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Multi-Site Pain May Be Associated with Fractures in Elderly

October 9, 2019
Risk is independent of falls and other confounders.

With Feng Pan, MD, PhD, and Don L. Goldenberg, MD

Multi-site musculoskeletal pain is associated with prevalent and incident fracture risk in the elderly,1 according to a study led by Feng Pan, MD, PhD, research fellow at the Menzies Institute for Medical Research at the University of Tasmania in Hobart, Australia.

The study’s hypothesis—individuals with a greater number of painful sites have a higher risk for fractures—is based on previous research showing that multi-site pain is common in older adults,2 associated with falls,3,4 and that aging, falls, and osteoporosis are the main risk factors for fractures.5,6

“Chronic widespread pain, particularly chronic pain in multiple parts of the body, has been found to be the risk factor for everything bad, including mortality [and] certainly for falls,” said Don L. Goldenberg, MD, emeritus professor of medicine at Tufts University School of Medicine in Boston, MA, and a member of PPM’s Editorial Advisory Board.

This new study’s findings shed light on the importance in general practice of assessing the number of painful sites in a patient, said Dr. Pan. “Treatment and management of pain may have the potential to reduce fracture risk in older populations,” he told PPM.

Risk is independent of falls and other confounders. (Source: 123RF)

Reported Pain and Fractures in Older Adults

Dr. Pan and his colleagues analyzed data from the Tasmanian Older Adult Cohort Study, a longitudinal, observational population-based study of 1,099 participants aged 50 to 80 years (mean age of 63 years) that recorded their number of painful sites and fractures at baseline and at 2.6, 5.1, and 10.7 years follow-up.

Participants were divided into three groups based on their number of painful sites: 0 to 2; 3 to 4; and 5 to 7. Painful locations included the neck, back, hands, shoulders, hips, knees, and feet. Subjects reported their number of fractures, categorized as any, vertebral, non-vertebral, hip, and major (femur, radius, vertebral, rib, humerus), at each follow-up. Body mass index (BMI), bone mineral density (BMD), and falls risk were also measured using the short-form Physiological Profile Assessment. The researchers used log-binomial regression for the analyses.

Participants reported 450 fractures at baseline; at 10.7 years of follow-up, they reported a total of 154 new fractures. The prevalent (baseline) fractures increased with the number of painful sites in a dose-response manner for fractures at any site, non-vertebral, and hip (P < 0.05). Likewise, incident fractures at any site, major, and vertebral were higher in participants with a greater number of painful sites, and there was a dose-response relationship between incident fractures and number of painful sites (P < 0.05).

Additionally, participants who reported pain at 5 to 7 sites had an increased risk of incident fractures at any site (relative risk [RR] 1.69, 95% CI, 1.13-2.53), major (RR 2.17, 95% CI, 1.12-4.22), and vertebral (RR 6.44, 95% CI, 1.64-25.33) compared to those with pain only at 0 to 2 sites.

The team also found that these associations remained significant after further adjustment for fall risk, BMD, and confounders (age, sex, BMI, physical activity, smoking history, pain medication, and comorbidities). Results suggested that widespread pain is an independent contributor to fracture risk.

Study Limitations

Dr. Pan’s team noted several limitations to their work, including that pain was measured by a self-reported questionnaire (pain/no pain) without x-ray confirmation and assessments of pain intensity, duration, and pattern. Therefore, the researchers were unable to assess whether these pain features were specifically associated with fractures. Secondly, it is possible that some yet unidentified conditions associated with pain could be markers of fracture risk.

Dr. Goldenberg, a noted rheumatologist and fibromyalgia expert, took exception. “There is some evidence that participants with widespread pain (eg, fibromyalgia), have modestly elevated levels of systemic inflammation,7 reduced anti-inflammatory markers,8 and enhanced innate immune response.9 In light of this, it is plausible that participants with multiple-site pain (MSP) had higher levels of inflammation, which lowers bone strength through bone remodeling, thereby increasing the risk of fractures.”

These are conditions of centralized pain rather than inflammation, explained Dr. Goldenberg. “Most experts in this area think that systemic inflammation is not a key issue in conditions like fibromyalgia or widespread pain. The key hypothesis is that it is a problem in the central nervous system and how people process pain messages.”

While Dr. Pan agreed with Dr. Goldenberg that multi-site pain may reflect a dysfunction in centralized pain processing, he mentioned that the study data did not show any association between MSP and fall risk. “Additionally, after adjusting for fall risk, the association between MSP and fracture risk remained statistically significant,” he explained. “Therefore, increased fracture risk may not be explained by an increased risk of falls potentially related to central sensitization mechanisms but may be due to systemic inflammation.”

Using Multi-Site Pain Assessment in Practice

The study report advises that clinicians should routinely count and assess the number of painful sites in their patients in relation to fractures. Dr. Goldenberg noted the dilemma facing clinicians who want to reduce their patients’ fracture risk by prescribing medications for centralized pain, such as amitriptyline. “This medication, particularly in the elderly, could make them more confused, increasing fall risk and more fractures,” he said.

Dr. Pan urged that further research is needed in order to confirm his results, saying that his team “aims to further explore the underlying mechanisms of the link between multi-site pain and fracture risk.

Last updated on: October 9, 2019
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Pain and Fall Risk in the Elderly
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