1813 ‘ =| [i a SPINE Volume 24, Number 17, pp 1813-1819 Lippicon Wiliams 8 Wilkins, Ie © The Prevalence of Low Back Pain in the Elderly A Systematic Review of the Literature Hartley B. Bressler, DC, MD, CCFP,"1+§ Warren J. Keyes, BSc{Hon), DC Paula A. Rochon, MPH, MD, FRCPC,"qi# and Elizabeth Badley, PhD* ** ‘Study Design. The prevalence of low back pain in the ‘older population (= 65 years) was reviewed in an analysis, Of the literature from 1966 to the present. Objective. To determine the prevalence of low back pain in the geriatric population. ‘Summary of Background Data. Back pain is one of the most frequentiy reported conditions affecting the adult population. However, the prevalence of low back pain in the older age population is not accurately known. ‘Methods. A methodologic search of five computerized bibliographic databases was performed to identity cita tions on the prevalence of low back pain in the elderly Data were summarized, and prevalence studies were crit- ically appraised in detail for their qual Results. There is wide variability in the reported prev: alence of back pain. Many factors have been proposed to fexplain these findings including sample source, study design, definitions of back pain, and use of patientre- ported data, Comorbidity among older patients also con- tributes to the variability in the reporting of prevalence of back pain. Conclusion. There is an under-representation of the ‘older population in the back pain literature. The data in the current study suggest that the prevalence of low back pain in this population is not known with certainty and is ‘ot comparable with that in the younger population. The ‘authors stress the need for future studies to improve the reporting of age information to make prevalence studies more informative and applicable. [Key words: elderly, 98 ries, low back pain, epidemiology, prevalencel Spine 1999;24:1813-1819 Back pain is one of the most frequently reported chronic health problems affecting the adult popula tion.!° However, the prevalence of back pain among the elderly is not accurately known. People aged 65 years and older are the fastest growing segment of the Cana dian population. In 1991, seniors constituted 12% of the population of Canada (3.5/29 million people). In the province of Ontario, the number of people aged 65 and older is expected to increase from approximately 1.2 mil: lion in 1991 to 1.9 million in 2011.™* This trend is echoed fa the United States and the United King. From the “University of Toronto, Toronco, the {Department of Fam and Community Medicine, Toronto, ¢Mount Sinai Hospital, Toronte Ajax Pickering General Hospital, Ajax, [Canadian Memorial Chico Dractie College, Research Division, Toronto, the {Kunin-Lunenfeld Applied Research Unit, Baycrest Centre for Geriatric Care, Toronto, ‘Department of Public Health Sciences, Toronto, and the “*Toronto Hospital Research Institue, Toronto, Ontario, Canada. Acknowledgment date; une 18, 1998 Fase revision date: September 17, 1998, Acceptance dae: November 3, 1998 Device status category: Increasing age has been associated with an increase in musculoskeletal symptoms. A U. S. national survey of physician visits among patients aged 75 and older re vealed that back pain is the third most frequently re ported symptom in general and the most commonly re- ported musculoskeletal symptom,’* In another study, 17.3% of total back problem visits occurred in the 65 years and older age group." An epidemiologic report by the Institute for Clinical Evaluative Sciences in On- tario, Canada," ranked back problems as the third lead ing cause of chronic health problems in the > 65-year- old age category for women and the fourth leading cause of such problems for men in the same age category. As the cost of caring for an aging population continues to mount, so does the need to clearly understand the impact of back pain on the health of the elderly. Whether back pain in the elderly is an identifiable health problem depends on at least two factors: its abso- lute prevalence and its impact on the well-being of the aging population. The intent of this study was to deter- ‘mine the prevalence of low back pain associated with ag ing, Prevalence data provide information on the magni tude of a problem and the potential demand on resources necessary to manage it,! thus demonstrating the burden ‘of such a problem to the populations concerned. The authors of the current study conducted a systematic re~ view of the literature on the prevalence of back pain in seniors (65 years of age and over). m Methods [A methodologic search of five computerized bibliographic da- tabases (MEDLINE [Index Medicus], EMBASE [Excerpta Medica - Gerontology & Rehabilitation), CINAHL [Cuomula tive Index of Nursing and Allied Health Literature], AGE LINE, and MANTIS (chiropractic, formerly ROLARS}) was performed to identify citations from 1966 to the present using the following search strategy. Data bases with later starting dates were searched from their inception. Search ing of these five data bases allowed for retrieval of citations from medical practices in North America and Europe and from known as CHI- the literature of manual medicine, chiropractic, osteopathic, physiotherapy, and nursing professions. Key words used in the fearch were low back pain, back pain, elderly, geriatrics, and aged, These terms were selected in cooperation with expert Iibratians (Baycrest Centre for Geriatric Care, Institute for ‘Work and Health, and the Canadian Memorial Chiropractic College, Toronto, Ontario} with experience in searching data bases for computerized health literature. In addition, unpub- lished and nonEnglish literature was searched. Content experts ‘epidemiologists, chiropractors, rheumatologists, general in1814 Spine + Volume 24 + Number 17 + 1999 Table 1. Sample Selection” 1st Round Relevancy ‘2nd Round Relevangy Database wirst Iby tiles & abstracts) (review of articles MEDLINE Index Medicus Ty 1" 3 cInHAL Cumulative Index of Nursing and Aled Heath Literature « % 1 AGELINE B 3 ° EMBASE Excerpta Medica-Gerontology Excerpta Medica-Rehabiitation n 2 0 ans Chiropractic database, formerly known as CHIROLARS. 8 " Content Experts 0 10 Manual Retrieval 132 n Total 54 152 ited tow Back pam and eldariy or S68 yor ternists, and geriatricians) provided citations for additional po- tentially relevant studies. Manual searching was performed on, Citations referenced in articles retrieved by the above method. ology. The search strategy identified 534 citations (Tables 1 and 2) The only studies selected were of individuals aged 65 years and older with back pain of any type and duration, localized to the lumbar spine. Articles were selected for relevaney in two rounds. Firs-round relevancy criteria excluded studies accord: ing to titles and abstracts, Second-round relevancy criteria in. volved a systematic review of reports selected in the first round. Excluded were studies involving those aged 64 and younger, ‘occupational injuries, back pain secondary to pathology, te cent trauma (e. g., fractures), clinieal trials, specific causes of back pain (e. g., osteoporosis, scoliosis, herniated dises), mus. cculoskeletal disability o¢ impairment ratings, diagnosis, asess- ‘ment, specific management strategies, and population studies, that intentionally under-sampled the = 65-year-old age group." other related musculoskeletal disorders also were excluded, such as “neck and back pain,” “hip and back pain,” and “musculoskeletal disorders.” !*- ‘These groupings of ana omic regions make it impossible to disentangle the relevant ** Several studies that grouped low back pain with Table 2. Process for Selection of Articles in Sample* No. of Articles Description Remaning Abstracts identied and catalogued su Prevalence of back pain and eideriy 152 Papers obtained and reviewed Exclusions (nonprevalence studies) Physiologic Studies (.e, aging spine) a Papers on specific diagnosis of LBP 19 Papers focusing in LBP treatment 2 pinion papers 2 Miscellaneous 3 Ailes available for collection and systematic review 2 prevalence rate for back pain and consequently led to exclusion from the current study Several studies of individuals ranging in age from 18 t0 91 years did not stratify to the 65+ age group when calculating the prevalence of back pain.'!427 Instead, the rota lifetime prevalence statistic for back pain is reported. It was not post ble to extract the prevalence of back pain in the elderly from their reported data, and those studies were eliminated. The final selection criteria yielded 12 articles pertaining to the pret- alence of back pain in the elderly (Tables 1 and 2 m Results ‘Stidy Design The study design of the 12 articles meeting the inclusion criteria involved 10 cross-sectional and 2 cohort sam ples. Of the 10 cross-sectional studies, 6 were question= naires (postal or telephone), 1 was questionnaire and interview, 1 was an interview plus examination, and 2 were interviews only. Of the 2 cohort studies, 1 was an interview with physical examination, and 1 was a fle audit (Table 3). Site In total, nine studies community, medical practice rmpled individuals in che general $8°-202830344754 two were derived from 2° and one involved a long-term cate facility.'* The reported prevalence of back pain among, the elderly within the community ranged from 12.8% f0 49%. Within the medical practice setting, the reported prevalence ranged from 23.6% to 51%. The long-ter care study reported a prevalence of 40% (Table 4). Prevalence According to Age and Type of Study Bight studies restricted their sample to individuals ovet age 64 exclusively.*?!8252590§454 OF these, only t¥0 hhad low back pain as a central focus.?™* Laysky-Shula et al’* investigated 671 of 3097 individuals reporting low back pain (21.7%) in the 1-year period before the lowa 65+ Regional Health Survey. In this sample, 40% had low back pain at the time of the survey. Isaessom Ier eee ee ee ee LBP in the Elderly: Literature Review + Bressler ct al_1815 Table 3. Prevalence and Lifetime Incidence of Low Back Pain (LBP) in the Elderly as Determined by ww of the Literature Population Age or Provence of BP Base (sample ‘ge in People 68 suey stuiy Design source) No, >64/Taa (%} Range (yr) LBP Defniton Years Trond Bergsm et a! Cross-sectonalintevew Community s73973(100%) 78 None 29% prevalonee la is ‘and examination oe Fava agsvem etal Cohorineriew and Community ——‘1S24824(100%) 70,78,79 None 58% prevalence Wa ‘iP ‘examination Mars Farm Lovsty.ShulanCross-sectionaVquestn- Community 3087/2097 (10%) 65+ ———Midimoder- 71% prevalence iets* naire atalsevere 184% (sr Fns% ferllet al Cohorinteriew + file Longsterm care $2/92((00%) 884." 59 None 40% prevalence wa (90) audit of nating home Mive Ena Mobiy eal Cross-sectionanterview Community 987097 (100%) 65+ None 283% prevonce nla ins M2 Fs09% March, Lat al Coss-sctinaVqueston- Community TS2I827(100%) 65-85 None 20% prevalence wa (isap" naire Ma Fe Isacsson otal Cross-sectionalqueston- Community Sons (100%) 68 Dail LBP past 68% prevalence n'a tis" nae + itervew Tmo Mn Fra Woo etal _CrosssectionaVauestion- Community 2002/2092 (100%) 70 “Sos of MSK Prevalence a M= T tise naire pain M6 Fo past year F 16% s+ ys MF Sudey EM, _Cross-sectonaVauestin- Community SHESIOZGBK)—6-85+ None 1as-158% nla Temart A naire prevalence (iss mina Fe Anderson tal Cross-sectionaliquestion- Primary heath sioeos 25-74 Chronic pain 23% prevalence | is naire care dstict (7.2%) (o3mo)" 238% Fe Stembach, RA Coss-sectinalintrview Community nt B+ Back pain 48% prevalence ‘rs (143) over past Mia voor Fa Von Kor et al Cros-sectonalquestin- Urban group Tin 18-75 ——LBP past mo Prevalencenja (ae nae health coop (18%) aos brat en Fst roles (M40) senna. = decreasing, ne = not eplzale, M= mali F= Yona et al? in 1982-1983, studied “backache” in all 68. year-old men born in even months of the year 1914 in Malm®, Sweden; 6.8% reported daily backache in the last 12 months, The remaining six reports described the prevalence of pain and musculoskeletal disorders, referring to back pain as one distinct manifestation of pain; prevalence for back pain ranged from 6.0° 47%49:1830045% Four reports were population studies that selected some seniors as a result of random sam pling, similarly not limiting their investigation to back pain; prevalence varied from 14.1% to 51%." "7° Ta Table 4. Population Source and Number of Studies for Prevalence of Low Back Pain Sample Source No. of Studies Prevalence Range (4) Community (rural urban) 9 128-48 Primary practice (cic, HMO} 2 B51 Long-term care [oursing home) 1 0 ble 3 lists the absolute number and percentage of indi- viduals in the senior age group and the prevalence of back pain (Table 3) Advanced Age Few studies included large numbers of individuals who were “very old,” i. ., 85 years or older. A subsample of the 12 articles reported the prevalence for very old indi. viduals ranging in age from 80 years to well over 90 years,*!828"4""4 The prevalence of back pain in this sub- group ranges from 6.0% to 40%. This range is not en. tirely dissimilar to that reported for the 65-80-year-old age group, bur the prevalence figures for the very old are slightly lower, demonstrating a trend of progressively decreasing prevalence of reported back pain with in- creasing age. This trend was found in all but two re ported studies. Ferrell etal’ cites a prevalence of 40% in the nursing home environment (higher than expected from every other study), whereas Woo et al cited minoe 1816 Spine + Volume 24 + Number 17 + 1999 Table 5. Prevalence of Low Back Pain in the Very Old” Study ge (yr Prevalence (%) Ferrel eta a Badley and Tennant 1581 Woo et al 37 M6 F ba F Mobiy t al ast Lavsky-Shulan eta 2) 80-88 a) 151 M217 F b) 85+ bei M142 F + No reported breakdown by gender M= male: P= female, imal differences among women in the older age catego- ries (Table 5) Gender With respect to gender differences, elderly women con- sistently reported a higher prevalence of low back pain than men (Table 3). Even among the very old (over 80. years of age), the prevalence of low back pain was greater or equal to that found among men (Table 5). This trend, was seen in all but one report. Definition of Back Pain There has been no consensus regarding the definition of back pain in the scientific literature. Commonly used diagnostic terms for nonpathologic types of low back pain have not been validated. The lack of consistency has, led to difficulty in interpreting studies dealing with the issue of back pain. Of the 12 reports identified, a wide range of terms were used to refer to back pain, Few clearly indicated accurate terms of reference for the area under study. Terms describing the precise location of pain are lacking in the studies reviewed. For example, only 1 study reported using a standardized anatomic pain diagram.? Most studies attempted to characterize back pain using various descriptive terms. In 5 of the 12 studies, the sample was selected based on the time frame during which back pain was experienced (Table 3).2°°775 In five studies, the authors inquired asto the severity of back pain.>"*25"- In several stud- ies, respondents were asked about the intermittency of their symptom. Time, severity, and intermittency are parametric descriptors of back pain, however, rather than definitions of back pain. The varying ways in which data were obtained and recorded in each study have lead to difficulty in the interpretation of data. The remaining 6 studies provided no back pain descriptors (Ta ble 3). 8218304 iscussion One of the major challenges with interpreting the back pain literature is the lack of standardized terminology The terms “back pain” and “low back pain” were both used in the current authors’ sample. Further, the defini tion of low back pain has been inconsistently used in the literature.*2960 Jack of a gold standard for the diagnosis of low back This problem may exist because of a pain. The validity and reliability of many diagnostic or thopedic resting maneuvers for back pain, such as the straight leg raise, have not been adequately estab- lished.'”** To complicate matters, there are no validity studies of either clinical or self report of location of back pain in the older adult. When dealing with patient reported data, itis important to consider that individual, often do not distinguish between primary and secondaty (c. g., pathologic causation vs. mechanical) back pain, Furthermore, study populations often include patients with multiple symptom complexes (e.g., back pain with and without leg pain, sciatica) and with inherently dif ferent prognoses (acute and chronic pain, traumatic and nontraumatic back pain). In this study, the authors used the generic term “back pain.” Back pain has been de scribed as “an illness in search of a disease.”¥ There iy an under-representation of the elderly in the back pain literature. Despite an extensive review ofthe literature, only 12 studies fit the inclusion criteria ofthis review. The older age group, which accounts for anit creasingly larger proportion of the population, is gener= ally omitted from the literature on back pain, Very few studies have focused on the subgroup of those individ als over the age of 65 years. Von Korff et al sampled members of a Health Maintenance Organization ranging from 18to olds their sample included 77 persons (7.5%) aged 65 and older. Sternbach*” selected 179 (16%) individuals over age 64 from theic random, stra ‘fied, unclustered sample. Similarly, Andersson sampled 179 (17.7%) individuals over age 64." Because these samples represent random regional sampling rather than stratified sampling, the number of individuals in the older age group is quite low, especially among the very old, largely because of survivorship issues and insti tionalization. Several reasons have been proposed for this under-representation. To a large extent, back pat research is focused on the young working population and is being driven by the socioeconomic demands ofthe workplace." 651° Back pain claims to Workers’ Com pensation account for a very large percentage of overall claims, at great cost to society.” Consequently, the need to accurately, effectively, and cost-effectively manage low back pain in the younger working population is im» plicit and given high priority, Nevertheless, itis clear that the study of back pain in the elderly has been overlooked in the geriatric community, perhaps relegated to second class status behind life-threatening health conditions This is unfortunate, given the frequency with which iti reported, and its potential for decreasing the functional ability of members of the community The data in the current report suggest that the prev lence of back pain in the elderly is not known with ce tainty but likely ranges between 13% and 49%, There are a number of patient factors contributing to vaviabil ity in the reporting of prevalence of back pain in older people (Table 6). Cognitive problems such as comptt hension and memory may influence the reporting of back pain. Furthermore, elderly patients’ recall of episodes J hhee eee ee ae Table 6. Patient Factors Contributing to Variability in the Reporting of Prevalence of Back Pain in Older People Cagnve impairment Depression Detreated pain perception Atered pain perception (decreased perception or increased tolerance) Comorbidity (respondent focus on other healt issues) Proxy reporting by other hausehold/nonhousehold members Language (foreign language speaker, literacy) Retsal to participate in study Decreased physical activity (immobility) ‘ude (does not wish to burden caregivers, ote) Resignation to perceived eects of aging us studies, respondents were asked to report whether they had experienced an episode of low back pain in the over extended time periods may be unreliable. In previ- . past 3 months, past 6 months,°” and the past | year.2334474 This type of question has the potential to cause errors in the reliability of an individual's recall of his or her history of back pain. Faulty reporting may have a significant influence on prevalence statistics, lead- | ingto either under- or overestimation. Zetterberg et al” comment that a certain degree of neglect or forgetful behavior in the elderly can contribute to the low preva- {lence results. Papageourgiow et al” point out that indi viduals who do not respond to surveys, some of whom having forgotten past back pain episodes, may introduce nonresponse bias, serving to increase the overall preva- lence; that argument assumes that most respondents an: {| _swer the survey because they have back pain. Recollec | tion of previous episodes of back pain is not reliable for establishing incidence and prevalence rates. Epidemio {logic research tends to rely on patient-reported data, be- cause it is difficult to validate diagnosis and outcome ‘measures in back pain. Although this review purposely disregarded studies dealing with pathologic causes of pain, individual respondents are often not able to make that distinction, Consequently, the answers to “do you have back pain?” likely contain a multitude of confound- cersthat can alter the prevalence rates. Weiner et al"' have criticized the use of patient-reported data, recommend ing pain behavior observation instead. Depression may lead to various biases, which in turn may lead to either increased or decreased reported prev- alence. Decreased pain perception or increased pain tol- crance as the result of the aging process can alter low back pain prevalence rate. Perhaps overlooked in other studies involving patient-reported data is the effect of attitudinal problems in the reporting of pain by elderly Patients; patients expect to have pain as part the agit process and may not report it or ask for help. Language “| canbe another factor influencing the responses of seniors t] being surveyed. An inaccurate response rate may occur I} Ontthe grounds of various literacy problems Decreased *] physical activity leading to physical deconditioning and t_avoidance of pain-provoking movements has the pote | ial to increase or decrease the reporting of back pain 1 4 well. rm mt LBP in the Elderly: Literature Review + Bressler et al_ 1817 An important variable in the analysis of survey data is the issue of proxy reporting. In a variety of circum- stances, it can not always be determined who actually answered the survey, i. e., whether the response is re ported directly by the patient or by proxy (e. g., another household member or caregiver). Specifically, cognitive, language, attitude, and depression issues may lend them- selves to third-party assistance in completing the survey, perhaps resulting in incorrect responses. Older individuals experience increasing morbidity complicated by multiple medical problems. Research into the prevalence of back pain in the elderly popu- lation has been overshadowed by attention to more serious health issues such as cancer, heart disease, and diabetes. Furthermore, the morbidity of back pain in the elderly does not rank among health issues in terms of its cost to society. This has led to a health care environment in which little emphasis is given to qual- ity of life with regards to effective pain management for non-life-threatening conditions. Indeed, only rela- tively recently have nonmalignant pain syndromes been investigated.'*?*" Reporting of this inform. tion is hampered by a lack of consistency in the defi- nition of back pain and by the low representation of older persons in the musculoskeletal literature. All 12 studies selected in the current sample relied on patient reported data. Biering-Sdrenson” investigated the re liability of patient-reported data from patients with low back pain and found that increasing patient age was associated with decreased reliability of reported age of onset and degree of disability or severity. It is important to note, however, that in terms of overall ranking, back pain is the third or fourth most com- monly reported symptom in the elderly.” This is fur- ther confounded by the broad spectrum of organic health problems that also result in back pain. ‘The prevalence of low back pain has been found to vary between studies, and there are a number of reasons to suspect that the prevalence of back pain in the elderly is underestimated in the literature (Table 6). The varia tion among studies with respect to sample source (e. nursing home, community, field practice), study design, use of different definitions of back pain (location, inter mittency, severity, chronicity, impact on life quality, time frame), and differing methods of data acquisition (ques- tionnaire, examination, interviews, or combination thereof) all rend to influence findings, introducing a wide degree of variability in results, Other explanations for variation in the reported prevalence in low back pain relate to the paucity of studies. A significant limitation of these studies relates to the validity and reliability of survey instruments used to gen- erate data. Survey instruments themselves need to be tested for validity and reliability for results to have sta- tistical relevance, In only 2 of the 12 studies accepted for review did the authors report having pretested their sur vey instrument for test-retest reliability and validity, with both studies citing high prevalence rates; Isacsson,0 1818 Spine « Volume 24 * Number 17+ 1999 however, did not perform validity studies on the mea surement of daily back pain with a questionnaire. Ferrell et al! used five previously established instruments, but relied on an untested semi-structured interview and file audit, It is not known from the text of the remaining, reports whether such statistical testing was performed. These limitations decrease the credibility and confidence with which conclusions can be drawn from these studies. Low back pain is potentially a very prevalent and sig- nificant cause of morbidity in the elderly. Given the pos- sible consequences of unmanaged low back pain in an older age group, such as depression,!???*#225 func. tional disability,!**") and compromised quality of life,** further in-depth functional assessment to identify low back pain-related behaviors is warranted. @ Conclu There is a need to improve reporting of epidemiologic data with respect to low back pain in the elderly, Epide- miologic studies must be more informative and applica- ble to older people."" Specifically, problems relating to definitions of back pain must be addressed. Effort must be made to standardize data collection with methods such as pain diagrams to permit standardized reporting of age data and comparisons between studies. Asa first step, studies need to focus on more accurate reporting of the prevalence and the effects of back pain in daily life. 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