercept 2.312 1.240

Trunk Muscle Attenuation .006† .004 .178


Covariates .336

Model R2=.537‡ Dependent Variable=Health ABC PPB

Point Estimate 95% CI

Trunk Muscle Attenuation

1st Quartile (Lowest Quality) 4.50 (1.55, 13.03)

2nd Quartile 3.10 (1.29, 7.46)

3rd Quartile 1.61 (.73, 3.58)

4th Quartile (Best Quality) 1.00 ------

Trunk Muscle Attenuation & Falls in Elders with Significant LBP

Model was adjusted for age, sex, race, BMI, disease status, thigh muscle composition, benzodiazepine use and year 1 functional performance score.

Hicks et al, Unpublished preliminary data


• Addressing trunk muscle composition/ core muscle integrity may be an important, yet overlooked, approach to manage symptoms, maintain functional mobility and potentially reduce balance impairments and falls in older adults with a history of significant back pain

Conclusions

Mobilization Sub-Group:Aging Factors

• Facet joint degeneration (OA) is associated with the aging spine

• Dessication of the disc occurs with time• Changes in the disc height also affect amount of loading

on the facet joints and can lead to approximation of spinous processes

• Which position is more likely to irritate facet joints--flexion or extension?

• What types of manipulation techniques to avoid?

Mobilization Sub-Group:Aging Factors

• Consider use of muscle energy techniques• Must consider entire patient history before undertaking

manipulation or mobilization• Any factors that would suggest manipulation/

mobilization as unsafe or questionable– osteoporosis, infection, fracture, spondylolysis/listhesis, CA,

prolonged steroid use, severe degenerative changes

– If any doubt, find another way to achieve the goal of increasing mobility

Specific Exercise:Key Examination Findings

• Extension Principle– symptoms centralize with lumbar extension– symptoms peripheralize with lumbar flexion

• Treatment– Extension exercises– Avoid flexion activities (bracing)

• Not typically seen in older adult

Specific Exercise:Key Examination Findings

• Flexion Syndrome– symptoms centralize with lumbar flexion– symptoms peripheralize with lumbar extension

• Treatment– Flexion exercises– Avoid extension activities (bracing)

• *Typically seen in older adult

Lumbar Spinal Stenosis (LSS):Flexion Syndrome Sub-Group

• LSS = narrowing of the spinal canal, nerve root canal, and/or intervertebral foramina

• Usually acquired due to degenerative changes– facet joint arthrosis, ligamentum flavum

thickening, posterior bulging of discs, spondylolisthesis

• Leg pain reported in 90% of cases• Neurologic changes in 50% of cases


• Extension results in narrowing of the dimensions of the central and lateral spinal canals

• Axial loading also narrows the canals


• Key Exam Findings– Age > 65 (+LR=2.5)– No pain when seated (+LR=6.6)– Symptoms improved when seated (+LR=3.1)– Improved walking tolerance with spinal flexion

(+LR=6.4)


Differential Diagnosis: Neurogenic vs. Vascular Claudication

• Both conditions may present as cramping pain, tightness and fatigue in LE’s during walking and relieved by sitting

• Vascular claudication is typically secondary to PAD



• Bicycle Test (Dyck & Doyle, 1977)– Neurogenic -- Pt would pedal further with

flexed spine than with extended spine– Vascular --Pt would pedal equal distances

regardless of position of the spine– Results were not sufficiently sensitive for this

test (Dong and Porter, 1989)



• Ankle Brachial Index– Supine– Typical systolic measurement from arm– Systolic measurement from leg

• Cuff around ankle• Dorsalis Pedis or Posterior Tibial Arteries

– <.90 indicates Peripheral Arterial Disease


Two-Staged Treadmill Test

• Pt walks on level surface (10 min or fatigue) followed by incline surface (10 min or fatique) with a 10 min rest break in between– Earlier onset of symptoms on level vs. incline

(+LR=4.1 for neurogenic claudication)– Longer recovery time after level vs. incline

(+LR=2.6 for neurogenic claudication)


• Surgical intervention is common– Fusion and Decompression Procedures

• Surgical rates are on the rise for LSS

• In 1994, nearly $1billion spent on LSS surgery

• 23% re-operation rate

• Increased complication rates when surgical interventions used on older adults

• Non-surgical treatment has not been well-explored yet.


• Comparison between 2 PT treatments for LSS (Whitman et al, Spine, 2006)

– Randomized to:• Flexion, Sub-therapeutic ultrasound and Level walking

on treadmill

or

• Manual Therapy, Exercise and Body-Weight Supported walking on treadmill

BWS Treadmill Ambulation• De-weighted ambulation

on a treadmill is also an option. (Fritz et al., Phys Ther, 1997)

• Shown to reduce compressive forces on the body. (Flynn et al., Phys Ther, 1997)

• Progression is made by decreasing the traction force.

Documents

Low Back Pain in the Older Adult Gregory E. Hicks, PT, PhD University of Delaware