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Pain Medicine 2014; 15: 1861–1871 Wiley Periodicals, Inc.

PAIN & AGING SECTION Original Research Article The Avoidance of Activities due to Fear of Falling Contributes to Sedentary Behavior among Community-Dwelling Older Adults with Chronic Musculoskeletal Pain: A Multisite Observational Study Brendon Stubbs, BSc (Hons), MSc, MCSP,* Sandhi Patchay, PhD,† Andy Soundy, PhD,‡ and Pat Schofield, PhD§ *School of Health and Social Care, †Departments of Psychology and §Nursing, University of Greenwich; ‡ Department of Physiotherapy, University of Birmingham, London, UK Reprint requests to: Brendon Stubbs, BSc (Hons), MSc, MCSP, School of Health and Social Care, University of Greenwich, Avery Hill Site, Gray Building, London SE9 2UG, UK. Tel: 0044 2008 333300; Fax: 0044 1604 696126; E-mail: [email protected]; [email protected]. Disclosure: None to declare from any author. Funding: BS is supported by a Vice Chancellors scholarship at the University of Greenwich, but this has no influence on the research at any stage or decision to publish.

Abstract Objective. Physical inactivity and sedentary behavior (SB) are leading causes of mortality. We investigated if older adults with chronic musculoskeletal pain (CMP) are more sedentary than a group of similar age and sex without CMP and possible contributory factors to this. Method. In this multisite observational study, 285 community-dwelling older adults (response rate 71%) took part. One hundred forty-four had CMP (78.4 years, 65.9% female), and 141 formed the comparison group without CMP. Details regarding falls were collected, and all participants completed the

brief pain inventory (BPI), modified version of the survey of activities and fear of falling in elderly scale (mSAFFE), and the International Physical Activity Questionnaire (IPAQ) to measure SB. Data were analyzed with hierarchical regression analysis. Results. Older adults with CMP spent approximately 3 1/2 hours a day more being sedentary than the comparison group (11.5 hours vs 7.9, P < 0.001). The addition of BPI interference and mSAFFE scores in the regression analysis resulted in an R2 change of 10.4% in IPAQ scores, over and above the variance explained by the background demographic, medical, and mobility factors. Excessive concerns about the consequences of falling did not increase the variance in SB. Within the final model, mSAFFE scores were the largest independent predictor of SB (β = 0.461, P < 0.001). Conclusions. Older adults with CMP are significantly more sedentary than those of a similar sex and age without CMP. It appears that the avoidance of activities due to fear of falling is a significant contributory factor to SB in older adults with CMP. Key Words. Elderly; Chronic Pain; Exercise; Avoidance Behavior; Sedentary behavior; fear of falling

Introduction It is widely established that physical activity has a beneficial effect upon the health and quality of life of older adults [1–3]. Conversely, low levels of physical activity are related to adverse health and well-being and physical inactivity is the fourth leading cause of global mortality, accounting for approximately 3.2 million deaths every year [4]. Physical activity refers to “any bodily movement produced by skeletal muscles that results in energy expenditure” [5]. With an aging population, it is important that physical activity is promoted as it is associated with positive aging [2] and 1861

Stubbs et al. has a beneficial effect upon a range of the common and burdensome noncommunicable diseases such as cancer, cardiovascular disease, high blood pressure, obesity and diabetes [4,6–8]. In addition, physical activity prolongs independence [9] and reduces depressive symptoms in community-dwelling older adults [10]. Recently, interest has grown in reducing sedentary behavior among older adults due to emerging evidence that it is associated with adverse health outcomes independent from physical activity participation [8,11,12]. Sedentary behavior is distinct from physical activity and is defined as participation in activities such as sitting, lying down, and reclining during waking hours that do not increase energy expenditure substantially above an individual’s basal metabolic rate [12,13]. Chronic musculoskeletal pain is a pervasive issue among community-dwelling older adults affecting approximately 50% of those living in the community [14]. Chronic pain is defined as pain that has persisted beyond normal tissue healing time [15] lasting for at least the last month and for 3 of the previous 12 months [16,17]. Both the promotion of physical activity and the prevention of sedentary behavior are particularly pertinent issues among older adults with chronic musculoskeletal pain. For instance, previous research has demonstrated that physical inactivity is a risk factor for development of chronic musculoskeletal pain [18]. Physical activity is also recommended for both the prevention and management of chronic musculoskeletal pain [14,19]. A recent systematic review of 60 randomized controlled trials demonstrated that physical activity had a beneficial impact on pain and disability in older adults with lower limb osteoarthritis [20]. Given this, it is concerning that older adults with chronic musculoskeletal pain are significantly less active than those without pain [21]. To the best of the author’s knowledge, only one study has investigated sedentary behavior in older adults with chronic musculoskeletal pain [22]. The authors [22] found that that sedentary behavior is more common in older adults with chronic pain. However, little is also known about the multiple factors that contribute to sedentary behavior among older adults with chronic musculoskeletal pain. For some time, research in the pain literature has suggested that older adults with chronic musculoskeletal pain may engage in less physical activity due to fear avoidance [23]. Although a previous review [21] established that older adults with chronic pain engage in less physical activity, it remains unclear if they are more sedentary than those without pain and what the possible contributing factors are. Assuming that the finding of Ryan et al. [22] is replicated and older adults with chronic musculoskeletal pain are more sedentary, a number of possible explanatory factors could potentially contribute to this. A recent qualitative study by Chastin et al. [24] reported that pain is an important determining factor in sedentary behavior and often causes a lack of energy and social isolation. Although this provides a useful insight, quantitative research is required to establish if these results are generalizable. However, pain and particularly pain that interferes with activities of daily living may contribute to 1862

sedentary behavior as it is associated with increasing mobility limitations [25]. Pain that causes interferences was recently found to be associated with the avoidance of activities due to fear of falling (FOF) and increased concerns about the consequences of falling (CoF) [26]. The potential avoidance of activities and concerns due to FOF in older adults with chronic musculoskeletal pain seems a pertinent factor as recent meta-analyses have demonstrated that older adults with chronic musculoskeletal pain are at increased risk of falls [27,28]. Thus, in addition to the factors identified within the general population such as increasing age, more commodities, depressive symptoms, and higher body mass index (BMI) [11,29], it seems plausible that the increased risk of falling, avoidance of activities due to an FOF and pain interference could increase sedentary behavior among older adults with chronic musculoskeletal pain. With an aging global population and the substantial proportion of older adults affected by chronic musculoskeletal pain, the potential impact of sedentary behavior among this population is profound. However, this requires quantitative investigation. In recognition of this, this study had two aims: 1) to establish if older adults with chronic musculoskeletal pain spend significantly more time being sedentary than a group of similar age and sex without chronic musculoskeletal pain; and 2) to investigate the factors that may contribute to the increased sedentary behavior among older adults with chronic musculoskeletal pain. It was hypothesized that pain interference, avoidance of activity due to FOF and increased concerns about the CoF would all significantly contribute to sedentary behavior among older adults with chronic musculoskeletal pain over and above risk factors previously identified. We hypothesized that these would be independent predictors in the variance sedentary behavior in older adults with chronic musculoskeletal pain. Method Study Design This was a multisite cross-sectional study conducted in the United Kingdom. Procedure, Setting, and Participants Data were collected from 10 sites including five day centers, three community activity “clubs” for older adults; and two sheltered housing schemes. Data collection took place over an 8-month period (from May 2013 to December 2013). Prior to the commencement of the study, the principle investigator met with an identified manager and groups of potential participants at each center to discuss the aims and methods of the research. The manager at each center was aware of the eligibility criteria and advised the principal investigator on who would be eligible to participate in the study as they had an overview of each individual’s medical history and current well-being. Only people that were deemed eligible by the manager at each participating center were approached in this convenience sample.

Pain and Sedentary Behavior The inclusion criteria included individuals who were: 1) community-dwelling older adults (60 years old and above); 2) mobile over 10 meters or more with or without a mobility aid; and 3) able to provide informed consent and understand written and verbal English. Exclusion criteria included individuals with 1) dementia or mild cognitive impairment (including those demonstrating any signs of cognitive impairment as advised by the a manager at each center); 2) had a recent self-reported history of stroke or major surgery (in the past 6 months); 3) were terminally ill; 4) had a mental illness, or 5) were not suitable for any other reason as identified by the manager at each center. The principal investigator attended each site at an agreed time to undertake the data collection in a quiet location. At some sites, the appointments were prearranged with participants, whereas at other centers the primary investigator approached suitable participants to take part on that particular day. Data were collected over one session by the principal investigator following a standardized format lasting up to 60 minutes. All questionnaires were administered by the primary investigator to maximize understanding and participation. Before the official commencement of the research, the principal investigator enquired about the eligibility criteria for the study with each potential participant. If any potential participant appeared to not meet the eligibility criteria, they were excluded before the start of the research. Ethical approval was obtained from the University of Greenwich research and ethics committee, and informed written consent was obtained from each individual.

Previous research [35] has demonstrated small differences between self-report and objective-based BMI. Quality of Life and Depressive Symptoms Each individual completed the European Quality of Life Instrument [36] (EuroQoL EQ-5D). Participants rated how they perceived their overall health from 0 to 100 with higher scores indicating better health-related quality of life (HRQOL). In recognition that depression may affect both pain [37] and sedentary behavior [38], all participants rated their depressive symptoms on a Likert scale from 1 (I am not anxious or depressed) to 5 (I am severely anxious or depressed [36]). Chronic Musculoskeletal Pain Assessment and Classification All participants were assessed for chronic musculoskeletal pain in accordance with international pain assessment guidelines [14,39] and in line with previous research in community-dwelling older adults [17]. Information regarding the site, duration and interference upon activities of the pain were established. Details of pain across seven bodily locations were ascertained (hands and wrists, shoulders, hip, knee, back, neck, and foot pain), and chronic musculoskeletal pain was confirmed when participants reported that pain was present over the past month and for at least 3 of the preceding 12 months [16,17]. Those who did not have chronic musculoskeletal pain according to these criteria formed the comparison group. Brief Pain Inventory (BPI)

Demographic and Medical Information Details of participants demographic information was ascertained including age (years), gender (male/female), and current living arrangements (based on a single question considering if individuals live alone and answered either as yes or no). Participants were asked if they were aware they had various comorbidities associated with falls risk including: cardiac comorbidity, respiratory problems, osteoarthritis, osteoporosis, and degenerative spinal conditions [30]. Dizziness is known to influence falls risk, and each participant was asked a single question regarding any dizziness they were currently experiencing [31]. The total number of self-reported comorbidities was calculated for each individual. In accordance with previous research [32], participants were asked to provide details of all medications over the past 2 weeks, and a frequency count of the total number of medications was identified for each individual. We enquired about specific medications, including analgesics, and all answers were recorded as yes or no. The use of walking aids by each participant was classified as either yes or no. Vision is known to influence falls [33], and participants were also asked to rate their vision on a Likert scale from 1 to 5 (1 = vision is very good, 5 = very poor vision [34]). Participants were asked to provide details of their self-reported height and weight in line with previous research [35], and BMI was calculated.

In order to assess the interference of the pain upon activities, all participants completed the BPI interference subscale (seven items [40]). The BPI measures general pain rather than site specific and is validated for use in older adults [41]. The BPI refers to pain over the previous 24 hours, but in accordance with previous research [32], we enquired about pain over the preceding 2 weeks. The BPI interference subscale asks participants to rate how their pain has interfered with seven different activities on a scale from 0 (= no interference) to 10 (= completely interferes). The seven activities include the influence of pain on 1) general activity; 2) mood; 3) walking ability; 4) normal work; 5) relations with over people; 6) sleep; and 7) enjoyment of life. In order to provide a summary of the influence of pain interference on activities, the mean for the seven items was calculated in accordance with previous research [17,32]. History of Falls Each participant was asked “In the past 12 months, have you had any falls including a slip or trip in which you lost your balance and landed on the floor or ground or lower level?” [42]. Participants responding yes were classified as fallers. A fall was defined as “an unexpected event in which the participants come to rest on the ground, floor, or lower level” [42]. 1863

Stubbs et al. Functional Mobility Assessment All participants completed the timed up and go test (TUG) [43], which is commonly used to assess lower limb function and mobility in community-dwelling older adults. The test requires the participant to stand up from a chair, walk 3 meters, turn around, walk back, and sit down again, and the time taken is measured in seconds. Higher TUG scores are related to more substantial mobility limitations in older adults with chronic musculoskeletal pain [44]. Sedentary Behavior All participants completed the questions regarding sedentary behavior from the International Physical Activity Questionnaire (IPAQ) [45]. The questions enquire about the amount of time spent sitting per day over the previous week (hours and minutes per day). Participants were provided with examples of sitting behavior such as sitting at home (e.g., watching television and reading), at work (sitting at a desk), and during leisure time (e.g., visiting a friend) to aid their answer. In accordance with previous research [46], if participants were unable to answer due to variations in the pattern of sitting from day to day, they were asked “what is the total amount of time you spent sitting yesterday?” Previous research [47] has demonstrated that the IPAQ is a valid, reliable, and useful tool to assess sedentary behavior in community-dwelling older adults. FOF and Avoidance of Activities due to FOF The modified version of the survey of activities and FOF in elderly scale (mSAFFE [48]) was used with all participants to determine avoidance of activities due to FOF. The mSAFFE is a valid and reliable measure for communitydwelling older adults [48–50]. The mSAFFE consists of 17 items enquiring if a participant would avoid doing a range of daily activities in case they believe they will fall over. Scores for each item range from 1 (= would never avoid) to 3 (= always avoid), and total scores range from 17 (low avoidance due to FOF) to 51 (high avoidance due to FOF). Concerns about the CoF Scale All participants completed the CoF scale ([48]). The CoF scale consists of 12 items that measure concerns about the CoF among community-dwelling older adults. The CoF measures four types of fear including fear of physical injury, fear of long-term physical incapacity, subjective anxiety, and social discomfort [48,51]. Each item is rated on a 4-point scale (1 = strongly disagree to 4 = strongly agree), and higher scores represent more concerns about the CoF. The CoF is different from the mSAFFE because it measures fear regarding the CoF, whereas the mSAFFE measures behavioral avoidance due to FOF [49,51]. Statistical Analysis Tests of normality were conducted on the data including a visual inspection of PP plots, and skew and kurtosis were calculated for continuous data. The data were assessed for 1864

outliers, and 10 cases were subsequently removed due to incomplete/missing data [52]. Non-normally distributed data (TUG scores) were log transformed, and Levene’s test for homogeneity of variances was assessed. When these assumptions were satisfied, independent t-tests and χ2 tests were used to analyze differences in continuous and categorical data, respectively, between those with chronic musculoskeletal pain and the comparison group (aim 1). When these assumptions were not met, nonparametric equivalents were used. We conducted an exploratory subgroup analysis of variance with a post hoc Tukey test to investigate if IPAQ scores differed between the comparison group and the seven different sites of chronic musculoskeletal pain (hands and wrists, shoulders, hip, knee, back, neck, and foot pain). In order to investigate the predictors of sedentary behavior, a hierarchical multiple regression analysis was performed with the IPAQ scores as the dependent variable. Within the first step, demographic (age, living arrangement, and BMI), medical (number of comorbidities, number of medications, analgesic medication (yes/no), osteoarthritis (yes/ no), osteoporosis (yes/no), dizziness, depression rating, and vision rating), quality of life (EQ 5D scores), and mobility measures (walking aid use, TUG scores, and history of falls) were inserted into the model. In the second step, pain interference (BPI interference scores) and avoidance of activities due to FOF (mSAFFE) were inserted into the model, and we investigated the influence of these on sedentary behavior by noting the R2 change in the model. In the final step, we inserted the concerns about the consequences of falling scale scores (CoF) to investigate the R2 change in IPAQ scores. We report the standardized beta-coefficients for each independent variable to establish their significance within the hierarchical regression model. In order to assess for multicollinearity, we calculated the variation inflation factor (VIF) and tolerance for each model, ensuring this was within satisfactory ranges (VIF 0.2 [52]). Sample Size Calculation An a priori sample size calculation was conducted with G power software (Heinrich Heine University, Dusseldorf, Germany). Using an alpha of 0.05 with a power of 0.80, and a medium effect size of 0.5 based upon previous research [21], a t-test power calculation was determined that 64 participants were required to detect a difference between the two groups. The current study was adequately powered. Results A total of 401 community-dwelling older adults were invited to take part in the study, and 285 participants had valid data for the study (71.1%). Among those that were eligible but did not take part, 75 (18.7%) were not interested in participating in the research and declined the offer to participate. In addition, 31 (7.7%) participants met one or more of the exclusion criteria, and 10 participant’s data were incomplete and could not be used in the data analysis.

Pain and Sedentary Behavior Of the included sample, 144 individuals met the criteria for chronic musculoskeletal pain (50.5%), and 141 individuals did not have chronic musculoskeletal pain and formed the comparison group. Although none of the comparison group had chronic musculoskeletal pain, a small proportion (14.8%, 21/141) had some minor pain over the previous 4 weeks, with 10 participants having lower limb nonchronic pain (one participant had foot pain). There were not any significant differences in the age of older adults with chronic musculoskeletal pain (78.4 years) compared with the comparison group (76.6 years), nor in the proportion of females in each group. However, compared with the comparison group, those with chronic musculoskeletal pain were more likely to live alone (71.5% vs 58.5%, P = 0.02), more likely to wear glasses (68.1% vs 54.6%, P = 0.02), and use a walking aid (63.8% vs 26.2%, P < 0.001). In addition, the chronic musculoskeletal pain had more comorbidities than the comparison group (3.9 vs 2.8, P < 0.001), and they rated their overall health-related quality of life substantially below the comparison group (58.4 vs 79.7; P < 0.001). The older adults with chronic musculoskeletal pain reported moderate pain interference with a mean score across the BPI interference subscale of 4.8 (± 1.9). In addition, 70.8% (102/144) of older adults with chronic musculoskeletal pain were taking analgesic medication, 68.1% (98/144) reported “ok” or better vision and 43.7% (63/144) reported feelings of slight anxiety or depression or greater. A summary of the demographic and medical differences between the two groups are presented in Table 1. Mobility, Falls, Avoidance of Activities due to FOF, and Sedentary Behavior among Participants Considerably more people in the chronic musculoskeletal group (86/144, 59.7%) reported a history of falls compared with the comparison group (47/141, 33.3%,

Table 1

P < 0.001). Older adults with chronic musculoskeletal pain were significantly slower completing the TUG test with a mean time of 14.7 seconds compared with 10.9 seconds in the comparison group indicating more pronounced mobility limitations. The older adults reported experiencing significantly higher levels of avoidance of activities due to an FOF (28.5 ± 7.8) compared with the comparison group (21.7 ± 6.2; P < 0.001). Older adults with chronic musculoskeletal pain also expressed significantly higher levels of concerns about the CoF compared with the age- and sex-matched comparison group (32.1 vs 25.7; P < 0.001). Older adults with chronic musculoskeletal pain spent on average 11.5 hours a day being sedentary compared with 7.9 hours a day in the comparison group (P < 0.001). This equated to an increase of approximately 3.6 hours a day being sedentary in those with chronic musculoskeletal pain. The exploratory subgroup analysis demonstrated that compared with the comparison group, those with chronic foot pain (N = 17, 11.8 hours, P < 0.001), knee pain (N = 60, 11.6 hours, P < 0.001), back pain (N = 32, 10.3 hours, P = 0.009), and hip pain (N = 13, 11.3 hours, P = 0.016) were all significantly more sedentary. The summary of the mobility, falls history, psychological concerns related to falling and sedentary behavior outcomes are presented in Table 2.

Hierarchical Regression Analysis of Factors Contributing to Sedentary Behavior The background demographic, medical, and mobility risk factors for sedentary behavior explained a significant amount of the variance within the sedentary behavior (IPAQ scores) accounting for approximately 40.4% (F[15,126] = 5.68, P < 0.001, R2 = 0.404, adjusted R2 = 0.333). Within the first step of the model, the largest unique contribution to the model was made by TUG

Demographic, medical, and health-related quality of life measures among the groups

Variable Age (years, SD) Females, N (%) Live alone, N (%) Wear glasses, N (%) Cardiac comorbidity, N (%) Respiratory comorbidity, N (%) Osteoarthritis, N (%) Osteoporosis Degenerative disc/spinal problems, N (%) Number of comorbidities, N ± SD Walking aid use, N (%) Overall HRQOL (± SD) BPI interference (± SD)

Comparison group (N = 141) 76.71 ± 8.51 95 (67.4%) 83 (58.8%) 77 (54.6%) 23 (16.3%) 19 (13.5%) 36 (25.5%) 16 (11.3%) 15 (10.6%) 2.79 ± 1.39 37 (26.2%) 79.74 ± 15.68

Chronic musculoskeletal pain group (N = 144) 78.47 ± 7.82 95 (65.9%) 103 (71.5%) 98 (68.1%) 59 (40.9%) 30 (20.8) 94 (65.2%) 32 (22.2%) 36 (25%) 3.93 ± 1.22 92 (63.8%) 58.42 ± 20.70 4.8 ± 1.9

P value 0.07 0.9 0.026 0.02 < 0.001 0.11 < 0.001 0.03 0.02 < 0.001 ≠ < 0.001 < 0.001

SD = standard deviation; N = number; HRQOL = health-related quality of life; BPI interference = brief pain interference subscale; ≠ = nonparametric test used.

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Table 2

Falls, psychological concerns related to falling and sedentary behavior among participants

Variable

Comparison group (N = 141)

Chronic musculoskeletal pain group (N = 144)

P value

Sitting time per day (hours a day, ± SD) History of falls, N (%) Timed up and go (seconds ± SD) CoF scale (± SD) mSAFFE (± SD)

7.93 ± 3.78 47 (33.3%) 10.96 ± 4.46 25.7 ± 5.9 21.76 ± 6.2

11.5 ± 3.0 86 (59.8%) 14.77 ± 6.32 32.1 ± 5.1 28.55 ± 7.8

< 0.001 < 0.001 < 0.001 < 0.001 < 0.001

SD = standard deviation; CoF = consequences of falling scale; N = number; mSAFFE = survey of activities and fear of falling in elderly scale; ≠ = nonparametric test used.

scores (β = 0.287, P < 0.001) followed by HRQOL scores (β = −0.254, P = 0.002), which was negatively associated with sedentary behavior.

ized beta-coefficients for the final model and unique contribution of each of the independent variables are presented in Table 3.

The introduction of the BPI interference and mSAFFE scores at the second step contributed to a significant increase in the variance explained within the IPAQ scores from 40.4% to 50.8% equating to an R2 change of 10.4% (F[2,124] = 13.1, P < 0.001; adjusted R2 = 0.441). Within the fully adjusted model, the mSAFFE scores were the largest independent significant predictor of sedentary behavior (β = 0.461, P < 0.001). Other significant contributors to the variance in sedentary behavior in the final model were HRQOL (β = −0.226, P = 0.002), TUG scores (β = 0.206, P = 0.012), and BMI (β = 0.157, P = 0.038). The standard-

Finally, we inserted the CoF scores into the model, but this did not make any detectable or significant change in the variance in the IPAQ scores (R2 change = 0.01, F[1,123] = 0.148, P = 0.701) and actually decreased the adjusted R2 from 0.441 to 0.437. Discussion Within this study, we found that older adults with chronic musculoskeletal pain spend approximately 3 1/2 hours a day more being sedentary than a comparison group

Table 3 Summary of hierarchical regression analysis for variables predicting sitting time in older adults with chronic musculoskeletal pain Step 1

Step 2

Variable

B

SE B

β

Constant Age years Gender Number of comorbidity Number medications History of falls Walking aid Dizziness HRQOL Timed get up and go Pain medication Anxiety and depression BMI Vision rating Osteoarthritis Osteoporosis BPI pain interference mSAFFE

540.180 1.288 12.392 20.944 6.378 29.450 55.263 −16.245 −2.222 8.217 −24.214 28.808 −4.427 4.455 −50.607 −25.766

190.501 1.866 28.596 14.317 7.992 27.474 32.213 12.742 0.685 2.485 29.690 15.514 3.384 16.241 30.824 33.213

0.055 0.032 0.142 0.071 0.080 0.147 −0.092 −0.254** 0.287*** −0.061 0.141 0.104 0.020 −0.133 −0.060

B

SE B

β

516.463 0.453 −14.845 6.972 10.097 17.306 17.495 −11.715 −1.972 5.903 −11.553 −3.440 −6.722 14.290 −55.546 −28.824 −3.699 10.613

174.913 1.722 26.775 13.401 7.354 26.115 30.944 11.764 0.633 2.320 27.708 15.586 3.204 14.994 28.250 30.436 7.627 2.083

0.019 −0.039 0.047 0.113 0.047 0.047 −0.066 −0.226** 0.206* −0.029 −0.017 0.157* 0.066 −0.146 −0.067 0.038 0.461***

* P < 0.05; ** P < 0.01; *** P < 0.001. Significant predictors are underlined. B and SE (standard error) B = unstandardized coefficients; β = standardized beta coefficients; HRQOL = health-related quality of life; BPI = brief pain inventory; mSAFFE = modified version of the survey of activities and fear of falling in elderly scale.

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Pain and Sedentary Behavior without chronic musculoskeletal pain of similar age and sex. The hierarchical regression analysis demonstrated that the introduction of pain interference and avoidance of activities due to FOF (mSAFFE scores) significantly increased the variance in the time older adults spend sitting each day with an R2 change of 10.4%. Within the fully adjusted model, mSAFFE scores were the largest significant predictor in sedentary behavior in older adults with chronic musculoskeletal pain. Surprisingly, however, pain interference was not an independent predictor of sedentary behavior. The addition of the CoF scores (concerns about the CoF scale) did not increase the variance observed within the amount of time older adults with chronic musculoskeletal pain were sedentary. These results provide provisional evidence that the avoidance of activities due to FOF is an important and significant contributor to sedentary behavior among older adults with chronic musculoskeletal pain. Relevance of Sedentary Behavior among Older Adults with Chronic Musculoskeletal Pain The amount of time that both those with and without chronic musculoskeletal pain in our study spent being sedentary is high and concerning. However, a recent meta-analysis [29] established that 65% of older adults in the general population spend in excess of 8.5 hours of their waking day being sedentary and those in the comparison group spent almost 8 hours per day being sedentary in our study. Older adults with chronic musculoskeletal pain were sedentary on average over 11 hours sitting during their waking hours. Our finding that older adults with chronic musculoskeletal pain are substantially more sedentary than those without chronic musculoskeletal pain may be of interest to clinicians, researchers, and policymakers for several reasons. First, sedentary behavior is associated with an increased risk of cardiovascular disease, obesity, and premature mortality [4,29]. Second, physical inactivity is related to the progression of disability [53] in people with chronic musculoskeletal pain. In addition, promoting physical activity is central to the management of chronic musculoskeletal pain [14] and reduces both pain and disability [20]. To our knowledge, only one study has previously investigated sedentary behavior in a sample of older adults with chronic musculoskeletal pain [22]. The authors found that sedentary behavior was high among older adults with chronic musculoskeletal pain and was an independent predictor of cardiovascular disease in older adults but not middle-aged adults. As sedentary behavior is a potential modifiable lifestyle factor that may reduce the risk of cardiovascular disease, it should be taken seriously. Clinicians should seek to encourage those with chronic pain to break up prolonged periods of sedentary behavior and engage in physical activity that can be adapted to the individuals needs ensuring it is safe. This could include any activity that increases their energy expenditure that they enjoy. Within the general older adult literature, there is overwhelming robust evidence that structured physical activity (exercise) reduces falls [54], including injurious falls [55] and is as effective on reducing mortality as some medications, including cardiovascular

disease [56]. However, there have been some reports in the literature that increasing physical activity may lead to falls [57]. If the clinician has concerns about the older persons’ falls risk. a physical therapists could oversee this process ensuring the safe implementation of physical activity. The education of the older adults with chronic musculoskeletal pain to disrupt sedentary behavior should also play a role. The need for this is exemplified in a recent qualitative study that established that older adults engaged in sedentary behavior to manage chronic musculoskeletal pain [24]. However, in this study, the participants did not see excessive sitting as being detrimental to their wider health and only acknowledged it may be harmful for them due to a worsening of pain and stiffness.

Possible Reasons for the Excessive Sedentary Behavior among Older Adults with Chronic Musculoskeletal Pain Our study provides some provisional explanation of the possible reasons why older adults with chronic musculoskeletal pain are more sedentary. Much in accordance with the chronic pain literature, our sample had a higher incidence of past falls, poor mobility, and increased depressive symptoms. When conducting the hierarchical regression analysis and all other factors were controlled for (including age, comorbidities, BMI, depressive symptoms, medications, and falls history), the avoidance of activities due to FOF remained the largest single predictor of sedentary behavior. However, this increased avoidance of activities due to an FOF may in part be warranted as numerous authors have established that pain is associated with an increased risk of falls [17,27,28,58–60], and others have found that older adults with chronic musculoskeletal pain have increased mobility limitations [25,44]. Within the wider literature, previous research has demonstrated that many for older adults FOF is commensurate with their physiological risk of falls [61]. Interestingly, although numerous authors have found that pain intensity increases the risk of falls [17,58] we did not find that it accounted for an increased amount of time spent being sedentary in the sample with pain. Reasons for this finding are unclear, but it may suggest that the other factors (particularly avoidance due to FOF and mobility limitations) may have a more important contribution to sedentary behavior, although pain interference undoubtedly contributes to these factors themselves. Thus, clearly the relationship is between chronic pain, mobility factors, avoidance of activities due to FOF, and sedentary behavior is complex, multifaceted, and some of these relationships are almost certainly bidirectional. Although our model explained 50.8% of the variance in sedentary behavior, there are almost certainly other factors that could contribute such as gait disturbances, medications, and muscle strength. In order to clearly elucidate the influence of the contributing factors to sedentary behavior, prospective longitudinal research is required to disentangle these complex relationships and answer 1867

Stubbs et al. the questions that we could not. Future research should include a particular focus on physiological falls risk factors. In line with the literature, we also found that avoidance due to FOF was a more important predictor than concerns about the consequences of falling over [62]. In the wider pain literature, Sions and Hicks [23] recently established that older adults with chronic low back pain that experienced fear-avoidance beliefs significantly increased their falls risk. However, to our knowledge, we are the first authors to establish that fear avoidance due to FOF contributes to the increased amount of sedentary behavior in older adults with chronic musculoskeletal pain. Taken together, the impact of chronic pain in older age on mobility [44], falls risk [27,28], physical activity [21], and now sedentary behavior is becoming increasingly evident. Thus, in response to this, multidisciplinary teams providing clinical care for older adults with chronic pain should seek to address these factors that may arise. Although this is the first study to establish that avoidance of activities due to FOF contributes to excessive sedentary behavior among older adults with chronic musculoskeletal pain, there are several limitations that need to be considered when interpreting the results. First, despite the fact that we made numerous attempts to ensure that we did not recruit participants with cognitive impairment and/or dementia, it is possible that some people with a degree of cognitive impairment entered the study. Second, although self-report measures to capture sedentary behavior have been used extensively in older adults [29], there are some concerns about this approach. We attempted to reduce this concern by using the IPAQ, which psychometric properties have been established in the general older adult population [47]. Despite this, the reliability and validity of the IPAQ in older adults with chronic musculoskeletal pain is unestablished. Third, this study employed a crosssectional design and so the directionality of the associations cannot be deduced with certainty. Fourth, the study participants were self-selected and did not include a random sample. Fifth, it was not possible to investigate the influence of specific pain medication (particularly anticonvulsants and opioids) on sedentary behavior. Future research should consider the influence of these and other types of medication on sedentary behavior. Finally, the principal investigator collected all data, and this may have introduced bias. Clinical Implications and Future Research Our results provide provisional evidence that avoidance of activities due to FOF appears to be an important contributing factor to the excessive sedentary behavior in older adults with chronic musculoskeletal pain. With this in mind, clinicians should consider addressing fear avoidance with patients while also decreasing their risk of falls and mobility limitations. In order for this to be successful, this should incorporate pain management strategies. Physical activity programs that meet the individual prefer1868

ences should be central to this as it can reduce pain and disability [20] and decrease falls risk [54]. Education and increasing self-efficacy is likely to be essential to achieve this particularly if older adults believe that physical activity is harmful to them. Future prospective studies should seek to establish the influence of chronic musculoskeletal pain on sedentary behavior and the contributing factors with a particular emphasis on the avoidance of activities due to an FOF. This should seek to use an objective measure of sedentary behavior and falls should be monitored prospectively using falls calendars. Qualitative research with a purposive sample of older adults with chronic musculoskeletal pain may also help disentangle the relationship between pain, falls, avoidance of activities due to FOF, and sedentary behavior. Conclusion The results from this study demonstrate that older adults with chronic musculoskeletal pain spend over 11 hours a day being sedentary. This represents approximately 3 1⁄2 hours more than a comparable group of similar age without chronic musculoskeletal pain. The avoidance of activities due to FOF appears to be the major contributing factor to this excessive sedentary behavior. With an aging population, the high proportion affected by chronic musculoskeletal pain and the fact that physical inactivity is a leading cause of avoidable death, future research is urgently required to disentangle this relationship and prevent sedentary behavior in older adults with chronic musculoskeletal pain. Acknowledgments We would like to thank the participants who took part in the study and the respective scheme managers for their support at each center. References 1 Hallal PC, Bo Andersen L, Bull FC, et al. Global physical activity levels: Surveillance progress, pitfalls, and prospects. Lancet 2012;380:247–57. 2 Dogra S, Stathokostas L. Sedentary behavior and physical activity are independent predictors of successful aging in middle-aged and older adults. J Aging Res 2012;2012:190654. 3 Kennedy AB, Blair SN. Motivating people to exercise. Am J Lifestyle Med 2014; in press. 4 World Health Organisation (WHO). WHO. 10 facts on physical activity. 2014. Available at: http://www.who. int/features/factfiles/physical_activity/en/ (accessed August 2014). 5 Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: Definitions and distinctions for health-related research. Public Health Rep 1985;100:126–31.

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