3. 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.
4. 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
5. 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
6. 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
8. Associations of back and leg pain with
health status and functional capacity of
older adults
Findings from the Retirement Community Back Pain Study
Gregory E. Hicks, PhD, PT
University of Delaware, Department of Physical Therapy
Jean M. Gaines, RN, PhD
The Erickson Foundation, Geriatric Medicine and Gerontology
Eleanor M. Simonsick, PhD
National Institute on Aging, Clinical Research Branch
9. • 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
10. • 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
11. Participant Characteristics
LBP status
No pain LBP only LBP + LP P-value
for trend
N=271 N=140 N=111
Age
Mean (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
13. 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
14. LBP Status and Functional Limitations
Odds Ratio (95% CI)
Any LBP vs. No pain LBP+LP vs. No pain
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)
Adjusted for age, sex, race, marital status, education, BMI and
chronic conditions
15. LBP Status and Functional Limitations
Odds Ratio (95% CI)
Any LBP vs. No pain LBP+LP vs. No pain
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)
Adjusted for age, sex, race, marital status, education, BMI and
chronic conditions
16. • 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
17. Characteristics of Care-Seekers
Sought care for LBP?
No Yes P-value
Age
Mean (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
18. Characteristics of Care-Seekers
Sought care for LBP?
No Yes P-value
PCS
Mean (SD)
44.3 (12.4) 37.3 (13.2) .0003
MCS
Mean (SD)
50.1 (11.4) 44.1 (13.4) .0016
Avg. LBP Intensity
Mean (SD)
3.9 (1.7) 5.3 (1.9) <.0001
Consecutive wks
of LBP
Mean (SD)
10.6 (19.9) 26.4 (23.6) <.0001
19. • 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
20. 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
24. First-Level Classification
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
25.
26. First-Level Classification
Abdominal 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
30. 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
31. 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 failed
back surgery syndrome
34. Kirkaldy-Willis Model of LBP
Dysfunction
Degenerative changes begin
Instability
Abnormal movement due to
degenerative changes
Stabilization
Severe degenerative changes
Development of osteophytes
Motion limitations
35. Spinal Stabilizing System
The spinal stabilizing system consists of
three inter-related subsystems:
Neuromuscular
Control
Passive
Subsystem
Active
Subsystem
36. No hypermobility with lumbar
spring testing
Age (<40 years old)
FABQ – physical activity
subscale (<9)
Average straight leg raise
(>910)
Aberrant movement absent
Aberrant movement present
Negative prone instability test
Positive prone instability test
Prediction of Failure
Prediction of Success
Immobilization: Key Examination Findings
37. 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
38. • 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
39. 14
16
18
20
22
24
Baseline
No LBP Mild LBP Mod LBP Severe/Extreme LBP
Back Pain & Trunk Muscle Composition
Hicks et al, J Gerontol Med Sci, Jul 2005
p-value for trend <.0001
44. 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
45. • 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
46. 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?
47. 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
48. 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
49. 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
50. 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
51. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• Extension results in narrowing of the
dimensions of the central and lateral spinal
canals
• Axial loading also narrows the canals
52. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• 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)
53. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
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
54. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
Differential Diagnosis: Neurogenic vs.
Vascular Claudication
• 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)
55. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
Differential Diagnosis: Neurogenic vs.
Vascular Claudication
• 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
56. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
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)
57. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• 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.
58. Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• 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
59. 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.
