Low back pain (LBP) is ranked as the top condition contributing to years lived with disability (YLD) globally.1 In Brazil, back complaints were the second most commonly reported health condition in 2003 and 20082 and the third cause for early retirement due to disability in 2007, bringing a high demand for health care services in older people.3,4 While both the prevalence and the associated burden of LBP in terms of disability increase with age,1 information about LBP in the older adults is very limited, and the majority of studies on LBP exclude these patients. Considering the fast growth of the aging population in developing countries, and the influence of socioeconomic context in many health outcomes, addressing LBP in this population is crucial. To date, there is no data available on LBP in older people from Latin America.

In the present study, we explored variables related to pain and disability in Brazilian older patients using the Brazilian baseline data collected for the Back Complaints in the Elder (BACE) international consortium, which was established by Australia, Brazil and the Netherlands to investigate the burden of back complaints in the older adult.5,6 Thus, the aim of this study was to describe the clinical characteristics of Brazilians aged 55 or more with an acute episode of LBP. Moreover, we also aimed to: (i) compare if these characteristics differ between different groups of age (55–74 years; 75 and over) and (ii) compare if pain and functional capacity related characteristics differ between groups of educational level and income status.

The research team screened 3711 older adults to participate in the Brazilian BACE study, later resulting in the inclusion of 602 participants (Fig. 1). Physicians directly referred 7.1% of participants, whereas allied health professionals referred the remaining participants. The median age of all 602 participants was 67 (IQ=10), and median duration of pain in days from the acute pain episode was 15 days (IQ=23). Approximately 85% of the participants were female, 40% reported having low income, and the majority had low levels of education. Almost 50% of participants were either married or had a partner, 99% were community dwellers, and 19% had a recent history of falls.

Figure 1.

Flowchart of participants for the Brazilian Back Complaints in the Elders study.

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This study presents the characteristics of 602 Brazilian older adults who suffered from a new episode of LBP. Our participants presented higher levels of pain, disability and psychological distress compared to international data.9,10 Present results demonstrate that age, educational levels, and income status appear to affect older people's report of pain, but even more of disability.

Results indicate that the relationship between LBP and disability is not linearly dependent on chronological aging. In contrast to the Dutch BACE findings,9 the younger group reporting slightly more pain-related disability than the older group, and worse quality of life related to physical function. We hypothesize that these differences could be due to some factors: younger adults were more active in the community, thus pain could have affected more significantly their daily functions; also, other factors influence pain and disability in the aged population, such as increased levels of inflammatory cytokines,11,12 sarcopenia,13,14 degenerative diseases, having poorer perception of health, psychosocial factors, and having more concurrent diseases.15–17 Additionally, these results might also lie in the peculiarity of the evolution of life expectancy in Brazil, which in 1940 was around 40 years old. Thus, Brazilians aged 75 and over from this study must have physical and functional characteristics that favored their survival over the years, thus being more resilient to their health condition.

We highlight the prevalence of falls in the sample, moreover the younger group having less self-efficacy for falls. A recent systematic review revealed that musculoskeletal pain is associated with an increased risk of falls in community-dwelling older adults (OR=1.56; 95% CI 1.36–1.79),18 thus LBP can also be associated with such events.19 In more active older adults, having reduced self-efficacy can be associated with some protective behavior in them triggered by falling, and this behavior could have a negative impact in function.20 Particularly comorbidities are also associated with the burden of pain whereas having other musculoskeletal conditions might negatively impact the lower back.21–25 Hence, we encourage understanding comorbidities in older patients with LBP, for they bring more complexity for LBP care. The older group had more participants with a history of cancer. Cancer is a red flag for LBP,26 and it might differently influence these groups in the course of the complaint, though this needs to be followed-up in the long term.

For aged people with LBP, limited evidence shows that LBP can be associated with poor performance of the TUG test14,22 and difficulty in performing daily life activities.27 In this study, those who were older, less educated, and with lower levels of income took longer to complete the TUG test. Also, while older participants had lower gait speed, we observed that the overall mean speed was lower than that from the general older population,28,29 suggesting that there might be an association between LBP and gait speed. Indeed, Leveille et al.,30 showed a negative, linear relationship between LBP intensity and gait speed in a prospective, population-based, 5-year follow-up study with 1002 American older women.

Our results suggest that these socio-demographic factors have a negative influence in overall function of older patients with LBP. There is some evidence in the LBP literature that having lower levels of education is linked to poorer prognosis for younger adults with chronic LBP.31 In general, older people with low socio economic status present worse health conditions,32 especially taking into account the influence of environmental exposure, adverse health behavior and the difficulty in accessing health care throughout life.33,34 On the other hand, there is evidence that more educated people present better health care, use more health services, and adopt more preventive measures in terms of the impact health in life.35 The present sample had predominantly lower levels of education and income status. In agreement with our findings, a survey conducted in 2003 demonstrated that 37.8% of Brazilian aged 60 years and more were illiterate, whereas 37.2% reported having 1–4 years of education.36,37 These data leads to reflection on the importance of dealing with LBP in a lifetime perspective, for it can negatively affect adults in later life in countries where many of them have unequal access to health care.

We acknowledge the study has limitations. Although we settled a formal agreement with the Primary Care Network of the city of Belo Horizonte, Brazil, it is likely we failed to consecutively include a significant proportion of participants because many patients who suffer from a new episode of pain do not have prompt access to care for this condition. Also, due to the workload of local staff, some patients might not have been referred to contact the research group. The cross sectional design of the present study prevented us from discussing causality; still, it gives us a clear scenario of older adults suffering from LBP in a country that has one of the largest older population globally. Moreover, the use of instruments of assessment that are used in the aging group gives clinicians who deal with these patients a practical framework for exploring this condition in them. Indeed, it gives researchers ground to discuss the relevance of investigating specific measurements aiming this target population. To our knowledge, this is the first study describing detailed data in LBP with older adults in Latin America.

In summary, LBP in Brazilian older people is disabling, associated with the number of comorbidities and general musculoskeletal pain, and brings significant psychological distress to those with an acute episode of pain. Within this population there are groups of people who behave worse in terms of pain, disability, physical capacity, and also psychological factors such as fear of falling and pain catastrophizing, especially considering those less educated and with lower income status. Our results highlight the need to better address both demographic and psychosocial factors in LBP in older adults, considering that the impact of pain in the older adult is context dependent. This is a starting point to pave the way for investigators and clinicians in the rehabilitation field for managing older patients with LBP especially at Primary Care level. The importance of the listed factors such as age, education and income status in the prognosis of LBP in them are the subject of further investigation by this consortium.

The authors declare no conflicts of interest.