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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 18  |  Issue : 4  |  Page : 208-212

Chronic musculoskeletal pain in older people


1 Department of General Medicine, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
2 Department of Geriatric Medicine, Sawai Man Singh Medical College, Jaipur, Rajasthan, India

Date of Submission11-Dec-2022
Date of Decision14-Dec-2022
Date of Acceptance14-Dec-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Dr. Ankita Agarwal
Flat No. F-2, K23 (Sapphire Heritage), Malviya Marg, C Scheme, Jaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiag.jiag_66_22

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  Abstract 


Musculoskeletal pain is a common and debilitating symptom in older adults. However, its importance is often underestimated. In this review article, we discuss its proper evaluation and management. Pain evaluation includes detailed history taking, physical examination, imaging, and laboratory investigations. Management of musculoskeletal pain requires a multidomain approach including nonpharmacological, pharmacological, and surgical modalities. A step-wise approach recommended by the World Health Organization can be used for pain management. Common musculoskeletal conditions causing pain are osteoarthritis, low-back pain, gout, pseudogout, rheumatoid arthritis, polymyalgia rheumatica, and fibromyalgia.

Keywords: Elderly, joint pain, pain ladder


How to cite this article:
Jain G, Singhal S, Goyal LK, Agarwal A, Mathur A. Chronic musculoskeletal pain in older people. J Indian Acad Geriatr 2022;18:208-12

How to cite this URL:
Jain G, Singhal S, Goyal LK, Agarwal A, Mathur A. Chronic musculoskeletal pain in older people. J Indian Acad Geriatr [serial online] 2022 [cited 2023 Feb 8];18:208-12. Available from: http://www.jiag.com/text.asp?2022/18/4/208/365784


  Introduction Top


Chronic musculoskeletal pain is a common disorder in older people.[1] Persistent pain which is defined as pain that extends beyond the usual time of healing, typically for longer than 3 to 6 months is highly prevalent among older adults. The World Health Organization (WHO) highlights pain as a key factor in the impact of musculoskeletal conditions to the global burden of disability.[2] These are, in turn, associated with falls, frailty, depression, anxiety, sleep disturbances, impaired cognitive functions, and decreased mobility.

With increasing longevity and population aging, there is a need to focus on active and healthy aging. This can help older people in maintaining an independent and productive life. The difference in psychological and socioeconomical characteristics along with multimorbidity and polypharmacy in older adults further increases the need for different pain management approaches as compared to their younger counterparts. Unfortunately, pain may be undertreated or inappropriately managed in older adults for many reasons such as lack of pain identification, false belief that pain is part of aging, and cognitive impairment. This highlights the importance of special consideration in the assessment and management of persistent musculoskeletal pain in older adults.

Domains relevant for assessing musculoskeletal pain in older adults:

  1. Location of pain
  2. Duration of pain
  3. Characteristics of pain: acute, subacute, and chronic
  4. Severity of pain (pain intensity with a numerical rating scale, based on recall from the past 7 days)
  5. Frequency and variability of pain
  6. Other sites of pain: Gastrointestinal, headache, widespread, etc.
  7. Prior surgeries
  8. Prior treatment modalities used for pain management
  9. Physical function (for example: walking, climbing stairs, running errands, etc.)
  10. Mental function (depression, anxiety, posttraumatic stress disorder, etc.)
  11. Sleep disturbance
  12. Substance abuse: Alcohol/tobacco use
  13. Other factors such as age, gender, race, ethnicity, employment status, literacy, and weight.



  Evaluation Top


This includes patients' clinical history taking, physical examination, imaging studies, and in some cases, laboratory tests. Besides the pain history, the medical history should also include general medical history, history of current illnesses, additional comorbidities, current medications, and drug abuse. As psychological pain can also manifest as physical pain, a focused psychological assessment is also part of the pain evaluation. The physical examination should include a general examination, local examination as well as examination for specific sensory, motor or autonomic changes, and deformity.[3],[4] Outside of these four principles, clinicians should tell or examine with location-specific maneuvers.

Abnormal findings on imaging are common in older patients. However, the presence of degenerative changes in the spine or joint on imaging does not always contribute meaningfully to the assessment of pain. The key to interpret imaging in musculoskeletal pain is to correlate with the clinical picture. Imaging findings often do not reliably correlate with pain frequency or intensity, and the use of imaging often does not lead to improve outcomes.[5]


  Management Approaches Top


There are multiple modalities for the management of persistent pain in older adults [Figure 1].
Figure 1: Various approaches for management of chronic musculoskeletal pain in an older adult

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  1. Nonpharmacological modalities
  2. Pharmacological modalities
  3. Surgical modalities.


Nonpharmacological modalities

Although often overlooked, nonpharmacological modalities are a crucial component of pain management in older people. As they do not possess any significant side effects, they are safer to use. However, they may require a longer duration for their complete beneficial effect.

  1. Physical modalities such as heat and cold application are useful, especially for spasmodic pain. Passive treatment programs such as hot packs, massages, and ultrasounds may be appropriate for a short duration. There are no large landmark clinical trials of these modalities, so the evidence is limited
  2. Transcutaneous electrical nerve stimulation (TENS) therapy is based on the gate control theory of pain from Melzack and the wall, where the preferential activation of large Aβ fibers inhibits the transmission of painful impulses.[6] It is used in patients with complex regional pain syndrome, phantom limb pain, and peripheral nerve injury. TENS has also been shown to be effective in osteoarthritis (OA) and neuropathic pain[7]
  3. Acupuncture depends on the use of thin metal needles that are inserted into specific body sizes and stimulated electrically. There is no evidence that acupuncture is more effective than other treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) for low back pain or neck pain[8]
  4. Exercise programs: physical activity is consistently recommended to be a key component of any treatment plan for persistent pain in older adults.[9],[10],[11] Exercise can improve function, increase strength, reduce the risk of cardiovascular disease, decrease mortality, and relieve pain
  5. Counseling and behavior therapy: Patients may often have psychological problems preceding or following the physical pain which may interfere with the pain resolution. Counseling or behavioral therapies such as psychotherapy, group therapy, and cognitive behavioral therapy, therefore, may be necessary in such patients.


Pharmacological modalities

A wide range of analgesics can be used for the treatment of chronic musculoskeletal pain [Table 1].
Table 1: Medications shown benefit in chronic musculoskeletal pain

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Pain ladder system, recommended by WHO [Figure 2], guides clinicians in the use of analgesics for pain.[12] This revised analgesic ladder along with integrative medicine principles and minimally invasive interventions is recommended for the control of chronic noncancer pain, including musculoskeletal pain.[13] It is important to know that opioids are not the first-line therapy for chronic pain; the risks, benefits, and availability of nonopioid treatment should be tried first with patients.[14]
Figure 2: Pain ladder for the use of analgesics as recommended by the World Health Organization. CNCP: Chronic noncancer pain

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Surgical modalities

Various surgical options for pain management are:

  1. Surgical procedures for the primary lesion or pathology
  2. Neurosurgical procedures for pain management
  3. Pain interventions.


Pain interventions are minimally invasive procedures that relieve acute and chronic pain and minimize the use of analgesics when appropriately indicated. Neural blockade can be used for diagnostic, prognostic, or therapeutic purposes. Image guidance tools such as ultrasound, C-arm, computed tomography, or magnetic resonance imaging (MRI) can be used during the intervention when clinically indicated.


  Common Musculoskeletal Conditions in Older Adults Top


In this section, common differentials of chronic musculoskeletal conditions in the elderly will be discussed.

Osteoarthritis

It is the most common cause of arthritis and a leading cause of disability. Its incidence and prevalence are rising, likely related to the aging of the population, physical inactivity, and increasing obesity.[15],[16] OA most commonly affects the knees, lower vertebrae, hands, and hips. Clinically, the patient presents with pain, impaired joint mobility, joint swelling, crepitus, and locking of the joint, the most common symptom being joint pain. OA is usually diagnosed clinically, on the basis of history and examination. Radiography helps in confirming the diagnosis and estimating the severity or degree of damage to the joint. Radiographic findings suggestive of OA include narrowing of joint space, subchondral sclerosis and cyst, osteophyte, and altered bone contour. Joint space loss is symmetric and nonuniform in the case of OA.[17]

The aim of treatment in OA is to alleviate joint pain and improve quality of life by increasing muscle strength and physical activity.[18] Both aerobic and muscle strengthening exercises have shown benefits in reducing symptoms and disability in knee and hip OA patients. Quadriceps muscle strengthening has shown to be particularly beneficial in knee OA patients. Weight loss in overweight or obese patients is recommended for OA knee or hip patients. Assistive devices such as canes reduce joint loading and thus decrease pain in OA patients. Topical analgesics such as NSAIDs and capsaicin can be used initially to decrease the dose and frequency of oral analgesics. Intra-articular steroids can also be used to provide short-term relief in severe OA pain. However, the long-term side effects on bone and cartilage are concerning, and therefore should be used in limited and severe pain. Nutraceuticals such as chondroitin sulfate and glucosamine have not shown any significant benefit and therefore are not recommended in OA patients. In advanced cases, surgical interventions such as arthroscopic debridement, osteotomy, or joint replacement can be done.

Chronic low back pain

Chronic low back pain in older adults is very common with prevalence ranging from 10% to 20% or more in those aged 65 years or above.[19] A definitive cause may not be identified in most of cases of chronic low back pain.

The diagnosis can be divided into two groups, patients with specific and those with nonspecific low back pain. Specific low back pain is defined as symptoms caused by a specific pathophysiological mechanism, such as infection, osteoporosis, rheumatoid arthritis (RA), fracture, or tumor. Nonspecific low back pain is defined as symptoms without a clear specific cause—that is, low back pain of unknown origin. About 90% of all patients with low back pain will have nonspecific low back pain, which, in essence, is a diagnosis based on the exclusion of specific pathology. No significant association is seen of nonspecific low back pain with abnormalities in X-ray and MRI.[20] Therefore, imaging should be considered only in patients with specific back pain or red flag conditions.

Exercise and intensive multidisciplinary pain treatment programs are effective for chronic low back pain and are supported by strong evidence. Some evidence supports the effectiveness of (cognitive) behavior therapy, analgesics, antidepressants, NSAIDs, and spinal manipulation. No evidence supports using other interventions (for example, steroid injections, lumbar supports, and traction). For most effective treatments, the effects are usually only small and short-term.

Crystal arthropathies: Gout and pseudogout

Gout is crystal arthritis characterized by an inflammatory reaction due to the deposition of monosodium urate in the joint. It is a common inflammatory arthropathy in older adults and its prevalence is increasing likely due to its relationship with hyperuricemia, hypertension, metabolic syndrome, diabetic use, and renal insufficiency.[21] When suspecting a diagnosis of gout, one should keep OA, RA, pseudogout, and infection in the differential diagnosis.

The gold standard for diagnosis of gout is the identification of negatively birefringent needle-like monosodium urate crystals on polarized light microscopic examination of synovial fluid. X-rays of joints can also help show erosive changes with preserved joint space. For the treatment of acute flare, colchicine and corticosteroids are used. Long-term treatment includes lifestyle modification and urate-lowering therapy (allopurinol and febuxostat) can be used to prevent recurrent attacks.

Pseudogout is a form of crystal arthritis usually characterized by an inflammatory reaction to the deposition of calcium pyrophosphate into cartilaginous structures of joints. Diagnosis is by synovial aspiration and demonstration of positively birefringent rhomboid crystals in polarized light. Treatment of acute flare of pseudogout is similar to gout.

Rheumatoid arthritis

The prevalence of RA in older people (more than 60 years of age) is about 2%.[22] RA in an older adult may be a continued manifestation of young-onset RA or late-onset RA (LORA). LORA which usually onset after the age of 60 years has few distinct clinical features. These patients usually have more equal gender distribution and are often seronegative. The joint involvement is also distinct with common involvement of large and proximal joints (e.g., shoulder joint). RA can be diagnosed on the basis of history and physical examination with laboratory data and imaging used to confirm the clinical suspicion. The aim of the treatment is to reduce disease activity and prevent deformities. The corner store for the treatment of RA is disease-modifying antirheumatic drugs (DMARDs). Although newer biological and target-specific DMARDs are now available, methotrexate remains the initial drug of choice. Besides pharmacologic therapy, nonpharmacologic therapies play a crucial part in the management of RA patients. Physiotherapy and occupational therapy should be advised and encouraged to every patient with RA. Physical modalities and exercise programs (mentioned earlier) can significantly help in reducing pain and functional disability.

Polymyalgia rheumatica

Polymyalgia rheumatica affects older adults (age more than 50) and has peak incidence in the eighth to the ninth decade of life with a prevalence of approximately 1% to 2% in older adults. It presents as slowly progressive, symmetrical pain, and stiffness in the neck and proximal limb muscles (shoulder > hip). Laboratory data typically show elevated inflammatory markers and are generally negative for auto-antibodies such as rheumatoid factor and anti-Anti-cyclic citrullinated peptide (CCP) antibody. The mainstay of treatment is low-dose systemic steroids.

Fibromyalgia

Fibromyalgia is characterized by an increase in sensitivity to pain and commonly presents with pain, fatigue, “mental fogginess,” and sleep disturbances. The exact cause of fibromyalgia is unknown and is considered to be due to a complex interplay of biopsychosocial factors. Its prevalence in older adults is 2% to 4%, with women being affected more commonly than men.[23] Patients usually report chronic diffuse moderate-to-severe pain “all over the body” and “all the time.” The diagnosis of fibromyalgia is made clinically using ACR diagnostic criteria. Fibromyalgia is treated using both pharmacological and nonpharmacological therapies. The class of medication with the greatest efficacy is antidepressants. Pregabalin also improves pain and other symptoms in these patients.


  Conclusion Top


Musculoskeletal pain in an older adult is a complex and multifaceted syndrome which is associated with adverse physical and psychological consequences leading to impaired function and quality of life. Hence, it should be comprehensively evaluated and treated using the multipronged approach of appropriate nonpharmacological, pharmacological, and surgical modalities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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WHO Scientific Group on the Burden of Musculoskeletal Conditions at the Start of the New Millennium. The Burden of Musculoskeletal Conditions at the Start of the New Millenium: Report of a WHO Scientific Group. Geneva S: World Health Organization; 2003. Available from: https://apps.who.int/iris/handle/10665/42721. [Last accessed on 2022 Nov 29].  Back to cited text no. 1
    
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Jarvik JG, Gold LS, Comstock BA, Heagerty PJ, Rundell SD, Turner JA, et al. Association of early imaging for back pain with clinical outcomes in older adults. JAMA 2015;313:1143-53.  Back to cited text no. 5
    
6.
Melzack R, Wall PD. Pain mechanisms: A new theory. Science 1965;150:971-9.  Back to cited text no. 6
    
7.
Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: The state of the evidence. Pain Manag 2014;4:197-209.  Back to cited text no. 7
    
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Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, et al. Acupuncture and dry-needling for low back pain: An updated systematic review within the framework of the Cochrane collaboration. Spine (Phila Pa 1976) 2005;30:944-63.  Back to cited text no. 8
    
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12.
Christo PJ, Mazloomdoost D. Cancer pain and analgesia. Ann N Y Acad Sci 2008;1138:278-98.  Back to cited text no. 12
    
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Yang J, Bauer BA, Wahner-Roedler DL, Chon TY, Xiao L. The modified WHO Analgesic ladder: Is it appropriate for chronic non-cancer pain? J Pain Res 2020;13:411-7.  Back to cited text no. 13
    
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Kroenke K, Alford DP, Argoff C, Canlas B, Covington E, Frank JW, et al. Challenges with Implementing the Centers for disease control and prevention opioid guideline: A consensus panel report. Pain Med 2019;20:724-35.  Back to cited text no. 14
    
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Neogi T, Zhang Y. Epidemiology of osteoarthritis. Rheum Dis Clin North Am 2013;39:1-19.  Back to cited text no. 15
    
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Dahlhamer J, Lucas J, Zelaya C, et al. Prevalence of Chronic Pain and High-Impact Chronic Pain Among Adults - United States, 2016. MMWR Morb Mortal Wkly Rep 2018;67:1001-6. Published 2018 Sep 14. doi:10.15585/mmwr.mm6736a2.  Back to cited text no. 16
    
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20.
van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976) 1997;22:427-34.  Back to cited text no. 20
    
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