Advertisement

Journal of General Internal Medicine

, Volume 34, Issue 1, pp 90–97 | Cite as

Association of Back Pain with All-Cause and Cause-Specific Mortality Among Older Women: a Cohort Study

  • Eric J. RoseenEmail author
  • Michael P. LaValley
  • Shanshan Li
  • Robert B. Saper
  • David T. Felson
  • Lisa Fredman
  • For the Study of Osteoporotic Fractures
Original Research

Abstract

Background

The impact of back pain on disability in older women is well-understood, but the influence of back pain on mortality is unclear.

Objective

To examine whether back pain was associated with all-cause and cause-specific mortality in older women and mediation of this association by disability.

Design

Prospective cohort study.

Setting

The Study of Osteoporotic Fractures.

Participants

Women aged 65 or older.

Measurement

Our primary outcome, time to death, was assessed using all-cause and cause-specific adjusted Cox models. We used a four-category back pain exposure (no back pain, non-persistent, infrequent persistent, or frequent persistent back pain) that combined back pain frequency and persistence across baseline (1986–1988) and first follow-up (1989–1990) interviews. Disability measures (limitations of instrumental activities of daily living [IADL], slow chair stand time, and slow walking speed) from 1991 were considered a priori potential mediators.

Results

Of 8321 women (mean age 71.5, SD = 5.1), 4975 (56%) died over a median follow-up of 14.1 years. A higher proportion of women with frequent persistent back pain died (65.8%) than those with no back pain (53.5%). In the fully adjusted model, women with frequent persistent back pain had higher hazard of all-cause (hazard ratio [HR] = 1.24 [95% CI, 1.11–1.39]), cardiovascular (HR = 1.34 [CI, 1.12–1.62]), and cancer (HR = 1.33, [CI 1.03–1.71]) mortality. No association with mortality was observed for other back pain categories. In mediation analyses, IADL limitations explained 47% of the effect of persistent frequent back pain on all-cause mortality, slow chair stand time, and walking speed, explained 27% and 24% (all significant, p < 0.001), respectively.

Limitations

Only white women were included.

Conclusion

Frequent persistent back pain was associated with increased mortality in older women. Much of this association was mediated by disability.

KEY WORDS

back pain mortality disability mediation 

Notes

Acknowledgements

We thank the participants and staff of the Study of Osteoporotic Fractures and Tuhina Neogi MD PhD for her thoughtful review of this manuscript.

Author Contributions

Drs. Roseen and Fredman had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Roseen, LaValley, Saper, Felson, and Fredman.

Acquisition, analysis, or interpretation of data: Roseen, LaValley, Saper, Li, Felson, and Fredman.

Drafting of the manuscript: Roseen and Fredman.

Critical revision of the manuscript for important intellectual content: Roseen, LaValley, Saper, Li, Felson, and Fredman.

Statistical analysis: Roseen, LaValley, Li, and Fredman.

Obtained funding: n/a.

Administrative, technical, or material support: Roseen and Fredman.

Study supervision: Roseen and Fredman.

Funding/Support

The Study of Osteoporotic Fractures (SOF) is supported by National Institutes of Health funding. The National Institute on Aging (NIA) provides support under the following grant numbers: R01 AG005407, R01 AR35582, R01 AR35583, R01 AR35584, R01 AG005394, R01 AG027574, R01 AG027576, and R01 AG026720. Dr. Roseen is supported by a Ruth L. Kirschstein National Research Service Award (1F32AT009272) from the National Center for Complementary and Integrative Health (NCCIH) and by the Boston University Clinical and Translational Science Institute (CTSI) Clinical Research Training Program (1UL1TR001430).

Compliance with Ethical Standards

This study was approved by the Institutional Review Boards at each SOF clinical site and at Boston University Medical Campus.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Disclaimer

The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of NIA or NCCIH.

Supplementary material

11606_2018_4680_MOESM1_ESM.docx (721 kb)
ESM 1 (DOCX 720 kb)

References

  1. 1.
    GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388:1545–1602.CrossRefGoogle Scholar
  2. 2.
    Hoy D, Bain C, Williams G, et al. A systematic review of the global prevalence of low back pain. Arthritis Rheum 2012;64(6): 2028–2037.CrossRefGoogle Scholar
  3. 3.
    Merrill SS, Seeman TE, Kasl SV, Berkman LF. Gender differences in the comparison of self-reported disability and performance measures. J Gerontol A Biol Sci Med Sci 1997;52(1):M19–26.CrossRefGoogle Scholar
  4. 4.
    Fillingim RB, King CD, Ribeiro-Dasilva MC, Rahim-Williams B, Riley JL. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10(5):447–485.CrossRefGoogle Scholar
  5. 5.
    Makris UE, Fraenkel L, Han L, Leo-Summers L, Gill TM. Epidemiology of restricting back pain in community-living older persons. J Am Geriatr Soc 2011;59(4):610–614.CrossRefGoogle Scholar
  6. 6.
    Patel KV, Guralnik JM, Dansie EJ, Turk DC. 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(12):2649–2657.CrossRefGoogle Scholar
  7. 7.
    Di Iorio A, Abate M, Guralnik JM, et al. From chronic low back pain to disability, a multifactorial mediated pathway: the InCHIANTI study. Spine. 2007;32(26):E809–815.CrossRefGoogle Scholar
  8. 8.
    Astrand NE, Isacsson SO. Back pain, back abnormalities, and competing medical, psychological, and social factors as predictors of sick leave, early retirement, unemployment, labour turnover and mortality: A 22 year follow up of male employees in a Swedish pulp and paper company. Br J Ind Med. 1988; 45(6):387–395.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Penttinen J. Back pain and risk of fatal ischaemic heart disease: 13 year follow up of Finnish farmers. BMJ. 1994;309(6964):1267–1268.CrossRefGoogle Scholar
  10. 10.
    Heliovaara M, Makela M, Aromaa A, Impivaara O, Knekt P, Reunanen A. Low back pain and subsequent cardiovascular mortality. Spine. 1995;20(19):2109–2111.CrossRefGoogle Scholar
  11. 11.
    Torrance N, Elliott AM, Lee AJ, Smith BH. Severe chronic pain is associated with increased 10 year mortality. A cohort record linkage study. Eur J Pain. 2010;14(4):380–386.CrossRefGoogle Scholar
  12. 12.
    Kareholt I, Brattberg G. Pain and mortality risk among elderly persons in Sweden. Pain. 1998;77(3):271–278.CrossRefGoogle Scholar
  13. 13.
    Fernandez M, Boyle E, Hartvigsen J, et al. Is this back pain killing me? All-cause and cardiovascular-specific mortality in older Danish twins with spinal pain. Eur J Pain. 2017;21(5):938–948.CrossRefGoogle Scholar
  14. 14.
    Zhu K, Devine A, Dick IM, Prince RL. Association of back pain frequency with mortality, coronary heart events, mobility, and quality of life in elderly women. Spine. 2007;32(18):2012–2018.CrossRefGoogle Scholar
  15. 15.
    Docking RE, Fleming J, Brayne C, et al. The relationship between back pain and mortality in older adults varies with disability and gender: results from the Cambridge City over-75s Cohort (CC75C) study. Eur J Pain. 2015;19(4):466–472.CrossRefGoogle Scholar
  16. 16.
    Jordan KP, Croft P. Mortality and cancer in patients with new musculoskeletal episodes: a cohort study. Br J Gen Pract. 2010;60(572):e105–111.CrossRefGoogle Scholar
  17. 17.
    Jette AM. Toward a common language of disablement. J Gerontol A Biol Sci Med Sci 2009;64(11):1165–1168.CrossRefGoogle Scholar
  18. 18.
    Cummings SR, Black DM, Nevitt MC, et al. Appendicular bone density and age predict hip fracture in women. The Study of Osteoporotic Fractures Research Group. JAMA. 1990;263(5):665–668.CrossRefGoogle Scholar
  19. 19.
    Kado DM, Browner WS, Palermo L, Nevitt MC, Genant HK, Cummings SR. Vertebral fractures and mortality in older women: a prospective study. Study of Osteoporotic Fractures Research Group. Arch Intern Med. 1999; 159(11):1215–1220.CrossRefGoogle Scholar
  20. 20.
    Ensrud KE, Nevitt MC, Yunis C, et al. Correlates of impaired function in older women. J Am Geriatr Soc. 1994; 42(5):481–489.CrossRefGoogle Scholar
  21. 21.
    Cesari M, Kritchevsky SB, Penninx BW, et al. Prognostic value of usual gait speed in well-functioning older people – results from the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2005;53(10):1675–1680.CrossRefGoogle Scholar
  22. 22.
    Cesari M, Kritchevsky SB, Newman AB, et al. Added value of physical performance measures in predicting adverse health-related events: results from the Health, Aging and Body Composition Study. J Am Geriatr Soc. 2009;57(2):251–259.CrossRefGoogle Scholar
  23. 23.
    Allison PD. Survival Analysis Using SAS: A Practical Guide, Second Edition. Crary, NC. SAS Institute Inc. 2010.Google Scholar
  24. 24.
    Vanderweele TJ. Explanation in Causal Inference: Methods for Mediation and Interaction. New York, NY: Oxford University Press. 2015.Google Scholar
  25. 25.
    Valeri L, VanderWeele TJ. SAS macro for causal mediation analysis with survival data. Epidemiology. 2015;26(2):e23–24.CrossRefGoogle Scholar
  26. 26.
    Kado DM, Huang MH, Karlamangla AS, Barrett-Connor E, Greendale GA. Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. J Am Geriatr Soc. 2004; 52(10):1662–1667.CrossRefGoogle Scholar
  27. 27.
    Kado DM, Lui LY, Ensrud KE, et al. Hyperkyphosis predicts mortality independent of vertebral osteoporosis in older women. Ann Intern Med. 2009;150(10):681–687.CrossRefGoogle Scholar
  28. 28.
    Nuesch E, Dieppe P, Reichenbach S, Williams S, Iff S, Juni P. All cause and disease specific mortality in patients with knee or hip osteoarthritis: population based cohort study. BMJ. 2011;342:d1165.CrossRefGoogle Scholar
  29. 29.
    Barbour KE, Lui LY, Nevitt MC, et al. Hip osteoarthritis and the risk of all-cause and disease-specific mortality in older women: a population-based cohort study. Arthritis Rheumatol. 2015;67(7): 1798–1805.CrossRefGoogle Scholar
  30. 30.
    Hoeven TA, Leening MJ, Bindels PJ, et al. Disability and not osteoarthritis predicts cardiovascular disease: A prospective population-based cohort study. Ann Rheum Dis. 2015; 74(4):752–756.CrossRefGoogle Scholar
  31. 31.
    Weiner DK, Haggerty CL, Kritchevsky SB, et al. How does low back pain impact physical function in independent, well-functioning older adults? Evidence from the Health ABC Cohort and implications for the future. Pain Med. 2003;4(4):311–320.CrossRefGoogle Scholar
  32. 32.
    Scudds RJ, Robertson JM. Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens. Pain. 1998;75(2–3):229–235.CrossRefGoogle Scholar
  33. 33.
    Edmond SL, Felson DT. Function and back symptoms in older adults. J Am Geriatr Soc. 2003;51(12):1702–1709.CrossRefGoogle Scholar
  34. 34.
    Cooper R, Strand BH, Hardy R, Patel KV, Kuh D. Physical capability in mid-life and survival over 13 years of follow-up: British birth cohort study. BMJ. 2014;348:g2219.CrossRefGoogle Scholar
  35. 35.
    Feeny D, Huguet N, McFarland BH, Kaplan MS, Orpana H, Eckstrom E. Hearing, mobility, and pain predict mortality: a longitudinal population-based study. J Clin Epidemiol. 2012;65(7):764–777.CrossRefGoogle Scholar
  36. 36.
    Ensrud KE, Lui LY, Paudel ML, et al. Effects of mobility and cognition on risk of mortality in women in late life: a prospective study. J Gerontol A Biol Sci Med Sci. 2016;71(6):759–765.CrossRefGoogle Scholar
  37. 37.
    Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011;305(1):50–58.CrossRefGoogle Scholar
  38. 38.
    Arem H, Moore SC, Patel A, et al. Leisure time physical activity and mortality: a detailed pooled analysis of the dose-response relationship. JAMA Intern Med. 2015;175(6):959–967.CrossRefGoogle Scholar
  39. 39.
    Moore SC, Lee IM, Weiderpass E, et al. Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016;176(6):816–825.CrossRefGoogle Scholar
  40. 40.
    Smith D, Wilkie R, Uthman O, Jordan JL, McBeth J. Chronic pain and mortality: A systematic review. PLoS One. 2014;9(6):e99048.CrossRefGoogle Scholar
  41. 41.
    Johnson ZI, Schoepflin ZR, Choi H, Shapiro IM, Risbud MV. Disc in flames: Roles of TNF-α and IL-1β in intervertebral disc degeneration. Eur Cells Mater. 2015;30:104–117.CrossRefGoogle Scholar
  42. 42.
    Dudli S, Fields AJ, Samartzis D, Karppinen J, Lotz JC. Pathobiology of Modic changes. Eur Spine J. 2016;25(11):3723–3734.CrossRefGoogle Scholar
  43. 43.
    Couzin-Frankel J. Inflammation bares a dark side. Science. 2010;330(6011):1621.CrossRefGoogle Scholar
  44. 44.
    Pinquart M. Correlates of subjective health in older adults: a meta-analysis. Psychol Aging. 2001;16(3):414–426.CrossRefGoogle Scholar
  45. 45.
    Schnittker J. When Mental Health Becomes Health: Age and the Shifting Meaning of Self-Rated Health. Milbank Q. 2005; 83:397–423.CrossRefGoogle Scholar
  46. 46.
    Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166:514–530.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Eric J. Roseen
    • 1
    Email author
  • Michael P. LaValley
    • 2
  • Shanshan Li
    • 3
  • Robert B. Saper
    • 1
  • David T. Felson
    • 3
  • Lisa Fredman
    • 4
  • For the Study of Osteoporotic Fractures
  1. 1.Department of Family Medicine Boston Medical Center, One Boston Medical Center PlaceBostonUSA
  2. 2.Department of BiostatisticsBoston University School of Public HealthBostonUSA
  3. 3.Clinical Epidemiology Research and Training UnitBoston University School of MedicineBostonUSA
  4. 4.Department of EpidemiologyBoston University School of Public HealthBostonUSA

Personalised recommendations