Review written by: Brynne Stainsby, DC, for RRS Education
Study Title: Hip symptoms, physical performance, and health status in older adults with chronic low back pain: A preliminary investigation
Authors: Hicks GE, Sions JM and Velasco TO
Publication Information: Archives of Physical Medicine and Rehabilitation 2018; 99: 1273-1278.
Chronic low back pain (CLBP) is one of the most common pain-related conditions in geriatric populations and is associated with potentially significant functional decline1-7. As pain conditions can coexist and contribute to poorer long-term outcomes, it is important to understand the potential relationship between CLBP and other pain complaints8,9.
Given the anatomical proximity between the hip and low back/pelvis and the overlapping patterns of pain distribution, coexisting hip pain and CLBP have often been linked (this is something practicing clinicians have noticed for years)10,11. While studies have often linked hip dysfunction and CLBP, understanding this clinical relationship in heterogeneous populations remains challenging, particularly in geriatric patients.
The aim of this study was to examine differences in prevalence of clinical hip symptoms in older adults with and without CLBP. Specifically, the authors hypothesized that the predictors of radiographic hip osteoarthritis (OA) would be associated with the presence of CLBP in older adults. The secondary objective was to assess whether the presence of clinical hip symptoms was associated with poorer physical performance and health-related quality of life (HRQOL) in this population.
- In this secondary analysis, 54 participants were compared with 54 age and sex matched controls.
- Hip joint pain, morning stiffness and pain with hip internal rotation were significantly more common in those with CLBP, and 53.7% of participants with CLBP had at least one hip symptom (compared to 13% of controls).
- 18.5% of the participants with CLBP reported a radiographic diagnosis of hip OA from their physician, compared with only 1.9% of the group without LBP.
- After controlling for BMI, participants with both CLBP and hip symptoms were significantly slower than those without pain (during stair ascent and repeated chair rise performance).
- CLBP (with or without hip symptoms) was associated with worse function in the physical domains of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36)12,13 as well as general health.
- The addition of hip symptoms to CLBP was associated with worse social function, mental health, and role limitations attributable to emotional problems.
Clinical Application and Conclusions
This study demonstrates a link between proposed symptomatic indicators of hip OA and CLBP. It demonstrated these predictive symptoms are more prevalent in older adults with CLBP, and the presence of both conditions is associated with poorer performance and HRQOL outcomes.
The findings of this study support the idea of a “regional interdependence” model14 and suggest the need for a thorough investigation of hip function in those with CLBP. Further, the authors suggest that future research may identify subgroups of patients with CLBP with and without hip symptoms to better understand appropriate management strategies and prognosis. In particular, the worsened performance on the stair ascent and repeated chair rising in those with both conditions is important to note, as worsening performance on these tests can be predictive of functional decline in a geriatric population. Clinicians should ensure that function is a key outcome in this population, as it is critical to the patient’s independence and safety.
Worsened outcomes on the social function and mental health domains were also observed in the population with both CLBP and hip symptoms, which may be associated with multisite (widespread) pain. Widespread pain has been associated with anxiety, depression, sleep disturbance and greater comorbidity burden and it is important for clinicians to recognize that in a geriatric population, poorer social functioning has been linked with decreased social interaction and decreased survival15-18.
- This study was a secondary analysis on subjects with CLBP enrolled in a preliminary trial comparing trunk muscle training to passive rehabilitation.
- Subjects were matched on a case-by-case basis with controls without CLBP based on age and sex for the final analysis.
- For the purpose of the secondary analysis, hip symptoms were assessed according to the American College of Rheumatology guidelines: hip joint pain, hip stiffness in the morning lasting less than or equal to 60 minutes, pain with hip internal rotation19.
- Functional mobility was assessed using the repeated chair rise test20, 21 and the stair-climbing test22-25.
- Health-related quality of life was assessed using the SF-36 to assess for health status in eight domains12, 13.
- Chi-square analysis was used to determine differences in the prevalence of hip symptoms in older adults with and without CLBP. The sample was then stratified into three groups for further analysis: 1) individuals without CLBP or hip symptoms; 2) individuals with CLBP and no hip symptoms; and 3) individuals with CLBP and at least one hip symptom. All statistical models were adjusted for body mass index (BMI) and Bonferroni correction for multiple comparisons were used. Effect sizes were also calculated for all outcomes.
Study Strengths / Weaknesses
- Participants were matched to controls by age and sex, however, those with CLBP did have higher average BMI (statistically significant) – the authors did adjust for this difference in the statistical analyses.
- The authors performed thorough statistical analyses and attempted to adjust for cofounders and make corrections for the number of tests performed.
- The authors identified the limitations of the study and used the findings to suggest future, more robust studies.
- The greatest weakness of this study is simply a result of its methodology: as a cross-sectional study, it is a snapshot in time and cannot fully explore the relationship between CLBP and hip symptoms. The authors addressed this limitation and suggested future longitudinal work.
- This study required self-reported radiographic hip OA diagnoses and thus the potential for recall bias must be considered.
- This study included a relatively small sample size (though effect sizes were calculated) and future studies should include more robust samples.
RRS Education has been a trusted source of continuing education solutions for chiropractors since 2006. RRS Education provides weekly Research Reviews like this one (subscription required) as well as evidence-based online courses to help busy clinicians review and integrate current research into their patient care. For more information, visit: www.rrseducation.com.
- Bressler HB, Keyes WJ, Rochon PA et al. The prevalence of low back pain in the elderly. A systematic review of the literature. Spine 1999; 24: 1813-9.
- Patel KV, Guralnik JM, Dansie EJ et al. Prevalence and impact of pain among older adults in the United States: findings from the 2011 National Health and Aging Trends Study. Pain 2013; 154: 2649-57.
- Weiner DK, Kim Y, Bonino P et al. Low back pain in older adults: are we utilizing healthcare resources wisely? Pain Med 2006; 7: 143.
- Engel CC, von Korff M, Katon WJ. Back pain in primary care: predictors of high health-care costs. Pain 1996; 65: 197-204.
- Reid MC, Williams CS, Gill TM. Back pain and decline in lower extremity physical function among community-dwelling older persons. J Gerontol A Biol Sci Med Sci 2005; 60: 793-7.
- Hicks GE, Simonsick EM, Harris TB, et al. Trunk muscle composition as a predictor of reduced functional capacity in the Health, Aging and Body Composition study: the moderating role of back pain. J Gerontol A Biol Sci Med Sci 2005; 60: 1420-4.
- Leveille SG, Guralnik JM, Hochberg M, et al. Low back pain and disability in older women: independent association with difficulty but not inability to perform daily activities. J Gerontol A Biol Sci Med Sci 1999; 54: M487-93.
- Institute of Medicine (U.S.) Committee on Advancing Pain Research, Care, and Education. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington (DC): National Academy of Sciences; 2011.
- Maixner W, Fillingim RB, Williams DA et al. Overlapping chronic pain conditions: implications for diagnosis and classification. J Pain 2016; 17(9 Suppl): T93-107.
- Lesher JM, Dreyfuss P, Hager N et al. Hip joint pain referral patterns: a descriptive study. Pain Med 2008; 9: 22-5.
- Offierski CM, MacNab I. Hip-spine syndrome. Spine 1983; 8: 316-21.
- McHorney CA, Ware JE Jr, Lu JF et al. The MOS 36-Item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups. Med Care 1994; 32: 40-66.
- McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 1993; 31: 247-63.
- Wainner RS, Whitman JM, Cleland JA et al. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther 2007; 37: 658-60.
- Chen Q, Hayman LL, Shmerling RH et al. Characteristics of chronic pain associated with sleep difficulty in older adults: the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study. J Am Geriatr Soc 2011; 59: 1385-92.
- Morales-Espinoza EM, Kostov B, Salami DC et al. Complexity, comorbidity, and health care costs associated with chronic widespread pain in primary care. Pain 2016; 157: 818-26.
- Mayer TG, Towns BL, Neblett R et al. Chronic widespread pain in patients with occupational spinal disorders: prevalence, psychiatric comorbidity, and association with outcomes. Spine 2008; 33: 1889-97.
- Glass TA, de Leon CM, Marottoli RA et al. Population based study of social and productive activities as predictors of survival among elderly Americans. BMJ 1999; 319: 478-83.
- Altman R, Alarcon G, Appelrouth D et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum 1991; 34: 505-14.
- Zhang F, Ferrucci L, Culham E et al. Performance on five times sit-to-stand task as a predictor of subsequent falls and disability in older persons. J Aging Health 2013; 25: 478-92.
- Wang CY, Yeh CJ, Hu MH. Mobility-related performance tests to predict mobility disability at 2-year follow-up in community-dwelling older adults. Arch Gerontol Geriatr 2011; 52: 1-4.
- Startzell JK, Owens DA, Mulfinger LM et al. Stair negotiation in older people: a review. J Am Geriatr Soc 2000; 48: 567-80.
- Mizner RL, Petterson SC, Stevens JE et al. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol 2005; 32: 1533-9.
- Zeni JA Jr, Snyder-Mackler L. Preoperative predictors of persistent impairments during stair ascent and descent after total knee arthroplasty. J Bone Joint Surg Am 2010; 92: 1130-6.
- Bean J, Herman S, Kiely DK et al. Weighted stair climbing in mobility-limited older people: a pilot study. J Am Geriatr Soc 2002; 50: 663-70.