Sex differences in musculoskeletal pain in older adults

Little is known about sex differences in musculoskeletal pain in older persons. There were 682 women and 380 men aged 72 years and older who participated in the 22nd biennial exam of the Framingham Study (1992-1993). Participants were asked to identify pain locations on a homunculus showing all regions of the body. Pain was categorized according to number of regions, with the most disseminated pain classified as widespread pain (back pain and upper and lower extremity pain with bilaterality). Among the women, 63% reported pain in one or more regions, compared to 52% of men. Widespread pain was more prevalent among women than men (15 versus 5%, respectively). In both men and women, pain was associated with fair or poor self-rated health, history of back pain before age 65, and disability. Factors associated with pain only in women included body mass index, systolic blood pressure, and depressive symptoms. In men but not women, pain was associated with polyarticular radiographic osteoarthritis. In conclusion, musculoskeletal pain was more prevalent and more widespread in older women than older men. Men and women differ in the factors associated with musculoskeletal pain in older ages. Further research is needed to understand sex differences in musculoskeletal pain the older population.     

Using facial expressions to assess musculoskeletal pain in older persons.

Past research examined measures of pain among seniors who were experiencing movement-related exacerbations of musculoskeletal pain and obtained clear support for the utility of the behavioural coding of pain-related body movements (e.g., bracing, guarding). Support for the utility of the Facial Action Coding System (FACS), which involves the objective coding of facial reactions, was not as strong. The findings concerning FACS could have been an artifact of the methodology that was used. Specifically, the duration of the facial reactions was not taken into account and the patients suffered from a variety of painful conditions. Thus, the physical activities involved in the study could have been painful for some patients but not for others. The present study corrected these methodological concerns by accounting for the duration of facial reactions and ensuring that all patients suffered from the same painful condition. Participants were 82 post-surgical (knee replacement) inpatients. Cognitive status was assessed using the Modified Mini Mental Status Examination. Under physiotherapist's supervision, the patients performed structured activities (i.e., reclining, standing, knee bends). Facial reactions were coded using FACS. Facial reactions varied as a function of the degree to which the various activities were strenuous. The results support the utility of FACS in the assessment of musculoskeletal pain among seniors undergoing rehabilitation following knee surgery.     

Basic aspects of musculoskeletal pain: from acute to chronic pain

The transition from acute to chronic musculoskeletal pain is not well understood. To understand this transition, it is important to know how peripheral and central sensitization are manifested and how they can be assessed. A variety of human pain biomarkers have been developed to quantify localized and widespread musculoskeletal pain. In addition, human surrogate models may be used to induce sensitization in otherwise healthy volunteers. Pain can arise from different musculoskeletal structures (e.g. muscles, joints, ligaments, or tendons), and differentiating the origin of pain from those different structures is a challenge. Tissue specific pain biomarkers can be used to tease these different aspects. Chronic musculoskeletal pain patients in general show signs of local/central sensitization and spread of pain to degrees which correlate to pain intensity and duration. From a management perspective, it is therefore highly important to reduce pain intensity and try to minimize the duration of pain.     

Predictors of mobility in community-dwelling women aged 85 and older

Purpose: To describe changes in mobility measured with the Timed Up and Go test (TUG) from baseline to follow-up 9 years later, and to examine which of the demographic, physical performance and health variables measured at baseline were predictors of the TUG at follow-up in a sample of women aged 85 or older. Method: This prospective cohort study included 113 community-dwelling women with a baseline mean age of 79.5 years. TUG was measured at baseline and at follow-up. The following baseline measurements were used as predictors: demographics, step-climbing ability, functional reach, and health. Results: At follow-up 110 women had decline in the TUG. Mean TUG scores at baseline and at follow-up were 6.7 s (SD = 1.3) and 13.2 s (SD = 6.8) respectively. Higher age, higher BMI, poorer results on; functional reach, step-climbing and self-rated health were independent predictors of poorer TUG at the 9-year follow-up. Exhibiting sufficient strength to climb a step of 40?cm or more protected significantly against mobility decline. Improving balance measured by the functional reach test by 1?cm lowered the probability of major mobility decline by 7%. Conclusions: Our results suggest that to decrease the risk of mobility decline focus should be on strength, balance and nutrition.

Implications for Rehabilitation

• A great reduction in mobility, measured with the Timed Up and Go was observed at the 9-year follow-up. Thirty-nine percent of the community dwelling women aged 85 and above scored below average for their age group and are at risk for adverse outcomes.

• The amendable baseline predictors of poorer Timed Up and Go at 9-year follow-up were: higher BMI, poor step climbing capacity and poor balance. Exhibiting sufficient muscle strength and muscle power to climb a step of 40?cm or higher protected significantly against mobility decline. Improving balance measured by the functional reach test by 1?cm lowered the probability of mobility decline by 7%.

• To decrease the risk for mobility decline, exercise programmes should focus on muscle strength and balance.

     

Pelvic musculoskeletal dysfunctions in women with and without chronic pelvic pain

Aim

This study aimed to compare the prevalence of pelvic musculoskeletal dysfunctions in women with and without Chronic Pelvic Pain (CPP).

Leg extension power asymmetry and mobility limitation in healthy older women

OBJECTIVE: To investigate the association of asymmetry in leg extension power (LEP) with walking and standing balance. DESIGN: Cross-sectional analysis. SETTING: Research laboratory. PARTICIPANTS: Healthy female twins (N=419), ages 63 to 75 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The LEP difference between the stronger and the weaker leg, measured with the Nottingham power rig, was calculated. Ten-meter maximal walking velocity was assessed in a laboratory corridor on a wide (170 cm) and narrow (35 cm) track, and the ability to maintain tandem stance for 20 seconds was recorded. RESULTS: The mean LEP difference +/- standard deviation between the legs was 15%+/-9% (P<.001). Those with large LEP difference had lower walking velocity and poorer standing balance than those with small LEP difference, in particular when the LEP of the stronger leg was below the median. CONCLUSIONS: Even in healthy older women, substantial LEP asymmetry between the lower limbs was present, encumbering walking and standing balance. Lower-limb muscle power asymmetry warrants further study in order to develop well-targeted strategies for preventing mobility limitation in older people.     

A diagnostic approach to musculoskeletal pain

Musculoskeletal pain or inflammation is one of the most common causes of primary care office visits. Musculoskeletal disorders exact a high toll in distress, disability, and direct health care costs. Given the wide range of disorders that may cause or contribute to musculoskeletal symptoms, differential diagnosis is challenging and a systematic approach is necessary. Patient history is the single most valuable source of diagnostic information, followed by a careful physical examination. The history also suggests which laboratory tests and imaging studies, if any, are indicated. The chronology, duration, and pattern of pain distribution offer clues to establishing an accurate diagnosis, along with evidence of other organ system involvement or underlying disease. Helpful distinctions are those between articular and nonarticular pain, between monarthritis and multiple joint involvement, and between inflammatory and noninflammatory conditions.     

Approach to musculoskeletal chest wall pain

Pain in the chest may be the presenting feature of a diverse number of musculoskeletal chest wall conditions. The more common causes are costochondritis, trauma to the chest wall, benign overuse myalgia, fibrositis, referred pain, and psychogenic regional pain syndrome. These disorders are often mistaken for angina pectoris and other serious disorders. Information about onset, location, character, duration and modulating factors of the pain and other symptoms, a meticulous examination of the ribs, spine, sternum and their articulations, and a few judiciously selected diagnostic studies will establish the diagnosis in most patients. Knowledge and understanding of the underlying pathogenic mechanisms of these musculoskeletal disorders is important for optimal management.     

Lower extremity physical performance, self-reported mobility difficulty, and use of compensatory strategies for mobility by elderly women

Ganesh SP, Fried LP, Taylor DH Jr, Pieper CF, Hoenig HM. Lower extremity physical performance, self-reported mobility difficulty, and use of compensatory strategies for mobility by elderly women.

Objective

To describe the relationship between lower extremity physical performance, self-reported mobility difficulty, and self-reported use of compensatory strategies (CSs) for mobility inside the home.

Design

Cross-sectional exploratory study.

Setting

Community-dwelling elders.

Participants

Disabled, cognitively intact women 65 years or older (N=1002), from the Women's Health and Aging Study I.

Interventions

Not applicable.

Main Outcome Measures

CS scale: no CS, behavioral modifications (BMs) only, durable medical equipment (DME) with or without use of BMs, and any use of human help (HH); and 3 dichotomous CS measures: any CS (vs none); DME+HH (vs BMs only, among users of any CS); any HH (vs DME only, among users of any DME/HH).

Results

Self-reported mobility difficulty and physical performance were significantly correlated with one another (r=−.57, P<.0001) and with the CS scale ([r=.51, P<.001] and [r=−.54, P<.0001], respectively). Sequential logistic regressions showed self-reported difficulty and physical performance were significant independent predictors of each category of CS. For the any CS and DME+HH models, the odds ratio for self-reported difficulty decreased by approximately 50% when physical performance was included in the model, compared with difficulty alone ([18.0 to 8.6] and [7.3 to 3.8], respectively), but both physical performance and difficulty remained significant predictors (P<.0001). The effects of covariates differed for the various CS categories, with some covariates having independent relationships to CS, and others appearing to have moderating or mediating effects on the relationship of self-reported difficulty or physical performance to CS.

Conclusions

Physical performance, self-reported difficulty, health conditions, and contextual factors have complex effects on the way elders carry out mobility inside the home.     

Sex differences in musculoskeletal pain

Epidemiologic, clinical, and experimental evidence points to sex differences in musculoskeletal pain. Adult women more often have musculoskeletal problems than do men. Discrepant findings regarding the presence of such differences during childhood and adolescence continue. Biologic and psychosocial factors might account for these differences. The authors review evidence showing that mechanically induced pressure is more likely to show sex differences than other noxious stimuli and to discriminate between individuals suffering from musculoskeletal pain and matched controls. The authors suggest that a state of increased pain sensitivity, with a peripheral or central origin, predisposes individuals to chronic muscle pain conditions, and that there are sex differences in the operation of these mechanisms; women are vulnerable to the development and maintenance of musculoskeletal pain conditions.     

Feeding difficulty in older adults with dementia

Aims and objectives. To use concept analysis to identify characteristics of feeding difficulty and its antecedents and consequences that provide direction for assessment and management. Background. Feeding difficulty is often recognised as a common problem for older adults and is associated with weight loss, poor nutrition and risk for aspiration pneumonia. The cognitive impairment found in persons with dementia impairs the ability of these adults to complete motor and perceptual tasks required for eating and often prevent the older adult from accepting help with feeding from caregivers. Design. Systematic review. Methods. In 2006, literature searches using keywords (feeding, eating, nutrition, malnutrition, feeding assessment, dementia, ageing and concept analysis, dementia and feeding and excluding enteral feeding, tube feedings, PEG and enteral nutrition) were done in Medline, CINHAL, AGELINE and Social Science Full Text. Seventy relevant articles in English were found. After a review of the relevant articles, concept analysis was used to develop a definition of feeding difficulty, its defining characteristics and to delineate feeding difficulty from its antecedents and consequences. Results. Feeding difficulties arise at the interface between the caregiver strategies to assist the older adult with getting food into the mouth and chewing and swallowing food. A model of feeding difficulty delineates the antecedents and consequences of feeding difficulties. Conclusions. The conceptual model of feeding difficulties provides a strong and clear organising structure for research that can be used to developed evidence based guidelines for practice. Relevance to clinical practice. The conceptual model provides directions for assessment of feeding difficulties and their antecedents. The model can be used to identify interventions that address antecedents of feeding difficulty (risk factors) and different types of feeding difficulties.     

Eating difficulty in older people with dementia

Difficulty with feeding is a common problem among people with dementia and may pose ethical problems for the care team if decisions about continued feeding arise. Thorough assessment can help with successful management and a team approach, with the full involvement of relatives, is advocated.     

Investigation of central pain processing in shoulder pain: converging results from 2 musculoskeletal pain models

Recent reports suggest deficits in conditioned pain modulation (CPM) and enhanced suprathreshold heat pain response (SHPR) potentially play a role in the development of chronic pain. The purpose of this study was to investigate whether central pain processing was altered in 2 musculoskeletal shoulder pain models. The goals of this study were to determine whether central pain processing: 1) differs between healthy subjects and patients with clinical shoulder pain; 2) changes with induction of exercise-induced muscle pain; and 3) changes 3 months after shoulder surgery. Fifty-eight patients with clinical shoulder pain and 56 age- and sex-matched healthy subjects were included in these analyses. The healthy cohort was examined before inducing EIMP, and 48 and 96 hours later. The clinical cohort was examined before shoulder surgery and 3 months later. CPM did not differ between the cohorts, however; SHPR was elevated for patients with shoulder pain compared to healthy controls. Induction of acute shoulder pain with EIMP resulted in increased shoulder pain intensity but did not change CPM or SHPR. Three months following shoulder surgery, clinical pain intensity decreased but CPM was unchanged from preoperative assessment. In contrast, SHPR was decreased and showed values comparable with healthy controls at 3 months. Therefore, the present study suggests that: 1) clinical shoulder pain is associated with measurable changes in central pain processing; 2) exercise-induced shoulder pain did not affect measures of central pain processing; and 3) elevated SHPR was normalized with shoulder surgery. Collectively our findings support neuroplastic changes in pain modulation were associated with decreases in clinical pain intensity only, and could be detected more readily with thermal stimuli. PERSPECTIVE: Longitudinal studies involving quantitative sensory testing are rare. In exploring 2 musculoskeletal shoulder pain models (exercise-induced muscle pain and surgical pain), conditioned pain modulation was unchanged from pre- to post-assessment in both models. Suprathreshold heat pain response decreased after shoulder surgery and was comparable to healthy controls, suggesting this measure may be sensitive to decreases in clinical pain intensity.