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Geriatr Gerontol Int 2015; 15: 54–64

ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH

Association between musculoskeletal pain and trips or falls in rural Japanese community-dwelling older adults: A cross-sectional study Jun Kitayuguchi,1,2 Masamitsu Kamada,3,4 Shimpei Okada,5 Hiroharu Kamioka6 and Yoshiteru Mutoh7 1

Physical Education and Medicine Research Center UNNAN, Unnan City, Shimane, 2Department of Environmental Symbiotic Studies, Faculty of Regional Environment Science, Tokyo University of Agriculture, 7The Research Institute of Nippon Sport Science University, Setagaya-ku, 3Department of Health Promotion and Exercise, National Institute of Health and Nutrition, Shinjuku-ku, 4Japan Society for the Promotion of Science, Chiyoda-ku, Tokyo, and 5Physical Education and Medicine Research Foundation, Tomi City, Nagano, Japan 6

Aim: The present study examined whether low back pain (LBP) and knee pain (KP) are associated with trips and falls in rural Japanese community-dwelling older adults. Methods: A population-based cross-sectional survey of community-dwelling older adults was carried out in Unnan City, Shimane Prefecture, in Japan. A total of 499 men and women aged 60 years and older living in the community were recruited from 2008 to 2010. The main outcome measures were self-rated recent trip frequency and self-reported experience of falls in the past year. Results: Trips and falls presented in 44.0% and 15.9% of participants, respectively. LBP was not associated with trips, but was significantly associated with falls: severe pain versus single fall (odds ratio [OR] 2.51, 95% confidence interval [CI] 1.04–6.03); and severe pain versus multiple falls (OR 11.09, 95% CI 2.41–51.10). KP was significantly associated with trips: mild pain versus trips (OR 1.81, 95% CI 1.20–2.72); mild pain versus multiple falls (OR 4.47, 95% CI 1.21–16.50); severe pain versus trips (OR 3.83, 95% CI 1.82–8.04); and severe pain versus multiple falls (OR 7.26, 95% CI 1.51–34.86). Participants with both pain sites were associated with trips (OR 2.44, 95% CI 1.45–4.12) and multiple falls (OR 10.79, 95% CI 1.33–87.19). Conclusions: Severe LBP was associated with single and multiple falls, whereas KP was associated with trips and multiple falls, irrespective of severity of pain. In addition, participants with both pain types were associated with trips and multiple falls. Geriatr Gerontol Int 2015; 15: 54–64. Keywords: community-dwelling elderly, falls, Japan, musculoskeletal pain, trips.

Introduction Falls in older adults are a major public health problem. One-third of the population aged 65 years and older fall at least once a year,1,2 and falls often lead to serious injury and death.3 Furthermore, trips are also known as a major cause of falls during walking.4–6 As the number of older adults continues to increase, this problem is also likely to grow. Thus, fall prevention in older adults

Accepted for publication 25 November 2013. Correspondence: Mr Jun Kitayuguchi MBSS, 1212-3 Mitoya, Mitoya Town, Unnan City, Shimane 690-2404, Japan. Email: [email protected]

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doi: 10.1111/ggi.12228

is a major concern, and clarifying risk factors for falls is important. As the population grows older, an increasing number of elderly people experience suffering caused by locomotive disabilities.7 In particular, care and prevention of chronic low back pain and knee osteoarthritis, which are experienced by many elderly people, are now a major concern in public health.8–11 Although many risk factors for falls have been examined in several longitudinal studies,1,2,12 musculoskeletal pain has rarely been evaluated as a fall hazard.2,13–15 Low back (LBP) and knee pain (KP) are common sites of pain for both sexes in the Japanese elderly population,9 and are major contributors to functional limitation and disability in older adults.16–22 Several studies have investigated the association between knee osteoarthritis or KP and falls,2,13 © 2014 Japan Geriatrics Society

Musculoskeletal pain related to trips and falls

and reported that increasing severity of KP was associated with a greater risk of falls.13 LBP is the most frequently reported musculoskeletal problem among older adults;23 however, data on the impact of LBP on falls in older persons are limited.14,15 In addition, although back and knee problems are common comorbidities in the older population,24,25 the impact of comorbid conditions on falls is poorly understood. Furthermore, to date, most previous studies have been carried out in Western countries, and few studies have evaluated the impact of musculoskeletal pain on falls in a Japanese elderly population.26 The aim of the present study was to examine the following by exploratory survey: (i) whether each pain site separately is associated with trips and falls; and (ii) whether a combination of both sites of pain is associated with trips and falls among rural Japanese communitydwelling older adults.

Methods A population-based cross-sectional survey was carried out concomitantly with a community fall prevention program in community-dwelling older adults in Unnan City (population 44 303, area 553.4 km2), Shimane Prefecture, in western rural Japan. All participants living in Unnan city were invited to participate in the study by circulars called “kairanban” and city newsletters. Figure 1 is a flow chart of the study recruitment. The following inclusion criteria were used for each participant: aged 60 years and over, community-dwelling and a participant in a community fall prevention program. A total of 499 men and women aged 60 years and older living in the community were recruited from 2008 to 2010. Individuals were excluded from the study if they were in assisted living facilities, required nursing care, walked using an assistive device, could not respond to the interview explicitly, or had pain as a result of injury from falls. Eight participants were excluded from the study because the interviewer evaluated them as indistinct responders to questions, according to the exclusion criteria. The present study was approved by the research ethics committee of the Physical Education and Medicine Research Center Unnan.

Figure 1

Study flow.

© 2014 Japan Geriatrics Society

Outcome measures: Trips and falls There were two outcome measures in this study: (i) self-rated recent trip frequency; and (ii) self-reported experience of falls in the past year. A trip was defined as “when the swing foot contacts an object or the ground”.27 A fall was defined as “unintentionally coming to rest on the ground, floor or other lower level”.28 Trips and falls data were assessed using a self-administered questionnaire and a face-to-face interview for confirmation. For trips, participants were asked “Have you been tripping recently?; none of the time, a little of the time, some of the time, most of the time”, and those who answered “some of the time/most of the time” were defined as trips.29 For falls, participants were asked “During the past 12 months, have you had any falls?”, and those who answered “yes” were then asked for the number of falls that had occurred.1,2 Based on their reported number of falls, respondents were divided into three categories: (i) not at all; (ii) once a year (single fall); and (iii) twice or more a year (multiple falls).

Primary explanatory variables: LBP and KP LBP and KP data were assessed using a selfadministered questionnaire and a face-to-face interview for confirmation. LBP and KP were defined by the response to the question, “How much pain have you had during the last week?; none, mild, severe, very severe”, and those who answered mild or severe or very severe were defined as having pain. The criterion for pain frequency was set at “at least once a week”.30 The 1-week test–retest reliability of LBP and KP was also assessed, and showed a moderate and acceptable value of weighted kappa (LBP 0.66, 95% confidence interval [CI] 0.49–0.84; KP 0.80, 95% CI 0.71–0.90) in 81 elderly people (33 men and 48 women) aged 74.5 ± 5.0 years.

Covariates (demographic and fall risk factors) The covariates included sex, age, body mass index (BMI) calculated from measured weight and height in kg/m2, self-rated health, self-reported psychological distress, the number of medications used, gait speed, and exercise time. Variables other than gait speed were assessed by a self-administered questionnaire and a face-to-face interview for confirmation. Age was categorized into three groups, by years: 60–64 years, 65–74 years and ≥75 years. Self-rated health was determined by the response to the following question: “In general, would you say your health is; very good, good, poor, very poor?”.31 Self-reported psychological distress of individuals was determined by the response to the following question: “Are you currently depressed?; none of the time, a little of the time, some of |

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the time, most of the time”.32 Gait speed was measured once by trained examiners using digital stopwatches on a 10-m course set between the 2 and 12-m marks of a 14-m straight, flat, indoor walkway. We asked participants to walk as fast as they safely could without running on the walkway course. Gait speed data were dichotomized using a reference value of maximum walking speed as a cut-off.33 The high reliability of walking (gait) speed measurements have been reported previously.33 Exercise time was determined by response to the following question: “How long do you usually engage in exercise (e.g. walking for recreation, sports)? Please answer the number of days per week and the mean number of minutes walked per day”, and categorized into three groups: 0 min/week, 1–149 min/week and ≥150 min/week). Threshold of exercise time (≥150 min/week) was based on the physical activity recommendation by the American College of Sports Medicine and the American Heart Association.34,35 The number of medications used was determined by the response to the following question: “How much medication do you currently take per day?”, and categorized into three groups:36 0, 1 and ≥2. Dichotomous variables were constructed for BMI (

Association between musculoskeletal pain and trips or falls in rural Japanese community-dwelling older adults: a cross-sectional study.

The present study examined whether low back pain (LBP) and knee pain (KP) are associated with trips and falls in rural Japanese community-dwelling old...
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