Low Back Pain in the Older Adult

1. Low Back Pain in the Older Adult Gregory E. Hicks, PT, PhD University of Delaware

2. Epidemiology of LBP Among Older Adults

3. Epidemiology • Low back pain (LBP) is the most frequently reported musculoskeletal problem and third most reported symptom of any kind in people over 75 (Bressler, 1999) • Evidence that older people experience more disabling LBP than younger people. • Between 1991 & 2002, Medicare data shows a 132% increase in LBP patients and a 387% increase in related costs for LBP (Weiner, 2006) • As the older population grows, it is important to pursue methods of delaying the natural history of the development of LBP.

4. LBP in Older Adults • Little research has been done in the area of LBP among the older population (>65yrs). • Reasons for lack of research interest in older adults with LBP? • Younger, working population • Less serious than other conditions/diseases • Societal attitudes

5. Epidemiology • Prevalence of LBP is uncertain in 65yo+ • 6.8% to 49% • Factors influencing prevalence reports • cognitive impairment, decreased pain perception, co-morbidities, resignation to perceived effects of aging, depression

6. What do we know so far? • Back Pain is associated with impaired function (ADL’s and mobility) • SOF (women) • Iowa 65+ Rural Health Study • WHAS (women) • Framingham • Health ABC *primarily measure self-reported function • Very little research done in the areas of underlying mechanisms or interventions in this age group

7. Back Pain and Function Health ABC Physical Performance Battery Year 4 Hicks et al, J Gerontol Med Sci, Nov 2005

8. Associations of back and leg pain with health status and functional capacity of older adultsFindings from the Retirement Community Back Pain Study Gregory E. Hicks, PhD, PT University of Delaware, Department of Physical Therapy Jean M. Gaines, RN, PhD The Erickson Foundation, Geriatric Medicine and Gerontology Eleanor M. Simonsick, PhD National Institute on Aging, Clinical Research Branch

9. Retirement Community Back Pain Study • Population-based survey study • 522 men (32%) and women • Aged 60 and above • Independently living resident in one of four CCRCs in MD and Northern VA

10. Objectives • To examine cross-sectional associations between back pain status (LBP alone or LBP with leg pain) and general health status, as well as functional capacity, in older adults living in a continuing care retirement community (CCRC) setting • To examine care-seeking behaviors related to back pain status in this population with high access to health care

11. Participant Characteristics

12. PCS and MCS Subscale Scores by LBP status Good Health P<.0001 P<.0001 Norm Poor Health

13. LBP Status and Functional Limitations Adjusted for age, sex, race, marital status, education, BMI and chronic conditions

14. LBP Status and Functional Limitations Adjusted for age, sex, race, marital status, education, BMI and chronic conditions

15. LBP Status and Functional Limitations Adjusted for age, sex, race, marital status, education, BMI and chronic conditions

16. Care-seeking and LBP • Less than half (45.2%) with LBP sought care • LBP only: 30% sought care • LBP + leg pain: 65% sought care • All sought care with a physician, but no other healthcare practitioners (i.e. PT, DC, CMT) • Only 37.7% took prescription meds for LBP

17. Characteristics of Care-Seekers

18. Characteristics of Care-Seekers

19. Summary • Two mainstays in conservative management of LBP are active rehabilitation and medication use • Interestingly, no one received PT services and <40% were prescribed medicine • Why do so few older adults seek care? • The combination of high prevalence and low care-seeking suggests that clinicians who see older adults should routinely: • Ask targeted questions about LBP and leg pain • Make appropriate referrals prn to prevent decline

20. Epidemiology • Depression and Back Pain in the Elderly • Depressive symptoms are common in older adults • Depressive symptoms and LBP are strongly associated in cross-sectional studies • Chronic pain can increase risk for depressive symptoms • Depressive symptoms are a strong, independent risk factor for onset of disabling back pain 1 year later (Reid, 2003) • Disabling LBP increases odds of depressive symptoms 2 years later (Meyer, 2007) • Relationship may be bi-directional

21. Classification and Staging of Older Patients with LBP

22. First-Level Classification Physical Therapy Only Consultation Referral Stage 1 Stage 2 Stage 3 Inflammatory Process (Medical) Psychological Medical Psychological Surgical

23. First-Level Classification Serious Pathology • Sleep disturbances • Bowel/Bladder Dysfunction • Unexplained Weight Loss • Recent Episodes of Fever Related to LBP • Trauma

24. First-Level Classification Serious Pathology • Abdominal Aortic Aneurysm (AAA) • Ballooning of the aorta • Risk factors- HTN and atherosclerosis • Most often seen in older, Caucasian men • Medical emergency when rupture occurs

26. First-Level Classification Abdominal Aortic Aneurysm (AAA) • Symptoms • Back pain—severe, sudden, persistent • Pulsating sensation in abdomen • Pain in abdomen • Nausea and vomiting • Light-headedness and fainting with upright posture • Signs • Bruit on auscultation “Whooshing sound” • Pulsatile mass sensitive to palpation around umbilicus • Rapid Pulse

27. Second-Level Classification

28. Immobilization Mobilization Sacroiliac Mobilization Lumbar Mobilization Specific Exercise Extension Syndrome Flexion Syndrome* Lateral Shift (able to centralize) Traction Third-Level Classification

29. Differential Diagnosis: LBP vs. Hip Pain

30. LBP vs. Hip Pain • Source = Lumbar spine • Provocation and amelioration of symptoms with spinal movement • Source = Hip • Hip Osteoarthritis (OA) • Hip fracture • Trochanteric bursitis Ben-Galim et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine 2007

31. Presence of all 5 findings Hip Pain Hip IR > 15 degrees Pain with Hip IR Morning Stiffness < 60 minutes >50 years of age Presence of all 3 findings Hip Pain Hip IR < 15 degrees Hip Flexion < 115 degrees Hip OA(Altman et al, 1991) Undiagnosed hip OA is one of the leading causes of failed back surgery syndrome

32. Management of the Patient in Stage I

33. Stabilization/Immobilization CategoryDo we need to address the core muscles to reduce pain and improve function in older adults with LBP?

34. Kirkaldy-Willis Model of LBP Dysfunction Degenerative changes begin Instability Abnormal movement due to degenerative changes Stabilization Severe degenerative changes Development of osteophytes Motion limitations

35. Spinal Stabilizing System The spinal stabilizing system consists of three inter-related subsystems: Neuromuscular Control Passive Subsystem Active Subsystem

36. Immobilization: Key Examination Findings Prediction of Success Prediction of Failure Positive prone instability test Negative prone instability test Aberrant movement present Aberrant movement absent Average straight leg raise (>910) FABQ – physical activity subscale (<9) Age (<40 years old) No hypermobility with lumbar spring testing

37. Active Subsystem:Aging Factors • Decreased muscle strength and mass associated with aging (Sarcopenia) • May be due to a decrease in number of muscle fibers, size of individual fibers or both • Type II (fast-twitch) fiber atrophy associated with aging • Results in slower muscle contractile properties • Can be reversed with training • Decreased muscle attenuation (increased intramuscular fat infiltration) is associated with aging muscle

38. Health, Aging and Body Composition Study • Longitudinal cohort study • 3075 black (42%) and white, men (48%) and women • Aged 70-79 years between 4/97 – 6/98 • Community-resident in Memphis or Pittsburgh • Well-functioning • no reported difficulty walking ¼ mile, up 10 steps, • or performing basic ADL • no need for a walking aid or proxy respondent • Present analysis—Pittsburgh site only • 1527 black (44%) and white, men (48%) and women • CT scans of paraspinous muscles only done in Pittsburgh

39. Back Pain & Trunk Muscle Composition Trunk Muscle Attenuation (HU) p-value for trend <.0001 Hicks et al, J Gerontol Med Sci, Jul 2005

40. Back Pain and Function Health ABC Physical Performance Battery Year 4 Hicks et al, J Gerontol Med Sci, Nov 2005

42. No/Mild Back Pain Health ABC Physical Performance Battery Year 4 Mod/Extreme Back Pain Muscle attenuation, HU, at Year 1

44. Trunk Muscle Attenuation & Falls in Elders with Significant LBP Model was adjusted for age, sex, race, BMI, disease status, thigh muscle composition, benzodiazepine use and year 1 functional performance score. Hicks et al, Unpublished preliminary data

45. Conclusions • Addressing trunk muscle composition/ core muscle integrity may be an important, yet overlooked, approach to manage symptoms, maintain functional mobility and potentially reduce balance impairments and falls in older adults with a history of significant back pain

46. Mobilization Sub-Group:Aging Factors • Facet joint degeneration (OA) is associated with the aging spine • Dessication of the disc occurs with time • Changes in the disc height also affect amount of loading on the facet joints and can lead to approximation of spinous processes • Which position is more likely to irritate facet joints--flexion or extension? • What types of manipulation techniques to avoid?

47. Mobilization Sub-Group:Aging Factors • Consider use of muscle energy techniques • Must consider entire patient history before undertaking manipulation or mobilization • Any factors that would suggest manipulation/ mobilization as unsafe or questionable • osteoporosis, infection, fracture, spondylolysis/listhesis, CA, prolonged steroid use, severe degenerative changes • If any doubt, find another way to achieve the goal of increasing mobility

48. Specific Exercise:Key Examination Findings • Extension Principle • symptoms centralize with lumbar extension • symptoms peripheralize with lumbar flexion • Treatment • Extension exercises • Avoid flexion activities (bracing) • Not typically seen in older adult

49. Specific Exercise:Key Examination Findings • Flexion Syndrome • symptoms centralize with lumbar flexion • symptoms peripheralize with lumbar extension • Treatment • Flexion exercises • Avoid extension activities (bracing) • *Typically seen in older adult

50. Lumbar Spinal Stenosis (LSS):Flexion Syndrome Sub-Group • LSS = narrowing of the spinal canal, nerve root canal, and/or intervertebral foramina • Usually acquired due to degenerative changes • facet joint arthrosis, ligamentum flavum thickening, posterior bulging of discs, spondylolisthesis • Leg pain reported in 90% of cases • Neurologic changes in 50% of cases