Low Back Pain in the Older Adult Gregory E. Hicks, PT, PhD University of Delaware.
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Transcript of Low Back Pain in the Older Adult Gregory E. Hicks, PT, PhD University of Delaware.
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Low Back Pain in the Older Adult
Gregory E. Hicks, PT, PhD University of Delaware
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Epidemiology of LBP Among Older Adults
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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.
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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
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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
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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
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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
lth A
BC
Phy
sica
l Per
form
ance
Bat
tery
Yea
r 4
Back Pain and Function
Hicks et al, J Gerontol Med Sci, Nov 2005
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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
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• 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
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• 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
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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
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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
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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
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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
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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
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• 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
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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
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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
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• 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
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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
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Classification and Staging of Older Patients with LBP
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First-Level Classification
Physical Therapy Only Consultation Referral
Stage 1 Stage 2Stage 3
Inflammatory Process(Medical)
Psychological
Medical Psychological
Surgical
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First-Level Classification
Serious Pathology
• Sleep disturbances
• Bowel/Bladder Dysfunction
• Unexplained Weight Loss
• Recent Episodes of Fever Related to LBP
• Trauma
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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
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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
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Second-Level Classification
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Third-Level Classification
• Immobilization
• Mobilization– Sacroiliac
Mobilization– Lumbar
Mobilization
• Specific Exercise– Extension Syndrome– Flexion Syndrome*– Lateral Shift (able
to centralize)
• Traction
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Differential Diagnosis: LBP vs. Hip Pain
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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
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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
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Management of the Patient in Stage I
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Stabilization/Immobilization Category
Do we need to address the core muscles to reduce pain and improve function in older adults with LBP?
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Kirkaldy-Willis Model of LBP
DysfunctionDysfunctionDegenerative changes begin
InstabilityInstabilityAbnormal movement due to degenerative changes
StabilizationStabilizationSevere degenerative changesDevelopment of osteophytesMotion limitations
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Spinal Stabilizing System
The spinal stabilizing system consists of three inter-related subsystems:
Neuromuscular Control
Passive Subsystem
Active Subsystem
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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
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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
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• 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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14
16
18
20
22
24
Baseline
No LBP Mild LBP Mod LBP Severe/Extreme LBP
Tru
nk M
uscl
e A
ttenu
atio
n (H
U)
Back Pain & Trunk Muscle Composition
Hicks et al, J Gerontol Med Sci, Jul 2005
p-value for trend <.0001
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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
lth A
BC
Phy
sica
l Per
form
ance
Bat
tery
Yea
r 4
Back Pain and Function
Hicks et al, J Gerontol Med Sci, Nov 2005
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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
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Muscle attenuation, HU, at Year 1Hea
lth
AB
C P
hysi
cal P
erfo
rman
ce B
atte
ryY
ear
4
No/Mild Back Pain
Mod/Extreme Back Pain
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Variable Parameter Estimate
Standard Error
Partial R2
No/Mild Back Pain
Intercept 2.500 .667
Trunk Muscle Attenuation .005* .002 .087
Thigh Muscle Attenuation -.001 .003 .025
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
Thigh Muscle Attenuation -.002 .006 .023
Covariates .336
Model R2=.537‡ Dependent Variable=Health ABC PPB
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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
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• 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
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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?
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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
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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
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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
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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
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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
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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)
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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
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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)
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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
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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)
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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.
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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
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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.
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