Jacobs et al. Another study revealed that comorbid chronic conditions were positively related to at least one LBP episode in the last month in low- and middle-income countries [ 31 ]. Specifically, the odds of LBP were 2. However, such pain can be alleviated by the administration of L-dopa [ ]. While comprehensive history taking, self-reports of pain characteristics and pain-related disability, as well as proper physical examination all are necessary for differential diagnosis among older adults with LBP [ ], attention should be also given to assessment and treatment of seniors with LBP so as to optimize pain management Fig.
The point NRS is commonly used in clinical settings, where 0 means no pain and 10 means the worst pain imaginable [ ]. They have been validated among different older populations [ , , — ] and were rated as preferred tools over the NRS by Chinese [ ] and African-Americans [ ]. The Iowa Pain Thermometer IPT is a descriptor scale presented alongside a thermometer to help patients conceptualize pain intensity as temperature levels [ ].
Although self-reported pain assessment is the gold standard, clinicians need to validate the self-reported pain with observed pain behavior during physical examination. While some seniors with cognitive impairment may report exaggerated pain without coherent pain behavior due to perseveration [ — ], others e. Currently, there is no consented guideline regarding the relation between the trustworthiness of self-reported pain and cognitive functioning [ ]. Therefore, health-care providers e. Some dementia screening tools e.
Patients with positive screening results should be referred to subspecialty dementia experts e. Collectively, early identification of cognitive impairment and psychiatric comorbidity e. Since people with moderate to severe dementia may display agitation, anxiety, or nonverbal pain behaviors e.
Several recent reviews have identified at least 24 observational pain assessment instruments for estimating pain in nonverbal patients [ — ]. Regardless, if the observational pain behavior assessment indicates the presence of significant pain in patients, the sources of pain should be identified through physical examination and proper treatment should be given. If inconsistency occurs between the observational assessment and self-report of pain, other causes e. If comprehensive evaluations and an analgesic trial cannot identify any sources of pain experienced by patients with dementia, the persistent pain complaint may be attributed to pain perseveration, which is the repetitive reporting of pain without actual distress.
Collectively, future studies should refine existing observational tools by identifying the most important behaviors for evaluating the presence and severity of pain including LBP in cognitively impaired patients. It is noteworthy that although certain physiological parameters e.
Additionally, older adults with dementia may have diminished autonomic reactions to pain [ , ]. Therefore, effective evaluation of pain behavior may be more relevant for older adults with severe dementia and pain. Given that older people usually display reduced physical capacity [ ], cardiac output [ ], muscle mass and strength [ ], and older adults with LBP are more likely to suffer from decreased mobility and functional deterioration than younger sufferers. In addition, older adults with musculoskeletal pain are more likely to experience fear of falling [ ] and fall incidents [ 23 ].
Specifically, LBP is known to be an independent risk factor for repeated falls in older women [ ]. Since falls is the leading cause of persistent pain, disability, and mortality among seniors [ 36 , ], physicians and nursing home workers should assess fall risks of older adults with LBP [ ] and refer them for fall prevention intervention, if necessary. The American Geriatrics Society has published recommendations on pain management of geriatric patients with nonmalignant pain. In particular, a standing order of analgesic e. Tramadol is recommended to be prescribed with caution for patients with a known risk of seizure e.
In addition, the guideline also suggests that if acetaminophen cannot control pain, non-steroidal anti-inflammatory drugs NSAIDs e. However, since some traditional NSAIDs may cause gastrointestinal upset, clinicians are recommended to prescribe non-acetylated salicylates for older patients with peptic ulcer and gastrointestinal bleeding. Although there is no ideal dose for opioid prescription among older adults with LBP, the effective dose should be carefully titrated to fit individual needs. To attain better pain relief with minimal side effects secondary to a high dose of a single medication, it is recommended to concurrently use two or more pain medications with different mechanisms of action or different drug classes e.
It is noteworthy that opioid e. Therefore, specific education and caution should be given to these patient groups.
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In addition, because older patients with chronic LBP are commonly associated with depression or anxiety, it is not uncommon for them to take antidepressants e. Since some of these psychoactive drugs may compromise their memory, cognition, alertness and motor coordination [ , ], special care should be given to these patients to minimize their risks of falls, hip fractures, or road traffic accidents [ ]. For instance, concurrent prescription of tramadol and the selective serotonin reuptake inhibitor an antidepressant may increase the risk of serotonin syndrome e.
If patients have an elevated risk of opioid overdose e. Naloxone is an opiate antidote for neutralizing the toxicity of opioid overdoses [ , ]. For patients who are taking long-acting opioids e.
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Collectively, existing medical guidelines generally recommend low-dose initiation and gradual titration of opioid therapy and constipation prophylaxis, increased awareness of potential interactions among concurrent medications, as well as close monitoring of treatment responses in patients. It is necessary to provide updated education to health-care providers so as to optimize pain management for older patients with chronic pain. Although analgesics are the first line treatment for older people with LBP, older people with LBP especially those with a prolonged history of LBP may require other conservative treatments to mitigate pain and to restore function.
Growing evidence has indicated that some, but not all, conservative treatments can benefit older people with LBP [ , ]. While the efficacy of various physiotherapy modalities in treating older people with LBP remains controversial [ ], a recent meta-analysis has highlighted that Tai Chi, a mind-body exercise therapy, is an effective intervention for older patients with chronic pain including LBP, osteoarthritis, fibromyalgia, and osteoporotic pain as compared to education or stretching [ ]. Importantly, in addition to pain relief, various systematic reviews on Tai Chi have revealed promising outcomes in improving balance [ ], fear of falling [ ], lower limb strength [ ], physical function [ ], hypertension [ ], cognitive performance [ ], and depression [ ] in seniors as compared to no treatment or usual care.
Given the high frequency of physical and psychological comorbidity among older adults e. Future studies should determine the dose response of Tai Chi in treating older people with LBP in community and institutional settings. Surgical intervention is indicated for older people only if there is a definite diagnosis of lumbar pathology e.
Decompression surgery i. Recent evidence suggests that minimally invasive spine surgery techniques have higher success rate than open lumbar decompression surgery [ ]. Unlike decompression surgery, spinal fusion surgery utilizes bone grafts autograft or allograft or surgical devices to fuse adjacent vertebrae anteriorly, posteriorly, or circumferentially.
Such surgery immobilizes the spinal motion segment, in theory removes key pain generating sources and eliminates intersegmental movement of vertebrae that may compress neural structures in order to alleviate symptoms [ ]. In general, both simple and complex spinal fusion surgeries are associated with a higher risk of major complications and postoperative mortality as compared to decompression surgery [ ].
However, two recent randomized controlled trials have reported conflicting results regarding the effectiveness of decompression surgery plus spinal fusion versus decompression surgery alone in treating patients with LSS and degenerative spondylolisthesis [ , ]. Decompression and spinal fusion are also indicated for patients with symptomatic degenerative lumbar scoliosis [ , ] although these procedures may increase the risk of complications in older adults especially those with comorbidities [ , , — ].
Although current evidence notes the safety and efficacy of such intervention for indication for cervical spine pathology in comparison to conventional interbody fusion procedures, outcomes for lumbar disc disorders remain under further evaluation. Percutaneous transpedicular vertebroplasty and balloon kyphoplasty are two minimally invasive techniques for treating patients with painful osteoporotic vertebral compression fracture [ ].
Low back pain in older adults: risk factors, management options and future directions
These procedures involve the injection of a small amount of bone cement into the collapsed vertebral body to alleviate excruciating pain and stabilize the fractured vertebral body [ ]. However, individual studies have found that these procedures may heighten the risk of new vertebral fractures at the treated or adjacent vertebrae, and other complications e. However, a recent meta-analysis reveals that these vertebral augmentation procedures may attenuate pain and correct deformity of patients with osteoporotic vertebral compression fractures without increasing the risk of complications or new vertebral fractures along the spine [ ].
In addition, the past decade alone has seen a significant interest in the concept of sagittal alignment and balance with respect to the preoperative planning and predictive outcome analyses of patients with various lumbar spinal disorders and spinal deformities [ , ]. Novel imaging software has been developed to quantify such parameters, such as pelvic incidence and tilt, and sacral slope, in a semi-automatic fashion [ , ]. Like conservative LBP treatments, some patients may experience persistent LBP with or without sciatica even after spinal surgery.
The reasons for the failed back surgery syndrome FBSS may be ascribed to technical failure, incorrect selection of surgical patients, surgical complications, or related sequelae [ ]. Additionally, since spinal surgery may alter the load distribution at vertebral structures adjacent to the operated segments e. Because patients with FBSS are unlikely to benefit from revision surgery, spinal cord stimulation has been suggested to manage pain in these patients. Specifically, spinal cord stimulation involves the placement of electrodes into the epidural space and the generation of electrical current by a pulse generator placed subcutaneously.
Studies have noted that there is fair evidence to support moderate effectiveness of spinal cord stimulation in attenuating persistent radicular pain of appropriately selected patients with FBSS although device-related complications are also common [ ]. It is noteworthy that while surgical intervention may benefit some patients with LBP, clinicians should weigh the risks and benefits of surgery for each individual patient.
A recent Cochrane review summarized the evidence regarding the effectiveness of surgical and conservative treatments for patients with LSS [ ].
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Given above, back surgery should be considered carefully for high-risk patients e. High-quality randomized controlled trials are warranted to compare the effectiveness of surgical versus nonsurgical interventions for older patients with LSS. While anecdotal evidence and clinical experience suggest that older people appear to have higher rates of LBP with definite pathology e. Given this knowledge gap, future research should quantify the prevalence of various LBP diagnoses so that health care resources can be better allocated to effectively manage the epidemic of LBP in the older population.
Although self-report of LBP is the gold standard for evaluating subjective pain experience, some patients with cognitive impairment may be unable to effectively verbalize their pain. Clinicians especially those working in the geriatric field should improve their competence in assessing nonverbal pain expression in patients with cognitive impairment.
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While multiple observational pain assessment scales have been developed, there is no consensus on the use of a particular assessment tool. Different clinical guidelines have recommended different scales [ , ]. Given the rapid development and validation of different observational scales in the last decade, it is necessary to update existing guidelines on this issue.
While the scores of several observational pain behavior assessment tools e. Future studies should establish this relation.
Further, most of the existing behavioral observational pain scales have only been validated in the nursing home setting. Future studies are warranted to compare various existing scales and evaluate their responsiveness and sensitivity to changes in pain following treatments in different settings, which can identify best assessment tools for different settings. Since recent findings suggest that facial expression can provide many useful indirect information of pain, training health-care providers on the recognition and interpretation of facial expression of pain may improve the accuracy and reliability of pain assessment among patients with dementia.
Importantly, future studies should adopt computer vision technology to develop automatic, real-time assessment of pain-related facial expression so as to facilitate the evaluation of pain condition in non-communicable patients with LBP [ ]. Currently, clinical assessments of LBP among older adults rely heavily on self-report or surrogate report of LBP or manual physical assessments.
With recent advances in technology, clinicians can use reliable novel objective measurements e. Given that age-related physical changes e. For example, ultrasonography may be used to quantify atrophy of lumbar multifidus that can guide clinical treatments e.
Likewise, computerized spinal stiffness tests can be used to identify patients with LBP who are likely to benefit from spinal manipulation [ ]. Novel yet more sensitive imaging, such as chemical exchange saturation transfer, T2 mapping, T1-rho, ultra-short time-to-echo and sodium MRI, may identify the pain-generating source allowing for more targeted therapies [ 50 , ]. Furthermore, a refinement of some of the imaging phenotypes e. Knowledge gained from such approaches may enhance the exploration of new pathways of pain and potential treatment options in appropriate animal models.
Moreover, the role of pain genetics and its actual utility toward the management of LBP in older individuals needs to be further explored. Taken together, while novel technology may gather new information from patients with LBP, clinicians should integrate these objective outcomes with other clinical findings in order to make proper diagnosis and clinical decision.