Back Pain

Back problems in Parkinson’s disease: an underestimated problem

STUDY DESIGN

Cross-sectional survey.

OBJECTIVES

To estimate the extent of back pain in Parkinson's disease (PD).

SUMMARY OF BACKGROUND DATA

PD is a common and disabling condition during the course of which back pain may develop. In contrast, the literature on the epidemiology of back pain in PD is poor.

METHODS

Patients with PD, seen consecutively in a neurology clinic over a period of 4 months, were inquired about back pain through a self-questionnaire and compared to an age- and sex-matched control group of chronically ill patients.

RESULTS

The study involved 104 parkinsonians (mean age: 67.3 years) who had had PD for an average of 11.6 years, and 100 controls (mean age: 65.8 years) who had chronic heart disease or diabetes for an average of 14.2 years. Sixty-two parkinsonians and 23 controls reported back pain. The prevalence was 59.6% in the parkinsonian group and 23.0% in the control group (P < 0.0001). Pain severity was evaluated with a visual analogic scale and averaged 54 +/- 23 mm in parkinsonians and 41 +/- 19 mm in control (P < 0.0001).

CONCLUSIONS

Chronic back pain is quite common in PD. It is responsible for a substantial functional impact and needs more attention to reduce disability of such patients.

Neck and Back Pain in the Elderly

Surgical intervention for neck and back pain in elderly patients without significant comorbidities can significantly improve a patient's symptoms and quality of life when more conservative therapies fail. Current spine literature strongly supports the paradigm of treating elderly patients with stable, chronic neck or back pain with conservative therapies first in order to optimize the risks and benefits of all available treatment options. If less-invasive methods fail to achieve satisfactory outcomes, more aggressive surgical options can, at that time, typically be implemented with excellent results in elderly patients without significant comorbidities. Clinical scenarios threatening to result in spine instability or nerve root or spinal cord compression require immediate intervention, especially in elderly patients, who, in general, have a higher risk of developing such conditions either through falls or trauma or acquired degenerative disease processes or malignancies. When an elderly patient enters a physician's office and asks "doctor, I've had pain for years, but it's getting worse. At my age, is it really worth having surgery?" The answer is a qualified "yes," if conservative treatments have failed and if the patient is otherwise in reasonably good health. Because the vast majority of these patients first interact with the medical system through their primary care doctors and neurologists, early recognition of situations requiring immediate attention, and those requiring referrals to spine specialists, can greatly expedite the appropriate use of scarce healthcare resources. Furthermore, knowledge of the various treatment options available to elderly patients complaining of the very common symptoms of neck or back pain can significantly improve patient care, especially in this new century when older patients will increasingly become a larger and more active force in all aspects of our society.

Geriatric pain management. The anesthesiologist's perspective

Geriatric patients have a unique physiology that makes their pain management problematic. This article reviews the issue of geriatric pain management from the perspective of the anesthesiologist. It looks at the main causes of geriatric chronic pain and emphasizes the different analgesic modalities available that can provide maximum relief and minimal potential side effects.

Management of patients with vertebral compression fractures

Osteoporosis is a disease of low bone mass that may not manifest until a patient has a fracture. Hip fracture is the most devastating, but vertebral fracture is the most common, occurring in 25% of women over 50 years of age and 40% of those age 80-85 years. Although 60% of vertebral fractures are clinically silent, they are easily diagnosed radiographically. They are associated with height loss, deformity, impaired mobility, and pain. Patients should be evaluated for the cause of both the fracture and osteoporosis. Therapy includes education about the disease, an exercise program, and advice about tailoring routine activities. Pharmacotherapy includes annual influenza vaccines, and daily calcium (1200-1500 mg elemental calcium/day) and vitamin D (400-800 IU/day) supplements. New antiresorptive agents alendronate, hormone replacement therapy, and salmon calcitonin should be offered to all patients as they reduce fracture rates.

Clinical consequences of vertebral fractures

People with vertebral fractures have greater pain, disability, and healthcare utilization, on average, than those without fractures. Most studies of acute pain and disability have been limited to patients with clinically diagnosed fractures (a subset of all symptomatic patients), representing about one third of all patients with fractures identified radiographically. Acute symptoms vary widely. Some patients experience intolerable pain that can be completely debilitating for several weeks or months, whereas about half of all patients with radiographically identified fractures report having had no symptoms. The reasons for this variability are unknown. Chronic pain and disability among patients with vertebral fractures are significantly greater on average than among people without fractures, even after adjusting for comorbid conditions that are common among the elderly. Similar to acute symptoms, chronic symptoms vary widely and often persist for at least several years. The risk of pain and disability increases progressively with the number and severity of vertebral deformities: the risk is multiplied several times with each additional fracture. On average, physical function is impaired among people with vertebral fractures, whether or not they currently report back pain. Declines in physical function and changes in appearance contribute to social isolation and loss of self-esteem, impairing quality of life. The cumulative impact of vertebral fractures on quality of life may rival that of hip fractures because hip fractures are less frequent and occur later in life. As many as 40% of symptomatic vertebral fractures are initially misdiagnosed, signaling a need for greater awareness among physicians and patients. Prevention of initial vertebral fractures should be actively encouraged; even if the initial fracture is asymptomatic, it indicates a greatly increased risk of subsequent fractures, pain, and physical impairment.

Back pain in the workplace. What you lift or how you lift matters far less than whether you lift or when

In spite of more than 50 years of concerted effort to diminish task demand, the incidence of compensable back injuries has not wavered. Before we persist for another 50 years in the quest for the "right way to lift," we should consider recent multivariate clinical investigations that suggest alternative approaches. Because task context is at least as important as task content in this regard, it follows that including regional backache under the rubric of "compensable injury" demands reconsideration. Likewise, rather than pursuing the "right way to lift," the more reasonable and humane quest might be for workplaces that are comfortable when we are well and accommodating when we are ill.

Vertebral fractures and other predictors of back pain among older women

We examined the prevalence and predictors of back pain (BKP) among 645 postmenopausal Japanese-American women in Hawaii with a mean age of 73.9 years (ranging from 55 to 93 years) and serial spine radiographs during the preceding 12 years. The overall prevalence of BKP was 32.9% and appeared to be constant up to age 80, with an increase thereafter. At most ages, pain in the lower back was the most common, upper BKP was less so, and mid-BKP was the least common. The overall prevalence of BKP among Japanese-American women in Hawaii was about half of that reported for U.S. Caucasians. Vertebral fractures were divided into three categories based on the length of time since the fracture was identified on radiographs. BKP was only associated with recent vertebral fractures (during the previous 4 years, on average) and increased progressively with the number and severity of fractured vertebrae. A history of a single recent fracture was associated with a 2.8-fold increase in the odds of BKP; two recent fractures with a 7.8-fold increase and three recent fractures with a 21.7-fold increase in the odds of BKP. In addition, self-reported disk problems, body mass index, and the number of other painful joints also showed independent associations with BKP. Height, spine bone mineral density (BMD), calcaneus BMD, smoking, and number of live births were not significantly associated with BKP.

Functional impairment among elderly women with osteoporotic vertebral fractures

Back pain is a significant cause of functional impairment in elderly women with vertebral fractures. To determine the degree of functional impairment due to painful osteoporotic vertebral fractures, investigators compared 75 white women with a mean age of 77 (+/- 7.2) years who had a mean number of 2.8 (+/- 0.87) vertebral fractures with 83 white women with a mean age of 74 (+/- 6.5) years who had no vertebral fractures. These patients were seen within a 2-year period. The Katz Activities of Daily Living scale was used to assess the patients' functional status. All patients underwent a comprehensive evaluation that included a detailed history and a physical examination. Bone density was evaluated in most of the patients and the evaluation revealed osteoporosis in all of the patients with vertebral fractures. The women with vertebral fractures were found to be more significantly dependent in the following activities of daily living: bathing, toileting, dressing, transfer, and continence. These findings have important nursing implications for rehabilitation of the elderly with this condition.