Aging Clin Exp Res. 2017 (Dec 11) [Epub] ~ FULL TEXT
Julie C. Kendall, Lars G. Hvid, Jan Hartvigsen, Azharuddin Fazalbhoy,
Michael F. Azari, Mathias Skjřdt, Stephen R. Robinson, Paolo Caserotti
School of Health and Biomedical Sciences,
PO Box 71,
Bundoora, Melbourne, 3083, VIC, Australia.
BACKGROUND: In older adults, musculoskeletal pain is associated with increased concerns of falling, reduced balance and increased occurrence of falls. In younger adults, the intensity of neck pain and low back pain is associated with increased postural sway. It is not known if pain further impairs balance and concerns of falling in mobility-limited older adults, and if so, whether this is associated with different intensities of pain.
OBJECTIVE: This study examined whether mobility-limited older adults with mild or intense neck pain and/or low back pain have significantly increased postural sway as measured by centre of pressure (COP) changes and concerns of falling compared to those without pain.
METHODS: 48 older adults with a gait speed of < 0.9 m/s from Odense, Denmark were recruited through the public health service. Self-reported neck pain, low back pain, and concerns of falling were recorded on questionnaires. Sway range, velocity and area were recorded on a force plate in a comfortable standing stance. Pain intensity was rated on an 11 point numerical rating scale (0-10). Participants were sub-grouped into mild (0-4) and intense (> 5) neck pain or low back pain.
RESULTS: Intense neck pain was associated with increased anterior-posterior sway range and area of sway. Intense low back pain was associated with increased concerns of falling.
CONCLUSION: Intense neck pain in mobility-limited older adults is associated with significant changes in postural balance, and intense low back pain is associated with significantly higher concerns of falling.
KEYWORDS: Balance; Falls risk; Mobility-limitation; Musculoskeletal pain; Older adults
From the FULL TEXT Article:
Falls are one of the leading health concerns facing older
adults, affecting their capacity to engage in activities of daily
living, loss of independence, and the risk of sustaining moderate–severe injury. Several factors have been identified that
lead to an increased risk of falls in this age group, including
reduced gait speed.  One of the determinants gait speed is
good postural control, and it has been observed that musculoskeletal
pain is associated with reduced balance, increased
concerns of falling, and increased occurrence of falls in
older adults. [2–4]
Previous studies have demonstrated that older adults with
a history of falls displayed an increased range and velocity
of sway when their balance was tested in a static standing
position on a force plate.  It has been hypothesised
that deteriorating anterior to posterior (AP) postural control
occurs as a natural consequence of ageing, particularly of
the lower limb muscles tibialis anterior and biceps femoris,
which demonstrate increased activity in static standing when
compared to young healthy controls.  The resulting flexed
posture and increase in rigidity may be an adaptation that
facilitates the forward displacement of the centre of gravity,
to reduce the likelihood of falling.  A retrospective
study, in older adults, conducted to analyse balance control
parameters in fallers and non-fallers suggested that fallers
had increased medial–lateral (ML) sway rather than AP sway.  Despite these preliminary observations, the relationship
between increased sway and falls risk in older adults remains
to be fully investigated.
The speed of postural sway is influenced by a range of
factors that are likely to be linked to the risk of falls. For
instance, it has been demonstrated in older adults that a
concern of falling, indicated by high Falls Efficacy Scale
International Questionnaire (FES-I) scores, is associated
with significant reductions in both AP and ML velocity. 
In contrast, in studies on younger adults, neck pain and low
back pain increase the extent of sway in the AP direction
more so than the ML direction, and high intensity neck pain
increases the velocity of both AP and ML sway. [9, 10] Yet,
these studies on balance and musculoskeletal pain have been
conducted in younger adults. There is a need to determine
if mobility-limited older adults with musculoskeletal pain
exhibit significant increases in sway and poor balance.
This retrospective cross-sectional study examined neck
pain, low back pain, postural stability, and concerns of falling
in a group of mobility-limited older adults (low gait
speed). Postural stability was assessed in terms of both the
range and velocity of AP sway and ML sway.
The aims of this study were to:
(1) examine whether
mobility-limited older adults with mild or intense neck pain
and/or low back pain have significantly increased centre of
pressure (COP) sway compared to those without pain; and
(2) examine whether concerns of falling are associated with
increases in COP sway in this population.
Older adults were recruited from Odense, Denmark, through
a preventative home visit program from the municipality.
This program includes interviews, with cognitive and physical
assessments, to evaluate risk factors for disability and
loss of independence. Participants included in this analysis
were those who underwent COP analysis recruited to a randomised
controlled trial aimed at increasing functional ability.  These data were baseline data before any intervention
was delivered. This trial was part of the Healthy Ageing
Network of Competence (HANC) study (Clinical trial registration
NCT02051725, The Regional Scientific Ethical
Committees for Southern Denmark approval S-20120149).
To be included in the HANC trial, participants had to be
≥ 75 years of age, have a self-paced gait speed of < 0.9 m/s,
and a mini-mental state examination score of > 21/30 .
The cutpoint for MMSE of 21/30 was chosen to take into
account those with low educational levels.  Additionally,
participants underwent a medical screening including a
general medical history and blood pressure assessment. They
were excluded if they had an amputated limb or other serious
physical impairment, terminal or critical disease (such
as cancer, severe heart failure, etc.), recent surgery (within
the last 6 months) or a recent bone fracture (within the last
3 months). A total of 65 participants were recruited into the
trial. Force plate data for 15 participants was not recorded
properly, of those remaining 50; two participants did not
respond to the neck pain and low back pain questionnaires,
leaving data from 48 participants included in this analysis.
Where there was additional missing data, these data were
excluded pairwise from analyses.
Self-reported neck pain and low back pain within the previous
4 weeks was recorded via two questionnaires based on
a low back pain questionnaire developed by an international
consensus of experts in the field of low back pain.  In the
first questionnaire, participants were asked whether they had
experienced low back pain within the previous 4 weeks, and
if so, to rate the intensity of pain on a numerical rating scale
(NRS) from 0 to 10 (0 = no pain, 10 = severe pain). The second
questionnaire was identical, except that it asked about
the presence and intensity of neck pain. Concerns of falling
were reported on the Falls Efficacy Scale Questionnaire
(FES-I), a 16–item questionnaire that measures the concerns
of falling whilst performing daily routines and activities.
FES-I is a valid and reliable measure of concerns of falling,
and the following cut-off points were used to denote
low (< 20), medium (20–27) and high (> 27) concerns of
Participants were instructed to remove their shoes before
stepping onto the force plate. Balance was measured on a
force plate (Kistler, 9281 B) in comfortable standing stance
with the participants’ heels separated by 13.5 cm. Participants
were given time to step onto the force plate, find the
correct foot position and compose themselves prior to testing.
Participants kept their eyes open, gazing straight ahead
and were asked to stay as still as possible during both trials,
carried out in quiet laboratory. 30 s of continuous recording
from the force plate was used for analysis. Two trials
were recorded and the second trial was used for analysis.
COP postural sway was analysed in three parameters: area
of sway, range and velocity. Range and velocity were calculated
in the AP and ML directions. Range was the difference
between the maximum points of sway in each direction
(mm). Velocity was the distance travelled divided by the
recording time in (mm/s). Area was calculated using the
area of an ellipse covering 90% of data points (mm2) .
Participants reporting neck pain or low back pain were categorised
into intense (≥ 5/10) or mild (1–4/10) pain according
to their numerical pain rating score.
Once the numerical data were extracted from the recordings,
further data analysis was conducted in IBM SPSS (version
22). Normality of the data was determined by examination
of histograms, Q–Q plots and Shapiro–Wilk tests of
normality. Non-parametric tests were used where data were
not normally distributed.
Demographic differences between groups of participants
with no pain compared to participants with neck pain were
analysed using t tests for continuous variables (height)
and chi-squared tests for dichotomous variables (gender).
Weight was not normally distributed and a Mann–Whitney
U test was conducted instead of t test. Similarly, differences
between groups of participants with and without low back
pain were compared for continuous, dichotomous and nonnormally
distributed data as above.
Data for all COP parameters and FES-I scores were not
normally distributed. Differences on each COP parameter
between groups of participants without pain, with mild
neck pain and intense neck pain were examined using
Kruskal–Wallis tests. Where these tests indicated a significant
difference between groups pairwise post hoc tests
were conducted and adjusted with a Bonferroni correction
(Dunn-Bonferroni test). To examine differences between
no pain, mild low back pain and intense low back pain,
Kruskall–Wallis and post hoc tests were conducted likewise.
Similarly, differences on FES-I scores were examined using
Kruskall–Wallis and post-hoc tests between intensities of
both neck pain and low back pain using the same methods
as with COP parameters.
Significance was set at p = 0.05. Data were plotted in
GraphPad Prism 7.02 with Tukey box and whisker plots.
Musculoskeletal pain was common, with 24 (48%) reporting
low back pain and 14 (28%) reporting neck pain. Of these
participants, 9 (18%) reported both neck pain and low back
pain. A total of 19 (38%) participants reported not having
experienced neck pain or low back pain within the previous
4 weeks. Of the 48 participants, 46 responded to the FES-I
questionnaire. Most of the participants reported concerns
of falling, with 24 (52%) respondents scoring between 20
and 27 (medium concern of falling), 6 (13%) scoring 28 or
more points (high), and 16 (35%) scoring 19 or less (low).
When comparing participants with or without neck pain
and /or low back pain, there were no significant differences
between groups with respect to gender, height, weight,
FES-I score or any COP parameter. However, participants
with neck pain were significantly older than participants
(84.21+/– 4.93, SD) without neck pain (81.11+/– 4.38, SD)
(t test p = 0.033) (Table 1). The maximum pain intensity rating
for either neck pain or low back pain was 8/10, indicating
a high-intensity of musculoskeletal pain.
Examination of the results from groups with no pain, mild
neck pain, and intense neck pain elucidated several differences
(Fig. 1). COP sway area was significantly different
between no pain, mild pain, and intense neck pain (p = 0.02)
(Fig. 1, Panel a). Post-hoc analysis identified that this difference
was primarily due to the difference between the mild
and intense pain groups (p = 0.02). Similarly, AP sway range
was different between pain intensities (p = 0.006). Again, the
post-hoc analysis identified a significant difference between
the mild and intense neck pain groups (p = 0.006). There
were no significant differences between the neck pain intensity
groups on sway velocity (both AP and ML), ML sway
range, or FES-I scores (Fig. 1 panels b, d, e and f).
Group characteristics [mean ± SD or n(%)]
between: all participants; those with neck pain;
low back pain; or no neck pain or low back pain
Median COP sway and concerns of falling in
groups without neck or low back pain, mild neck pain
and intense neck pain. Boxes extend to 25th and
75th percentiles. Whiskers are data points equal to
or less than the sum of 75th percentile and 1.5IQR
(equal to or greater than 25th percentile for
lower whiskers). Individual data points are values
outside of these ranges. Overall group effects:
*p < 0.05, **p < 0.01. Post hoc specific group effects:
#p < 0.05, ##p < 0.01
Participants with no low back pain, mild back pain
or intense low back pain did not show any significant
differences on any COP parameter (Fig. 2 panels a, c,
d, e and f). Participants with intense low back pain had
significantly higher FES-I scores (mean 26.77, 95% CI
21.87–31.67) compared to those with no neck pain or
low-intensity back pain (mean 20.44 95% CI 18.77–22.12)
(p = 0.046) (Fig. 2, panel b). When comparing participants
with high concerns of falling to participants with low concerns
of falling, there was a general trend for the former
group of participants to have increased range, velocity and
area of sway (Table 2). However, none of these trends
reached statistical significance.
Participants with higher FES-I scores,
indicating an increased concern of falling, showed
a non-significant increase across all
parameters of COP
Median COP sway and concerns of falling in
groups without neck or low back pain, mild low back pain
and intense low back pain. Boxes extend to 25th and 75th
percentiles. Whiskers are data points equal to or less
than the sum of 75th percentile and 1.5IQR (equal to or
greater than 25th percentile for lower whiskers).
Individual data points are values outside of these ranges.
Overall group effects: *p < 0.05, **p < 0.01.
Post hoc-specific group effects: #p < 0.05, ##p < 0.01
This study examined mobility-limited older adults with
slow gait speed (< 0.9 m/s), and explored the relationships
between back and neck pain, postural stability and concerns
of falling. Participants with higher intensity of neck pain
were found to have a significantly increased range of AP
sway and area of sway, and those with higher intensity of
low back pain had significantly increased concerns of falling.
In experimental pain studies, significant changes in postural
stability have been observed with strong pain intensity
induced by noxious electrical stimulation of the skin overlying
the upper trapezius muscle , and not with mild pain
intensity induced by bolus injections into the upper trapezius
muscle belly.  Results of the current study show that in
mobility-limited older adults postural sway is only increased
with high intensity of neck pain. This is also consistent with
findings in younger adults with neck pain  where a linear
relationship has been reported between neck pain intensity
and increased postural sway. Indeed, these findings indicate
that there may be a tendency for mild neck pain to increase
COP sway; however, this was not the case with mild low
back pain. This result is in contrast to a previous study in
younger adults, which did observe a relationship between
increasing COP sway and increasing intensities of low back
Neck pain has been shown to alter the muscle recruitment
pattern in the neck during balance correction tasks , and this may contribute to the reduced balance and
motor coordination in older adults with poor mobility and
neck pain, above and beyond expected deterioration due to
the ageing process.  The high density of proprioceptors
in the neck, particularly the upper neck , may explain
why high intensity neck pain was significantly associated
with increased sway, and not low back pain. Whilst there was no statistically significant difference in
COP parameters when comparing participants with high,
medium, or low concerns of falling, the trend observed
may suggest that COP parameters tend to be higher in those
with high concerns of falling. Medium concerns of falling
was similar, or slightly higher compared to those with low
One of the strengths in the current study was that the
participants are representative of the mobility-limited older
population of Denmark, due to the recruitment process
within the public healthcare system. This study is of clinical
relevance, since all of the participants were over the age
of 75 years and had reduced gait speed, placing them at
high risk of experiencing a fall in the future.  The present
results suggest that a subgroup of this sample population,
those with intense neck or back pain, may have an increased
risk of having a fall, and hence it might be prudent to target
interventions alleviating this pain. However, the study
sample was relatively small; consequently, it was not possible
to conduct detailed subgroup analyses of the effects
of age and gender on neck pain and low back pain. The
group with neck pain was significantly older than the group
without neck pain. So, it is possible that a proportion of
the difference observed in sway between the groups may be
attributable to age. Furthermore, the sample size was too
small to subgroup participants into neck pain only or low
back pain only groups. Also, the study did not consider additional
factors that affect balance such as, cognitive function , current medications , and the presence of dizziness.  Increased medication use is associated with mobility
impairment and spinal pain in older people.  It is therefore,
possible that people in this study with pain, particularly
intense pain, may be taking more medications and this may
have produced their poor performance on COP. Likewise,
dizziness is associated with spinal pain  and could have
similarly impacted the results. As a fairly small sample from
Odense, Denmark, the findings in this study will need to be
confirmed with larger numbers of participants and drawn
from other populations.
This study demonstrated that mobility-limited older adults
with intense neck pain have significantly poorer postural
balance when compared to frail older adults without neck
pain. Also, intense low back pain is associated with significantly
higher concerns of falling. While these findings
support the view that intense neck or back pain contribute
to an increased risk of falls, consistent with data observed in
younger adults, the current study and cross-sectional design
did not permit a prospective examination of the participants’
subsequent falls history. Future studies may examine
whether high intensity neck or back pain are predictive of
future falls risk in older frail individuals.
Conflict of interest
All authors declare they do not have any conflict
This work was supported by an international stipend from
the Foundation for Chiropractic Research and Postgraduate Education
(Denmark) (Grant No. 14/603). The HANC study is supported by
the European funding program INTERREG Iva (Grant No. 11/23147).
Neither funding source had any involvement in: study design; in the
collection, analysis and interpretation of data; in the writing of the
report; or in the decision to submit the article for publication.
Statement of human and animal rights
This trial was part of the
Healthy Ageing Network of Competence (HANC) study (Clinical
trial registration NCT02051725) and obtained ethics approval from
the Regional Scientific Ethical Committees for Southern Denmark
All participants gave informed consent as part of
the HANC study.
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