Aging Clin Exp Res DOI 10.1007/s40520-015-0340-5

ORIGINAL ARTICLE

Multi-chronic musculoskeletal pain is a useful clinical index to predict the risk of falls in older adults with normal motor function Tsuyoshi Asai • Shogo Misu • Ryuichi Sawa Takehiko Doi • Minoru Yamada



Received: 21 October 2014 / Accepted: 18 February 2015 Ó Springer International Publishing Switzerland 2015

Abstract Background The number of chronic musculoskeletal pain sites (nCMSP) is reportedly associated with risk of falls. Older participants in community-based research show a wide range of physical functions, but few studies have focused on the risk of falls in older adults with normal motor function (NMF). Clarification of the effects of pain on dual-tasking performance is also important, given the strong link between falls and dual-tasking. Aims The objectives were to investigate the associations between: (1) nCMSP and falls; and (2) nCMSP and dualtask performance in older adults with NMF.

This work was carried out at Toyotomi Elementary School, 925 Mikage, Toyotomi-cho, Himeji, Hyogo 679-2122, Japan. T. Asai (&) Department of Physical Therapy, Faculty of Rehabilitation, Kobe Gakuin University, 518 Ikawadanicho, Arise, Nishi-ku, Kobe, Hyogo 651-2180, Japan e-mail: [email protected] S. Misu Kobe City Hospital Organization, Kobe City Medical Center West Hospital, 1-2-4 Nagata-ku, Kobe, Hyogo 653-0013, Japan R. Sawa Kobe University Graduate School of Health Sciences, 7-10-2 Tomogaoka, Suma-ku, Kobe, Hyogo 654-0142, Japan T. Doi Section for Health Promotion, Department of Health and Medical Care Center for Development of Advanced Medicine for Dementia, National Center for Geriatrics and Gerontology, 35 Gengo, Morioka, Obu, Aichi 474-8511, Japan M. Yamada Graduate School of Comprehensive Human Sciences, University of Tsukuba, 3-29-1 Otsuka, Bunkyo-ku, Tokyo 112-0012, Japan

Methods A total of 112 older adults with NMF (44 men, 68 women; 73.4 ± 4.6 years) were classified as fallers (n = 22) or non-fallers (n = 90) according to their fall history. Musculoskeletal pain in the lower body was assessed using questions ascertaining pain in musculoskeletal sites (back, hip, knee, foot, or toe). Participants were assigned to three pain groups according to nCMSP. Basic physical performances and gait performances (normal gait, fast gait, or dual-task gait) were measured. Results The nCMSP represented a significant risk factor for falls according to logistic regression modeling after adjusting for the five chair stand test and fear of falls. The nCMSP was not associated with any gait variables. Discussion Potential fall risk may be increased by nCMSP, even in older adults with NMF. Pain-related reduction in attention resources may not represent a risk factor for falls among older adults with NMF. Conclusions The nCMSP represents a potential risk factor for falls in older adults with NMF. Keywords Chronic musculoskeletal pain  Risk factor of fall  Community-dwelling older adults  Dual-tasking

Introduction Chronic musculoskeletal pain (CMSP) is a common clinical symptom among older adults. The prevalence of chronic pain in the older population is high, with up to 50–60 % of community-dwelling older adults reporting CMSP [1, 2]. CMSP may lead to a range of deleterious effects among older adults, including functional disability and decreased quality of life [3–5]. In addition, CMSP increases the risk of falls in older adults [1, 2, 6]. Interestingly, the number of CMSP sites (nCMSP) was

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associated with a greater risk of falls in a population-based longitudinal study of community-dwelling older adults [2]. To predict the potential risk of falls for older adults, nCMSP offers a useful clinical index [2]. Older adults who participate in community-based research generally display a wide range of physical functions [e.g., from so-called frail older adults to older adults with normal motor function (NMF)] [2, 7]. Risk factors for falls among older adults with impaired motor function have been investigated in many studies [7–10], but few have focused on the risk of falls in older adults with NMF. The incidence of falling has been reported to be highest in frail older adults and lowest in vigorous older adults [11]. However, the rate of injurious falls resulting in serious injury was higher among vigorous older adults than among frail subjects [11]. A similar tendency may be observed in older adults with NMF [11, 12]. Fall-related injuries also represent a serious health problem for these individuals, so identifying risk factors for falls is clinically important. Extending the healthy life expectancy represents an important issue for aging societies such as Japan. Risk factors associated with falling in older adults with NMF may provide crucial insights to care providers working in the health care community. The primary objective of the present study was thus to investigate the association between nCMSP and falls in older adults with NMF. Dual-tasking is a useful physical performance test that requires the subject to perform a motor task, while simultaneously undertaking another cognitive or motor task [13, 14]. Previous studies have indicated that dual-task performance is readily reduced by the presence of pain [15, 16]. Given the strong link between reduced dual-tasking performance and falls in older adults, clarification of the effects of pain on dual-tasking performance appears clinically important [17–19]. Inappropriate allocation of attention induced by CMSP may predispose older individuals to falls. The second objective of present study was thus to investigate the association between nCMSP and dual-task performance.

Methods Participants Suitable sample size was obtained as follows. The sample size was based on the v2 test (history of fall and nCMSP) with a 5 % level of significance, a power level of 0.80, and an effect size of 0.3. The resulting sample size was 108. With an expected exclusion rate of 20 %, 135 recruitments were required to appropriately conduct the v2 test with two degrees of freedom.

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A total of 149 community-dwelling older adults, C65 years old, were recruited through a local community association center. Inclusion criteria were the ability to independently perform activities of daily living and absence of self-reported neurological or musculoskeletal conditions that could affect mobility or balance. Exclusion criteria were acute illness or cognitive impairment (rapid dementia screening test score \7), low physical performance over 10 s in a timed up and go (TUG) test as the cutoff point to identify potentially disabled individuals, and a score of less than 10 in the short physical performance battery (SPPB) test as the cutoff point to identify frail elderly individuals [20–23]. In total, 112 older adults with NMF (44 men, 68 women; mean age 73.4 ± 4.6 years) met the criteria and participated in this study. Measurements Medical condition, history of falls during the previous year (yes or no), and fear of falling (yes or no) were recorded using a questionnaire. In addition, the rapid dementia screening test was performed using the appropriate questionnaire [20]. Musculoskeletal pain in the lower body was assessed using questions ascertaining pain at musculoskeletal sites (back, hip, knee, foot, or toe) lasting 1 month or more in the previous year and also present in the previous month [2, 6]. The number of pain sites was counted, and participants were assigned to three pain groups according to the nCMSP: zero-site group, participants with no pain sites; single-site group, participants with one pain site; or multi-site group, participants with pain at two or more sites. Basic physical performance was assessed using the TUG, SPPB, and five chair stand test (5CS), all of which are widely used in human health-related studies and for which validity and reliability have been confirmed. The procedures of these tests have been described previously [21, 22]. Gait performance was measured under three conditions: normal gait; fast gait; and dual-task gait. Participants were instructed to walk on a smooth, horizontal, 25-m walkway at a self-selected preferred speed (normal gait), fast speed (fast gait), or while counting backwards aloud (dual-task gait) [13, 24]. Prior to taking measurements, we explained how to perform the dual-task gait until the participants understood the requirements precisely. Measurements were taken in random order and no instructions were given regarding which task to prioritize in the dual-task gait [25]. The time taken to walk over the central 10 m of the walkway was measured using an electronic stopwatch. In addition, stride time was measured using a tri-axial accelerometer (MVP-RF8-BC; size 45 mm wide, 45 mm deep, 18 mm high; range 4 G; weight 60 g; sampling rate 500 Hz; Microstone, Nagano, Japan) attached to the heel

Aging Clin Exp Res

on the subject’s dominant side using surgical tape [26]. All acceleration data were low-pass filtered using a dual pass zero-lag Butterworth filter with a cutoff frequency of 20 Hz. Analyses were performed on data from all strides over the central 10 m of the walkway for each gait measurement. Stride time variability has been widely used to detect potential fallers among older adults [27]. STV ð%Þ ¼

standard deviation of stride time  100 mean stride time

Musculoskeletal mass was obtained by segmental bioelectrical impedance using eight tactile electrodes, according to the instructions from the manufacturer (In Body 2.0; Biospace, Seoul, Korea). To compensate for any influence of body size, muscle mass was converted into the skeletal muscle mass index (SMI) using weight by height squared (kg/m2). This index has been used in several epidemiological studies [28, 29]. Statistical analysis Unpaired t tests (for parametric variables) and Pearson’s v2 tests (nominal variables) were used to identify differences in all variables between non-fallers and fallers. Logistic regression analyses were performed with history of falls in the previous year as a dependent binominal variable. Confounding factors were selected as those that differed significantly between non-fallers and fallers at the P \ 0.05 level in bivariate analyses. In all logistic regression models, v2 value, P values, and odds ratios (OR) were computed. One-way analysis of variance (ANOVA) was performed to investigate associations between nCMSP and gait variables (normal gait, fast gait, and dual-task gait). Values of P \ 0.05 were considered significant for unpaired t tests, Pearson’s v2 test, logistic regression analyses and one-way ANOVA. All statistical analyses were performed using JMP version 10.0 software (SAS Institute Japan, Tokyo, Japan).

Results Demographic data for all participants are shown in Table 1 and comparisons of characteristics between non-faller and faller groups are shown in Table 2. The nCMSP was associated with fall history in the previous year (P = 0.026). Participants in the faller group also exhibited significantly slower performance of the 5CS (P = 0.007) and higher rate of fear of falls (P = 0.032) compared with participants in the non-faller group. The results of logistical regression modeling are shown in Table 3. In bivariate logistic analyses, nCMSP, 5CS and fear of falls were significantly associated with fall history (Model 1: nCMSP, OR 5.02,

P = 0.030; 5CS, OR 0.78, P = 0.017; fear of falls, OR 2.83, P = 0.039). Three variables (nCMSP, 5CS and fear of falls) were independently associated with the fall history (Model 2: nCMSP, OR 5.31, P = 0.032; 5CS, OR 0.73, P = 0.019; fear of falls, OR 3.05, P = 0.044). Associations between nCMSP and gait variables (normal gait, fast gait, and dual-task gait) are shown in Table 4. The nCMSP was not associated with any gait variables.

Discussion The main finding was that nCMSP was independently associated with fall history among older adults with NMF. The index of nCMSP is a useful clinical index to predict the risk of falls in older adults with NMF. Many community-dwelling older adults attribute their falls to trips or slips inside the home or intermediate home surroundings [30]. Balancing reactions that involve rapid stepping or reaching movements are critical for preventing falls [31]. However, the neuromuscular effects of pain could lead to slowed neuromuscular responses to an impending fall due to reflex muscle inhibition [32]. Even older adults with NMF may thus lose the ability for rapid lower limb movement in hazardous situations such as tripping. Our results extend the findings of previous investigations, which have shown an association between falls and nCMSP in a disabled woman and community-dwelling older adults [2, 6]. Potential fall risk may be increased by nCMSP even in older adults with NMF. The assessment of nCMSP should be applied to frail and older adults with NMF in the initial fall risk assessment. The 5CS was also independently associated with fall history. This result indicates that lower-extremity muscle weakness may be attributed to the occurrence of falls in older adults with NMF. This is broadly consistent with other fall-related studies [33–35]. The 5CS is included in the SPPB, which is a useful clinical physical performance test to discriminate the disable older adults among older adults [22]. A cutoff of 5CS B11.19 s is applied to maximum score (4 points) in this test. The mean value of 5CS was 9.4 ± 3.3 s even in fallers in the present sample, so subjects in the present study showed relatively higher physical performance of the lower limbs. Compared with falls among frail older adults, falls in vigorous older adults are likely to occur on stairs and away from home, in the presence of environmental hazards, or during displacing activities [11]. Together, older adults with NMF are more likely to fall while performing daily activities at high intensity, and letting such individuals know of the hazardous activities in their life may be effective for fall prevention. A systematic review of falls in older adults showed that fear of falls represents an important risk factor [36]. Our

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Aging Clin Exp Res Table 1 Demographic data (n = 112) Characteristics

Fallers (n = 22)

Non-fallers (n = 90)

P value# 0.269

Age (years)

74.4 ± 3.7

73.2 ± 4.8

Sex (men/women), n (%)

7 (31.8)/15 (68.2)

37 (41.1)/53 (58.9)

0.424

Height (cm)

154.9 ± 8.2

155.7 ± 8.3

0.656

Weight (kg)

57.0 ± 10.1

57.2 ± 10.6

0.944

Hypertension, n (%)

11, 50.0

37, 33.0

0.450

Heart disease, n (%)

2, 1.8

8, 7.2

0.988

Diabetes mellitus, n (%)

2, 1.8

6, 5.4

0.692

Values are given as mean ± standard deviation unless otherwise indicated #

Unpaired t test and Chi-square test were used to compare characteristics between fallers and non-fallers

Table 2 Association between fall history and characteristics in older adults with normal motor function Characteristics

Fallers (n = 22)

Non-fallers (n = 90)

P value#

6 (27.3)/8 (36.4)/8 (36.4)

49 (54.4)/28 (31.1)/13 (14.4)

0.026

2.5 ± 2.0

2.0 ± 1.9

0.237

8.4 ± 0.9

8.8 ± 1.2

0.191

Chronic musculoskeletal pain Number of pain sites (zero/single/multi), n (%) Physical status and medication Drugs taken per day 2

SMI (kg/m ) Physical function and medication TUG (s)

6.5 ± 1.0

6.3 ± 1.0

0.418

5CS (s)

9.4 ± 3.3

8.1 ± 1.7

0.007

Gait function Normal gait (s)

7.5 ± 1.3

7.1 ± 0.9

0.080

Fast gait (s) Dual-task gait (s)

5.9 ± 0.5 8.4 ± 1.7

5.8 ± 0.8 8.0 ± 1.6

0.843 0.298

Normal gait STV (%)

2.4 ± 1.3

2.0 ± 1.0

0.166

Fast gait STV (%)

2.3 ± 1.0

2.3 ± 1.1

0.894

Dual-task gait STV (%)

3.7 ± 2.3

3.7 ± 3.0

0.937

RDST

10.6 ± 1.4

10.2 ± 1.4

0.279

Fear of falls (yes/no), n (%)

10 (45.5)/12 (54.5)

20 (22.7)/68 (77.3)

0.032

Cognitive and mental status

Values are given as mean ± standard deviation unless otherwise indicated SMI skeletal mass index for whole body, TUG timed up and go test, 5CS five chair stand test, Normal gait time taken to walk 10 m at normal gait speed, Fast gait time taken to walk 10 m at Fast gait speed, Dual-task gait time taken to walk 10 m while counting backwards, Normal gait STV stride time variability in five strides when walking at normal gait speed, Fast gait STV stride time variability in five strides when walking at fast gait speed, Dual-task gait STV stride time variability in five strides when walking while counting backwards, RDST rapid dementia screening test #

Unpaired t test and Chi-square test were used to compare characteristics between fallers and non-fallers

results showed that fear of falls was associated with fall history, again broadly consistent with that previous report. Interestingly, the association between fear of falls and history of falls was independent, even in the regression model that included nCMSP and 5CS. Fear of falls refers to the lack of self-confidence that normal activities can be performed without falling, and is associated with anxiety [37]. Considering our results and the findings of the previous study, previous falls may be attributed to a fear of falls, and this psychological consequence may occur irrespective of physical impairments.

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Musculoskeletal pain may increase the risk of falls through more than one pathway [6]. There may be underlying mechanisms for the pain–fall relationship, such as pain-induced deficit of attention [2, 15]. However, contrary to our hypothesis, no significant associations were evident between nCMSP and fall history, or between nCMSP and any gait variables, including dual-task gait. Dual-task-related observational studies have revealed that even minor dual-task-related changes are observed in normal healthy older adults [12]. According to several research papers, a decline in executive function (including attention)

Aging Clin Exp Res Table 3 Falls, number of chronic musculoskeletal pain sites in the lower body, performance in the five chair stand test, and fear of falls Variables

Model 1

Model 2

OR (95 % CI)

Chi value

P

OR (95 % CI)

Chi value

P value

nCMSP

5.02 (1.50–17.88) 

7.02

0.030

5.31 (1.40–21.50) 

6.90

0.032

5CS

0.78 (0.96–0.62)

5.67

0.017

0.73 (0.96–0.56)

5.51

0.019

Fear of falls

2.83 (1.06–7.57)

4.26

0.039

3.05 (1.03–9.17)

4.05

0.044

Logistic regression analyses were conducted with fall/non-fall as the dependent variable. Model 1 shows the odds ratios obtained in bivariate analyses for each independent variable. Model 2 shows the odds ratio in logistic regression analysis included all independent variables (nCMSP, 5CS, fear of falls) OR odds ratio; 95 % CI 95 % confidence interval, nCMSP number of chronic musculoskeletal pain sites, 5CS five chair stand test  

Zero-multi-site

Table 4 Association between gait variables in normal, fast, and dual-task gaits and chronic musculoskeletal pain in older adults with normal motor function Gait variables

Zero (n = 55)

Single (n = 36)

Multi (n = 21)

P value#

Normal gait (s)

7.1 ± 1.0

7.2 ± 1.0

7.3 ± 1.3

0.786

Fast gait (s)

5.8 ± 0.7

5.9 ± 0.8

5.8 ± 0.7

0.701

Dual-task gait (s)

8.1 ± 1.7

8.0 ± 1.5

8.2 ± 2.0

0.890

Normal gait STV (%)

2.0 ± 1.0

2.1 ± 1.1

2.2 ± 1.2

0.797

Fast gait STV (%)

2.1 ± 0.9

2.3 ± 1.1

2.4 ± 1.4

0.526

Dual-task gait STV (%)

3.9 ± 3.4

3.5 ± 1.9

3.5 ± 2.3

0.831

Values are given as mean ± standard deviation unless otherwise indicated Zero participants with no pain sites, Single participants with one pain site, Multi participants with two or more pain sites, Normal gait time taken to walk 10 m at normal gait speed, Fast gait time taken to walk 10 m at fast gait speed, Dual-task gait time taken to walk 10 m while counting backwards, Normal gait STV stride time variability in five strides when walking at normal gait speed, Fast gait STV stride time variability in five strides when walking at fast gait speed, Dual-task gait STV stride time variability in five strides when walking while counting backwards #

One-way analysis of variance was used to compare gait variables among pain groups

represents an important risk factor for falls in people with Parkinson’s disease and dementia [38, 39]. Attention resources may be only slightly affected by pain when healthy physical and motor conditions are maintained. Pain-related reductions in attention resources may not represent a risk factor for falls among older adults with NMF. Some limitations must be considered when interpreting the present findings. First, the occurrence of falls was not evaluated in a longitudinal manner. We investigated associations between nCMSP and history of falls during the previous year, but it remains uncertain whether older adults felt pain because of a fall-related injury or if the pain was a contributing factor to the fall. Second, the number of participants was relatively small. The number of participants (n = 112) was sufficient to conduct bivariate analysis, but insufficient to allow logistic regression modeling, because at least ten outcomes are needed for an independent variable. The extent to which the present results can be generalized remains unclear. Further investigation is clearly warranted. In conclusion, nCMSP represented a potential fall risk factor among older adults with NMF. These results indicate

that the consideration of musculoskeletal pain represents an important clinical index when assessing physical disability and risk of falls. Acknowledgments This study was supported by a Grant-in-Aid for Young Scientists (B) (22700685) from KAKENHI in Japan. We wish to thank all individuals who volunteered for the study. The following contributors to data collection, analysis, and manuscript preparation are gratefully acknowledged: T. Ogaya and Y. Fukumoto. Conflict of interest disclosed.

No potential conflicts of interest were

Human and Animal Rights This study was carried out in accordance with the principles of the Declaration of Helsinki and its later amendents. The Research Ethics Committee of Kobe Gakuin University approved the study (Approval No. HEB100806-1). Informed consent Informed consent was obtained from all participants prior to participation.

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Multi-chronic musculoskeletal pain is a useful clinical index to predict the risk of falls in older adults with normal motor function.

The number of chronic musculoskeletal pain sites (nCMSP) is reportedly associated with risk of falls. Older participants in community-based research s...
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