Characteristics of older patients with back pain in general practice: BACE cohort study

External validation and updating of prognostic prediction models for nonrecovery among older adults seeking primary care for back pain

ABSTRACT

Prognostic prediction models for 3 different definitions of nonrecovery were developed in the Back Complaints in the Elders study in the Netherlands. The models' performance was good (optimism-adjusted area under receiver operating characteristics [AUC] curve ≥0.77, R2 ≥0.3). This study aimed to assess the external validity of the 3 prognostic prediction models in the Norwegian Back Complaints in the Elders study. We conducted a prospective cohort study, including 452 patients aged ≥55 years, seeking primary care for a new episode of back pain. Nonrecovery was defined for 2 outcomes, combining 6- and 12-month follow-up data: Persistent back pain (≥3/10 on numeric rating scale) and persistent disability (≥4/24 on Roland-Morris Disability Questionnaire). We could not assess the third model (self-reported nonrecovery) because of substantial missing data (>50%). The models consisted of biopsychosocial prognostic factors. First, we assessed Nagelkerke R2 , discrimination (AUC) and calibration (calibration-in-the-large [CITL], slope, and calibration plot). Step 2 was to recalibrate the models based on CITL and slope. Step 3 was to reestimate the model coefficients and assess if this improved performance. The back pain model demonstrated acceptable discrimination (AUC 0.74, 95% confidence interval: 0.69-0.79), and R2 was 0.23. The disability model demonstrated excellent discrimination (AUC 0.81, 95% confidence interval: 0.76-0.85), and R2 was 0.35. Both models had poor calibration (CITL <0, slope <1). Recalibration yielded acceptable calibration for both models, according to the calibration plots. Step 3 did not improve performance substantially. The recalibrated models may need further external validation, and the models' clinical impact should be assessed.

The influence of comorbidities on outcomes for older people with back pain: BACE-D cohort study

BACKGROUND

Comorbidities are common in older people with back pain but little is known about the influence of comorbidities on outcomes.

OBJECTIVES

To explore the influence of the most prevalent comorbidities, and the number of comorbidities, on short (at 3 months) and long-term (at 12 months) outcomes of back pain in older people.

METHODS

We analyzed data from the 'Back Complaints in the Elders' Dutch study cohort (BACE-D) and included participants aged >55 years. We used the modified Self-Administered Comorbidities Questionnaire (SCQ), the Numeric Rating Scale (NRS) and the Roland-Morris Disability Questionnaire (RMDQ) to assess the number of comorbidities, pain intensity and back-related physical functioning, respectively. We conducted separate linear regression models to analyze the association between comorbidities and outcomes including potential confounders of age, sex, body mass index, smoking and alcoholic drinking status, back pain history, and baseline NRS and RMDQ scores.

RESULTS

Our study included 669 participants with a mean age of 66.5 (SD 7.7) years of whom 394 were female. More comorbidities were positively associated with higher pain intensity (3-month regression coefficient (β) =0.27, 95% CI 0.14-0.39; 12-month β = 0.31, 95% CI 0.17-0.45) and worse physical functioning (3-month β = 0.54, 95% CI 0.31-0.77; 12-month β = 0.64, 95% CI 0.37-0.92). Four of the 5 commonest comorbidities were musculoskeletal problems. Older participants with musculoskeletal comorbidities had higher pain intensity (3-month β = 0.89 95% CI 0.41-1.37; 12-month β = 1.17, 95% CI 0.65-1.69), and worse physical functioning (3-month β = 1.61, 95% CI 0.71-2.52; 12-month β = 1.85, 95% CI 0.82-2.89, P-value < 0.001) compared to participants without musculoskeletal comorbidities.

CONCLUSIONS

More comorbidities are associated with worse back pain outcomes in older adults. Participants with musculoskeletal comorbidities had worse back pain outcomes than those without.

The one-year clinical course of back-related disability and the prognostic value of comorbidity among older adults with back pain in primary care

ABSTRACT

Back pain and comorbidity are common in older adults. Comorbidity is a promising prognostic factor for the clinical course of back-related disability, but confirmatory studies assessing its prognostic value are needed. Thus, the aims of this study were to describe the clinical course of back-related disability during 1-year follow-up in patients aged ≥55 years visiting primary care (general practitioner, physiotherapist, or chiropractor) with a new episode of back pain and assess the prognostic value of comorbidity on back-related disability during 1-year follow-up. A prospective cohort study was conducted, including 452 patients. The outcome measure was Roland-Morris Disability Questionnaire (RMDQ, range 0-24) measured at baseline and at 3-, 6-, and 12-month follow-up. The Self-Administered Comorbidity Questionnaire was used to assess comorbidity count (CC, range 0-15) and comorbidity burden (CB, range 0-45). The RMDQ scores improved from median (interquartile range) 9 (4-13) at baseline to 4 (1-9), 4 (0-9), and 3 (0-9) at 3, 6, and 12 months, respectively. Using linear mixed-effects models, we found that CC and CB were independently associated with RMDQ scores. A 1-point increase in CC was associated with an increase in RMDQ score of 0.76 points (95% confidence interval [0.48-1.04]) over the follow-up year, adjusted for known prognostic factors. A 1-point increase in CB was associated with an increased RMDQ score of 0.47 points (95% confidence interval [0.33-0.61]). In conclusion, the clinical course of back-related disability for older adults presenting in primary care was favorable, and increased comorbidity was an independent prognostic factor for increased disability levels.

Healthcare utilization and related costs among older people seeking primary care due to back pain: findings from the BACE-N cohort study

OBJECTIVES

To describe healthcare utilization and estimate associated costs during 1 year of follow-up among older people seeking primary care due to a new episode back pain and to describe healthcare utilization across patients with different risk profiles stratified using the StarT Back Screening Tool (SBST).

DESIGN

Prospective cohort study.

PARTICIPANTS AND SETTING

A total of 452 people aged ≥55 years seeking Norwegian primary care with a new episode of back pain were included.

OUTCOME MEASURES

The primary outcome of this study was total cost of healthcare utilization aggregated for 1 year of follow-up. Secondary outcomes included components of healthcare utilization aggregated for 1 year of follow-up. Healthcare utilization was self-reported and included: primary care consultations, medications, examinations, hospitalisation, rehabilitation stay, and operations. Costs were estimated based on unit costs collected from national pricelists. Healthcare utilization across patients with different SBST risk profiles was compared using Kruskal-Wallis test, post hoc Mann-Whitney U tests and Bonferroni adjustment.

RESULTS

In total, 438 patients were included in the analysis. Mean (BCa 95% CI) total cost per patient over 1 year was €825 (682-976). Median (BCa 95% CI) total cost was €364 (307-440). The largest cost category was primary care consultations, accounting for 56% of total costs. Imaging rate was 34%. The most commonly used medication was paracetamol (27%-35% of patients). Medium- and high-risk patients had a significantly higher degree of healthcare utilization compared with low-risk patients (p<0.030).

CONCLUSION

This study estimated a 1 year mean and median cost of healthcare utilization of €825 and €364, respectively. Patients within the top 25th percentile accounted for 77% of all costs. Patients classified as medium risk and high risk had a significantly higher degree of healthcare utilization compared with patients classified as low risk.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04261309, results.

Primary care providers' experiences treating low back pain

CONTEXT

Our original work addresses the biological sex impact on low back pain (LBP) management and prognosis in primary care settings. To our knowledge, our study is the first in the United States to evaluate the differences in clinicians' approaches to LBP in the ambulatory setting specifically based on patient gender. Our findings suggest that there is a knowledge gap among primary care providers (PCPs) toward the potential impact of biological sex on LBP and a bias toward gender roles when counseling patients for home chores or occupational tasks. Further evaluation of this knowledge gap and its impact on LBP management and prognosis is recommended in US healthcare settings.

OBJECTIVES

This study aims to explore PCP experiences and practice patterns regarding LBP in females compared to males in US healthcare settings.

METHODS

We utilized a cross-sectional study design and convenience sampling. Data were collected anonymously utilizing a 27-item online survey sent periodically via email to PCPs working in Ohio. We had 58 responses for analysis; data were analyzed utilizing bivariate and multivariate analyses.

RESULTS

On average, approximately 9 out of 10 responding clinicians reported experiencing LBP. PCPs were not in agreement that LBP is different in women than men. Clinicians with a women's health, osteopathic, or sport's medicine background were more likely to agree that LBP is different in women than in men. PCPs were more likely to counsel female patients about pelvic floor exercises; however, their intake of present pelvic symptoms in LBP female patients is suboptimal. PCPs were more likely to counsel females for home chores than males, which is aligned with the perceived traditional gender roles among PCPs.

CONCLUSIONS

There may be a knowledge gap among PCPs toward the potential impact of biological sex on LBP and a bias toward gender roles when counseling patients for home chores or occupational tasks. Further investigation of this knowledge gap and counseling approaches is recommended to better bridge the gender disparity.

Characteristics of older adults with back pain associated with choice of first primary care provider: a cross-sectional analysis from the BACE-N cohort study

OBJECTIVES

To describe characteristics of older adults with back pain in primary care, and to assess associations between patient characteristics and type of first primary care provider (general practitioner (GP), physiotherapist (PT) or chiropractor).

DESIGN

Cross-sectional analysis from the Back Complaints in the Elders-Norway cohort study.

SETTING

Norwegian GP, PT and chiropractic primary care centres.

PARTICIPANTS

Patients aged ≥55 years seeking Norwegian primary care with a new episode of back pain were invited to participate. Between April 2015 and February 2020, we included 452 patients: 127 first visited a GP, 130 first visited a PT and 195 first visited a chiropractor.

PRIMARY AND SECONDARY OUTCOME MEASURES

For the first objective, the outcome measure was descriptive statistics of patient characteristics, covering the following domains: sociodemographic, general health, current and previous back pain, psychological and clinical factors. For the second objective, first primary care provider was the outcome measure. Associations between patient characteristics and visiting a GP or PT compared with a chiropractor were assessed with multiple multinomial regression analyses.

RESULTS

Median (IQR) age was 66 (59-72) years. Levels of back-related disability was moderate to severe, with a median (IQR) Roland-Morris Disability Questionnaire (range 0-24) score of 9 (5-13). Recurring episodes were common, 301 (67%) patients had monthly or yearly recurrences. Patients with worse back-related disability, longer duration of symptoms, lower expectations for full recovery and worse physical performance measured with the Back Performance Scale had higher odds of visiting a GP or PT compared with a chiropractor (p<0.05).

CONCLUSION

Older back pain patients in primary care had moderate to severe levels of back-related disability, and most had recurring episodes. Our results suggest that older adult's choice of first primary care provider was associated with important patient characteristics, which highlights the need for caution with generalisations of study results across primary care populations.

TRIAL REGISTRATION NUMBER

NCT04261309.

Developing clinical prediction models for nonrecovery in older patients seeking care for back pain: the back complaints in the elders prospective cohort study

ABSTRACT

Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer-Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.

Comparison of the Characteristics of Back Pain in Women with Postmenopausal Osteoporosis with and without Vertebral Compression Fracture: A Retrospective Study at a Single Osteoporosis Center in Poland

Background

The incidence of unspecific back pain and osteoporotic vertebral compression fractures increases significantly with age. Considering the difficulties in the diagnosis of spontaneous osteoporotic vertebral fractures, this retrospective study aimed to compare the characteristics of back pain in women with postmenopausal osteoporosis with and without vertebral compression fractures.

Material/Methods

This study enrolled 334 women with postmenopausal osteoporosis; 150 had vertebral fractures, and 184 had no vertebral fractures. Densitometric vertebral fracture assessment and bone mineral density measurements in the central skeleton were performed for each patient. The participants completed a survey about features of their back pain.

Results

Patients with vertebral fractures had more severe back pain based on the numeric rating scale: 6.14 vs 4.33 (P<0.001, odds ratio [OR]=1.43, 95% confidence interval [CI]: 1.29–1.59). Among these individuals, back pain caused reduction in normal activity during the day (P<0.001, OR=4.68, 95% CI: 2.86–7.68), and pain occurred more often (P<0.001, OR=1.77, 95% CI: 1.47–2.13), lasted longer (P<0.001, OR=2.01, 95% CI: 1.65–2.46), predominantly occurred in the lumbar spine (P<0.001, OR=4.70, 95% CI: 1.96–11.29), and intensified during normal everyday activities (P<0.001). Based on these results, a new survey was created. It demonstrated a sensitivity of 70.67% and a specificity of 67.37% in predicting a current compression fracture.

Conclusions

Patients with vertebral compression fractures experience higher pain intensity and exhibit specific features of back pain. The new survey can be considered a supportive tool in assessing the possibility of vertebral compression fractures.

Routinely collected data as real-world evidence for physiotherapy practice

Evidence-based practice is the current undisputed predominant paradigm within medicine and allied health care, particularly in physiotherapy. Despite its potential benefits, over the years various points of criticism have been formulated one of which is the overreliance on randomized clinical trials as the highest level of evidence for treatment effectiveness. In the current era, where the availability of large amounts of clinical data gathered during the course of care delivery is rapidly increasing as well as our ability to access, process, link, and analyze these data in fairly efficient ways, alternative sources to supplement rather than replace evidence from RCTs look promising. In this Editorial, we discuss the opportunities and limitations of these routinely collected data in physiotherapy research and provide several examples from the literature. We conclude that the use of routinely collected data in physiotherapy research has the potential to increasingly contribute to real-world evidence, particularly in musculoskeletal primary care physiotherapy, provided that researchers are aware of methodological limitations and adhere to reporting standards.

Cross-cultural adaptation and reliability of the pain response to activity and position questionnaire

BACKGROUND

The World Health Organization reports that one of the main incapacitating conditions in older adults is osteomusculoskeletal disorders, and among these is low back pain. There are few instruments translated and transculturally adapted with psychometric properties evaluated for older adults with this health condition in Brazil. The Pain Response to Activity and Positioning (PRAP) questionnaire enables classification of older adults through functional performance. The objective of this study was to perform a cross-cultural adaptation and verify the reliability of the PRAP for older Brazilian people with chronic low back pain.

METHODS

A cross-sectional methodological study from the international study "Back Complaints in the Elders". We included individuals aged ≥60 years, with chronic lumbar pain complaints lasting ≥3 months. The transcultural translation and adaptation process followed the criteria proposed by Beaton and Guilhemeim, 1993. Reliability was tested using an unweighted Cohen's Kappa.

RESULTS

Thirty-six (36) older adults participated in the study (71.15 ± 7.23 years, 94.4% female). The intra-rater reliability for Low Back Pain (LBP) was between 0.50-1.00 and 0.23-0.84 for lower limbs, while the inter-rater reliability for LBP was between 0.25-0.63 and between 0.18-0.53 for lower limbs. The criteria for low back pain diagnosis showed intra and inter-rater agreement of 0.52 and 0.47, respectively.

CONCLUSION

The Brazilian version of the instrument showed adequate reliability and ability to classify older adults in the diagnosis of LBP by reporting the performance of daily activities, and is indicated for use in the context of research and clinical practice.

TRIAL REGISTRATION

There is no trial registration. This is a methodological study.

Biopsychosocial factors associated with disability in older adults with acute low back pain: BACE-Brasil study

This cross-sectional study evaluated the association of biopsychosocial factors with disability in older adults with a new episode of acute low back pain. Older patients with a new episode of acute low back pain were included and those with cognitive alterations and severe motor impairment were excluded. Disability was assessed using the Roland Morris Disability Questionnaire. The biopsychosocial factors (clinical, functional, health status, psychological and social variables) were evaluated by a structured multidimensional questionnaire and physical examination. A multivariate linear regression was used to analyze data with a statistical significance of 0.05. A total of 386 older individuals with a mean age of 71.6 (± 4.2) years and disability of 13.7 (± 5.7) points were enrolled. Our regression analyses identified that worse physical and mental health (assessed through SF-36), low falls self-efficacy, trouble sleeping due to pain, worse kinesiophobia levels, higher body mass indexes, lumbar morning stiffness, increased pain intensity, female gender and worse functional mobility were significantly associated with baseline disability (p < 0.05). Low back pain-related disability is significantly associated with worse biopsychosocial health conditions in older adults.

Interprofessional Attitudes and Interdisciplinary Practices for Older Adults With Back Pain Among Doctors of Chiropractic: A Descriptive Survey

OBJECTIVE

The purpose of this study is to report on attitudes of doctors of chiropractic (DCs) toward integrative medicine and their self-reported interdisciplinary practices for older adults with back pain.

METHODS

This descriptive survey was conducted with licensed DCs in a Midwestern community in the United States. Respondents completed a 53-item postal survey of demographics, practice characteristics, referral and co-management patterns, attitudes toward interdisciplinary practice, and the Integrative Medicine-30 Questionnaire (IM-30). Descriptive statistical analysis was performed.

RESULTS

Fifty-seven DCs completed the survey (29% response). Geriatric-focused chiropractic practices were uncommon (<15%), although 56% reported that 25% to 49% of the patients treated each week were older adults. Respondents had a moderate orientation toward collaboration with other health care providers (IM-30 mean [standard deviation] 61.3 [11.5]). The IM-30 subscales placed DCs high on measures of integrative medicine safety; moderate on patient-centeredness, openness to working with other providers, and referral readiness; and low on learning from alternative paradigms. Doctors of chiropractic most referred older patients to neurologists, family physicians, massage therapists, orthopedists, and other chiropractors. Doctors of chiropractic reported the highest levels of co-management with family physicians, physical therapists, and massage therapists. Most DCs (92%) were confident in their own ability to manage back pain in older adults, with modest confidence expressed for treatments from professionals using manual therapies. Most (77%) responded that older patients would experience the most improvement if DCs collaborated with another chiropractor, rather than with medical professionals.

CONCLUSION

Doctors of chiropractic in one geographic community are moderately oriented toward interprofessional practice with other health care providers for older adults with back pain. Follow-up studies in representative national and international samples are recommended.

Depression Symptoms Among Older Adults With and Without Subacute Low Back Pain

PURPOSE

Lumbago, or low back pain (LBP), is a common musculoskeletal complaint among older adults that may also be associated with depression. The study objective was to investigate differences in Beck Depression Inventory depression symptoms scores among older adult patients with and without LBP.

DESIGN

This was a case-control study.

METHODS

A total of 152 older adult patients, recruited at an outpatient healthcare clinic (47 men, 105 women; 74.81 ± 6.9 years), were classified as having subacute LBP (n = 76) or non-LBP (n = 76) according to clinic records.

FINDINGS

Beck Depression Inventory scores (mean ± SD) among LBP patients (10.93 ± 6.18) were significantly higher compared to the non-LBP group (7.62 ± 5.70; p = .000085), whose scores indicated no depression symptoms.

CONCLUSION

Subacute LBP may represent a potential risk for increased depression among older adults.

CLINICAL RELEVANCE

Early detection of depression will assist rehabilitation nurses in prescribing the beneficial physical rehabilitation and exercise programs or provide the information and treatment recommendations to older adults with subacute LBP and their families. Also, it should be part of a nursing staff prevention strategy for patients who suffer this common musculoskeletal disorder.

Neuropathic Pain Prevalence of Older Adults in an Urban Area of Iran: A Population-Based Study

BACKGROUND

Pain prevalence would increase as the population grows older, but the exact prevalence rate is not apparent in Iran.

OBJECTIVES

This study, therefore, set out to reveal the prevalence of pain, especially neuropathic type and explore its associated comorbidities among Iranian older adults in a large urban population-based survey.

METHODS

5326 older people, aged ≥ 60 years, were randomly chosen by a multistage, cluster sampling method. The selected people then were interviewed by using the following instruments: a standard questionnaire about pain, questions of interview part of Douleur Neuropathique 4 Questions (DN4) and its comorbidities, GHQ-28, and a sociodemographic checklist. Descriptive statistics and multiple regression analysis were conducted to analyze the gathered data.

RESULTS

The average of the participants' age was 68.92 ± 7.02 years. Of 5326 participants, 2529 (47.5%) of participants were male. About one-third of this population had chronic pain. Chronic neuropathic pain prevalence was 13.7% and nociceptive in 30%. Knee pain (20.6%) and feet dysesthesia (7.8%) were the most common sites of nociceptive and neuropathic pain, respectively. Results of multiple regression analysis revealed that the major comorbidities of chronic pain were osteoporosis, disability, diabetes mellitus, and stroke. Neuropathic pain experiences were significantly associated with GHQ-28 scores (t=-11.42, P<0.001).

CONCLUSIONS

In addition to neuropathic pain, other subtypes of pain prevalence and the comorbidities are determined in the community-dwelling elder adults. This study highlights the importance of neuropathic pain and its adverse consequences and can be used to manage this populations' needs in Iran effectively.

Back Stiffness Is Associated with Physical Health and Low Back Pain-Related Disability in Community-Dwelling Older Adults

Objective

Back stiffness is a common complaint among older adults with low back pain. Nonetheless, self-reported back stiffness has received little exploration in this patient population. The purpose of this study was to examine the associations of self-reported low back stiffness with physical health and low back pain-related disability among older adults with low back pain.

Design

Cross-sectional analysis.

Subjects

Data included in this study were obtained from the Retirement Community Back Pain Study, a population-based survey of older adults.

Methods

Participants completed the Medical Outcomes Survey Short-Form 36 and the modified Oswestry Low Back Pain Questionnaire. Physical health, derived from the Short Form-36, was represented by the physical component summary score. Back stiffness was rated on a 0-10 scale, where 0 indicated "no back stiffness."

Results

Covariates-that is, intensity and duration of low back pain, age, sex, weight, education level, and comorbidities-explained 27% of the variance in physical health ( P  < 0.0001) and 38% of the variance in low back pain-related disability ( P  = 0.0002). Self-reported stiffness explained an additional 6% of the variance in physical health ( P  < 0.0001) and 10% of the variance in low back pain-related disability ( P  < 0.0001).

Conclusions

Back stiffness in older, community-dwelling adults with low back pain may help explain physical health and low back pain-related disability, above and beyond demographics and pain. Future longitudinal research is needed to evaluate low back stiffness as a predictor of physical health and disability. Ultimately, assessment and treatment of back stiffness in older adults with low back pain may improve patient outcomes.

The impact of low back pain on health-related quality of life in old age: results from a survey of a large sample of Swiss elders living in the community

PURPOSE

The present study aims at investigating the effects of low back pain (LBP), i.e., type of symptoms, activity limitations, frequency, duration, and severity on health-related quality of life (HRQoL) in a sample of 707 community-dwelling men and women aged ≥ 65 years living in Switzerland.

METHODS

The study is part of a larger survey conducted in Switzerland on a sample of older adults selected randomly from population records, stratified by age and sex. The Standardized Back Pain Definition was used to investigate LBP, and HRQoL was assessed by means of the EQ-5D, including Health Utility Index (HUI) measures.

RESULTS

For more than half of the sufferers, pain was chronic, occurred most days or every day and induced activity limitations. One-third of the sufferers reported sciatica symptoms. Individuals reporting every day pain, severe pain and more than 3 years since the last episode without pain lost nearly 10 points of HRQoL. Amongst the dimension of HRQoL, Mobility was the most affected by LBP.

CONCLUSIONS

These results provide further insight into the impact of qualitative aspects of LBP and in particular the importance of radiating leg pain and pain frequency and duration. While LBP-related activity limitations had little impact on both self-rated overall health and HUI, radiating leg pain and pain frequency and duration were associated with significantly decreased scores on both dimensions.

The Brazilian Back Complaints in the Elders (Brazilian BACE) study: characteristics of Brazilian older adults with a new episode of low back pain

OBJECTIVE

Low back pain (LBP) is little explored in the aging population especially when considering age-relevant and culturally dependent outcomes. We aimed to describe socio-demographic and clinical characteristics of Brazilian older people with a new episode of LBP presenting to primary care.

METHODS

We sourced baseline information on socio-demographic, pain-related and clinical characteristics from 602 older adults from the Brazilian Back Complaints in the Elders (Brazilian BACE) study. We analyzed differences in pain, disability, functional capacity and psychosocial factors between sub-groups based on age (i.e. participants aged 55-74 or ≥75 years), education (i.e. those with four years or less of schooling or those with more than four years of schooling) and income (i.e. participants who reported earning two or less minimal wages or three and more).

RESULTS

Participants presented severe LBP (7.18/10, SD: 2.59). Younger participants were slightly more disabled (mean difference 1.29 points, 95% confidence interval [CI]: 0.03/5.56), reporting poorer physical health, and less fall-related self-efficacy (mean difference of 2.41, 95% CI 0.35/4.46). Those less educated, and those with income equal or less than two minimum wages had more disability, pain catastrophizing and worse functional capacity.

CONCLUSIONS

This was the first study showing that Brazilian older adults with LBP present high levels of functional disability and psychological distress, especially those with low socioeconomic status.

Prevalence of chronic pain in the elderly Polish population - results of the PolSenior study

INTRODUCTION

Pain is the most common complaint of elderly people. In Poland, no large studies on the prevalence of chronic pain in the elderly were conducted until recently.

MATERIAL AND METHODS

The study was a part of the PolSenior project, a cross-sectional multidisciplinary study on ageing of the Polish population, and included a randomly selected group of 716 people aged 55-59 years, and 4979 people over 65 years. The survey was conducted through a standardized questionnaire. An evaluation of pain occurrence, location, intensity and coexistence of pains in relation to gender, age and use of health care was performed.

RESULTS

Chronic pain affected 42.0% of respondents aged 65 years and over (48.6% of women and 35.8% of men) as compared to 35.2% of the pre-elderly. The most common pain locations were the lumbar region (51.6%) and knees (41.0%). The average number of pain sites was 3.1 ±2.3. Average intensity of pain was 6.2 points on the VAS scale in people over 65 years and 6.0 points in the pre-elderly (NS). Average pain intensity increased significantly from 5.7 points in patients reporting pain in one place to 7.2 points in those reporting six pain sites. Elderly respondents with pain compared to those without pain more frequently reported physician visits performed at least once a month (54.6% vs. 48.4%, p < 0.001).

CONCLUSIONS

Polish elderly most frequently complained of low back and lower limb pain. In respondents reporting many sites of pain, an increase in the intensity of pain was observed. Elderly patients with chronic pain often use medical care.

Disability in older adults with acute low back pain: the study Back Complaints in the Elderly - (Brazil)

•

Older adults reported moderate to severe acute low back pain.

•

Irrelevant association between acute pain intensity with disability was observed.

•

There is interaction between age groups and marital status with disability.

Background

The increase in the older adult and oldest old population in Brazil is growing. This phenomenon may be accompanied by an increase in musculoskeletal symptoms such as low back pain. This condition is usually associated with disability.

Objective

To verify the association between pain intensity and disability in older adults with acute low back pain and assess whether these variables differ depending on the age group and marital status.

Methods

This is a cross-sectional study conducted with 532 older adults with acute low back pain episodes. Pain intensity was assessed through the Numeric Pain Scale and disability through the Late Life Function and Disability Instrument, which shows two dimensions: “frequency” and “limitation” in performing activities. The association between pain and disability was analyzed.

Results

For the interaction effect between age groups and marital status, we found that the oldest old living with a partner performed activities of the personal domain less often compared to the oldest old living alone. The oldest old group living with a partner had a lower frequency of performing activities, but did not report feeling limited. The association of pain with disability was minimal (rho < 0.20) and thus considered irrelevant.

Conclusion

Disability in older adults with acute low back pain was influenced by the interaction between age groups and marital status and is not associated with pain intensity.

Associations between disc space narrowing, anterior osteophytes and disability in chronic mechanical low back pain: a cross sectional study

Background

Radiographic features of lumbar disc degeneration (LDD) are common findings in patients with chronic mechanical low back pain; however, its role in disability and intensity of pain is debatable. This study aims to investigate the associations of the x-ray features of LDD and lumbar spondylolisthesis with severity of disability and intensity of pain.

Methods

A cross-sectional study was conducted on 439 patients with chronic mechanical low back pain who attended the rheumatology clinic, National Hospital of Sri Lanka, Colombo, from May 2012 to May 2014. Severity of disability was measured using Modified Oswestry Disability Index and intensity of pain was assessed using numeric rating scale (0–100). X-ray features of LDD (disc space narrowing, anterior osteophytes and overall LDD) and spondylolisthesis were assessed in lateral recumbent lumbar x-rays (L1/L2 to L5/S1) and graded by a consultant radiologist blinded to clinical data. Generalised linear model with linear response was used to assess the associations of x-ray features of LDD with severity of disability and intensity of pain adjusting for age, gender, body mass index and pain radiating into legs.

Results

Mean age was 48.99 ± 11.21 and 323 (73.58%) were females. 87 (19.82%) were obese. Mean severity of disability was 30.95 ± 13.67 and mean intensity of pain was 45.50 ± 20.37. 69 (15.72%), 26 (5.92%) and 85 (19.36%) patients had grade 2 disc space narrowing, anterior osteophytes and overall LDD, respectively. 51 (11.62%) patients had lumbar spondylolisthesis. Grade of disc space narrowing and overall LDD were not associated with severity of disability or intensity of pain. The presence of lumbar spondylolisthesis was associated with severity of disability. Female gender and pain radiating into legs were associated with severity of disability and intensity of pain. Advancing age was associated with x-ray features of LDD and lumbar spondylolisthesis.

Conclusions

Lumbar spondylolisthesis is associated with severity of disability in patients with chronic mechanical low back pain. Associations of x-ray features of LDD with severity of disability and intensity of pain are inconclusive. Female gender and pain radiating into legs are significant confounders.

Back Complaints in the Elders in Brazil and the Netherlands: a cross-sectional comparison

Background

although back pain is most prevalent in older adults, there is a paucity of studies investigating back pain in older people. Our objective was to characterize and compare Brazilian and Dutch older adults presenting to primary care with a new episode of back pain. We also aimed to investigate whether socio-demographic characteristics were associated with pain severity and disability.

Methods

we sourced data on 602 Brazilian and 675 Dutch participants aged ≥55 years with a new episode of back pain from the Back Complaints in the Elders consortium. We analyzed country differences in participants' characteristics, and associations between socio-demographic/clinical characteristics and pain severity and pain-related disability.

Results

the two populations differed in most characteristics. More Dutch participants were smokers, heavy drinkers, and reported back stiffness. More Brazilian participants were less educated, had higher prevalence of comorbidities; higher levels of pain intensity, disability and psychological distress. When controlling for the effect of country, being female and having altered quality of sleep were associated with higher pain intensity. Altered quality of sleep, having two or more comorbidities and physical inactivity were associated with higher disability. Higher educational levels were negatively associated with both pain and disability outcomes.

Conclusions

back pain is disabling in the older population. Our country comparison has shown that country of residence is an important determinant of higher disability and pain in older people with back pain. Irrespective of country, women with poor sleep quality, comorbidities, low education and who are physically inactive report more severe symptoms.

Do older adults with chronic low back pain differ from younger adults in regards to baseline characteristics and prognosis?

BACKGROUND

Low back pain (LBP) in older adults is poorly understood because the vast majority of the LBP research has focused on the working aged population. The aim of this study was to compare older adults consulting with chronic LBP to middle aged and young adults consulting with chronic LBP, in terms of their baseline characteristics, and pain and disability outcomes over 1 year.

METHODS

Data were systematically collected as part of routine care in a secondary care spine clinic. At initial presentation patients answered a self-report questionnaire and underwent a physical examination. Patients older than 65 were classified as older adults and compared to middle aged (45-65 years old) and younger adults (17-44 years old) for 10 baseline characteristics. Pain intensity and disability were collected at 6 and 12 month follow-ups and compared between age groups.

RESULTS

A total of 14,479 participants were included in the study. Of these 3087 (21%) patients were older adults, 6071 (42%) were middle aged and 5321 (37%) were young adults. At presentation older adults were statistically different to the middle aged and younger adults for most characteristics measured (e.g. less intense back pain, more leg pain and more depression); however, the differences were small. The change in pain and disability over 12 months did not differ between age groups.

CONCLUSIONS

This study found small baseline differences in older people with chronic LBP compared to middle aged and younger adults. There were no associations between age groups and the clinical course.

SIGNIFICANCE

Small baseline differences exist in older people with chronic low back pain compared to middle aged and younger adults referred to secondary care for chronic low back pain. Older adults present with slightly less intense low back pain but slightly more intense leg pain. Changes in pain intensity and disability over a 12 month period were similar across all age groups.

A qualitative study of older people's experience of living with neurogenic claudication to inform the development of a physiotherapy intervention

PURPOSE

The aim of this study was to explore older people's experiences of living with neurogenic claudication (NC), their preferences for physiotherapy treatment provision and associated outcomes in order to inform an intervention to be tested in a clinical trial.

METHOD

Patients with a diagnosis of NC and/or lumbar spinal stenosis were recruited through a UK NHS tertiary care center. Semi-structured interviews and self-report questionnaires were used to obtain data. A thematic analysis was conducted.

RESULTS

15 participants were recruited; half were classed as frail older adults. Pain and the threat of pain was a prominent feature of participants' experience of NC. This led to a loss of engagement in meaningful activities and sense of self. Discourses of ageing influenced experiences as well as treatment preferences, particularly the acceptability of walking aids. A combination of one-to-one and group setting for treatment was preferred. Outcome preferences related to re-engagement in meaningful activities and pain reduction. Limitations relate to generalisability of the findings for NC patients not under physiotherapy treatment.

CONCLUSION

We have obtained important findings about older people's experiences of living with NC and preferences for physiotherapy treatment and outcomes. These will be incorporated into an evidence-based intervention and evaluated in a randomized controlled trial. Implications for rehabilitation Older people living with NC want to get back to meaningful activities and learn how to live with the threat of pain. Allied health professionals (AHPs) should be sensitive to the complex and ambiguous ways in which older people live with ageing and age-related decline. AHPs are in a position to support patients' successful transition to the use of walking aids thereby reducing stigmatizing effects and increasing activity. AHPs should consider a mixture of one-to-one and group classes to enable rehabilitation for older NC patients.

Prevalence of low back pain in older Brazilians: a systematic review with meta-analysis

INTRODUCTION

Prevalence of low back pain (LBP) is expected to increase worldwide with aging of the population but its prevalence in older people is not clear, mainly in developing countries.

OBJECTIVE

To estimate the prevalence of LBP in older Brazilians.

METHODS

Electronic searches on SciELO, LILACS, MEDLINE, EMBASE and CINAHL, as well as hand-searching identified studies investigating prevalence of LBP in older Brazilians aged 60 years or over. Two independent reviewers selected studies fulfilling the inclusion criteria, assessed risk of bias for each included study and extracted relevant data. Meta-analysis was conducted when enough homogeneity allowed and the GRADE system was used to summarize the overall quality of the evidence.

RESULTS

Sixteen studies were included with a total of 28,448 participants. Data from point- and period-prevalence of LBP were obtained. Meta-analysis was conducted for 13 studies reporting point-prevalence. Pooled point-prevalence of LBP was 25.0% (95% CI 18.0-32.0). Other three studies investigated period-prevalence: one-week prevalence=15.0% (95% CI 13.0-18.0); six-month prevalence=43.0% (95% CI 42.0-44.0); and 12-month prevalence=13.0% (95% CI 11.0-16.0). Sensitivity analyses were performed for point-prevalence and exclusion of studies with poorer methodological quality tended to increase the estimated prevalence of LBP.

CONCLUSION

Moderate-quality evidence showed that at any point in time one in four older Brazilians suffers from LBP. This was the first systematic review investigating nationwide data on the prevalence of LBP in older people and contributes important clinical and epidemiological evidence for policymakers.

Qigong or Yoga Versus No Intervention in Older Adults With Chronic Low Back Pain-A Randomized Controlled Trial

The aim of this study was to assess the effectiveness of the reduction of chronic lower back pain in older adults using either yoga classes or qigong classes compared with no intervention. Older adults (65 years of age and older) with chronic low back pain were enrolled in and randomly allocated to: 1) yoga (24 classes, 45 minutes each, during 3 months), 2) qigong (12 classes, 90 minutes each, during 3 months), or 3) a control group who received no additional intervention. The pain intensity item of the Functional Rating Index after 3 months was used as primary outcome parameter. A total of 176 patients were randomized (n = 61 yoga, n = 58 qigong, n = 57 control; mean age 73 ± 5.6 years, 89% female). The mean adjusted pain intensity after 3 months was 1.71 for the yoga group (95% confidence interval [CI], 1.54-1.89), 1.67 for the qigong group (95% CI, 1.45-1.89), and 1.89 for no intervention (95% CI, 1.67-2.11). No statistically significant group differences were observed. Possible explanations for this lack of pain relief might include the ineffectiveness of interventions, inappropriate outcomes, or differences in pain perception and processing in older adults.

PERSPECTIVE

The aim of this study was to assess the effectiveness of the reduction of chronic lower back pain in older adults using either yoga classes or qigong classes compared with no intervention. This 3-armed randomized trial with 176 older adults showed that yoga and qigong were not superior to no treatment in reducing pain and increasing quality of life.

Effects of spinal manipulation on sensorimotor function in low back pain patients--A randomised controlled trial

BACKGROUND

Low back pain (LBP) is a major health problem in industrialized societies. Spinal manipulation (SM) is often used for treating LBP, though the therapeutic mechanisms remain elusive. Research suggests that sensorimotor changes may be involved in LBP. It is hypothesized that SM may generate its beneficial effects by affecting sensorimotor functions.

OBJECTIVES

To compare changes in sensorimotor function, as measured by postural sway and response to sudden load, in LBP patients following the delivery of high-velocity low amplitude (HVLA)-SM or low-velocity variable amplitude (LVVA)-SM versus a sham control intervention.

DESIGN

A three-arm (1:1:1 ratio) randomized controlled trial.

METHODS

A total of 221 participants who were between 21 and 65 years, having LBP intensity (numerical rating scale) ≥4 at either phone screen or the first baseline visit and ≥2 at phone screen and both baseline visits, and Quebec Task Force diagnostic classifications of 1, 2, 3 or 7 were enrolled to receive four SM treatments over two weeks. Study outcomes were measured at the first and fifth visits with the examiners blinded from participant group assignment.

RESULTS

The LVVA-SM group demonstrated a significant increase in medial-to-lateral postural excursion on the soft surface at the first visit when compared to the control group. No other significant between-group differences were found for the two sensorimotor tests, whether during the first visit or over two weeks.

CONCLUSIONS

It appears that short-term SM does not affect the sensorimotor functions as measured by postural sway and response to sudden load in this study.

Back pain in seniors: the Back pain Outcomes using Longitudinal Data (BOLD) cohort baseline data

BACKGROUND

Back pain represents a substantial burden globally, ranking first in a recent assessment among causes of years lived with disability. Though back pain is widely studied among working age adults, there are gaps with respect to basic descriptive epidemiology among seniors, especially in the United States. Our goal was to describe how pain, function and health-related quality of life vary by demographic and geographic factors among seniors presenting to primary care providers with new episodes of care for back pain.

METHODS

We examined baseline data from the Back pain Outcomes using Longitudinal Data (BOLD) registry, the largest inception cohort to date of seniors presenting to a primary care provider for back pain. The sample included 5,239 patients ≥ 65 years old with a new primary care visit for back pain at three integrated health systems (Northern California Kaiser-Permanente, Henry Ford Health System [Detroit], and Harvard Vanguard Medical Associates [Boston]). We examined differences in patient characteristics across healthcare sites and associations of patient sociodemographic and clinical characteristics with baseline patient-reported measures of pain, function, and health-related quality of life.

RESULTS

Patients differed across sites in demographic and other characteristics. The Detroit site had more African-American patients (50%) compared with the other sites (7-8%). The Boston site had more college graduates (68%) compared with Detroit (20%). Female sex, lower educational status, African-American race, and older age were associated with worse functional disability as measured by the Roland-Morris Disability Questionnaire. Except for age, these factors were also associated with worse pain.

CONCLUSIONS

Baseline pain and functional impairment varied substantially with a number of factors in the BOLD cohort. Healthcare site was an important factor. After controlling for healthcare site, lower education, female sex, African-American race, and older age were associated with worse physical disability and all of these factors except age were associated with worse pain.

TRIAL REGISTRATION

Clinical Trials.gov NCT01776242; Registration date: June 13, 2012.

Cost Utility Analysis of Percutaneous Adhesiolysis in Managing Pain of Post-lumbar Surgery Syndrome and Lumbar Central Spinal Stenosis

BACKGROUND

The increase in the number of interventions for the management of chronic pain and associated escalation of healthcare costs has captured the attention of health policymakers, in no small part due to the lack of documentation of efficacy, cost-effectiveness, or cost utility analysis. A recent cost utility analysis of caudal epidural injections in managing chronic low back pain of various pathologies showed a high cost utility with improvement in quality of life years, competitive with various other modalities of treatments. However, there are no analyses derived from high-quality controlled studies related to the cost utility of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome or lumbar central spinal stenosis.

STUDY DESIGN

This analysis is based on 2 previously published controlled studies.

OBJECTIVE

To assess the cost utility of percutaneous adhesiolysis procedures in managing chronic low back and lower extremity pain secondary to post-lumbar surgery syndrome and lumbar central spinal stenosis.

SETTING

A private, specialty referral interventional pain management center in the United States.

METHODS

Two controlled studies were conducted assessing the clinical effectiveness of percutaneous adhesiolysis for post-lumbar surgery syndrome and lumbar central spinal stenosis in an interventional pain management setting utilizing contemporary interventional pain management practices. A cost utility analysis was performed with direct payment data for a total of 130 patients in treatment groups over a 2-year period. Various outcome measures were included with significant improvement, defined as at least 50% improvement with reduction in pain and disability status.

RESULTS

The results of 2 controlled studies of low back pain with 60 and 70 patients and a 2-year follow-up with the actual reimbursement data showed cost utility for 1 year of quality-adjusted life year (QALY) of USD $2,652 for post-lumbar surgery syndrome and USD $2,649 for lumbar central spinal stenosis. The results of this assessment show that the cost utility of managing chronic, intractable low back pain with percutaneous adhesiolysis at a QALY that is similar or lower in price than medical therapy only, physical therapy, manipulation, spinal cord stimulation, and surgery.

LIMITATIONS

The limitations of this cost utility analysis are that it is a single-center evaluation, with the inclusion of costs of adhesiolysis procedures in an ambulatory surgery center and physician visits, rather than all related costs including drug therapy and costs of disability in multiple settings.

CONCLUSION

This cost utility analysis of percutaneous adhesiolysis in the treatment of post-lumbar surgery syndrome and lumbar central spinal stenosis shows the clinical effectiveness and cost utility of these procedures at USD $2,650 per one year of QALY when performed in an ambulatory surgery center.