Hip Symptoms, Physical Performance, and Health Status in Older Adults With Chronic Low Back Pain: A Preliminary Investigation

Association of Number of Comorbid Conditions and Pain among United States Adults

Studies have explored the association of particular conditions, or combinations of conditions, and pain among specific populations. However, there is limited information regarding the association of the number of comorbid conditions, as well as other demographic, economic, health, and limitation variables, with pain among adults in the United States. This cross-sectional database study aimed to examine the relationships between number of comorbid conditions (including cancer, arthritis, joint pain, stroke, heart attack, angina, coronary heart disease, high cholesterol, high blood pressure, other heart diseases, diabetes, asthma, chronic bronchitis, and emphysema), demographic, economic, health, and limitation variables with pain among United States adults using 2021 Medical Expenditure Panel Survey data. A multivariable logistic model assessed the association between the number of comorbid conditions (≥6, 5, 4, 3, 2, 1, versus 0 conditions) and quite a bit/extreme (versus little/moderate) pain, adjusting for demographic, economic, health, and limitation variables. The study found that greater numbers of comorbid conditions were associated with higher odds of quite a bit or extreme pain. In addition, age, education, employment, income, overall health, regular physical activity, and three limitation variables were each associated with pain in the multivariable model. These findings offer insight into the association between number of comorbid conditions and other variables with pain and suggest areas where interventions may be helpful to help improve pain outcomes for United States adults.

Considerations beyond spine pain: do different co-occurring lower body joint pains differentially influence physical function and quality of life ratings?

BACKGROUND

Patients seeking medical care for back pain often have coexisting painful joints and the effects of different combinations and number of coexisting pain sites (hip, knee, foot/ankle) to back pain on physical function domains and quality of life rating are not yet established. The purpose of this study was to determine the differences in functional outcomes and QOL among individuals with back pain who have concurrent additional pain sites or no pain sites.

METHODS

Data from the Osteoarthritis Initiative (OAI) cohort were used for this cross-sectional analysis. Men and women aged 45-79 years with back pain were binned into nine groups by presence or not of coexisting hip, knee, ankle/foot pain and combinations of these sites (N = 1,642). Healthy controls reported no joint pain. Main outcomes included Knee Injury and Osteoarthritis Outcome score (KOOS; quality of life and function-sports-and-recreation), Western Ontario McMaster Universities Osteoarthritis Index (WOMAC; Activities of Daily Living, Pain), Medical Outcomes Short Form-12 (SF-12) Physical Component score, and self-reported function in last 7-30 days (lifting 25-pound objects, housework). 20-m and 400-m walk times and gait speed and repeated chair rise test times were collected.

RESULTS

Compared to back pain alone, pain at all five sites was associated with 39%-86% worse KOOS, WOMAC, and SF-12 scores (p < .0001). Back-Hip and Back-Knee did not produce worse scores than Back pain alone, but Back-Hip-Knee and Back-Knee-Ankle/Foot did. The 20-m, 400-m walk, and repeated chair times were worse among individuals with pain at all five sites. Additional hip and knee sites to back pain, but not ankle/foot, worsened performance-based walk times and chair rise scores.

CONCLUSIONS

The number and type of coexistent lower body musculoskeletal pain among patients with back pain may be associated with perceived and performance-based assessments. Management plans that efficiently simultaneously address back and additional coexistent pain sites may maximize treatment functional benefits, address patient functional goals in life and mitigate disability.

Pain symptoms and physical performance in older adults: cross-sectional findings from the International Mobility in Aging Study (IMIAS)

PURPOSE

To analyze the associations between pain and physical performance in different aging contexts.

METHODS

Data from 1725 older adults from Canada, Brazil, Colombia, and Albania from the 2014 wave of the IMIAS were used to assess the associations between Back Pain (BP) or Lower Limb Pain (LLP) and physical performance by the Short Physical Performance Battery (SPPB). Three binary logistic regression models adjusted for sex, age, study site, education, income sufficiency, BMI, depressive symptoms, and chronic conditions were used to estimate the associations between LLP or BP and SPPB. The SPPB was classified into good performance (8 points or more) and poor physical performance (< 8 points).

RESULTS

The mean age of the older men was 71.2 (± 3.0) and the mean age of the women was 71.2 (± 2.8) years. Older men (72.8%, p < 0.05) and women (86.1%, p-value < 0.05) from Albania had the highest frequencies of self-reported general pain. Older women in Colombia had the highest frequencies of LLP or BP (33.5%, p-value < 0.05). In the fully adjusted logistic regression model, LLP or BP was significantly associated with poor SPPB (OR = 0.48, 0.35 to 0.66 95% CI, p < 0.01).

CONCLUSIONS

Pain symptoms are associated with reduced physical performance in older people, even when adjusted for other clinical and sociodemographic factors. Protocols for aiming to increase the level of physical activity to manage pain should be incorporated into health care strategies.

The effectiveness of hip interventions in patients with low-back pain: A systematic review and meta-analysis

BACKGROUND

Low-back pain (LBP) may be directly or indirectly related to impairments from the hip joint.

OBJECTIVE

To evaluate the effectiveness of hip interventions on pain and disability in patients with LBP in the short-, medium-, and long-term.

METHODS

PubMed, Cochrane Library, PEDro, Web of Science, and SCOPUS databases were searched in November 2022. Randomized controlled trials involving hip-targeted interventions compared to specific low back interventions in patients with LBP were selected. The outcomes were pain intensity and disability. The quality of the studies was assessed with the risk of bias tool. GRADE was used to rate the certainty of evidence. Meta-analyses were conducted using random effects models.

RESULTS

A total of 2581 studies were screened. Eight were included in the meta-analysis involving 508 patients with LBP. The results provided very low certainty that both hip strengthening and hip stretching improved pain (MD = -0.66; 95% CI -0.86, -0.48; I²:0%) (MD = -0.55; 95% CI -1.02, -0.08) and disability (SMD = -0.81; 95% CI -1.53, -0.10; I²: 80%) (SMD = -1.03; 95% CI -1.82, -0.25) in the short-term, respectively. No benefits were found in the medium- or long-term. The risk of bias, heterogeneity, and imprecision of the results downgraded the level of evidence.

CONCLUSIONS

Very low certainty evidence suggest a positive effect of hip strengthening in isolation or combined with specific low back exercise and hip stretching combined with specific low back exercise for decreasing pain intensity and disability in the short-term, in patients with LBP.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022303173.

Predictors of Lumbar Spine Degeneration and Low Back Pain in the Community: The Johnston County Osteoarthritis Project

OBJECTIVE

To determine the incidence and worsening of lumbar spine structure and low back pain (LBP) and whether they are predicted by demographic characteristics or clinical characteristics or appendicular joint osteoarthritis (OA).

METHODS

Paired baseline (2003-2004) and follow-up (2006-2010) lumbar spine radiographs from the Johnston County Osteoarthritis Project were graded for osteophytes (OST), disc space narrowing (DSN), spondylolisthesis, and presence of facet joint OA (FOA). Spine OA was defined as at least mild OST and mild DSN at the same level for any level of the lumbar spine. LBP, comorbidities, and back injury were self-reported. Weibull models were used to estimate hazard ratios (HRs) and 95% confidence intervals (95% CIs) of spine phenotypes accounting for potential predictors including demographic characteristics, clinical characteristics, comorbidities, obesity, and appendicular OA.

RESULTS

Obesity was a consistent and strong predictor of incidence of DSN (HR 1.80 [95% CI 1.09-2.98]), spine OA (HR 1.56 [95% CI 1.01-2.41]), FOA (HR 4.99 [95% CI 1.46-17.10]), spondylolisthesis (HR 1.87 [95% CI 1.02-3.43]), and LBP (HR 1.75 [95% CI 1.19-2.56]), and worsening of DSN (HR 1.51 [95% CI 1.09-2.09]) and LBP (HR 1.51 [95% CI 1.12-2.06]). Knee OA was a predictor of incident FOA (HR 4.18 [95% CI 1.44-12.2]). Spine OA (HR 1.80 [95% CI 1.24-2.63]) and OST (HR 1.85 [95% CI 1.02-3.36]) were predictors of incidence of LBP. Hip OA (HR 1.39 [95% CI 1.04-1.85]) and OST (HR 1.58 [95% CI 1.00-2.49]) were predictors of LBP worsening.

CONCLUSION

Among the multiple predictors of spine phenotypes, obesity was a common predictor for both incidence and worsening of lumbar spine degeneration and LBP.

The Manual Therapy and Strengthening for the Hip (MASH) Trial: Protocol for a Multisite Randomized Trial of a Subgroup of Older Adults With Chronic Back and Hip Pain

OBJECTIVE

Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment.

METHODS

This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively.

IMPACT

This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP.

Musculoskeletal pain in Parkinson's disease: a narrative review

The prevalence of musculoskeletal (MSK) pain in people with Parkinson's disease (PD) is higher than that of age-matched controls. In this review, we outline what is known about MSK pain in PD, focusing on the neck, shoulder, knee, hip and low back. We also compare what is known about MSK pain in PD to what is known in older adults without PD. Finally, we outline areas of for future research related to MSK pain in people with PD.

Classification of Geriatric Low Back Pain Based on Hip Characteristics With a 12-Month Longitudinal Exploration of Clinical Outcomes: Findings From Delaware Spine Studies

OBJECTIVE

The purpose of this study is to identify geriatric chronic low back pain (LBP) subgroups based on the presence of potentially modifiable hip impairments, using Latent Variable Mixture Modeling (LVMM), and to examine the prospective relationship between these subgroups and key outcomes over time.

METHODS

Baseline, 3-month, 6-month, and 12-month data were collected from a prospective cohort of 250 community-dwelling older adults with chronic LBP. Comprehensive hip (symptoms, strength, range of motion, and flexibility), LBP (intensity and disability), and mobility function (gait speed and 6-Minute Walk Test) examinations were performed at each timepoint. Baseline hip measures were included in LVMM; observed classes/subgroups were compared longitudinally on LBP and mobility function outcomes using mixed models.

RESULTS

Regarding LVMM, a model with 3 classes/subgroup fit best. Broadly speaking, subgroups were differentiated best by hip strength and symptom presence: subgroup 1 = strong and nonsymptomatic, subgroup 2 = weak and nonsymptomatic, and subgroup 3 = weak and symptomatic (WS). Regarding longitudinal mixed models, all subgroups improved in most outcomes over time. Specifically, over 12 months, the nonsymptomatic subgroups had lower LBP intensity and disability levels compared with the WS subgroup, whereas the strong and nonsymptomatic subgroup had better mobility function than the 2 "weak" subgroups.

CONCLUSION

These subgroup classifications may help in tailoring specific interventions in future trials. Special attention should be given to the WS subgroup given their consistently poor LBP and mobility function outcomes.

IMPACT

Among older adults with chronic low back pain, there are 3 hip subgroups: "strong and nonsymptomatic," "weak and nonsymptomatic," and "weak and symptomatic." People in these subgroups demonstrate different outcomes and require different treatment; proper identification will result in tailored interventions designed to benefit individual patients. In particular, people in the WS subgroup deserve special attention, because their outcomes are consistently poorer than those in the other subgroups.

Hip Range of Motion and Strength Predict 12-Month Physical Function Outcomes in Older Adults With Chronic Low Back Pain: The Delaware Spine Studies

Objective

The objective of this study was to investigate whether poor hip range of motion (ROM) and strength predict 12‐month physical function decline among older adults with chronic low back pain (LBP) and whether hip osteoarthritis modifies those relationships.

Methods

At baseline, passive ROM and strength measurements were taken for hip flexion, extension, abduction, adduction, internal rotation, and external rotation; ultrasound images and self‐reported symptoms were used to evaluate hip osteoarthritis presence (eg, osteophytes and hip pain). At baseline and 12 months, performance‐based (repeated chair rise, self‐selected gait speed, 6‐minute walk test [6MWT]) and self‐reported (Quebec LBP Disability Questionnaire, Late‐Life Function & Disability Instrument [LLFDI] basic and advanced lower extremity scales) physical function outcomes were assessed. Regression models were constructed for each outcome predicted by baseline hip ROM and strength measures, with adjustment for potential covariates. To avoid collinearity, hip ROM and strength measures with the strongest unadjusted correlations were included in final models. The hip osteoarthritis presence by hip ROM/strength interaction was also explored.

Results

Hip abduction strength predicted repeated chair rise (β = −0.297, P < 0.001), gait speed (β = 0.160, P = 0.003), 6MWT (β = 0.159, P ≤ 0.001), Quebec LBP Disability Questionnaire (β = −0.152, P = 0.003), and LLFDI basic lower extremity scale (β = 0.171, P = 0.005) outcomes. Regarding hip ROM, extension predicted repeated chair rise (β = −0.110, P = 0.043) and LLFDI advanced lower extremity scale (β = 0.090, P = 0.007) outcomes, external rotation predicted gait speed (β = 0.122, P = 0.004) outcomes, and abduction predicted LLFDI basic lower extremity scale (β = 0.114, P = 0.026) outcomes. The hip osteoarthritis interaction was not significant for any model.

Conclusion

Reduced hip strength and ROM predict physical function decline; hip osteoarthritis presence may not modify these relationships.

Associations of Multiple Chronic Conditions With Physical Performance and Falls Among Older Adults With Back Pain: A Longitudinal, Population-based Study

OBJECTIVE

To determine the association of chronic conditions measured at baseline with physical performance and falls over time among older adults with back pain. We examined both number and type (depression, anxiety, arthritis) of chronic conditions.

DESIGN

Retrospective cohort study.

SETTING

National Health and Aging Trends Study.

PARTICIPANTS

A total of 2438 community-dwelling Medicare beneficiaries aged ≥65 years with bothersome back pain (N=2438). The sample was mostly female (62%; 95% confidence interval [CI], 59%-64%) and aged 65-74 years (56%; 95% CI, 53%-58%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Short Physical Performance Battery (SPPB) (range, 0-12, lower indicates worse function) and recurrent falls measured annually over 6 years.

RESULTS

Multiple chronic conditions were highly prevalent (82%; 95% CI, 79%-84%) among those reporting back pain. Adjusted regressions using survey weights with Taylor series linearization method and containing interaction terms for comorbidity and time showed having 2-3 chronic conditions vs 0-1 was associated with lower SPPB scores, and differences grew over time (for example 0.61 points lower [95% CI, -0.88 to -0.34] and 1.22 points lower [95% CI, -1.76 to -0.67] in rounds 3 and 6, respectively). Having ≥4 chronic conditions was associated with lower SPPB scores at all time points vs 0-1 (point estimate range, -1.72 to -2.31). Arthritis alone; the combination of arthritis with depression; and the triad of arthritis, depression, and anxiety were associated with lower SPPB scores at all time points. Logistic regression models showed presence of 2-3 and ≥4 chronic conditions was associated with increased odds of recurrent falls in any given year (odds ratio, 1.91; 95% CI, 1.35-2.69 and odds ratio, 3.92; 95% CI, 2.81-5.46, respectively). Those with the triad of arthritis, depression, and anxiety had greater odds of recurrent falls vs none or 1 condition.

CONCLUSIONS

Among older adults with back pain, those with multiple chronic conditions, including co-occurrence of arthritis, depression, and anxiety, have greater risk for poor physical functioning and falls over time.

Multi-Dimensional Impact of Chronic Low Back Pain among Underserved African American and Latino Older Adults

Chronic low back pain is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. The existing low back pain research has relied almost exclusively on White/Caucasian participant samples. This study examines the correlates of chronic low back pain among a sample of underserved urban African American and Latino older adults. Controlling for age, gender, race/ethnicity, education, living arrangement, and number of major chronic conditions, associations between low back pain and the following outcome variables are examined: (1) healthcare utilization, (2) health-related quality of life (HR-QoL) and self-rated quality of health; and (3) physical and mental health outcomes.

METHODS

We recruited nine hundred and five (905) African American and Latino older adults from the South Los Angeles community using convenience and snowball sampling. In addition to standard items that measure demographic variables, our survey included validated instruments to document HR-QoL health status, the Short-Form McGill Pain Questionnaire-2, Geriatric Depression Scale, sleep disorder, and healthcare access. Data analysis includes bivariate and 17 independent multivariate models.

RESULTS

Almost 55% and 48% of the Latino and African American older adults who participated in our study reported chronic low back pain. Our data revealed that having low back pain was associated with three categories of outcomes including: (1) a higher level of healthcare utilization measured by (i) physician visits, (ii) emergency department visits, (iii) number of Rx used, (iv) a higher level of medication complexity, (v) a lower level of adherence to medication regimens, and (vi) a lower level of satisfaction with medical care; (2) a lower level of HR-QoL and self-assessment of health measured by (i) physical health QoL, (ii) mental health QoL, and (iii) a lower level of self-rated health; and (3) worse physical and mental health outcomes measured by (i) a higher number of depressive symptoms, (ii) a higher level of pain, (iii) falls, (iv) sleep disorders, (v) and being overweight/obese.

DISCUSSION

Low back pain remains a public health concern and significantly impacts the quality of life, health care utilization, and health outcomes of underserved minority older adults. Multi-faceted and culturally sensitive interventional studies are needed to ensure the timely diagnosis and treatment of low back pain among underserved minority older adults. Many barriers and challenges that affect underserved African American and Latino older adults with low back pain simply cannot be addressed in over-crowded EDs. Our study contributes to and raises the awareness of healthcare providers and health policymakers on the necessity for prevention, early diagnosis, proper medical management, and rehabilitation policies to minimize the burdens associated with chronic low back pain among underserved older African American and Latino patients in an under-resourced community such as South Los Angeles.

Hip osteoarthritis signs and symptoms are associated with increased fall risk among community-dwelling older adults with chronic low back pain: a prospective study

Background

Older adults with concurrent low back and hip pain are predisposed to reductions in physical performance and health-related quality of life. Yet no study to date has assessed whether or not coexisting hip impairments increase fall risk in older adults with chronic low back pain (CLBP). The objective of this study was to determine if hip osteoarthritis (OA) signs and symptoms per American College of Rheumatology (ACR) criteria are associated with fall risk over a 1-year span.

Methods

Falls were prospectively monitored for 1 year via fall calendars. Age, sex, body mass index (BMI), anxiolytic use, balance confidence, LBP-related disability, and prior fall history were identified as covariates. Hip pain, pain with hip internal rotation (IR), hip IR range of motion (ROM) ≥ 15°, and morning stiffness lasting ≤ 60 min were evaluated at baseline and summed to represent hip OA impairment burden. A generalized linear model with a Poisson distribution and log link function assessed the association between ACR criteria and fall risk beyond established covariates. As a secondary analysis, binary logistic regression assessed ACR criteria and the odds of falling two or more times within a year.

Results

Data from two-hundred and ten participants were analyzed. Hip OA signs and symptoms were present in 97.1% of the participants, and hip OA impairment burden was significantly greater (p < 0.050) in participants who fell ≥ 2 times compared to single and non-fallers. Higher hip OA impairment burden was associated with significantly increased fall risk (p = 0.001, risk ratio = 1.23, 95% CI 1.09–1.38) and odds of falling multiple times (p < 0.05, odds ratio = 1.41, 95% CI 1.01–1.95) after adjustment for covariates.

Conclusions

Older adults with CLBP and concomitant hip impairments are an at-risk group for falling. Healthcare professionals should employ falls screening and preventive measures to avoid negative sequelae in this vulnerable population.

Iliopsoas the Hidden Muscle: Anatomy, Diagnosis, and Treatment

The iliopsoas is a deep muscle group which anatomically connects the spine to the lower limbs. It is composed of the iliacus, psoas major, and psoas minor muscles. The iliopsoas functions as the primary hip flexor. Because the iliopsoas is important for daily activities, including sports, impairments and pathology associated with this muscle group can cause significant limitations. Evaluating pathology associated with the iliopsoas muscle group can be challenging because the patient's complaints are often vague and difficult to discern from other hip problems. This article will review relevant anatomy, discuss common pathologies, present clinical based examination methods, and outline conservative treatment interventions focusing on manual therapy and active exercises.

Links between the Hip and the Lumbar Spine (Hip Spine Syndrome) as they Relate to Clinical Decision Making for Patients with Lumbopelvic Pain

This narrative review focuses on the links between the hip and lumbar spine in the context of lumbopelvic pain. The literature regarding this topic is variable, found in many disciplines of care using different terminology. Collectively these inconsistencies add to the complexity of understanding the current evidence as it pertains to clinical practice. We have chosen to review studies that describe and assess overlapping pain distributions between the lumbar spine and hip, hip osteoarthritis and lumbopelvic pain, improvements in low back pain following hip arthroplasty, association of hip range of motion and lumbopelvic pain, and lumbopelvic motion and hip motion as they relate to low back pain and gender. The links between the hip and lumbar spine may provide the clinician important information to make decisions and recommendations for people presenting with the clinical symptom complex including lumbopelvic pain.

Paradigm Shift in Geriatric Low Back Pain Management: Integrating Influences, Experiences, and Consequences

Geriatric low back pain (LBP) can have a profound impact on physical activity and can cause a decline in physical function, which is a major health risk for older adults. Within the last decade, physical therapist management of LBP has shifted from an emphasis on pathoanatomical mechanisms, such as spine degeneration, to addressing psychological distress factors. Although this approach is promising, the complexity of LBP in older adults (including biological, psychological, cognitive, and social influences), which may differ from that in younger adults, must be considered. Further, outcome assessment should represent not only the LBP experience (eg, pain intensity, pain with movement) but also LBP consequences, such as physical activity decline and physical function decline. This perspective discusses influences on geriatric LBP, experiences, and consequences with the goal of facilitating standardized and comprehensive physical therapist management.