Elderly Spine Related Disability Thomas E. (Ted) Dreisinger, PhD, FACSM North American Spine Foundation 10 x 25 Spine Research Summit July 18, 2015 President.

Elderly Spine Related Disability

Thomas E. (Ted) Dreisinger, PhD, FACSM

North American Spine Foundation10 x 25 Spine Research Summit

July 18, 2015

President – Therapy AdvisorsTucson, AZ

– Debra Weiner, MDPsychiatry University of

Pittsburgh

“ Physical disability is one of the most feared consequences of aging…”

“We don’t cure chronic diseases, we manage them”

– Vert Mooney, MD

There is nothing to declare in this presentation

Objectives

• Disability in older adults

• Prevalence & Comorbidity

• Function and CLBP

Aging Trends

www.agingstats.gov/agingstatsdotnet/Main_Site/Data/2008_Documents/Population.aspx

• Average life expectancy in the developed world is increasing at a rate of 2 yr per decade

• By the year 2020, one in five of the population will be aged 65 yr and older

Effects of Aging

Anaerobic Threshold

Joint ROM

Max VO2

.

Muscleendurance,

force and power

Coordinationspeed of

movement

Static and dynamic balance

Greater perception of effort and lactate response to sub maximal aerobic work

Age related changes in physiology that impair functional

capacity

International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland: World Health Organization, 2013

Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, et al. American College of Sports Medicine position stand. Exercise and physical activity for older adults. Medicine and science in sports and exercise.

2009;41(7):1510-1530.

ICF Interactive Model

Health Condition(disorder/disease)

Body Functions and Structures

Activities Participation

Environmental

Factors

PersonalFactors

DisabilityFunctional consequences, abilities lost

International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland: World Health Organization, 2013

of Daily Living

Disability in Older Adults

1999

Rates

Cases30

27

24

21

18

15

1982 1984 1989 1994 2004

8.0

7.5

7.0

6.5

6.0

Dis

ab

led

ra

tes

(%)

Dis

ab

led

Ca

ses

(mill

ion

)

National Long-Term Care Survey (year)

28.3% reduction

Age adjusted Prevalence Rates vs Cases

Manton KG, Recent Declines in Chronic Disability in the Elderly U.S. Population: Risk Factors and Future Dynamics, Annu. Rev. Public Health 2008. 29, 91-113

7.5% points

34.6% growth in elderly population

Implies improving health among elderly

Self-reported well-being, on scale of 1-10

7.0

6.8

6.6

6.4

6.2

18-2

1

26-2

8

34-3

7

42-4

6

50-5

3

58-6

1

66-6

9

74-7

7

82-8

5

Age, yearsn = 340,847

Wellbeing and Aging

Stone AA, Schwartz JE, Broderick JE, Deaton A. A snapshot of the age distribution of psychological well-being in the United States. Proceedings of the National Academy of Sciences of the United States of America. 2010;107(22):9985-9990.

Global wellbeing• Overall judgement of

aspirations, achievements and current circumstances

State (Hedonic) wellbeing• Affective components

such as happiness and/or stress

Increased• Wisdom• Emotional Intelli-

gence and regula-tion

• Recall fewer nega-tive memories

BackPain Prevalence

100

80

60

40

20

0

Ba

ck p

ain

pre

vale

nce

(%

)

Age (years)

21

23

.5

24

.5

30

.5

34

.5

40

.5

44

.5

50

.5

54

.5

60

.5

64

.5

74

.5 83

85

90

100

80

60

40

20

0Ba

ck p

ain

pre

vale

nce

(%

)

Age (years)

17

20

22

24

.5 27

30

.5

39

.5 42

49

.5 52

57

60

.5

64

.5 72

75

81

82

.5 95

90

84

.5

Prevalence of mixed and benign back pain suggest a curvilinear arc

When severe episodes of back pain over the age of 60 are added to the mix, the trend continues to climb

Dionne CE, Dunn KM, Croft PR, Does back pain prevalence really decrease with increasing age? A systematic Review. Age and Ageing 2006; 35: 229–234

Degree of pain interference

Comorbidity in the Elderly

van den Bussche, et al. Which chronic diseases and disease combinations are specific to multimorbitity in the Elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 11:101,

2011

Comorbidity in the Elderly

HypertensionLipid metabolism disordersChronic low back painSevere vision reductionOsteoarthritisDibetes mellitusChronic ischemic heard diseaseThyroid dysfunctionCardiac arrhythmiasObesity

46 chronic conditions considered in studyPurine/pyrimidine metabolism disorders/goutProstatic hyperplasialower limb varicoseLiver diseaseDepressionAsthma/COPDNoninflammatory gynecological problemsAtherosclerosis/PAODOsteoporosisRenal Insufficiency

Cerebral ischemia/chronic strokeCardiac insufficiencySevere hearing lossChronic cholecystitis/GallstonesSomatoform disordersHemorrhoidsIntestinal diverticulosisRheumatoid arthritis/Chronic polyarthritisCardiac valve disordersNeuropathies

DizzinessDementiaUrinary incontinenceUrinary tract calculiAnemiaAnxietyPsoriasisMigrane/chronic headacheCancers

AllergiesChronic gastritis/GERDSexual dysfunctionInsomniaTobacco abuseHypotension

van den Bussche, et al. Which chronic diseases and disease combinations are specific to multimorbitity in the Elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 11:101,

2011

Comorbidity in the Elderly

Ranking chronic disease with at least three comorbid conditions

HypertensionLipid metabolism disordersChronic low back pain+ +1

OsteoarthritisHypertensionChronic low back pain+ +2

Lipid metabolism disorders OsteoarthritisChronic low back pain+ +6

Hypertension Chronic ischemic heart diseaseChronic low back pain+ +8

Hypertension Diabetes mellitusChronic low back pain+ +9

These data are in relative agreement with other multimorbitidy studies from Europe, the U.K.and the

Americasvan den Bussche, et al. Which chronic diseases and disease combinations are specific to multimorbitity in the Elderly? Results of a claims data based cross-sectional study in Germany. BMC Public Health 11:101,

2011

Chronic low back pain occupied 5 of the top 10

Function and CLBP• Disability leads to depression, fear

avoidance and reduced function (Amstein, Pain 1999; Camacho-Soto, PM R 2012)

• Modestly strong correlation between self reported pain and measured ADL specific tasks (Weiner, Pain Med 1996)

• Increased pain associated with standing in one place, pushing-pulling large objects, walking 1/2 mile (Edmond, J Am Geriatr Soc 2003)

• Self reported ‘perceived’ functional deficits not observed with measured functional performance (Weiner, Pain Med 2003)

Function and CLBP• CLBP elderly performed as well as NP in

static lift, dynamic lift, chair stand, gait speed and stair climb (Rudy, Pain Med 2007)

• At two years post rehabilitation, 72% of CLBP elderly continued active exercise (Mailloux, Am J Phys Med Rehabil 2007)

• Elderly women performed aggressive lumbar strengthening safely with reductions in pain and increase in function - normalized to NP control (Holmes, J Spinal Disord 1996)

• Resistance training increases strength, aerobic capacity, flexibility and balance in elders.Mayer, Dtsch Arztebl Int. 2011: Morton Ozaki, Eur Rev

Aging Phys Act 2013; Fatouros, J Strength Cond Res 2006; Lee, J Phys Ther Sci 2013)

Rudy TE, et al. The impact of Chronic low back pain on older adults: A comparative study of patients and controls. Pain 131(3), 293-301, 2007

Function and CLBP

• Believe pain is part of aging process

• Slowly developing pathology• More robust coping mechanisms

Elderly with CLBP manage ADLs in spite of pain (Rudy Pain 2007)

Function and CLBP

Singh, J Gerontol 2002; Pedersen Scand J Med Sci Sports 2006; Chodzko-Zajko Med sci in sports and exer. 2009; Sari, Maturitas 2011

Aggressive exercise should be seen as a barrier to the progression of CLBP and

therefore disability in the elderly

• Disability is a complex multivariate phenomenon

• While data on younger adults for fear avoidance, depression and functional performance have been studied, the elderly spine disabled have received less attention

• It is clear, however, elderly patients with CLBP respond well to aggressive exercise programs geared to improve strength, endurance, flexibility and balance

• Aggressive safely administered exercise is key to maintain function as long as possible

Rudy TE, et al. The impact of Chronic low back pain on older adults: A comparative study of patients and controls. Pain 131(3), 293-301, 2007

Conclusions

In the end, it is not death…

but rust we fear the most!