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

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Presentation on theme: "Low Back Pain in the Older Adult Gregory E. Hicks, PT, PhD University of Delaware."— Presentation transcript:

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

8 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

9 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 Retirement Community Back Pain Study

10 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 Objectives

11 Participant Characteristics LBP status No painLBP onlyLBP + LPP-value for trend N=271N=140N=111 Age Mean (SD) 81.7 (5.36)81.0 (5.48)19.8 (6.27).061 % Female 63.171.065.5.305 % White 98.697.899.1.617 % College grad 42.548.238.7.406 % Married 50.247.955.9.438

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

13 LBP Status and Functional Limitations Odds Ratio (95% CI) Any LBP vs. No painLBP+LP vs. No pain Difficulty with… Lifting or carrying grocery bags 1.16 (0.93, 1.46)4.60 (2.51, 8.43) Climbing a flight of stairs 2.03 (1.29, 3.17)4.69 (2.31, 9.51) Bending, kneeling or stooping 1.68 (1.10, 2.57)3.68 (1.82, 7.42) Adjusted for age, sex, race, marital status, education, BMI and chronic conditions

14 LBP Status and Functional Limitations Odds Ratio (95% CI) Any LBP vs. No painLBP+LP vs. No pain Difficulty with… Walking several blocks 1.18 (0.95, 1.46)3.97 (2.19, 7.20) Walking one block1.00 (0.80, 1.25)3.79 (2.05, 6.99) Bathing and dressing 1.08 (0.83, 1.39)3.53 (1.54, 8.09) Adjusted for age, sex, race, marital status, education, BMI and chronic conditions

15 LBP Status and Functional Limitations Odds Ratio (95% CI) Any LBP vs. No painLBP+LP vs. No pain Fallen in past year1.10 (0.90, 1.34)2.05 (1.11, 3.78) Assistive device for walking 1.02 (0.82, 1.27)2.81 (1.45, 5.46) Fair/poor self- rated health 1.09 (0.87, 1.38)2.64 (1.34, 5.31) Social interference due to physical problems 1.08 (0.80, 1.46)8.94 (2.73, 29.26) Adjusted for age, sex, race, marital status, education, BMI and chronic conditions

16 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 Care-seeking and LBP

17 Characteristics of Care-Seekers Sought care for LBP? NoYesP-value Age Mean (SD) 81.0 (5.67)79.6 (5.88)>.05 % Female 64.274.7>.05 % College grad 45.242.9>.05 % Married 47.855.4>.05 % Osteoarthritis 31.169.7<.0001

18 Characteristics of Care-Seekers Sought care for LBP? NoYesP-value PCS Mean (SD) 44.3 (12.4)37.3 (13.2).0003 MCS Mean (SD) 50.1 (11.4)44.1 (13.4).0016 Avg. LBP Intensity Mean (SD) 3.9 (1.7)5.3 (1.9)<.0001 Consecutive wks of LBP Mean (SD) 10.6 (19.9)26.4 (23.6)<.0001

19 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 Summary

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 OnlyConsultationReferral 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

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

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 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

32 Management of the Patient in Stage I

33 Stabilization/Immobilization Category Do 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 No hypermobility with lumbar spring testing Age (<40 years old) FABQ – physical activity subscale (<9) Average straight leg raise (>91 0 ) Aberrant movement absentAberrant movement present Negative prone instability testPositive prone instability test Prediction of FailurePrediction of Success Immobilization: Key Examination Findings

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 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 Health, Aging and Body Composition Study

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

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

41 VariableParameter Estimate Standard Error Partial R 2 Intercept 2.585.590 Trunk Muscle Attenuation.006*.002.123 Thigh Muscle Attenuation-.002.003.024 Back Pain Severity-.088*.029.003 Covariates.369 Model R 2 =.519† Dependent Variable=Health ABC PPB

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

43 VariableParameter Estimate Standard Error Partial R 2 No/Mild Back Pain Intercept 2.500.667 Trunk Muscle Attenuation.005*.002.087 Thigh Muscle Attenuation -.001.003.025 Covariates.372 Model R 2 =.484‡ Dependent Variable=Health ABC PPB Moderate/Extreme Back Pain Intercept 2.3121.240 Trunk Muscle Attenuation.006†.004.178 Thigh Muscle Attenuation-.002.006.023 Covariates.336 Model R 2 =.537‡ Dependent Variable=Health ABC PPB

44 Point Estimate 95% CI Trunk Muscle Attenuation 1 st Quartile (Lowest Quality)4.50(1.55, 13.03) 2 nd Quartile3.10(1.29, 7.46) 3 rd Quartile1.61(.73, 3.58) 4 th Quartile (Best Quality)1.00------ 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 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 Conclusions

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

51 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

52 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)

53 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

54 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)

55 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

56 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)

57 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 well- explored yet.

58 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

59 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.

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