How Does Low Back Pain Impact Physical Function in Independent, Well-Functioning Older Adults? Evidence from the Health ABC Cohort and Implications for the Future

Relationships Between Applied Mindfulness Practice, Chronic Pain, and Pain-Related Functioning in Veterans

Mindfulness-based interventions (MBIs) have been shown to improve chronic pain and associated conditions like depression, anxiety, and sleep disorders. However, there is limited research on how veterans with chronic pain apply mindfulness skills to manage pain in daily life. This cross-sectional study examined the association between applied mindfulness practice, pain, and several pain-related conditions among 1,737 veterans with chronic pain prior to enrollment in a trial of 2 MBIs. Applied mindfulness practice was assessed using the Applied Mindfulness Process Scale (AMPS). The outcomes included pain interference, pain intensity, pain catastrophizing, fatigue, sleep disturbance, anxiety, depression, post-traumatic stress disorder, physical function, and social participation. Higher overall AMPS scores, as well as the positive and negative emotional regulation subscales of the AMPS, were associated with less pain interference and catastrophizing, as well as better outcomes for all pain-related conditions. The positive emotional regulation subscale had the strongest associations with outcomes. There was no significant association between the AMPS and pain intensity. The results suggest applied mindfulness practice, especially positive emotional regulation, may improve pain and functioning. In addition, the AMPS shows promise as a process measure of mindfulness skills applied in daily life. Additional research is needed to examine different aspects of mindfulness in the context of MBIs. PERSPECTIVE: This article describes the relationship between applied mindfulness practice and pain-related outcomes, prior to a MBI, using a novel measure of mindfulness practice. These findings underscore the importance of measuring applied mindfulness practice prior to and during clinical interventions to treat chronic pain.

Functional vs. dual-task training effects on trunk muscle function and functional fitness in older women with and without chronic low back pain: A randomized clinical trial

INTRODUCTION

Non-specific chronic low back pain (CLBP) predominantly affects women aged 40-80 years. Physical exercise is a primary treatment form, with functional training (FT) and dual-task training (DT) emerging as potential modalities due to their distinct characteristics. However, limited information exists regarding the effects of these exercise modalities on CLBP.

OBJECTIVE

To compare the FT and DT effects on trunk function and functional fitness in CLBP older women.

METHODOLOGY

This was a randomized clinical trial with two training groups (FT and DT) and CLBP and non-CLBP individuals. We assessed the trunk stability, maximum isometric strength, endurance of trunk muscles, and functional fitness before and after 16 weeks of training RESULTS: We found only time effects for circular stability and instability (p <.001), flexors (p =.006), and extensors endurance (p <.001). For the lateral flexors, there was an average reduction of 17.3 units in lateral flexor endurance in the FT compared to the DT in CLBP individuals. For the strength of the flexor, CLBP individuals exhibited an increase of 69.3 units compared to non-CLBP. For the strength of extensors, CLBP individuals showed a decrease of 75.1 units compared to non-CLBP individuals. We identified a time effect for all functional fitness measures (p <.050) CONCLUSION: FT and DT increase trunk stability, maximum isometric strength, and endurance of trunk muscles, besides the functional fitness of CLBP older women SIGNIFICANCE: Professionals can choose either training type, as there are no differences in the initial 16 weeks of intervention.

Race-specific associations: inflammatory mediators and chronic low back pain

ABSTRACT

Chronic low back pain (cLBP) is a global health crisis that disproportionately burdens non-Hispanic Black (NHB) individuals, compared with those who identify as non-Hispanic White (NHW). Despite the growing personal and societal impact of cLBP, its biological underpinnings remain poorly understood. To elucidate the biological factors that underlie the racial disparities in cLBP, this study sought to determine whether inflammatory mediators associated with pain interference (PI), pain at rest (PAR), and movement-evoked pain (MEP) differ as a function of racial identity. Blood samples were collected from 156 individuals with cLBP (n = 98 NHB participants, n = 58 NHW participants). Enzyme-linked immunosorbent assay and multiplex assays were used to quantify concentrations of proinflammatory (fibrinogen, C-reactive protein [CRP], serum amyloid A, tumor necrosis factor α [TNF-α], and interleukin [IL]-1α, IL-1β, and IL-6) and anti-inflammatory markers (IL-4 and IL-13). Spearman rho correlations were used to assess associations among markers of inflammation and PI, PAR, and MEP using the Brief Pain Inventory-Short Form. Analyses revealed that for NHW patients, CRP, serum amyloid A, and IL-6 were positively associated with cLBP outcomes and IL-4 was inversely associated with PAR and MEP. However, for NHB patients, only IL-1α was positively associated with PAR. Our findings suggest that, while there are associations between inflammation and cLBP outcomes, the biomarkers that underlie the inflammation could very well differ as a function of racialized minority group. However, more research with racially inclusive samples is needed to elucidate the mechanisms that may contribute to racial disparities in cLBP.

Determinants of physical activity engagement in older adults

In order to increase engagement in physical activity, it is important to determine which factors contribute to physical activity engagement in older adults. The current study examined the relative predictive ability of several potential determinants, in terms of both the concurrent level as well as longitudinal trajectories. Clinically normal adults aged 61-92 completed the Physical Activity Scale for the Elderly (n = 189 for cross-sectional models; n = 214 for longitudinal models). Potential determinants included age, gender, education, physical health, sensory health, mood, cardiovascular health, cognitive status, and biomarkers of Alzheimer disease (AD). We observed a novel finding that both concurrent physical health (p < 0.001) and change in physical health (p < 0.001) were significant predictors above and beyond other determinants. Concurrent mood predicted levels of physical activity (p = 0.035), particularly in females. These findings suggest that poor physical health and low mood might be important to consider as potential barriers to physical activity engagement in older adults.

A descriptive study of physical function and performance in older black men with low back pain

The purpose of this paper is to describe physical function and performance scores and examine the relationships between measures of physical performance in older Black men with low back pain. The Mobility, Aging, Pain, and Disparities study used a cross-sectional, observational design to objectively measure physical performance on the Short Physical Performance Battery (SPPB), the Back Performance Scale (BPS), and the 400-meter Walk Test along with subjective ratings of pain intensity in the past 24 hours. Sixty community-based Black men aged 61-87 (x̄= 70 ± 6) years had an average BPS score of 7.0 ± 4 and total score on the SPPB 8.5 ± 2.1. Average 400-meter Walk time was 6.3 ± 3.1 minutes. Men's average pain intensity in the past 24 hours was 5.7 ± 2, indicating moderate pain. In conclusion, older Black men with low back pain demonstrated low physical function scores and a higher level of disability.

Evaluation of Paraspinal Muscle Degeneration on Pain Relief after Percutaneous Epidural Adhesiolysis in Patients with Degenerative Lumbar Spinal Disease

Background and Objectives: The analgesic effectiveness of epidural adhesiolysis may be influenced by morphological changes in the paraspinal muscles, particularly in elderly patients. The objective of this study was to assess whether the cross-sectional area or fatty infiltration of the paraspinal muscles impacts the treatment outcomes of epidural adhesiolysis. Materials and Methods: The analysis included a total of 183 patients with degenerative lumbar disease who underwent epidural adhesiolysis. Good analgesia was defined as a reduction in pain score of ≥30% at the 6-month follow up. We measured the cross-sectional area and fatty infiltration rate of the paraspinal muscles and divided the study population into age groups (≥65 years and <65 years). Variables were compared between the good and poor analgesia groups. Results: The results revealed that elderly patients experienced poorer analgesic outcomes as the rate of fatty infiltration in the paraspinal muscles increased (p = 0.029), predominantly in female patients. However, there was no correlation between the cross-sectional area and the analgesic outcome in patients younger than or older than 65 years (p = 0.397 and p = 0.349, respectively). Multivariable logistic regression analysis indicated that baseline pain scores < 7 (Odds Ratio (OR) = 4.039, 95% Confidence Interval (CI) = 1.594-10.233, p = 0.003), spondylolisthesis (OR = 4.074, 95% CI = 1.144-14.511, p = 0.030), and ≥ 50% fatty infiltration of the paraspinal muscles (OR = 6.576, 95% CI = 1.300-33.268, p = 0.023) were significantly associated with poor outcomes after adhesiolysis in elderly patients. Conclusions: Fatty degeneration of paraspinal muscles is correlated with inferior analgesic outcomes following epidural adhesiolysis in elderly patients, but not in young and middle-aged patients. The cross-sectional area of the paraspinal muscles is not associated with pain relief after the procedure.

Physical functioning following spinal cord stimulation: a systematic review and meta-analysis

BACKGROUND

Spinal cord stimulation (SCS) has emerged as an important treatment for chronic pain disorders. While there is evidence supporting improvement in pain intensity with SCS therapy, efforts to synthesize the evidence on physical functioning are lacking.

OBJECTIVE

The primary objective of this meta-analysis was to assess long-term physical function following 12 months of SCS for chronic back pain.

EVIDENCE REVIEW

PubMed, EMBASE, Scopus, and CENTRAL databases were searched for original peer-reviewed publications investigating physical function following SCS. The primary outcome was physical function at 12 months following SCS therapy for chronic back pain compared with baseline. A random effects model with an inverse variable method was used. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) framework was used to determine the certainty of evidence.

FINDINGS

A total of 518 studies were screened, of which 36 were included. Twenty-two studies were pooled in the meta-analysis. There was a significant reduction in Oswestry Disability Index (ODI) scores at all time frames up to 24 months following implantation. Pooled results revealed significant improvement in ODI scores at 12 months with a mean difference of -17.00% (95% CI -23.07 to -10.94, p<0.001). There was a very low certainty of evidence in this finding as per the GRADE framework. There was no significant difference in subgroup analyses based on study design (randomised controlled trials (RCTs) vs non-RCTs), study funding, or stimulation type.

CONCLUSION

This meta-analysis highlights significant improvements in physical function after SCS therapy. However, this finding was limited by a very low GRADE certainty of evidence and high heterogeneity.

Challenges, Concerns, and Experiences of Community-Dwelling Older Women with Chronic Low Back Pain—A Qualitative Study in Hong Kong, China

Background and Objectives: Although chronic low back pain (CLBP) is known to negatively affect multiple aspects of the lives of older people, prior qualitative studies mainly focused on the lived experiences of older people with CLBP in Western countries. Given cultural and contextual differences and poor understanding of CLBP in older women with CLBP, it is important to better understand the concerns and lived experiences of Chinese older women with CLBP. The current study aimed to investigate the experiences, challenges, concerns, and coping strategies of older women with CLBP in Hong Kong. Research Design and Methods: A total of 15 community-dwelling older women with CLBP aged ≥60 years were recruited from a physiotherapy clinic or a community center for semi-structured interviews. The interviews were audio recorded and transcribed ‘verbatim’. The transcription was imported to NVivo 12 software. Thematic analysis was conducted using Braun and Clarke’s method. Results: Five themes were identified: (1) physical impacts of CLBP on daily life; (2) psychological influences of CLBP; (3) management of CLBP; (4) family support; and (5) social activities and support. Discussion and implications: Negative physical and psychosocial impacts of CLBP were common among older women, and they adopted diverse pain management strategies, although some of their treatment options were influenced by the Chinese culture. Misbeliefs and responses of family and friends also affected their management strategies. Elderly community centers are a significant source of social support for older women with CLBP, making it an ideal platform for establishing self-help groups to facilitate their self-management of CLBP.

Association between low back pain and functional disability in the elderly people: a 4-year longitudinal study after the great East Japan earthquake

BACKGROUND

Functional disability is a major health issue in an aging population. Low back pain (LBP) is a common health concern that can lead to functional disability in the elderly; nonetheless, their association has not yet been clarified. This study aimed to examine the association between LBP and functional disability in the elderly, with a focus on its dose-dependent effects.

METHODS

This study used the 4-year longitudinal data of people living in disaster-affected areas after the Great East Japan Earthquake (aged ≧65, n = 914). LBP and physical function were assessed at 2, 4, and 6 years after the disaster. Multivariate logistic regression analyses were performed to assess the association between LBP and low physical function, as well as the effect of preceding LBP on the onset of low physical function.

RESULTS

LBP was significantly associated with low physical function, and the association became stronger as the duration of LBP increased. Adjusted odds ratios (95% confidence intervals) were 1.27 (0.79-2.06) in "< 2 years," 1.95 (1.01-3.77) in "≥2 years and <4 years," and 2.34 (1.35-4.06) in "≥4 years" (p for trend = 0.009). Additionally, preceding LBP was significantly associated with the onset of low physical function, and the effect became prominent as the duration of LBP increased. Adjusted odds ratios (95% confidence intervals) were 2.28 (1.19-4.37) in "< 2 years" and 2.82 (1.35-5.90) in "≥2 years" (p for trend = 0.003).

CONCLUSIONS

LBP is associated with physical disability among the elderly in a dose-dependent manner. Therefore, prevention and treatment of LBP are important for preventing functional disability.

Chronic low back pain and its impact on physical function, mental health, and health-related quality of life: a cross-sectional study in Singapore

Chronic low back pain, defined as low back pain lasting more than 3 months, is a globally prevalent health problem with significantly high medical and economic burden on individuals and the society. This study aimed to estimate the prevalence of chronic low back pain and examine its association with health outcomes including physical function, mental health, and quality of life among adult population in Singapore. Cross-sectional secondary data analysis was performed using baseline data of the 1941 adults (mean age: 52.6 years, range: 21-97 years) from a representative population health survey conducted in the Central region of Singapore. Those with self-reported chronic low back pain in past six months were identified. The Late-Life Function and Disability Instrument, Patient Health Questionnaire-9, and EQ-5D-5L were used to measure physical function and limitation, mental health, and health-related quality of life, respectively. Generalized Linear Regressions were used to examine the association of chronic low back pain with physical function, limitation, depressive symptoms, and health-related quality of life. There were 8.1% (n = 180) participants reporting having chronic low back pain in past six months, among whom 80.5% sought treatments at either primary care, specialist outpatient, or Traditional Chinese Medicine clinics. Individuals with chronic low back pain reported poorer physical function, more limitations in performing major life tasks and social activities, more depressive symptoms, and lower health-related quality of life (all p < 0.01), even after adjusting for socio-demographics, lifestyle factors, and number of morbidities. The prevalence of chronic low back pain was 8.1% among the study population. Chronic low back pain was associated with poorer physical function, more limitations and depressive symptoms, and lower health-related quality of life. The findings highlight the significant impact of chronic low back pain on physical function and limitation, mental health, and health-related quality of life in a general population. Increased awareness on prevention, early and proper management of low back pain, and rehabilitation policies are required to better tackle the burden of low back pain at the population level.

Association of non-chronic low back pain with physical function, endurance, fatigability, and quality of life in middle- and older-aged adults: Findings from Baltimore Longitudinal Study of Aging

Low back pain (LBP) is an important condition associated with high healthcare burden. However, the relationship of this condition with physical function (PF) and health-related quality of life (HRQoL) remains unclear. This is a cross-sectional study that aims to investigate the association between presence and intensity of non-chronic LBP with PF and HRQoL in middle-and older-aged adults. Participants answered questions about presence and intensity of LBP in the previous year, self-reported their PF and HRQoL (SF-12), and underwent objective measures of PF ([ExSPPB] including usual gait speed, narrow walk, chair stands, and standing balance), endurance performance ([EP] long-distance corridor walk) and fatigability. Generalized linear models and logistic regression models were performed. A total of 1500 participants (52.5% women, 70.3% white) aged 69.0 (SD 13.1) years were included. Of those, 642 (42.8%) reported LBP and the mean pain intensity was 4.1 (SD 2.2). After adjustments for potential confounders, presence of LBP was associated with lower self-reported PF (OR 1.73, 95% CI 1.27 to 2.37), lower physical component of HRQoL (β -0.03, 95% CI -0.04 to -0.02) and poorer chair stand performance (β -0.05, 95% CI -0.09 to -0.008). Higher intensity of LBP was associated with lower physical component of HRQoL (β -0.01, 95% CI -0.02 to -0.007), poorer ExSPPB performance (β -0.01, 95% CI -0.02 to -0.004), slower usual gait speed (β -0.01, 95% CI -0.02 to -0.004), lower total standing balance time (β -0.01, 95% CI -0.02 to -0.001) and higher fatigability (OR 1.13, 95% CI 1.01 to 1.25). The presence of non-chronic LBP was more consistently associated with lower self-reported PF, while higher intensity non-chronic LBP was associated with poorer objectively measured PF and fatigability. Collectively, this evidence suggests that although presence of pain may affect perception of function, greater pain intensity appears more strongly associated with unfavorable functional performance in mid-to-late life.

Association of Functional Disability and Biopsychosocial Factors in Older Adults With Low Back Pain Who Live in the Amazonas State Brazil: A Cross-Sectional Study

OBJECTIVE

The purpose of this study was to identify social and clinical factors associated with levels of functional disability (FD) in older adults with low back pain (LBP) in the city of Manaus, Amazonas, Brazil.

METHODS

A cross-sectional study of 557 adults with LBP aged ≥60 years was completed. Sociodemographic and clinical features, pain intensity (Numeric Rating Scale), FD (Roland Morris Disability Questionnaire), physical activity (International Physical Activity Questionnaire-short version), body mass index, educational level, health perception, emotional level, and self-reported diseases were evaluated. Statistical analysis was used to verify the association between quantitative variables and a group; Student t test or Mann-Whitney test, and analysis of variance (normality assumption) or Kruskal-Wallis test (non-parametric), P value of less than .05.

RESULTS

There were 81.3% female participants, 54.9% self-reported their race and/or skin color as brown, and 37.8% were sedentary. Pain intensity scores were 6.26 ± 2.19 in female participants and 5.82 ± 1.84 in male participants. Mean FD scores were 11.68 ± 6.08 for female participants and 9.61 ± 5.76 for males participants, although 39.7% of the total group presented with severe disability (score ≥14) and FD was associated with female sex (P = .001), physical activity (P≤ 0.001), body mass index (P≤ .001), emotional level (P < .001), and health perception (P < .001).

CONCLUSION

In this group of older adults with LBP, FD was associated with female sex, level of physical activity, body mass index, emotional level, and health perception. Many factors that were identified with FD are modifiable; therefore, interventions, such as nutrition education and re-conceptualization of self-emotional and health perception, may have potential to help in preventing and reducing FD.

Two-year validation and minimal clinically important difference of the Veterans RAND 12 Item Health Survey Physical Component Score in patients undergoing minimally invasive transforaminal lumbar interbody fusion

OBJECTIVE

The Physical Component Score of the Veterans RAND 12 Item Health Survey (VR-12 PCS) has been assessed for use at short-term and intermediate-term time points for lumbar fusion populations. This study assesses the long-term validity and establishes minimal clinically important difference (MCID) values of VR-12 PCS in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

METHODS

A surgical registry was retrospectively reviewed for primary, elective, single-level MIS TLIF procedures with posterior instrumentation. Patients missing preoperative and 2-year postoperative VR-12 PCS survey data were excluded. VR-12 PCS, SF-12 Health Survey Physical Component Summary (SF-12 PCS), Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), and Oswestry Disability Index (ODI) patient-reported outcome measures (PROMs) were recorded preoperatively and postoperatively. Responsiveness of the VR-12 measure was assessed in two ways. First, the mean postoperative PROM scores were compared with preoperative baseline values using a paired Student t-test. Second, MCID values were calculated using both distribution-based and anchor-based methods and used to assess improvement in VR-12 score at the 2-year time point. Discriminant validity of the VR-12 was assessed using cross-sectional and longitudinal anchors. Convergent validity of the VR-12 measure was assessed using Pearson's correlation coefficient and partial time-independent correlation. Floor and ceiling effects were assessed.

RESULTS

A total of 74 patients who underwent MIS TLIF were included. The VR-12 PCS demonstrated significant improvements at all time points from 12 weeks to 2 years (p < 0.001 for all). VR-12 PCSs were significantly different for patients classified using cross-sectional anchors (p < 0.001) and longitudinal anchors (p ≤ 0.005). Calculated MCID values ranged from 4.1 to 8.5, and 4.1 was selected as the optimal MCID, which 87.8% of patients achieved. Strong, significant correlations of the VR-12 PCS with SF-12 PCS and PROMIS PF were demonstrated at all time points (p < 0.001 for all). No significant floor or ceiling effects were detected.

CONCLUSIONS

The VR-12 PCS demonstrated excellent responsiveness, discriminant and convergent validity, and no significant floor or ceiling effects up to 2 years after MIS TLIF. Therefore, VR-12 PCS may serve as a valid measure of long-term physical function.

Health-related quality of life of Malaysian patients with chronic non-malignant pain and its associated factors: a cross-sectional study

Background

Chronic pain has a major impact on a patient’s quality of life, affecting physical and psychological functioning. It has debilitating consequences on social and economic aspects too. This study aimed to explore the status of health-related quality of life (HRQoL) of Malaysian patients suffering from chronic non-malignant pain.

Methods

Four hospitals offering pain clinic services were involved in this multicentre cross-sectional study conducted between June and September 2020. Adult patients who had been diagnosed with non-malignant chronic pain lasting for at least three months and able to communicate in English or Malay language were recruited in this study. Participants were informed about the study and were made aware that their participation was entirely voluntary. A battery of questionnaires consists of the EuroQol-5 dimensions-5 levels questionnaire (EQ-5D-5L) and the EuroQol visual analogue scale (EQ VAS), the Pain Self-Efficacy questionnaire (PSEQ) and the Pain Catastrophizing Scale (PCS) were self-administered by the patients. Besides, a structured questionnaire was used to collect their socio-demographic information, pain condition, sleep quality and working status. Participants’ usage of pain medications was quantified using the Quantitative Analgesic Questionnaire (QAQ).

Results

A total of 255 patients participated in this study. A median EQ-5D index value of 0.669 (IQR: 0.475, 0.799) and a median EQ VAS score of 60.0 (IQR: 50.0, 80.0) were recorded. Malay ethnicity (Adj. B: 0.77; 95% CI: 0.029, 0.126; p = 0.002) and a higher level of self-efficacy (Adj. B: 0.008; 95% CI: 0.006, 0.011; p < 0.001) were predictors of a better HRQoL, while suffering from pain in the back and lower limb region (Adj. B: -0.089; 95% CI: − 0.142, − 0.036; p = 0.001), the use of a larger amount of pain medications (Adj. B: -0.013; 95% CI: − 0.019, − 0.006; p < 0.001), and a higher degree of pain magnification (Adj. B: -0.015; 95% CI: − 0.023, − 0.008; p < 0.001) were associated with a poorer HRQoL.

Conclusions

These findings suggested that Malay ethnicity and a higher level of self-efficacy were predictors of a better HRQoL in patients with chronic pain, whereas pain-related factors such as higher usage of medication, specific pain site and pain magnification style were predictors of poorer HRQoL.

Trunk Dynamic Stability Assessment for Individuals With and Without Nonspecific Low Back Pain During Repetitive Movement

OBJECTIVE

This study aimed to employ nonlinear dynamic approaches to assess trunk dynamic stability with speed, symmetry, and load during repetitive flexion-extension (FE) movements for individuals with and without nonspecific low back pain (NSLBP).

BACKGROUND

Repetitive trunk FE movement is a typical work-related LBP risk factor contingent on speed, symmetry, and load. Improper settings/adjustments of these control parameters could undermine the dynamic stability of the trunk, hence leading to low back injuries. The underlying stability mechanisms and associated control impairments during such dynamic movements remain elusive.

METHOD

Thirty-eight male volunteers (19 healthy, 19 NSLBP) enrolled in the current study. All participants performed repetitive trunk FE movements at high/low speeds, in symmetric/asymmetric directions, with/without a wearable loaded vest. Trunk instantaneous rotation angle was computed for each trial to be assessed in terms of local and orbital stability, using maximum finite-time Lyapunov exponents (LyEs) and Floquet multipliers (FMs), respectively.

RESULTS

Both groups demonstrated equivalent competency in terms of trunk control and stability, suggesting functional adaptation strategies may be used by the NSLBP group. Wearing the loaded vest magnified the effects of trunk control impairment for the NSLBP group. The combined presence of high-speed and symmetrical FE movements was associated with least trunk local stability.

CONCLUSION

Nonlinear dynamic techniques, particularly LyE, are potentially effective for assessing trunk dynamic stability dysfunction for individuals with NSLBP during various activities.

APPLICATION

This work can be applied toward the development of quantitative personalized spinal evaluation tools with a wide range of potential occupational and clinical applications.

Trajectories of low back pain from midlife to retirement and functional ability at old age

BACKGROUND

This study aimed to identify trajectories of low back pain (LBP) over a 16-year follow-up from midlife to retirement and investigate their association with mobility limitations and disability in activities of daily living (ADL-disability) in later life.

METHODS

The study population consisted of 6257 baseline (1981) respondents aged 44-58 years from Finnish Longitudinal study on Aging Municipal Employees. Repeated measurements of LBP were collected in 1985, 1992 and 1997. We studied persons who had data on LBP at baseline and in at least one of the follow-ups and had information on mobility limitations (n = 2305) and ADL-disability (n = 2359) at a 28-year follow-up in 2009. Latent class growth analysis was used to identify LBP trajectories. Odds ratios (ORs) with 95% confidence intervals (CIs) for the associations of LBP trajectory and later life mobility limitations and ADL-disability were estimated and adjusted for confounders.

RESULTS

Three LBP trajectories with parallel shapes were identified: high-decreasing (19%), intermediate-stable (60%) and low (21%). After adjustment for confounders, high-decreasing trajectory had 3.2 times the odds (95% CI 2.1-4.9) of mobility limitations and 2.9 times the odds (95% CI 2.0-4.2) of ADL-disability as compared to low trajectory. The respective ORs for intermediate-stable trajectory were 1.6 (95% CI 1.2-2.1) and 1.7 (95% CI 1.3-2.3).

CONCLUSIONS

Among majority of respondents, LBP remained stable over the follow-up. The respondents belonging to intermediate-stable and high-decreasing trajectories of LBP had higher odds of mobility limitations and ADL-disability at old age. This highlights that LBP during midlife to retirement has far-reached consequences on functional ability at old age.

Association of Back Pain with Mortality: a Systematic Review and Meta-analysis of Cohort Studies

BACKGROUND

Back pain is the most common cause of disability worldwide. While disability generally is associated with greater mortality, the association between back pain and mortality is unclear. Our objective was to examine whether back pain is associated with increased mortality risk and whether this association varies by age, sex, and back pain severity.

METHODS

A systematic search of published literature was conducted using PubMed, Web of Science, and Embase databases from inception through March 2019. We included English-language prospective cohort studies evaluating the association of back pain with all-cause mortality with follow-up periods >5 years. Three reviewers independently screened studies, abstracted data, and appraised risk of bias using the Quality in Prognosis Studies (QUIPS) tool. A random-effects meta-analysis estimated combined odds ratios (OR) and 95% confidence intervals (CI), using the most adjusted model from each study. Potential effect modification by a priori hypothesized factors (age, sex, and back pain severity) was evaluated with meta-regression and stratified estimates.

RESULTS

We identified eleven studies with 81,337 participants. Follow-up periods ranged from 5 to 23 years. The presence of any back pain, compared to none, was not associated with an increase in mortality (OR, 1.06; 95% CI, 0.97 to 1.16). However, back pain was associated with mortality in studies of women (OR, 1.22; 95% CI, 1.02 to 1.46) and among adults with more severe back pain (OR, 1.26; 95% CI, 1.14 to 1.40).

CONCLUSION

Back pain was associated with a modest increase in all-cause mortality among women and those with more severe back pain.

Characterization of thoracic spinal manipulation and mobilization forces in older adults

BACKGROUND

Spinal mobilization and spinal manipulation are common interventions used by manual therapists to treat musculoskeletal conditions in older adults. Their force-time characteristics applied to older adults' thoracic spine are important considerations for effectiveness and safety but remain unknown. This study aimed to describe the force-time characteristics of posterior-to-anterior spinal mobilization and manipulation delivered to older adults' thoracic spine.

METHODS

Twenty-one older adults (≥65 years) with no thoracic pain received posterior-to-anterior thoracic spinal mobilization and/or manipulation with the force characteristics a chiropractor deemed appropriate. Six-degree-of-freedom load cells and an instrumented treatment table recorded the force characteristics of both interventions at the clinician-participant and participant-table interfaces, respectively. Preload force, total peak force, time to peak and loading rate were analyzed descriptively.

FINDINGS

Based on data from 18 adults (56% female; average: 70 years old), mean resultant spinal mobilization forces at the clinician-participant interface were: 220 ± 51 N during preload, 323 ± 67 N total peak force, and 312 ± 38 ms time to peak. At the participant-table interface, mobilization forces were 201 ± 50 N during preload, 296 ± 63 N total peak force, and 308 ± 44 ms time to peak. Mean resultant spinal manipulation forces at the clinician-participant interface were: 260 ± 41 N during preload, 470 ± 46 N total peak force, and 165 ± 28 ms time to peak. At the participant table interface, spinal manipulation forces were 236 ± 47 N during preload, 463 ± 57 N total peak force, and 169 ± 28 ms time to peak.

INTERPRETATION

Results suggest older adults experience unique, but comparable force-time characteristics during spinal mobilization and manipulation delivered to their thoracic spine compared to the ones delivered to younger adults described in the literature.

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.

Validation of VR-12 Physical Function in Minimally Invasive Lumbar Discectomy

BACKGROUND

Although the Veterans RAND 12-item Physical Component Survey (VR-12 PCS) has been broadly used to evaluate patient-reported outcome measures (PROMs) in spine surgery, its feasibility for use in patients undergoing minimally invasive lumbar discectomy (MIS LD) has not been well studied. This study aimed to assess the feasibility of VR-12 PCS for use up to 2 years postoperatively for MIS LD by correlation with PROMs for physical function.

METHODS

Patients undergoing primary single-level MIS LD procedures were reviewed retrospectively. Results on the VR-12 PCS, 12-Item Short Form (SF-12) PCS, and Patient-Reported Outcomes Measurement Information System (PROMIS PF) were recorded preoperatively and up to 2 years postoperatively. Improvements in postoperative PROMs were calculated and assessed for significant differences from baseline values. Correlation significance and strength were evaluated between VR-12 PCS and SF-12 PCS or PROMIS PF. Scatterplots were constructed to demonstrate relationships of VR-12 PCS with SF-12 PCS and PROMIS PF at each time point.

RESULTS

Our cohort comprised 402 patients. Patients improved significantly from preoperative baseline for all 3 PROMs at all postoperative time points. Both Pearson's correlation and time-independent partial correlation revealed statistically significant strong correlations of VR-12 PCS with SF-12 PCS and PROMIS PF through 2-years.

DISCUSSION

Physical function scores for VR-12, SF-12, and PROMIS PF all demonstrated significant improvements following MIS LD. Strongly statistically significant correlations of VR-12 PCS with SF-12 PCS and PROMIS PF from preoperative measures through 2 years demonstrate the feasibility of VR-12 for assessing patient-reported physical function in MIS LD patients.

Cross-cultural adaptation and validation of the Amharic version of Roland Morris Disability Questionnaire in people with low back pain in Ethiopia

PURPOSE

Cross-culturally translate, adapt, and validate Roland Morris Disability Questionnaire (RMDQ) in Amharic language in Ethiopia.

METHODS

The English version RMDQ was translated into Amharic and back-translated into English. An expert review committee reviewed the translations and created Amharic version of the RMDQ (RMDQ-Am). Pilot testing and cognitive debriefing of the RMDQ-Am were conducted with a sample of 20 individuals with LBP. The RMDQ-Am was administered to 240 individuals with LBP from three rehabilitation centers to determine its psychometric properties. Internal consistency of the tool was determined by Cronbach's alpha. Test-retest reliability was determined by the Intraclass correlation coefficient. The Standard Error of Measurement (SEM), Minimum Detectable Change (MDC), and the Bland Altman Limit of Agreement (LOA) was also determined. The Short-Form Health Survey (SF-36) Bodily Pain and Physical Functioning subscales were used to assess convergent validity. Exploratory Factor Analysis (EFA) was used to determine the dimensionality of the tool.

RESULTS

RMDQ-Am demonstrated good internal consistency (α = 0.88), excellent test-retest reliability (ICC = 0.91), SEM (1.64), MDC (3.55), and good LOA. There is a significant moderate correlation between RMDQ-Am and the Physical Functioning (Rho = -0.62, p < 0.01) and Bodily Pain (BP) (Rho = -0.41, p < 0.01) subscales of the SF-36. Exploratory Factor Analysis demonstrates that the Amharic version of RMDQ is a primary one and secondary four-factor model [The Kaiser Meyer Olkin = 0.877, X² (df) =1413.278/190, p < 0.001].

CONCLUSION

RMDQ-Am is a reliable and valid tool that can be used in both clinical practice and research with the Ethiopian LBP population.IMPLICATION FOR REHABILITATIONDespite LBP being a concern in Ethiopia, the magnitude of disability related to this phenomenon is not studied in the country, mainly due to the absence of validated LBP specific patient-reported outcome measures such as the Roland Morris Disability Questionnaire (RMDQ).The RMDQ was successfully translated, adapted, and validated into the Amharic language and the Ethiopian context (RMDQ-Am).The RMDQ-Am is a reliable outcome measure among the Ethiopian population with LBP, as demonstrated by the good internal consistency (α = 0.88) and excellent test-retest reliability (ICC = 0.91).There is a moderate negative correlation between the RMDQ-Am and the Physical Functioning (Rho = -0.62, p < 0.01) and Bodily Pain (Rho = -0.41, p < 0.01) subscales of the SF-36.The RMDQ-Am can be used in clinical and research settings to measure LBP-related disability and its impact among individuals living with LBP in Ethiopia.

Maintaining Bone Health in the Lumbar Spine: Routine Activities Alone Are Not Enough

Public health organisations typically recommend a minimum amount of moderate intensity activities such as walking or cycling for two and a half hours a week, combined with some more demanding physical activity on at least 2 days a week to maintain a healthy musculoskeletal condition. For populations at risk of bone loss in the lumbar spine, these guidelines are particularly relevant. However, an understanding of how these different activities are influential in maintaining vertebral bone health is lacking. A predictive structural finite element modelling approach using a strain-driven algorithm was developed to study mechanical stimulus and bone adaptation in the lumbar spine under various physiological loading conditions. These loading conditions were obtained with a previously developed full-body musculoskeletal model for a range of daily living activities representative of a healthy lifestyle. Activities of interest for the simulations include moderate intensity activities involving limited spine movements in all directions such as, walking, stair ascent and descent, sitting down and standing up, and more demanding activities with large spine movements during reaching and lifting tasks. For a combination of moderate and more demanding activities, the finite element model predicted a trabecular and cortical bone architecture representative of a healthy vertebra. When more demanding activities were removed from the simulations, areas at risk of bone degradation were observed at all lumbar levels in the anterior part of the vertebral body, the transverse processes and the spinous process. Moderate intensity activities alone were found to be insufficient in providing a mechanical stimulus to prevent bone degradation. More demanding physical activities are essential to maintain bone health in the lumbar spine.

Perceived Injustice Helps Explain the Association Between Chronic Pain Stigma and Movement-Evoked Pain in Adults with Nonspecific Chronic Low Back Pain

OBJECTIVE

For most patients with chronic low back pain (cLBP), the cause is "nonspecific," meaning there is no clear association between pain and identifiable pathology of the spine or associated tissues. Laypersons and providers alike are less inclined to help, feel less sympathy, dislike patients more, suspect deception, and attribute lower pain severity to patients whose pain does not have an objective basis in tissue pathology. Because of these stigmatizing responses from others, patients with cLBP may feel that their pain is particularly unjust and unfair. These pain-related injustice perceptions may subsequently contribute to greater cLBP severity. The purpose of this study was to examine whether perceived injustice helps explain the relationship between chronic pain stigma and movement-evoked pain severity among individuals with cLBP.

METHODS

Participants included 105 patients with cLBP who completed questionnaires assessing chronic pain stigma and pain-related injustice perception, as well as a short physical performance battery for the assessment of movement-evoked pain and physical function.

RESULTS

Findings revealed that perceived injustice significantly mediated the association between chronic pain stigma and cLBP severity (indirect effect = 6.64, 95% confidence interval [CI] = 2.041 to 14.913) and physical function (indirect effect = -0.401, 95% CI = -1.029 to -0.052). Greater chronic pain stigma was associated with greater perceived injustice (P = 0.001), which in turn was associated with greater movement-evoked pain severity (P = 0.003).

CONCLUSIONS

These results suggest that perceived injustice may be a means through which chronic pain stigma impacts nonspecific cLBP severity and physical function.

Temporal summation of mechanical pain prospectively predicts movement-evoked pain severity in adults with chronic low back pain

BACKGROUND

Biopsychosocial factors above and beyond pathoanatomical changes likely contribute to the severity of chronic low back pain. A pro-nociceptive endogenous pain modulatory balance (↓inhibition and ↑facilitation) may be an important contributor to chronic low back pain severity and physical function; however, additional research is needed to address this possibility. The objective of this study was to determine whether quantitative sensory tests of endogenous pain inhibition and facilitation prospectively predict movement-evoked pain and cLBP severity self-reported on a validated questionnaire.

METHODS

One hundred thirty-four individuals with chronic low back pain were enrolled in this two-session study. During the first study session, temporal summation of mechanical pain and conditioned pain modulation were assessed at the lumbar spine to determine endogenous pain facilitation and inhibition, respectively. One week later, participants returned for a second study session whereby they reported their pain severity and pain interference using the Brief Pain Inventory-Short Form. Movement-evoked pain and physical function capacity were assessed upon completion of the balance, walking, and transition from sit to stand tests of the Short Physical Performance Battery.

RESULTS

Temporal summation of mechanical pain, but not conditioned pain modulation, significantly and prospectively predicted greater movement-evoked pain and poorer physical function on the Short Physical Performance Battery. Neither temporal summation nor conditioned pain modulation were significantly related to self-reported pain severity or pain interference on the Brief Pain Inventory-Short Form.

CONCLUSIONS

Findings suggest that a pro-nociceptive pain modulatory balance characterized by enhanced pain facilitation may be an important driver of movement-evoked pain severity and poor physical function in individuals with chronic low back pain.

The profile of older adults seeking chiropractic care: a secondary analysis

BACKGROUND

Musculoskeletal conditions are the primary reason older adults seek general medical care, resulting in older adults as the highest consumers of health care services. While there is high use of chiropractic care by older adults, there is no recent, specific data on why older adults seek chiropractic care and how chiropractors manage conditions. Therefore, the purpose of this study was to describe the demographic characteristics of older adults seeking chiropractic care, and to report problems diagnosed by chiropractors and the treatment provided to older adults who seek chiropractic care.

METHODS

A secondary data analysis from two, large cross-sectional observational studies conducted in Australia (COAST) and Canada (O-COAST). Patient encounter and diagnoses were classified using the International Classification of Primary Care, 2nd edition (ICPC-2), using the Australian ICPC-2 PLUS general practice terminology and the ICPC-2 PLUS Chiro terminology. Descriptive statistics were used to summarize chiropractor, patient and encounter characteristics. Encounter and patient characteristics were compared between younger (< 65 years old) and older (≥65 years old) adults using χ² tests or t-tests, accounting for the clustering of patients and encounters within chiropractors.

RESULTS

A total of 6781 chiropractor-adult patient encounters were recorded. Of these, 1067 encounters were for persons aged > 65 years (16%), from 897 unique older patients. The most common diagnosis within older adult encounters was a back problem (56%), followed by neck problems (10%). Soft tissue techniques were most frequently used for older patients (85 in every 100 encounters) and in 29 of every 100 encounters, chiropractors recommended exercise to older patients as a part of their treatment.

CONCLUSIONS

From 6781 chiropractor-adult patient encounters across two countries, one in seven adult chiropractic patients were > 65 years. Of these, nearly 60% presented with a back problem, with neck pain and lower limb problems the next most common presentation to chiropractors. Musculoskeletal conditions have a significant burden in terms of disability in older adults and are the most commonly treated conditions in chiropractic practice. Future research should explore the clinical course of back pain in older patients seeking chiropractic care and compare the provision of care to older adults across healthcare professions.

Back pain and heart failure in community-dwelling older adults: Findings from the Health ABC study

This study explored the association of back pain and heart failure (HF) with health outcomes among community-dwelling older adults. Older adults who completed a follow-up in the 11th year (2007-2008) of the Health, Aging, and Body Composition (Health ABC) study were included. The mean age was 83.4 ± 2.78 years. Back pain and heart failure were reported by 55.40% (n = 657) and 8.09 % (n = 96) of the total subjects (N = 1186), respectively. Regression analysis indicated that older adults with back pain reported worse depressive symptoms, fatigue, and physical performance and function compared with those without back pain (p < 0.05), and HF presence increased fatigue levels and decreased physical function (p < 0.05) among older adults with back pain. The high incidence and negative impact of back pain highlight the need to develop strategies for pain management among older adults with and without HF.

Distribution and prevalence of musculoskeletal pain co-occurring with persistent low back pain: a systematic review

BACKGROUND

Co-occurring musculoskeletal pain is common among people with persistent low back pain (LBP) and associated with more negative consequences than LBP alone. The distribution and prevalence of musculoskeletal pain co-occurring with persistent LBP has not been systematically described, which hence was the aim of this review.

METHODS

Literature searches were performed in MEDLINE, Embase, CINAHL and Scopus. We considered observational studies from clinical settings or based on cohorts of the general or working populations involving adults 18 years or older with persistent LBP (≥4 wks) and co-occurring musculoskeletal pain for eligibility. Study selection, data extraction and risk of bias assessment were carried out by independent reviewers. Results are presented according to study population, distribution and location(s) of co-occurring pain.

RESULTS

Nineteen studies out of 5744 unique records met the inclusion criteria. Studies were from high-income countries in Europe, USA and Japan. A total of 34,492 people with persistent LBP were included in our evidence synthesis. Methods for assessing and categorizing co-occurring pain varied considerably between studies, but based on the available data from observational studies, we identified three main categories of co-occurring pain - these were axial pain (18 to 58%), extremity pain (6 to 50%), and multi-site musculoskeletal pain (10 to 89%). Persistent LBP with co-occurring pain was reported more often by females than males, and co-occurring pain was reported more often in patients with more disability.

CONCLUSIONS

People with persistent LBP often report co-occurring neck pain, extremity pain or multi-site pain. Assessment of co-occurring pain alongside persistent LBP vary considerable between studies and there is a need for harmonisation of measurement methods to advance our understanding of how pain in different body regions occur alongside persistent LBP.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017068807 .

Pain as a predictor of frailty over time among older Mexican Americans

The objective of this study was to examine pain as a predictor of frailty over 18 years of follow-up among older Mexican Americans who were nonfrail at baseline. Data were from a prospective cohort study of 1545 community-dwelling Mexican Americans aged ≥67 years from the Hispanic Established Populations for the Epidemiological Study of the Elderly (1995/1996-2012/2013). Frailty was defined as meeting 2 or more of the following: unintentional weight loss of >10 pounds, weakness, self-reported exhaustion, and slowness. The independent predictor was self-reported pain. Covariates included age, sex, marital status, education, comorbid conditions, body mass index, Mini-Mental State Examination, depressive symptoms, and limitation in activities of daily livings. General equation estimation was performed to estimate the odds ratio of frailty as a function of pain. A total of 538 participants (34.8%) reported pain at baseline. The prevalence of frailty among those with pain ranged from 24.4% in wave 3 to 41% in wave 8. The odds ratio of becoming frail over time as a function of pain was 1.71; 95% confidence interval: 1.41 to 2.09 after controlling for all covariates. Older age, hip fracture, high depressive symptoms, and activities of daily living disability were also associated with higher odds of becoming frail over time. Female participants and those with higher levels of education and high Mini-Mental State Examination scores were less at risk. In conclusion, pain was a significantly predictor of frailty. Early assessment and better management of pain may prevent early onset of frailty in older Mexican Americans.

Web-information surrounding complementary and alternative medicine for low back pain: a cross-sectional survey and quality assessment

Background

Low back pain (LBP) is expected to globally affect up to 80% of individuals at some point during their lifetime. While conventional LBP therapies are effective, they may result in adverse side-effects. It is thus common for patients to seek information about complementary and alternative medicine (CAM) online to either supplement or even replace their conventional LBP care. The present study sought to assess the quality of web-based consumer health information available at the intersection of LBP and CAM.

Methods

We searched Google using six unique search terms across four English-speaking countries. Eligible websites contained consumer health information in the context of CAM for LBP. We used the DISCERN instrument, which consists of a standardized scoring system with a Likert scale from one to five across 16 questions, to conduct a quality assessment of websites.

Results

Across 480 websites identified, 32 were deemed eligible and assessed using the DISCERN instrument. The mean overall rating across all websites 3.47 (SD = 0.70); Summed DISCERN scores across all websites ranged from 25.5-68.0, with a mean of 53.25 (SD = 10.41); the mean overall rating across all websites 3.47 (SD = 0.70). Most websites reported the benefits of numerous CAM treatment options and provided relevant information for the target audience clearly, but did not adequately report the risks or adverse side-effects adequately.

Conclusion

Despite some high-quality resources identified, our findings highlight the varying quality of consumer health information available online at the intersection of LBP and CAM. Healthcare providers should be involved in the guidance of patients’ online information-seeking.

Pain assessment for chronic lower back pain: performance of the PAL-S and PAL-I patient-reported measures for symptoms and impacts

Objective: The Patient Assessment for Low Back Pain-Symptoms (PAL-S) and the Patient Assessment for Low Back Pain-Impacts (PAL-I) were developed to incorporate patient perspective of treatment benefit in chronic low back pain (cLBP) trials. This study documents psychometric measurement properties of the PAL-S and PAL-I.Methods: In this multicenter, observational study, eligible participants clinically diagnosed with cLBP provided sociodemographic information and completed PAL measures and other patient-reported outcome measures of pain and/or disability. Confirmatory factor analyses (CFA), construct validity, and reliability were assessed.Results: The 104 participants were 61% female, 89% white, and mean age of 55 years; mean cLBP duration was 11.4 (range 0-47) years. Using painDETECT scores, 36.5% reported small likelihood of neuropathic pain, 30.8% reported unclear likelihood, and 32.7% reported definite likelihood. Persistent pain with pain attacks was reported by 38.5% of participants. CFA confirmed single components with adequate fit indices. Cronbach's alpha was 0.83 (PAL-S) and 0.87 (PAL-I), indicating reliable scales. Intraclass correlation coefficients (test-retest reproducibility, n = 44) were 0.81 (PAL-S) and 0.85 (PAL-I). PAL-S score correlation was 0.49 with Roland-Morris Disability Questionnaire (RMDQ) and 0.77 with Neuropathic Pain Symptom Inventory (NPSI). PAL-I correlated at 0.73 with RMDQ and -0.60 with Medical Outcomes Study (MOS)-36 Bodily Pain. Both measures significantly differentiated between pain intensity levels (based on numeric response scale) and painDETECT groups.Conclusion: The PAL-S and PAL-I generated highly reliable scores with substantial evidence of construct validity. Routine use of these measures in treatment trials will enhance comparability of LBP-related symptom and impact results, including patient perspective of treatment benefit.

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults

Objective

To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions.

Methods

A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models.

Results

About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures.

Conclusions

New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.

Linking Persistent Pain and Frailty in Older Adults

OBJECTIVE

In older adults, the impact of persistent pain goes beyond simple discomfort, often contributing to worsening functional outcomes and ultimately frailty. Frailty is a geriatric syndrome that, like persistent pain, increases in prevalence with age and is characterized by a decreased ability to adapt to common stressors such as acute illness, thereby increasing risk for multiple adverse health outcomes. Evidence supports a relationship between persistent pain and both the incidence and progression of frailty, independent of health, social, and lifestyle confounders.

DESIGN AND SETTING

In this article, we synthesize recent evidence linking persistent pain and frailty in an effort to clarify the nature of the relationship between these two commonly occurring geriatric syndromes.

SETTING

We propose an integration of the frailty phenotype model by considering the impact of persistent pain on vulnerability toward external stressors, which can ultimately contribute to frailty in older adults.

RESULTS AND CONCLUSIONS

Incorporating persistent pain into the frailty construct can help us better understand frailty and ultimately improve care for patients with, as well as those at increased risk for, pain and frailty.

Trends in Prescription Analgesic Use Among Adults With Musculoskeletal Conditions in the United States, 1999-2016

IMPORTANCE

Monitoring trends in prescription analgesic use among adults with musculoskeletal conditions provides insight into how changing prescribing practices, guidelines, and policy measures may affect those who need pain management.

OBJECTIVE

To evaluate trends in prescription opioid use and nonopioid analgesic use among adults with functional limitations attributable to musculoskeletal conditions.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study uses data from the National Health and Nutrition Examination Study from 1999 to 2016. Data were analyzed from January to July 2019. The participants were adults aged 30 to 79 years who reported functional limitations due to back or neck problems and/or arthritis or rheumatism.

MAIN OUTCOMES AND MEASURES

Any use of a prescription opioid or exclusive use of a prescription nonopioid analgesic.

RESULTS

In this population of 7256 adults with 1 or more functional limitations attributable to a musculoskeletal condition (4226 women [59.9%]; 3508 [74.4%] non-Hispanic white individuals; median [interquartile range] age, 63 [53-70] years), opioid use and exclusive nonopioid analgesic use exhibited approximately reciprocal patterns of change from 1999 to 2016. Opioid use increased significantly (difference in prevalence for 2015-2016 vs 1999-2000, 7.2%; 95% CI, 1.3% to 13%; P for trend = .002), and exclusive use of nonopioid analgesics decreased significantly (difference in prevalence for 2015-2016 vs 1999-2000, -13%; 95% CI, -19% to -7.5%; P for trend < .001) during this period. The increase in any opioid use was driven by long-term rather than short-term use. A crossover in the prevalence of opioid use and exclusive use of nonopioid analgesics occurred between 2003 and 2006, after which opioid use was more prevalent. Between 2013 and 2016, decreases in opioid use were observed among men (difference in prevalence for 2015-2016 vs 2013-2014, -11%; 95% CI, -21% to 1.8%) and participants with less than a high school education (difference, -15%; 95% CI, -24% to -6.1%). During this same period, exclusive nonopioid analgesic use also decreased markedly across the population (difference, -5.3%; 95% CI, -9.1% to -1.5%).

CONCLUSIONS AND RELEVANCE

The substitution of opioids for nonopioid analgesics between 2003 and 2006 may have occurred as evidence emerged on the cardiovascular risks associated with nonopioid analgesics. Reductions in opioid use between 2013 and 2016 were most substantial among those with low socioeconomic status, who may encounter barriers in accessing alternatives. Despite those decreases, opioid use remained more prevalent in 2015 to 2016 than in 1999 to 2000, suggesting a potentially long tail for the opioid epidemic.

Prevalence of low back pain in the elderly population: a systematic review

The aim of this study was to estimate the prevalence of low-back pain (LBP) and to identify the level of functional disability in elderly individuals in different populations. From January 1985 to October 2018, a search was performed using the following databases: Embase, LILACS, SciELO, Scopus, Medline, and the Web of Science. The descriptors were low-back pain, back pain, lower-back pain, prevalence, and elderly in Portuguese and English. Two independent reviewers conducted a search for studies and evaluated their methodological quality. The search strategy returned 2186 titles, and 35 were included in this review. The studies evaluated 135,059 elderly individuals aged between 60 and 102 years, and the prevalence of LBP ranged from 21% to 75%. The levels of functional disability, as well as functional difficulties, activities of daily living, and physical capacity, were identified in 60% of the studies. This review indicated a high prevalence of LBP in elderly individuals and functional disability that affects factors important for independence. However, the studies used different methodologies, suggesting that more studies be conducted with scientific accuracy, methodological quality, and low risk of bias to contribute to the proposal of preventive actions for elderly populations.

Pain resilience moderates the influence of negative pain beliefs on movement-evoked pain in older adults

Negative pain beliefs are associated with adverse pain outcomes; however, less is known regarding how positive, adaptive factors influence pain and functioning. These relationships are especially important to examine in older adults with pain, given increased disability and functional limitations in this population. We investigated whether pain resilience moderated the relationships between negative pain beliefs (fear-avoidance, pain catastrophizing) and pain outcomes (functional performance, movement-evoked pain) in sixty older adults with low back pain. Higher pain resilience was associated with lower fear-avoidance (p < .05) and pain catastrophizing (p = .05). After controlling for demographic variables, higher fear-avoidance (p = .03) and catastrophizing (p = .03) were associated with greater movement-evoked pain in individuals with low pain resilience, but not among those high in resilience. No significant moderation effects were observed for functional performance. Resilience may attenuate the relationship between negative psychological processes and pain-related disability, highlighting the need for interventions that enhance pain resilience in older adults.

Epidural Fat and Its Association with Pain, Physical Function, and Disability Among Older Adults with Low Back Pain and Controls

Objective

To examine epidural fat and its relationship to pain, physical function, and disability among older adults with chronic low back pain, chronic low back pain plus leg pain, and controls.

Design

Cross-sectional, comparative study.

Setting

Standardized examinations were conducted in a research laboratory, and magnetic resonance images were obtained.

Subjects

A total of 93 adults age 60 to 85 years (24 with chronic back pain, 25 with chronic back pain plus leg pain, and 44 controls).

Methods

Reliability for assessment of epidural fat diameter, averaged across spinal levels, was established (intraclass correlation coefficient = 0.95). Linear regression was used to explore how epidural fat diameter related to self-reported (Short Form-36 Health Survey: physical component summary score) and performance-based (stair climb performance) measures of physical function among adults with chronic back pain with and without leg pain, as compared with controls, while controlling for age, sex, and body mass index. Associations between epidural fat and pain intensity and low back pain-related disability were also explored (P ≤ 0.050).

Results

Epidural fat helped explain self-reported function (P < 0.001); adults with axial low back pain (LBP) may have a relationship between epidural fat and self-report function that is different from controls (P = 0.015). Relationships between epidural fat and stair performance were significantly different from controls for those with LBP (P = 0.000) but not for those with LBP plus leg pain (P = 0.366). Relationships between epidural fat and pain intensity and/or disability were not found.

Conclusions

Increased epidural fat may help explain better function among older adults with chronic axial back pain, but not among those who also report leg pain.

Multisystem Resiliency as a Predictor of Physical and Psychological Functioning in Older Adults With Chronic Low Back Pain

Evidence supports the benefits of resilience among older adults with chronic pain. While numerous factors confer resilience, research has largely examined these measures in isolation, despite evidence of their synergistic effects. Conceptualizing resilience from a multisystem perspective may provide a deeper understanding of adaptive functioning in pain. Sixty adults (ages 60+ years) with chronic low back pain completed measures of physical function, pain intensity, disability, and a performance-based task assessing back-related physical functioning and movement-evoked pain (MEP). Depressive symptoms, quality of life, and general resilience were also evaluated. To examine multisystem resiliency, principal components analysis (PCA) was conducted to create composite domains for psychological (positive affect, hope, positive well-being, optimism), health (waist–hip ratio, body mass index, medical comorbidities), and social (emotional, instrumental, informational support) functioning measures, followed by cluster analysis to identify participant subgroups based upon composites. Results yielded four clusters: Cluster 1 (high levels of functioning across psychological, health, and social support domains); Cluster 2 (optimal health and low psychosocial functioning); Cluster 3 (high psychological function, moderate-to-high social support, and poorer health); and Cluster 4 (low levels of functioning across the three domains). Controlling for sociodemographic characteristics, individuals with a more resilient phenotype (Cluster 1) exhibited lower levels of disability, higher quality of life and psychological functioning, and greater functional performance when compared to those with a lower degree of personal resources (Cluster 4). No significant cluster differences emerged in self-reported pain intensity or MEP. These findings signify the presence of resiliency profiles based upon psychological, social, and health-related functioning. Further examination of the additive effects of multiple adaptive behaviors and resources may improve our understanding of resilience in the context of pain, informing novel interventions for older adults.

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.

Development of pain in older adults: a latent class analysis of biopsychosocial risk factors

Pain significantly restricts the quality of life and well-being of older adults. With our increasingly ageing population, it is important to examine whether differing classes of biopsychosocial risk factors can predict the development of pain in older adults. Latent class analysis provides a model-based approach to identifying underlying subgroups in a population, based on some measured characteristics. In this study, latent class analysis was used to identify biopsychosocial risk classes in people aged 50 years and older, from The Irish Longitudinal Study on Ageing, who reported not often being troubled by pain at wave 1 and completed the 2-year follow-up at wave 2 (n = 4458). Four classes were identified based on 11 potential risk factors at wave 1. These classes were characterised as "Low Risk," "Physical Health Risk," "Mental Health Risk," and "High Risk." The Low-Risk class accounted for over half the sample (51.2%), whereas the High-Risk class represented 7.8% of the sample. At follow-up (wave 2), 797 (17.9%) participants reported being troubled by pain. Associations between the biopsychosocial risk classes and developing pain were examined using logistic regression, adjusting for sociodemographic variables. The High-Risk class was more likely to develop pain compared with the Low-Risk class (adjusted OR = 3.16, 95% CI = 2.40-4.16). These results add to existing data in other populations supporting the role of a range of biopsychosocial risk factors that increase the risk of developing pain. These findings have important implications for the identification, and potential moderation, of these risk factors.

Association of Back Pain with All-Cause and Cause-Specific Mortality Among Older Women: a Cohort Study

BACKGROUND

The impact of back pain on disability in older women is well-understood, but the influence of back pain on mortality is unclear.

OBJECTIVE

To examine whether back pain was associated with all-cause and cause-specific mortality in older women and mediation of this association by disability.

DESIGN

Prospective cohort study.

SETTING

The Study of Osteoporotic Fractures.

PARTICIPANTS

Women aged 65 or older.

MEASUREMENT

Our primary outcome, time to death, was assessed using all-cause and cause-specific adjusted Cox models. We used a four-category back pain exposure (no back pain, non-persistent, infrequent persistent, or frequent persistent back pain) that combined back pain frequency and persistence across baseline (1986-1988) and first follow-up (1989-1990) interviews. Disability measures (limitations of instrumental activities of daily living [IADL], slow chair stand time, and slow walking speed) from 1991 were considered a priori potential mediators.

RESULTS

Of 8321 women (mean age 71.5, SD = 5.1), 4975 (56%) died over a median follow-up of 14.1 years. A higher proportion of women with frequent persistent back pain died (65.8%) than those with no back pain (53.5%). In the fully adjusted model, women with frequent persistent back pain had higher hazard of all-cause (hazard ratio [HR] = 1.24 [95% CI, 1.11-1.39]), cardiovascular (HR = 1.34 [CI, 1.12-1.62]), and cancer (HR = 1.33, [CI 1.03-1.71]) mortality. No association with mortality was observed for other back pain categories. In mediation analyses, IADL limitations explained 47% of the effect of persistent frequent back pain on all-cause mortality, slow chair stand time, and walking speed, explained 27% and 24% (all significant, p < 0.001), respectively.

LIMITATIONS

Only white women were included.

CONCLUSION

Frequent persistent back pain was associated with increased mortality in older women. Much of this association was mediated by disability.

Factors Influencing Longitudinal Stair Climb Performance from Midlife to Early Late Life: The Study of Women's Health Across the Nation Chicago and Michigan Sites

OBJECTIVES

To quantify the longitudinal change in stair climb performance (a measure indicative of both physical function and muscle power), determine whether physical activity is related to slower decline in performance, and to identify factors that modify the longitudinal change in performance among women from midlife to late life.

DESIGN

Longitudinal cohort study with up to 15 study visits.

SETTING

Two sites of the Study of Women's Health Across the Nation.

PARTICIPANTS

Black (n=411) and white (N=419) women followed from median age 47.0 (44.6-49.6) to 62.0 (55.8-65.3) years.

INTERVENTIONS

N/A.

MEASUREMENTS

Performance on a stair climb test (ascend/descend 4 steps, 3 cycles) was timed. Physical activity (PA) was assessed using the Kaiser Physical Activity Survey (KPAS; possible range 0-15 points). Sociodemographic and health factors were assessed via self-report. BMI was calculated with measured height and weight. Mixed-effects regression modeled longitudinal change in stair climb performance.

RESULTS

Average baseline stair climb time was 18.12 seconds (95% CI: 17.83-18.41), with 0.98% (95% CI: 0.84%-1.11%) annual slowing. In fully adjusted models, higher levels of PA were associated with faster stair climb times (2.09% faster per point higher, 95% CI: -2.87%- -1.30%), and black women had 5.22% (95% CI: 2.43%-8.01%) slower performance compared to white women. Smoking, financial strain, diabetes, osteoarthritis, fair/poor health, and stroke were associated with 3.36% (95% CI: 0.07%-6.65%), 7.56% (95% CI: 4.75%-10.37%), 8.40% (95% CI: 2.89%-13.92%), 8.46% (95% CI: 5.12%-11.79%), 9.16% (95% CI: 4.72%-13.60%), and 16.94% (95% CI: 5.37%-28.51%) slower performance, respectively. In separate models, higher BMI (per 1-unit), osteoarthritis, fair/poor health, and diabetes, were each associated with 0.06% (95% CI:0.04%-0.08%), 0.48% (95% CI:0.12%-0.84%), 0.81% (95% CI:0.35%-1.28%), and 0.84% (95% CI:0.22%-1.46%), additional slowing per year over time.

CONCLUSION

Significant declines in function were evident as women transitioned from midlife to early late life. Declines were amplified by indicators of poor health, emphasizing the importance of health in midlife for promoting healthy aging.

Interaction between low back pain and knee pain contributes to disability level in individuals with knee osteoarthritis: a cross-sectional study

OBJECTIVE

To test the hypothesis that the interaction between low back pain (LBP) and knee pain intensity contributes to the disability level of individuals with knee osteoarthritis (OA).

DESIGN

Community-dwelling participants with knee OA (Kellgren/Lawrence [K/L] grade ≥1) were enrolled. LBP and its severity were identified using questionnaires. Knee pain severity and disability level were evaluated using the Japanese Knee Osteoarthritis Measure (JKOM) subscale. Multiple linear regression analyses were performed to examine the effect of the LBP-knee pain interaction, an independent variable, on disability, a dependent variable.

RESULTS

A total of 260 participants (age, 48-88 years; 77.7% women) were included. Of them, 151 (58.1%) had LBP. The LBP-knee pain interaction was significantly associated with disability after the adjustment for covariates. A post-hoc subgroup analysis revealed that the relationship between knee pain intensity and disability level was higher in individuals with LBP (beta: 0.621 points; 95% confidence interval [CI]: 0.511 to 0.731 points) than in those without LBP (beta: 0.402 points; 95% CI: 0.316 to 0.487 points).

CONCLUSIONS

LBP interacts with knee pain intensity and contributes to disability level in individuals with knee OA. Coexisting LBP and knee pain had a stronger impact on disability level than LBP or knee pain alone. These findings highlight the potential deteriorative effects of the LBP-knee interaction on disability. Maximal treatment effects for disability might be achieved when LBP and knee pain are targeted simultaneously, rather than separately.

Do incident musculoskeletal complaints influence mortality? The Nord-Trøndelag Health study

Background

Musculoskeletal complaints (MSC) are common in the general population, causing a major disease burden to the individual and society. The association between MSC and mortality is still unclear. To our knowledge, no study has hitherto evaluated the association between MSC onset within the last month (incident MSC) on the one hand, and all-cause and cause-specific mortality on the other.

Methods

This prospective population-based cohort study was done using data from the second Nord-Trøndelag Health Study (HUNT2) linked with data from a comprehensive national registry of cause of death. A total of 25,931 participants at risk for incident MSC were included. Hazard ratios (HR) of mortality were estimated for participants with incident MSC using Cox regression based on a mean of 14.1 years of follow-up.

Results

Participants who reported incident MSC did not have an excess mortality compared to those with no MSC in the analyses of all-cause mortality (HR 0.99, 95% CI 0.89–1.10) and cause specific mortality. This was true also after adjustment for several potential confounding factors. No clear association between the number of MSC body sites and mortality was found.

Conclusion

Incident MSC were not associated with an increased mortality, neither for all-cause mortality, nor cause-specific mortality.

Effects of a Home-Based Telephone-Supported Physical Activity Program for Older Adult Veterans With Chronic Low Back Pain

BACKGROUND

Chronic low back pain (CLBP) is highly prevalent in older adults, leading to functional decline.

OBJECTIVE

The objective of this study was to evaluate physical activity (PA) only and PA plus cognitive-behavioral therapy for pain (CBT-P) among older adult veterans with CLBP.

DESIGN

This study was a pilot randomized trial comparing a 12-week telephone-supported PA-only intervention group (PA group) or PA plus CBT-P intervention group (PA + CBT-P group) and a wait-list control group (WL group).

SETTING

The study setting was the Durham Veterans Affairs Health Care System.

PARTICIPANTS

The study participants were 60 older adults with CLBP.

INTERVENTIONS

The PA intervention included stretching, strengthening, and aerobic activities; CBT-P covered activity pacing, relaxation techniques, and cognitive restructuring.

MEASUREMENTS

Feasibility measures included enrollment and completion metrics; acceptability was measured by completed phone calls. Primary outcomes included the Timed "Up & Go" Test and the PROMIS Health Assessment Questionnaire. Generalized linear mixed models were used to estimate changes within and between groups. Effect sizes were calculated with the Cohen d. Adverse effects were measured by self-report.

RESULTS

The mean participant age was 70.3 years; 53% were not white, and 93% were men. Eighty-three percent of participants completed the study, and the mean number of completed phone calls was 10 (of 13). Compared with the results for the WL group, small to medium treatment effects were found for the intervention groups in the Timed "Up & Go" Test (PA group: -2.94 [95% CI = -6.24 to 0.35], effect size = -0.28; PA + CBT-P group: -3.26 [95% CI = -6.69 to 0.18], effect size = -0.31) and the PROMIS Health Assessment Questionnaire (PA group: -6.11 [95% CI = -12.85 to 0.64], effect size = -0.64; PA + CBT-P group: -4.10 [95% CI = -11.69 to 3.48], effect size = -0.43). Small treatment effects favored PA over PA + CBT-P. No adverse effects were noted.

LIMITATIONS

This was a pilot study, and a larger study is needed to verify the results.

CONCLUSIONS

This pilot trial demonstrated that home-based telephone-supported PA interventions were feasible, acceptable, and safe for older adult veterans. The results provide support for a larger trial investigating these interventions.

Prevalence, associated factors, and limitations related to chronic back problems in adults and elderly in Brazil

The objective was to analyze the epidemiological characteristics of chronic back problems in Brazil and study the association between their prevalence and demographic and socioeconomic factors, lifestyle, and health conditions. The study used micro-data from the Brazilian National Health Survey (PNS), 2013. The epidemiological indicators were: prevalence, time with chronic back problems, life cycle (from young adults to the elderly), limitations in activities of daily living, and mean age at onset of symptoms, according to sex and age bracket. In order to analyze inequality in chronic back problems according to socioeconomic characteristics and risk factors, a multivariate logistic regression model was used, based on life cycle stages, with the presence of chronic back problems as the dependent variable and the following independent variables: sex, schooling, area of residence, race/color, self-rated health, types of chronic diseases, body mass index (BMI), and physical activity. Prevalence of chronic back problems in Brazil was 18.5%, and was higher in women than in men (21.1%; 95%CI: 20.2-21.9). Mean age at onset of chronic back problems was 35 years. There was an association between chronic back problems and lower schooling, poor self-rated health, and presence of the majority of the selected chronic diseases. Area of residence, BMI, age, and race/color were weakly associated or not associated with chronic back problems. Prevalence of chronic back problems stabilized at 50 years of age, but the severity of limitations increased at older ages. As in other countries, high prevalence and the impact on living conditions revealed the need for epidemiological studies on chronic back problems in Brazil. The results suggest that health promotion and the prevention of chronic back problems should be intensified, especially before 50 years of age, considering the on-going population aging in Brazil.

Lumbopelvic Pain and Threats to Walking Ability in Well-Functioning Older Adults: Findings from the Baltimore Longitudinal Study of Aging

OBJECTIVES

To examine the potential contribution of severity of lumbopelvic pain (LPP) in well-functioning older adults to poorer walking efficiency, lack of endurance, slower gait speed, and decline in these mobility parameters over 1 to 5 years.

DESIGN

Longitudinal analysis of Baltimore Longitudinal Study of Aging data.

SETTING

National Institute on Aging, Clinical Research Unit, Baltimore, Maryland.

PARTICIPANTS

Well-functioning men and women aged 60 to 89 (N=878).

MEASUREMENTS

An interviewer-administered questionnaire was used to ascertain reported presence and severity of back and hip pain in the preceding 12 months and reported walking ability, including ease of walking a mile. Certified examiners assessed usual gait speed, the energetic cost of walking (oxygen consumption, mL per kg/m), and time taken to walk 400 m as quickly as possible. Covariates included sex, age, age-squared, race, height, weight, exercise, and smoking.

RESULTS

Overall, 31.4% had mild LPP, and 15.7% had moderate to severe LPP. In adjusted analyses, reported walking ability (p<.001), endurance walk performance (p=.007), and energetic cost of walking (p=.049) were worse with increasing LPP severity. Usual gait speed did not vary according to LPP (p=.31). Longitudinally, over an average 2.3 years, persons with new or sustained LPP had worse follow-up level, greater mean decline, and higher likelihood of meaningful decline in reported walking ability than persons free of LPP or whose LPP resolved. Walking performance did not differ according to LPP follow-up status.

CONCLUSION

LPP was common in well-functioning older adults and was associated with greater energetic cost of walking and poorer perceived and observed walking endurance. The longitudinal effect of LPP is unclear, but worsening perception of walking ability and its contribution to future mobility loss warrants further attention.