Low Back Pain in the
Older Adult
Gregory E. Hicks, PT, PhD
University of Delaware
Epidemiology of LBP
Among Older Adults
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.
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
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
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
Back Pain and Function
2.27
2.17
2.07
1.97
1.87
1.77
1.67
Year 1
No/Mild Back Pain
Year 4
Mod/Extreme Back Pain
Hicks et al, J Gerontol Med Sci, Nov 2005
Associations of back and leg pain with
health status and functional capacity of
older adults
Findings 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
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
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
Participant Characteristics
LBP status
Age
No pain
LBP only
N=271
N=140
LBP + LP P-value
for trend
N=111
81.7 (5.36) 81.0 (5.48) 19.8 (6.27)
.061
Mean (SD)
% Female
% College grad
63.1
98.6
42.5
71.0
97.8
48.2
65.5
99.1
38.7
.305
.617
.406
% Married
50.2
47.9
55.9
.438
% White
PCS and MCS Subscale Scores
by LBP status
Good Health 70
65
60
55
Norm
P<.0001
P<.0001
PCS
MCS
50
45
40
35
Poor Health 30
No pain LBP only LBP + leg pain
LBP Status and Functional Limitations
Odds Ratio (95% CI)
Any LBP vs. No pain
LBP+LP vs. No pain
Difficulty with…
Lifting or carrying 1.16 (0.93, 1.46)
grocery bags
Climbing a flight 2.03 (1.29, 3.17)
of stairs
Bending, kneeling 1.68 (1.10, 2.57)
or stooping
4.60 (2.51, 8.43)
4.69 (2.31, 9.51)
3.68 (1.82, 7.42)
Adjusted for age, sex, race, marital status, education, BMI and
chronic conditions
LBP Status and Functional Limitations
Odds Ratio (95% CI)
Any LBP vs. No pain
LBP+LP vs. No pain
Difficulty with…
Walking several
1.18 (0.95, 1.46)
blocks
Walking one block 1.00 (0.80, 1.25)
3.97 (2.19, 7.20)
Bathing and
dressing
3.53 (1.54, 8.09)
1.08 (0.83, 1.39)
3.79 (2.05, 6.99)
Adjusted for age, sex, race, marital status, education, BMI and
chronic conditions
LBP Status and Functional Limitations
Odds Ratio (95% CI)
Any LBP vs. No pain
LBP+LP vs. No pain
Fallen in past year 1.10 (0.90, 1.34)
2.05 (1.11, 3.78)
Assistive device
1.02 (0.82, 1.27)
for walking
Fair/poor self1.09 (0.87, 1.38)
rated health
Social interference 1.08 (0.80, 1.46)
due to physical
problems
2.81 (1.45, 5.46)
2.64 (1.34, 5.31)
8.94 (2.73, 29.26)
Adjusted for age, sex, race, marital status, education, BMI and
chronic conditions
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
Characteristics of Care-Seekers
Sought care for LBP?
No
Yes
81.0 (5.67)
79.6 (5.88)
>.05
% Female
64.2
74.7
>.05
% College grad
45.2
47.8
31.1
42.9
55.4
69.7
>.05
>.05
<.0001
Age
P-value
Mean (SD)
% Married
% Osteoarthritis
Characteristics of Care-Seekers
Sought care for LBP?
PCS
No
Yes
P-value
44.3 (12.4)
37.3 (13.2)
.0003
50.1 (11.4)
44.1 (13.4)
.0016
3.9 (1.7)
5.3 (1.9)
<.0001
10.6 (19.9)
26.4 (23.6)
<.0001
Mean (SD)
MCS
Mean (SD)
Avg. LBP Intensity
Mean (SD)
Consecutive wks
of LBP
Mean (SD)
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 careseeking suggests that clinicians who see older adults
should routinely:
– Ask targeted questions about LBP and leg pain
– Make appropriate referrals prn to prevent decline
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
Classification and Staging
of Older Patients with LBP
First-Level Classification
Physical Therapy Only
Stage 1
Stage 2
Stage 3
Consultation
Inflammatory Process
(Medical)
Psychological
Referral
Medical
Psychological
Surgical
First-Level Classification
Serious Pathology
• Sleep disturbances
• Bowel/Bladder Dysfunction
• Unexplained Weight Loss
• Recent Episodes of Fever Related to LBP
• Trauma
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
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
Second-Level Classification
Third-Level Classification
• Immobilization
• Mobilization
– Sacroiliac
Mobilization
– Lumbar
Mobilization
• Specific Exercise
– Extension Syndrome
– Flexion Syndrome*
– Lateral Shift
(able to centralize)
• Traction
Differential Diagnosis:
LBP vs. Hip Pain
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
Hip OA
(Altman et al, 1991)
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
Undiagnosed hip OA is one of the leading causes of failed
back surgery syndrome
Management of the Patient
in Stage I
Stabilization/Immobilization
Category
Do we need to address the core
muscles to reduce pain and improve
function in older adults with LBP?
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
Spinal Stabilizing System
The spinal stabilizing system consists of
three inter-related subsystems:
Neuromuscular
Control
Passive
Subsystem
Active
Subsystem
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
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
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
Back Pain & Trunk Muscle Composition
24
22
20
18
16
14
Baseline
No LBP
Mild LBP
Mod LBP
p-value for trend <.0001
Severe/Extreme LBP
Hicks et al, J Gerontol Med Sci, Jul 2005
Back Pain and Function
2.27
2.17
2.07
1.97
1.87
1.77
1.67
Year 1
No/Mild Back Pain
Year 4
Mod/Extreme Back Pain
Hicks et al, J Gerontol Med Sci, Nov 2005
Variable
Intercept
Parameter
Estimate
2.585
Standard
Error
.590
Partial
R2
Trunk Muscle Attenuation
.006*
.002
.123
Thigh Muscle Attenuation
-.002
.003
.024
Back Pain Severity
-.088*
.029
.003
Covariates
.369
Model R2=.519†
Dependent Variable=Health ABC PPB
Health ABC Physical Performance Battery
Year 4
No/Mild Back Pain
Mod/Extreme Back Pain
Muscle attenuation, HU, at Year 1
Variable
No/Mild Back Pain
Intercept
Trunk Muscle Attenuation
Thigh Muscle Attenuation
Covariates
Parameter
Estimate
Standard
Error
2.500
.667
.005*
-.001
.002
.003
Partial
R2
.087
.025
.372
Model R2=.484‡
Dependent Variable=Health ABC PPB
Moderate/Extreme Back Pain
Intercept
2.312
1.240
Trunk Muscle Attenuation
.006†
.004
.178
Thigh Muscle Attenuation
-.002
.006
.023
Covariates
.336
Model R2=.537‡
Dependent Variable=Health ABC PPB
Trunk Muscle Attenuation & Falls in
Elders with Significant LBP
Point
Estimate 95% CI
Trunk Muscle Attenuation
1st Quartile (Lowest Quality)
2nd Quartile
3rd Quartile
4th Quartile (Best Quality)
4.50
3.10
1.61
1.00
(1.55, 13.03)
(1.29, 7.46)
(.73, 3.58)
------
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
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
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?
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
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
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
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
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• Extension results in narrowing of the
dimensions of the central and lateral spinal
canals
• Axial loading also narrows the canals
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• Key Exam Findings
–
–
–
–
Age > 65 (+LR=2.5)
No pain when seated (+LR=6.6)
Symptoms improved when seated (+LR=3.1)
Improved walking tolerance with spinal flexion
(+LR=6.4)
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
Differential Diagnosis: Neurogenic vs.
Vascular Claudication
• Both conditions may present as cramping
pain, tightness and fatigue in LE’s during
walking and relieved by sitting
• Vascular claudication is typically secondary
to PAD
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
Differential Diagnosis: Neurogenic vs.
Vascular Claudication
• Bicycle Test (Dyck & Doyle, 1977)
– Neurogenic -- Pt would pedal further with
flexed spine than with extended spine
– Vascular --Pt would pedal equal distances
regardless of position of the spine
– Results were not sufficiently sensitive for this
test (Dong and Porter, 1989)
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
Differential Diagnosis: Neurogenic vs.
Vascular Claudication
• Ankle Brachial Index
– Supine
– Typical systolic measurement from arm
– Systolic measurement from leg
• Cuff around ankle
• Dorsalis Pedis or Posterior Tibial Arteries
– <.90 indicates Peripheral Arterial Disease
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
Two-Staged Treadmill Test
• Pt walks on level surface (10 min or
fatigue) followed by incline surface (10 min
or fatique) with a 10 min rest break in
between
– Earlier onset of symptoms on level vs. incline
(+LR=4.1 for neurogenic claudication)
– Longer recovery time after level vs. incline
(+LR=2.6 for neurogenic claudication)
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• Surgical intervention is common
– Fusion and Decompression Procedures
•
•
•
•
Surgical rates are on the rise for LSS
In 1994, nearly $1billion spent on LSS surgery
23% re-operation rate
Increased complication rates when surgical
interventions used on older adults
• Non-surgical treatment has not been wellexplored yet.
Lumbar Spinal Stenosis (LSS):
Flexion Syndrome Sub-Group
• Comparison between 2 PT treatments for LSS
(Whitman et al, Spine, 2006)
– Randomized to:
• Flexion, Sub-therapeutic ultrasound and Level walking
on treadmill
or
• Manual Therapy, Exercise and Body-Weight Supported
walking on treadmill
BWS Treadmill Ambulation
• De-weighted ambulation
on a treadmill is also an
option. (Fritz et al., Phys
Ther, 1997)
• Shown to reduce
compressive forces on
the body. (Flynn et al.,
Phys Ther, 1997)
• Progression is made by
decreasing the traction
force.