Abstract
the aim of this study was to identify whether factors beyond anatomical abnormalities are associated with low back pain (LBP) and LBP with sciatica (SCI) in older men.
Mister Osteoporosis Sweden includes 3,014 men aged 69–81 years. They answered questionnaires on lifestyle and whether they had experienced LBP and SCI during the preceding 12 months. About 3,007 men answered the back pain (BP) questions, 258 reported BP without specified region. We identified 1,388 with no BP, 1,361 with any LBP (regardless of SCI), 1,074 of those with LBP also indicated if they had experienced LBP (n = 615), LBP+SCI (n = 459).
about 49% of those with LBP and 54% of those with LBP+SCI rated their health as poor/very poor (P < 0.001). Men with any LBP to a greater extent than those without BP had poor self-estimated health, depressive symptoms, dizziness, fall tendency, serious comorbidity (diabetes, stroke, coronary heart disease, pulmonary disease and/or cancer) (all P < 0.001), foreign background, were smokers (all P < 0.01), had low physical activity and used walking aids (all P < 0.05). Men with LBP+SCI to a greater extent than those with LBP had lower education, lower self-estimated health, comorbidity, dizziness and used walking aids (all P < 0.001).
in older men with LBP and SCI, anatomical abnormalities such as vertebral fractures, metastases, central or lateral spinal stenosis or degenerative conditions may only in part explain prevalent symptoms and disability. Social and lifestyle factors must also be evaluated since they are associated not only with unspecific LBP but also with LBP with SCI.
Introduction
Low back pain (LBP) is a common musculoskeletal disorder [1] with a life time prevalence of 60–80% [2, 3]. In the industrialised world, LBP is a major reason for high health-care costs [4] and in all countries a common cause of disability [1]. Several studies suggest that LBP affects more people of working age than in old age [5, 6]. The reason is claimed to be that LBP is associated with social and work-related factors [6–8] and epidemiology and risk factors for LBP have therefore been thoroughly described in middle-aged adults [9–11]. There are however studies suggesting that the prevalence of LBP increases with age [12–14]. There is also emerging evidence of a secular trend in older people with increasing prevalence in individuals aged 65 and older from 5.9% in 1992 to 12.3% in 2006 [15]. In Sweden the prevalence varies from 9% to 45% in the older population over the age of 65 [3]. As older people are the fastest growing subgroup in the population [16], the impact of LBP will become even greater in the future.
But it is also postulated that LBP in older people, especially when accompanied by sciatica (SCI), is more associated with anatomical abnormalities such as osteoporotic vertebral fractures, metastases, central or lateral spinal stenosis, degenerative spondylolisthesis and degenerative scoliosis [17, 18]. Evaluations in the clinical situation therefore often focus on radiologically identifying anatomical abnormality that should be corrected. But there may be risk factors beyond the anatomical abnormalities influencing the clinical appearance of LBP [19]. Since LBP+SCI is associated with greater disability than LBP [20], it is also questioned whether the risk factor profile is different between older people with LBP and those with LBP+SCI. Furthermore, since society and lifestyle are continuously changing, with more active older people today than previously, it is imperative to update risk factor profiles continuously. We believe an updated description of risk factors for LBP is necessary including factors beyond anatomical abnormalities, evaluated separately for individuals with LBP and those with also SCI. If such factors could be identified, it emphasises the need not only to focus on anatomical abnormalities but also to consider other factors that may influence the clinical presentation of the patient. This is especially important in the clinical setting when establishing treatment strategies, since interventions should take into account both lifestyle factors and abnormal anatomy.
The aim of this study was to identify risk factors for LBP beyond anatomical abnormalities in older community-living men, and determine whether risk factors are different in men with LBP and those also with SCI. We hypothesised that social risk factors would be more associated with unspecific LBP than with LBP+SCI. We asked: which risk factors profile is found in older community-living men in those with (i) LBP and (ii) LBP+SCI and (iii) are non-anatomical risk factors more associated with unspecified LBP than LBP+SCI?
Material and methods
Mister Osteoporosis (MrOS) Sweden is a multi-centre population-based study of 3,014 men aged 69–81 years, enrolled in the cities of Malmö, Gothenburg and Uppsala. Among the 1,427 in this cohort with a readable spine radiograph at inclusion, 15% had at least one prevalent vertebral fracture. The study protocol has been described in detail previously [21]. The primary aim of the study is to evaluate risk factors for osteoporosis and fractures in a prospective observational design. Men were randomly selected from the national population registry and invited to the study by mail. To be included, the men had to be community-dwelling and able to walk without assistance and provide self-reported data. This approach rendered a participation rate of 45%.
At baseline, the men answered the international MrOS questionnaire on background data with special reference to history of back pain (BP) during the preceding 12 months. The questions regarding BP evaluated whether the participants during the 12 preceding months had experienced any BP (yes/no) and where the pain was located. In those who localised the pain as LBP, we added questions to specify whether they also had SCI (yes/no) and/or neurological deficits (NEU) (yes/no). The definition of LBP was pain in the lower back but not specified further, SCI as pain radiating from the lower back down towards the lower extremity below the buttocks, but with no distinction between whether pain terminated above or below the knee and NEU as subjective sensory and motor symptoms in the lower extremity such as tingling or weakness. In this report, we divide the men into those having (i) no BP (Table 1), (ii) LBP (with or without SCI, NEU) (Table 1), (iii) LBP (no SCI or NEU) (Table 2) and (iv) LBP with SCI and/or NEU, referred to as LBP+SCI (Table 2). Information regarding duration of episodes of disability or whether having thoracic pain was not registered.
Baseline characteristics and medical history of 2,749 Swedish men aged 69–81 years who answered questions regarding BP and LBP during the preceding 12-month period. Data are provided as means ± SD, numbers with proportions (%) and for difference and risk ratio mean with 95% confidence interval. Group comparisons were made by Student's t-test, Chi-square or Fischer exact tests. Statistically significant differences are bolded. n = numbers that provided data
| Men with any LBP (n = 1,361) | Men without BP (n = 1,388) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.4 ± 3.2 | 75.5 ± 3.1 | 0.150 | −0.1 (−0.3, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 174.9 ± 6.5 | 0.817 | −0.1 (−0.6, 0.4) |
| Weight (kg) | 81.3 ± 12.3 | 80.3 ± 11.9 | 0.048 | 1.0 (0.1, 1.9) |
| BMI (kg/m2) | 26.6 ± 3.7 | 26.3 ± 3.5 | 0.019 | 0.3 (0.0, 0.6) |
| Social factors | Risk ratio | |||
| Living condition | n = 1,325 | n = 1,353 | ||
| Live alone | 232 (46.0%) | 272 (54.0%) | 0.086 | 0.92 (0.83, 1.02) |
| Live with someone | 1,093 (50.3%) | 1,081 (49.7%) | ||
| Education | n = 1,358 | n = 1,384 | ||
| Compulsory school | 780 (49.2%) | 806 (50.8%) | 0.672 | 0.98 (0.91, 1.06) |
| Higher education | 578 (50.0%) | 578 (50.0%) | ||
| Country of origin | n = 1,360 | n = 1,387 | ||
| Not born in Sweden | 112 (60.9%) | 72 (39.1 %) | 0.001 | 1.25 (1.11, 1.41) |
| Born in Sweden | 1,248 (48.7%) | 1,315 (51.3%) | ||
| Smoker | n = 1,358 | n = 1,383 | ||
| Current/past | 915 (51.8%) | 853 (48.2%) | 0.002 | 1.14 (1.05, 1.23) |
| Never | 443 (45.5%) | 530 (54.5%) | ||
| Alcohol (drinks/day) | n = 1,104 | n = 1,146 | ||
| ≥2 drinks/day | 101 (47.6%) | 111 (52.4%) | 0.663 | 0.97 (0.83, 1.12) |
| <2 drinks/day | 1,003 (49.2%) | 1,035 (50.8%) | ||
| Physical activity—daily walks | n = 1,359 | n = 1,387 | ||
| No | 511 (52.8%) | 457 (47.2%) | 0.011 | 1.11 (1.02, 1.20) |
| Yes | 848 (47.7%) | 930 (52.3%) | ||
| Self-estimated health status | ||||
| Self-perceived health | n = 1,359 | n = 1,385 | ||
| Poor/very poor | 469 (66.1%) | 241 (33.9%) | 0.000 | 1.51 (1.40, 1.62) |
| Excellent/good | 890 (43.8%) | 1,144 (56.2%) | ||
| Feeling of depression | n = 1,359 | n = 1,384 | ||
| Some of the time/most of the time | 617 (59.4%) | 421 (40.6%) | 0.000 | 1.37 (1.27, 1.47) |
| None of the time | 742 (43.5%) | 963 (56.5%) | ||
| Serious comorbiditya | n = 1,340 | n = 1,382 | ||
| Yes | 574 (54.8%) | 474 (45.2%) | 0.000 | 1.20 (1.11, 1.29) |
| No | 766 (45.8%) | 908 (54.2%) | ||
| Disabilities | ||||
| Dizziness | n = 1,357 | n = 1,386 | ||
| Yes | 433 (63.7%) | 247 (36.3%) | 0.000 | 1.42 (1.32, 1.53) |
| No | 924 (44.8%) | 1,139 (55.2%) | ||
| Fallers | n = 1,355 | n = 1,385 | ||
| Yes | 267 (59.1%) | 185 (40.9%) | 0.000 | 1.24 (1.14, 1.36) |
| No | 1,088 (47.6%) | 1,200 (52.4%) | ||
| Walking ability | n = 1,345 | n = 1,375 | ||
| Cane/crutch/rollator/wheelchair | 92 (61.3%) | 58 (38.7%) | 0.003 | 1.26 (1.10, 1.44) |
| No walking aids | 1,253 (48.8%) | 1,317 (51.2%) | ||
| Men with any LBP (n = 1,361) | Men without BP (n = 1,388) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.4 ± 3.2 | 75.5 ± 3.1 | 0.150 | −0.1 (−0.3, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 174.9 ± 6.5 | 0.817 | −0.1 (−0.6, 0.4) |
| Weight (kg) | 81.3 ± 12.3 | 80.3 ± 11.9 | 0.048 | 1.0 (0.1, 1.9) |
| BMI (kg/m2) | 26.6 ± 3.7 | 26.3 ± 3.5 | 0.019 | 0.3 (0.0, 0.6) |
| Social factors | Risk ratio | |||
| Living condition | n = 1,325 | n = 1,353 | ||
| Live alone | 232 (46.0%) | 272 (54.0%) | 0.086 | 0.92 (0.83, 1.02) |
| Live with someone | 1,093 (50.3%) | 1,081 (49.7%) | ||
| Education | n = 1,358 | n = 1,384 | ||
| Compulsory school | 780 (49.2%) | 806 (50.8%) | 0.672 | 0.98 (0.91, 1.06) |
| Higher education | 578 (50.0%) | 578 (50.0%) | ||
| Country of origin | n = 1,360 | n = 1,387 | ||
| Not born in Sweden | 112 (60.9%) | 72 (39.1 %) | 0.001 | 1.25 (1.11, 1.41) |
| Born in Sweden | 1,248 (48.7%) | 1,315 (51.3%) | ||
| Smoker | n = 1,358 | n = 1,383 | ||
| Current/past | 915 (51.8%) | 853 (48.2%) | 0.002 | 1.14 (1.05, 1.23) |
| Never | 443 (45.5%) | 530 (54.5%) | ||
| Alcohol (drinks/day) | n = 1,104 | n = 1,146 | ||
| ≥2 drinks/day | 101 (47.6%) | 111 (52.4%) | 0.663 | 0.97 (0.83, 1.12) |
| <2 drinks/day | 1,003 (49.2%) | 1,035 (50.8%) | ||
| Physical activity—daily walks | n = 1,359 | n = 1,387 | ||
| No | 511 (52.8%) | 457 (47.2%) | 0.011 | 1.11 (1.02, 1.20) |
| Yes | 848 (47.7%) | 930 (52.3%) | ||
| Self-estimated health status | ||||
| Self-perceived health | n = 1,359 | n = 1,385 | ||
| Poor/very poor | 469 (66.1%) | 241 (33.9%) | 0.000 | 1.51 (1.40, 1.62) |
| Excellent/good | 890 (43.8%) | 1,144 (56.2%) | ||
| Feeling of depression | n = 1,359 | n = 1,384 | ||
| Some of the time/most of the time | 617 (59.4%) | 421 (40.6%) | 0.000 | 1.37 (1.27, 1.47) |
| None of the time | 742 (43.5%) | 963 (56.5%) | ||
| Serious comorbiditya | n = 1,340 | n = 1,382 | ||
| Yes | 574 (54.8%) | 474 (45.2%) | 0.000 | 1.20 (1.11, 1.29) |
| No | 766 (45.8%) | 908 (54.2%) | ||
| Disabilities | ||||
| Dizziness | n = 1,357 | n = 1,386 | ||
| Yes | 433 (63.7%) | 247 (36.3%) | 0.000 | 1.42 (1.32, 1.53) |
| No | 924 (44.8%) | 1,139 (55.2%) | ||
| Fallers | n = 1,355 | n = 1,385 | ||
| Yes | 267 (59.1%) | 185 (40.9%) | 0.000 | 1.24 (1.14, 1.36) |
| No | 1,088 (47.6%) | 1,200 (52.4%) | ||
| Walking ability | n = 1,345 | n = 1,375 | ||
| Cane/crutch/rollator/wheelchair | 92 (61.3%) | 58 (38.7%) | 0.003 | 1.26 (1.10, 1.44) |
| No walking aids | 1,253 (48.8%) | 1,317 (51.2%) | ||
aSerious comorbidity include diabetes, stroke, coronary heart disease, pulmonary disease and malignancy.
Baseline characteristics and medical history of 2,749 Swedish men aged 69–81 years who answered questions regarding BP and LBP during the preceding 12-month period. Data are provided as means ± SD, numbers with proportions (%) and for difference and risk ratio mean with 95% confidence interval. Group comparisons were made by Student's t-test, Chi-square or Fischer exact tests. Statistically significant differences are bolded. n = numbers that provided data
| Men with any LBP (n = 1,361) | Men without BP (n = 1,388) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.4 ± 3.2 | 75.5 ± 3.1 | 0.150 | −0.1 (−0.3, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 174.9 ± 6.5 | 0.817 | −0.1 (−0.6, 0.4) |
| Weight (kg) | 81.3 ± 12.3 | 80.3 ± 11.9 | 0.048 | 1.0 (0.1, 1.9) |
| BMI (kg/m2) | 26.6 ± 3.7 | 26.3 ± 3.5 | 0.019 | 0.3 (0.0, 0.6) |
| Social factors | Risk ratio | |||
| Living condition | n = 1,325 | n = 1,353 | ||
| Live alone | 232 (46.0%) | 272 (54.0%) | 0.086 | 0.92 (0.83, 1.02) |
| Live with someone | 1,093 (50.3%) | 1,081 (49.7%) | ||
| Education | n = 1,358 | n = 1,384 | ||
| Compulsory school | 780 (49.2%) | 806 (50.8%) | 0.672 | 0.98 (0.91, 1.06) |
| Higher education | 578 (50.0%) | 578 (50.0%) | ||
| Country of origin | n = 1,360 | n = 1,387 | ||
| Not born in Sweden | 112 (60.9%) | 72 (39.1 %) | 0.001 | 1.25 (1.11, 1.41) |
| Born in Sweden | 1,248 (48.7%) | 1,315 (51.3%) | ||
| Smoker | n = 1,358 | n = 1,383 | ||
| Current/past | 915 (51.8%) | 853 (48.2%) | 0.002 | 1.14 (1.05, 1.23) |
| Never | 443 (45.5%) | 530 (54.5%) | ||
| Alcohol (drinks/day) | n = 1,104 | n = 1,146 | ||
| ≥2 drinks/day | 101 (47.6%) | 111 (52.4%) | 0.663 | 0.97 (0.83, 1.12) |
| <2 drinks/day | 1,003 (49.2%) | 1,035 (50.8%) | ||
| Physical activity—daily walks | n = 1,359 | n = 1,387 | ||
| No | 511 (52.8%) | 457 (47.2%) | 0.011 | 1.11 (1.02, 1.20) |
| Yes | 848 (47.7%) | 930 (52.3%) | ||
| Self-estimated health status | ||||
| Self-perceived health | n = 1,359 | n = 1,385 | ||
| Poor/very poor | 469 (66.1%) | 241 (33.9%) | 0.000 | 1.51 (1.40, 1.62) |
| Excellent/good | 890 (43.8%) | 1,144 (56.2%) | ||
| Feeling of depression | n = 1,359 | n = 1,384 | ||
| Some of the time/most of the time | 617 (59.4%) | 421 (40.6%) | 0.000 | 1.37 (1.27, 1.47) |
| None of the time | 742 (43.5%) | 963 (56.5%) | ||
| Serious comorbiditya | n = 1,340 | n = 1,382 | ||
| Yes | 574 (54.8%) | 474 (45.2%) | 0.000 | 1.20 (1.11, 1.29) |
| No | 766 (45.8%) | 908 (54.2%) | ||
| Disabilities | ||||
| Dizziness | n = 1,357 | n = 1,386 | ||
| Yes | 433 (63.7%) | 247 (36.3%) | 0.000 | 1.42 (1.32, 1.53) |
| No | 924 (44.8%) | 1,139 (55.2%) | ||
| Fallers | n = 1,355 | n = 1,385 | ||
| Yes | 267 (59.1%) | 185 (40.9%) | 0.000 | 1.24 (1.14, 1.36) |
| No | 1,088 (47.6%) | 1,200 (52.4%) | ||
| Walking ability | n = 1,345 | n = 1,375 | ||
| Cane/crutch/rollator/wheelchair | 92 (61.3%) | 58 (38.7%) | 0.003 | 1.26 (1.10, 1.44) |
| No walking aids | 1,253 (48.8%) | 1,317 (51.2%) | ||
| Men with any LBP (n = 1,361) | Men without BP (n = 1,388) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.4 ± 3.2 | 75.5 ± 3.1 | 0.150 | −0.1 (−0.3, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 174.9 ± 6.5 | 0.817 | −0.1 (−0.6, 0.4) |
| Weight (kg) | 81.3 ± 12.3 | 80.3 ± 11.9 | 0.048 | 1.0 (0.1, 1.9) |
| BMI (kg/m2) | 26.6 ± 3.7 | 26.3 ± 3.5 | 0.019 | 0.3 (0.0, 0.6) |
| Social factors | Risk ratio | |||
| Living condition | n = 1,325 | n = 1,353 | ||
| Live alone | 232 (46.0%) | 272 (54.0%) | 0.086 | 0.92 (0.83, 1.02) |
| Live with someone | 1,093 (50.3%) | 1,081 (49.7%) | ||
| Education | n = 1,358 | n = 1,384 | ||
| Compulsory school | 780 (49.2%) | 806 (50.8%) | 0.672 | 0.98 (0.91, 1.06) |
| Higher education | 578 (50.0%) | 578 (50.0%) | ||
| Country of origin | n = 1,360 | n = 1,387 | ||
| Not born in Sweden | 112 (60.9%) | 72 (39.1 %) | 0.001 | 1.25 (1.11, 1.41) |
| Born in Sweden | 1,248 (48.7%) | 1,315 (51.3%) | ||
| Smoker | n = 1,358 | n = 1,383 | ||
| Current/past | 915 (51.8%) | 853 (48.2%) | 0.002 | 1.14 (1.05, 1.23) |
| Never | 443 (45.5%) | 530 (54.5%) | ||
| Alcohol (drinks/day) | n = 1,104 | n = 1,146 | ||
| ≥2 drinks/day | 101 (47.6%) | 111 (52.4%) | 0.663 | 0.97 (0.83, 1.12) |
| <2 drinks/day | 1,003 (49.2%) | 1,035 (50.8%) | ||
| Physical activity—daily walks | n = 1,359 | n = 1,387 | ||
| No | 511 (52.8%) | 457 (47.2%) | 0.011 | 1.11 (1.02, 1.20) |
| Yes | 848 (47.7%) | 930 (52.3%) | ||
| Self-estimated health status | ||||
| Self-perceived health | n = 1,359 | n = 1,385 | ||
| Poor/very poor | 469 (66.1%) | 241 (33.9%) | 0.000 | 1.51 (1.40, 1.62) |
| Excellent/good | 890 (43.8%) | 1,144 (56.2%) | ||
| Feeling of depression | n = 1,359 | n = 1,384 | ||
| Some of the time/most of the time | 617 (59.4%) | 421 (40.6%) | 0.000 | 1.37 (1.27, 1.47) |
| None of the time | 742 (43.5%) | 963 (56.5%) | ||
| Serious comorbiditya | n = 1,340 | n = 1,382 | ||
| Yes | 574 (54.8%) | 474 (45.2%) | 0.000 | 1.20 (1.11, 1.29) |
| No | 766 (45.8%) | 908 (54.2%) | ||
| Disabilities | ||||
| Dizziness | n = 1,357 | n = 1,386 | ||
| Yes | 433 (63.7%) | 247 (36.3%) | 0.000 | 1.42 (1.32, 1.53) |
| No | 924 (44.8%) | 1,139 (55.2%) | ||
| Fallers | n = 1,355 | n = 1,385 | ||
| Yes | 267 (59.1%) | 185 (40.9%) | 0.000 | 1.24 (1.14, 1.36) |
| No | 1,088 (47.6%) | 1,200 (52.4%) | ||
| Walking ability | n = 1,345 | n = 1,375 | ||
| Cane/crutch/rollator/wheelchair | 92 (61.3%) | 58 (38.7%) | 0.003 | 1.26 (1.10, 1.44) |
| No walking aids | 1,253 (48.8%) | 1,317 (51.2%) | ||
aSerious comorbidity include diabetes, stroke, coronary heart disease, pulmonary disease and malignancy.
Baseline characteristics and medical history in the 1,074 Swedish men aged 69–81 years who had differentiated if they had had LBP or LBP with SCI, with or without NEU, during the preceding 12-month period. Data are provided as means ± SD, numbers with proportions (%) and for difference and risk ratio mean with 95% confidence interval.Group comparisons were made by Student's t-test, Chi-square or Fischer exact tests. Statistically significant differences are bolded. n = numbers that provided data
| Men with LBP, SCI and/or NEU (n = 459) | Men with LBP (n = 615) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.1 ± 3.2 | 75.4 ± 3.2 | 0.187 | −0.3 (−0.7, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 175.3 ± 6.6 | 0.318 | −0.5 (−1.3, 0.3) |
| Weight (kg) | 81.9 ± 12.7 | 80.5 ± 11.8 | 0.078 | 1.4 (−0.1, 2.9) |
| BMI (kg/m2) | 26.8 ± 3.9 | 26.2 ± 3.4 | 0.011 | 0.5 (0.1, 0.9) |
| Social factors | Risk ratio | |||
| Living condition | n = 448 | n = 597 | ||
| Live alone | 89 (48.1%) | 96 (51.9%) | 0.113 | 1.15 (0.97, 1.36) |
| Live with someone | 359 (41.7%) | 501 (58.3%) | ||
| Education | n = 458 | n = 614 | ||
| Compulsory school | 301 (49.3%) | 310 (50.7%) | 0.000 | 1.45 (1.24, 1.68) |
| Higher education | 157 (34.1%) | 304 (65.9%) | ||
| Country of origin | n = 459 | n = 614 | ||
| Not born in Sweden | 44 (51.2%) | 42 (48.8%) | 0.101 | 1.22 (0.98, 1.51) |
| Born in Sweden | 415 (42.0%) | 572 (58.0%) | ||
| Smoker | n = 459 | n = 613 | ||
| Current/past | 319 (44.2%) | 403 (55.8%) | 0.194 | 1.10 (0.95, 1.29) |
| Never | 140 (40.0%) | 210 (60.0%) | ||
| Alcohol (drinks/day) | n = 373 | n = 501 | ||
| ≥2 drinks/day | 38 (44.70%) | 47 (55.3%) | 0.691 | 1.05 (0.82, 1.35) |
| <2 drinks/day | 335 (42.50%) | 454 (57.5%) | ||
| Physical activity—daily walks | n = 458 | n = 614 | ||
| No | 179 (44.3%) | 225 (55.7%) | 0.415 | 1.06 (0.92, 1.22) |
| Yes | 279 (41.8%) | 389 (58.2%) | ||
| Self-perceived health | n = 457 | n = 615 | ||
| Poor/very poor | 191 (53.5%) | 153 (48.6%) | 0.000 | 1.49 (1.30, 1.71) |
| Excellent/good | 266 (37.2%) | 449 (62.8%) | ||
| Feeling of depression | n = 458 | n = 615 | ||
| Some of the time | 219 (45.7%) | 234 (55.7%) | 0.071 | 1.20 (1.05, 1.38) |
| None of the time | 239 (40.2%) | 355 (61.1%) | ||
| Serious comorbiditya | n = 452 | n = 609 | ||
| Yes | 208 (47.9%) | 226 (52.1%) | 0.000 | 1.23 (1.07, 1.41) |
| No | 244 (38.9%) | 383 (61.1%) | ||
| Dizziness | n = 459 | n = 613 | ||
| Yes | 166 (51.1%) | 159 (48.9%) | 0.000 | 1.30 (1.13, 1.50) |
| No | 293 (39.2%) | 454 (60.8%) | ||
| Fallers | n = 455 | n = 613 | ||
| Yes | 97 (41.8%) | 114 (54.0%) | 0.269 | 1.10 (0.93, 1.30) |
| No | 358 (46.0%) | 499 (58.2%) | ||
| Walking ability | n = 453 | n = 607 | ||
| Cane/crutch/rollator/wheelchair | 40 (66.7%) | 20 (33.3%) | 0.000 | 1.61 (1.33, 1.96) |
| No walking aids | 413 (41.3%) | 587 (58.7%) | ||
| Men with LBP, SCI and/or NEU (n = 459) | Men with LBP (n = 615) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.1 ± 3.2 | 75.4 ± 3.2 | 0.187 | −0.3 (−0.7, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 175.3 ± 6.6 | 0.318 | −0.5 (−1.3, 0.3) |
| Weight (kg) | 81.9 ± 12.7 | 80.5 ± 11.8 | 0.078 | 1.4 (−0.1, 2.9) |
| BMI (kg/m2) | 26.8 ± 3.9 | 26.2 ± 3.4 | 0.011 | 0.5 (0.1, 0.9) |
| Social factors | Risk ratio | |||
| Living condition | n = 448 | n = 597 | ||
| Live alone | 89 (48.1%) | 96 (51.9%) | 0.113 | 1.15 (0.97, 1.36) |
| Live with someone | 359 (41.7%) | 501 (58.3%) | ||
| Education | n = 458 | n = 614 | ||
| Compulsory school | 301 (49.3%) | 310 (50.7%) | 0.000 | 1.45 (1.24, 1.68) |
| Higher education | 157 (34.1%) | 304 (65.9%) | ||
| Country of origin | n = 459 | n = 614 | ||
| Not born in Sweden | 44 (51.2%) | 42 (48.8%) | 0.101 | 1.22 (0.98, 1.51) |
| Born in Sweden | 415 (42.0%) | 572 (58.0%) | ||
| Smoker | n = 459 | n = 613 | ||
| Current/past | 319 (44.2%) | 403 (55.8%) | 0.194 | 1.10 (0.95, 1.29) |
| Never | 140 (40.0%) | 210 (60.0%) | ||
| Alcohol (drinks/day) | n = 373 | n = 501 | ||
| ≥2 drinks/day | 38 (44.70%) | 47 (55.3%) | 0.691 | 1.05 (0.82, 1.35) |
| <2 drinks/day | 335 (42.50%) | 454 (57.5%) | ||
| Physical activity—daily walks | n = 458 | n = 614 | ||
| No | 179 (44.3%) | 225 (55.7%) | 0.415 | 1.06 (0.92, 1.22) |
| Yes | 279 (41.8%) | 389 (58.2%) | ||
| Self-perceived health | n = 457 | n = 615 | ||
| Poor/very poor | 191 (53.5%) | 153 (48.6%) | 0.000 | 1.49 (1.30, 1.71) |
| Excellent/good | 266 (37.2%) | 449 (62.8%) | ||
| Feeling of depression | n = 458 | n = 615 | ||
| Some of the time | 219 (45.7%) | 234 (55.7%) | 0.071 | 1.20 (1.05, 1.38) |
| None of the time | 239 (40.2%) | 355 (61.1%) | ||
| Serious comorbiditya | n = 452 | n = 609 | ||
| Yes | 208 (47.9%) | 226 (52.1%) | 0.000 | 1.23 (1.07, 1.41) |
| No | 244 (38.9%) | 383 (61.1%) | ||
| Dizziness | n = 459 | n = 613 | ||
| Yes | 166 (51.1%) | 159 (48.9%) | 0.000 | 1.30 (1.13, 1.50) |
| No | 293 (39.2%) | 454 (60.8%) | ||
| Fallers | n = 455 | n = 613 | ||
| Yes | 97 (41.8%) | 114 (54.0%) | 0.269 | 1.10 (0.93, 1.30) |
| No | 358 (46.0%) | 499 (58.2%) | ||
| Walking ability | n = 453 | n = 607 | ||
| Cane/crutch/rollator/wheelchair | 40 (66.7%) | 20 (33.3%) | 0.000 | 1.61 (1.33, 1.96) |
| No walking aids | 413 (41.3%) | 587 (58.7%) | ||
aSerious comorbidity includes diabetes, stroke, coronary heart disease, pulmonary disease and malignancy.
Baseline characteristics and medical history in the 1,074 Swedish men aged 69–81 years who had differentiated if they had had LBP or LBP with SCI, with or without NEU, during the preceding 12-month period. Data are provided as means ± SD, numbers with proportions (%) and for difference and risk ratio mean with 95% confidence interval.Group comparisons were made by Student's t-test, Chi-square or Fischer exact tests. Statistically significant differences are bolded. n = numbers that provided data
| Men with LBP, SCI and/or NEU (n = 459) | Men with LBP (n = 615) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.1 ± 3.2 | 75.4 ± 3.2 | 0.187 | −0.3 (−0.7, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 175.3 ± 6.6 | 0.318 | −0.5 (−1.3, 0.3) |
| Weight (kg) | 81.9 ± 12.7 | 80.5 ± 11.8 | 0.078 | 1.4 (−0.1, 2.9) |
| BMI (kg/m2) | 26.8 ± 3.9 | 26.2 ± 3.4 | 0.011 | 0.5 (0.1, 0.9) |
| Social factors | Risk ratio | |||
| Living condition | n = 448 | n = 597 | ||
| Live alone | 89 (48.1%) | 96 (51.9%) | 0.113 | 1.15 (0.97, 1.36) |
| Live with someone | 359 (41.7%) | 501 (58.3%) | ||
| Education | n = 458 | n = 614 | ||
| Compulsory school | 301 (49.3%) | 310 (50.7%) | 0.000 | 1.45 (1.24, 1.68) |
| Higher education | 157 (34.1%) | 304 (65.9%) | ||
| Country of origin | n = 459 | n = 614 | ||
| Not born in Sweden | 44 (51.2%) | 42 (48.8%) | 0.101 | 1.22 (0.98, 1.51) |
| Born in Sweden | 415 (42.0%) | 572 (58.0%) | ||
| Smoker | n = 459 | n = 613 | ||
| Current/past | 319 (44.2%) | 403 (55.8%) | 0.194 | 1.10 (0.95, 1.29) |
| Never | 140 (40.0%) | 210 (60.0%) | ||
| Alcohol (drinks/day) | n = 373 | n = 501 | ||
| ≥2 drinks/day | 38 (44.70%) | 47 (55.3%) | 0.691 | 1.05 (0.82, 1.35) |
| <2 drinks/day | 335 (42.50%) | 454 (57.5%) | ||
| Physical activity—daily walks | n = 458 | n = 614 | ||
| No | 179 (44.3%) | 225 (55.7%) | 0.415 | 1.06 (0.92, 1.22) |
| Yes | 279 (41.8%) | 389 (58.2%) | ||
| Self-perceived health | n = 457 | n = 615 | ||
| Poor/very poor | 191 (53.5%) | 153 (48.6%) | 0.000 | 1.49 (1.30, 1.71) |
| Excellent/good | 266 (37.2%) | 449 (62.8%) | ||
| Feeling of depression | n = 458 | n = 615 | ||
| Some of the time | 219 (45.7%) | 234 (55.7%) | 0.071 | 1.20 (1.05, 1.38) |
| None of the time | 239 (40.2%) | 355 (61.1%) | ||
| Serious comorbiditya | n = 452 | n = 609 | ||
| Yes | 208 (47.9%) | 226 (52.1%) | 0.000 | 1.23 (1.07, 1.41) |
| No | 244 (38.9%) | 383 (61.1%) | ||
| Dizziness | n = 459 | n = 613 | ||
| Yes | 166 (51.1%) | 159 (48.9%) | 0.000 | 1.30 (1.13, 1.50) |
| No | 293 (39.2%) | 454 (60.8%) | ||
| Fallers | n = 455 | n = 613 | ||
| Yes | 97 (41.8%) | 114 (54.0%) | 0.269 | 1.10 (0.93, 1.30) |
| No | 358 (46.0%) | 499 (58.2%) | ||
| Walking ability | n = 453 | n = 607 | ||
| Cane/crutch/rollator/wheelchair | 40 (66.7%) | 20 (33.3%) | 0.000 | 1.61 (1.33, 1.96) |
| No walking aids | 413 (41.3%) | 587 (58.7%) | ||
| Men with LBP, SCI and/or NEU (n = 459) | Men with LBP (n = 615) | P-value | ||
|---|---|---|---|---|
| Anthropometry | Difference | |||
| Age (years) | 75.1 ± 3.2 | 75.4 ± 3.2 | 0.187 | −0.3 (−0.7, 0.1) |
| Height (cm) | 174.8 ± 6.6 | 175.3 ± 6.6 | 0.318 | −0.5 (−1.3, 0.3) |
| Weight (kg) | 81.9 ± 12.7 | 80.5 ± 11.8 | 0.078 | 1.4 (−0.1, 2.9) |
| BMI (kg/m2) | 26.8 ± 3.9 | 26.2 ± 3.4 | 0.011 | 0.5 (0.1, 0.9) |
| Social factors | Risk ratio | |||
| Living condition | n = 448 | n = 597 | ||
| Live alone | 89 (48.1%) | 96 (51.9%) | 0.113 | 1.15 (0.97, 1.36) |
| Live with someone | 359 (41.7%) | 501 (58.3%) | ||
| Education | n = 458 | n = 614 | ||
| Compulsory school | 301 (49.3%) | 310 (50.7%) | 0.000 | 1.45 (1.24, 1.68) |
| Higher education | 157 (34.1%) | 304 (65.9%) | ||
| Country of origin | n = 459 | n = 614 | ||
| Not born in Sweden | 44 (51.2%) | 42 (48.8%) | 0.101 | 1.22 (0.98, 1.51) |
| Born in Sweden | 415 (42.0%) | 572 (58.0%) | ||
| Smoker | n = 459 | n = 613 | ||
| Current/past | 319 (44.2%) | 403 (55.8%) | 0.194 | 1.10 (0.95, 1.29) |
| Never | 140 (40.0%) | 210 (60.0%) | ||
| Alcohol (drinks/day) | n = 373 | n = 501 | ||
| ≥2 drinks/day | 38 (44.70%) | 47 (55.3%) | 0.691 | 1.05 (0.82, 1.35) |
| <2 drinks/day | 335 (42.50%) | 454 (57.5%) | ||
| Physical activity—daily walks | n = 458 | n = 614 | ||
| No | 179 (44.3%) | 225 (55.7%) | 0.415 | 1.06 (0.92, 1.22) |
| Yes | 279 (41.8%) | 389 (58.2%) | ||
| Self-perceived health | n = 457 | n = 615 | ||
| Poor/very poor | 191 (53.5%) | 153 (48.6%) | 0.000 | 1.49 (1.30, 1.71) |
| Excellent/good | 266 (37.2%) | 449 (62.8%) | ||
| Feeling of depression | n = 458 | n = 615 | ||
| Some of the time | 219 (45.7%) | 234 (55.7%) | 0.071 | 1.20 (1.05, 1.38) |
| None of the time | 239 (40.2%) | 355 (61.1%) | ||
| Serious comorbiditya | n = 452 | n = 609 | ||
| Yes | 208 (47.9%) | 226 (52.1%) | 0.000 | 1.23 (1.07, 1.41) |
| No | 244 (38.9%) | 383 (61.1%) | ||
| Dizziness | n = 459 | n = 613 | ||
| Yes | 166 (51.1%) | 159 (48.9%) | 0.000 | 1.30 (1.13, 1.50) |
| No | 293 (39.2%) | 454 (60.8%) | ||
| Fallers | n = 455 | n = 613 | ||
| Yes | 97 (41.8%) | 114 (54.0%) | 0.269 | 1.10 (0.93, 1.30) |
| No | 358 (46.0%) | 499 (58.2%) | ||
| Walking ability | n = 453 | n = 607 | ||
| Cane/crutch/rollator/wheelchair | 40 (66.7%) | 20 (33.3%) | 0.000 | 1.61 (1.33, 1.96) |
| No walking aids | 413 (41.3%) | 587 (58.7%) | ||
aSerious comorbidity includes diabetes, stroke, coronary heart disease, pulmonary disease and malignancy.
Flowchart of the subjects in this study from MrOS Sweden.
Height and weight were measured by standard equipment [21]. Body mass index (BMI) was calculated as the weight divided by the square of the height (kg/m2).
The study was approved by the Central Ethical Review Board at each centre. All participants gave written informed consent before study start and the study was performed in accordance with the Declaration of Helsinki. We used the Statistical Package of Social Sciences ® (SPSS, version 19) for statistical calculations. Data are presented as numbers (n) and proportions (%) for categorical variables and as means with standard deviations (SD) for continuous variables. When comparing men with unspecified LBP with men without and men with LBP with men with LBP+SCI, we utilised Fishers test and Chi2 test for categorical variables and Student's t-test for continuous variables. P < 0.05 was regarded as a statistically significant difference.
Results
About 49% of those with LBP and 54% of those with LBP+SCI rated their health as poor/very poor (P < 0.001). Almost 56% of men with LBP and 46% of men with LBP+SCI had depressive feelings and 33% of men with LBP and 67% of men with LBP+SCI used walking aids (Table 1).
Men with any LBP (with or without SCI/NEU) were more commonly of foreign origin (P < 0.01) and, to a larger extent than men without BP, had depressive symptoms, serious diseases, dizziness and poorer self-estimated health (all P < 0.001). Among the diseases, we found that coronary heart disease and malignancy (both P < 0.05) were more frequent in men with any LBP than in those with no BP. The men with any LBP were also to a larger extent smokers (P < 0.01), walked less regularly and used walking aids more commonly (both P < 0.05) than men with no BP (Table 1).
Men with LBP+SCI, to a larger extent than men with LBP, had poor self-estimated health, serious diseases, dizziness and used more often walking aids (all P < 0.001) (Table 2). Among the diseases, we found that coronary heart disease and diabetes (both P < 0.05) were more frequent among men with LBP+SCI than among those with LBP (Table 2). Men with LBP+SCI also had higher BMI and lower education level (P < 0.001) than men with LBP (Table 2).
Discussion
This study show that close to half of all community-living men aged 69–81 years experience LBP during a 12-month period, and that also non-anatomical risk factors is associated with LBP. Even if the pain is associated with anatomical abnormalities, such as osteoporotic fractures, metastases, spinal stenosis, degenerative spondylolisthesis and scoliosis [17, 18], non-anatomical factors also seem to influence the subjective experience of the pain problem [22]. In the clinical situation, any evaluation should therefore not only focus on radiological evaluation, in order to find anatomical abnormalities, but also address non-anatomical risk factors. Only when these are also taken into account, is it feasible to decide treatment strategies, since interventions should possibly also address these factors and not only the anatomical problem.
In the current study, we identified nine non-anatomical risk factors associated with LBP. These could be divided into social, lifestyle, medical diseases and self-estimated health. Our data support previous cross-sectional [23, 24] and prospective studies [25–27] inferring that poor self-rated health, poor physical function and depression in older people are associated with LBP. Older people with depressive symptoms have also been reported to be at greater risk of developing disabling LBP than those without depression [25]. Also we found a higher degree of depression in the men with LBP. Our study could not state whether this disability followed or proceeded the BP. Regardless of this, however, in older men with LBP and also a depressive mood, it seems reasonable that both conditions should be addressed when trying to improve the clinical status of the patient.
Jacobs et al. [24] found when following individuals aged 70–77 years that those who reported loneliness were at greater risk of developing LBP. The same has been found by others [28]. We, like others [26], have in contrast found no difference in older men with and without LBP regarding marital status or living conditions. This ambiguity of results could be related to differences in study design, definition of BP and study populations with regard to social and ethnic background, gender distribution, age and comorbidities.
As in previous reports [26] we found no difference in older people with and without LBP in respect of educational level [26]. But we add knowledge when showing that men with LBP+SCI had a higher educational level than men with only LBP. We speculate that high education may be associated with sedentary and physically inactive work, increasing the risk of inactivity-related unspecific LBP, while lower education are associated with physically demanding jobs [29] including vibrations that might cause disc degeneration and lumbar disc herniation that results in nerve compression [30, 31].
Alcohol is a known risk factor for LBP in the middle aged [32]. We nevertheless found no association between alcohol intake and LBP in old men, supporting the conclusion in a recent systematic review [33]. Since mean alcohol consumption in our cohort was low, we cannot rule out a possible associations with excessive alcohol intake. We found in contrast that smoking was associated with LBP, supporting previous reports in both middle aged and older adults [7, 12, 14, 34]. We could also add new knowledge when showing that smoking is a similar risk factor in men with LBP and men with LBP+SCI.
We also found that men with any LBP walked less frequently than men with no BP. This supports previous publications [14, 35, 36]. It should however be emphasised that a low walking ability could be both a risk factor for LBP and the result of LBP. But as regular exercise and walking are activities known to reduce the prevalence of LBP [37], we speculate that low physical activity in old age may increase the risk of sustaining LBP.
Men with any LBP also had a higher morbidity and lower self-perceived health than men with no pain and men with LBP+SCI had higher morbidity and poorer self-perceived health than men with LBP. This is not unexpected since several diseases such as metastases and chronic conditions that require steroid treatment may lead to multiple vertebral fractures and LBP [24]. But also other diseases, not associated with fractures, may be associated with LBP. Cardiovascular disease may result in atherosclerosis of the lumbar vessels and the following ischaemia may result in LBP and SCI due to disc degeneration [38, 39]. Low quality of life has been reported to be associated with neuropathic pain [40]. In summary, then the many associated non-anatomical risk factors highlight the complexityof clinically evaluating older men with LBP.
The strengths of this study include the large population-based sample, the population-based design, the narrow age span and the evaluation of a variety of risk factors. Limitations include the hypothesis generating cross-sectional design precluding any causal inferences. The retrospective design yields a risk of recall bias and the lack of a clinical examination is also a weakness. It would also have been advantageous to evaluate additional risk factors and the duration of each LBP episode as well as having older institutionalised men and women included as separate cohorts.
We conclude that when evaluating older men with LBP or LBP+SCI, it is essential to include both anatomical abnormalities and non-anatomical risk factors when deciding treatment strategies, since it seems reasonable that any evaluation should address not only the deranged anatomy.
Close to half of all community-living men aged 69–81 years experience any LBP during a 12-month period.
Half of older men that experience LBP rate their health as poor.
In older men with LBP and SCI also social and lifestyle factors must be evaluated.
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