Research Review: Hip Impairment and Chronic Low Back Pain in Seniors

February 5, 2019
By , DC

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.

Introduction

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.

Pertinent Results

  • 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.

Study Methods

  • 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

Strengths:

  • 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.

Weaknesses:

  • 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.

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Additional References

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  2. 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.
  3. 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.
  4. Engel CC, von Korff M, Katon WJ. Back pain in primary care: predictors of high health-care costs. Pain 1996; 65: 197-204.
  5. 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.
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  8. 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.
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  16. 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.
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  19. 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.
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