We all know that falling over hurts, but can pain come before a fall?

We have all fallen over, haven’t we? Well you know that it hurts, and you can imagine this is also the case for those of an older age with an increased risk for falls. But how about vice versa? Is pain itself a risk factor for falls in this older group?  This is important as preventing falls is a serious public health issue since fall related injuries are a leading cause of decreased independence, admission to long term care facilities and avoidable death in older adults across the world [1].  With an ageing population and the substantial financial costs following a fall it’s easy to see why the prevention of falls in old age is an international priority [1].

Clearly, in order to reduce the risk of falls it is important to identify and manage factors that increase an older adult’s propensity to fall. Well-recognised risk factors include impaired gait, balance deficits, and reduced muscle strength, all factors which are also strongly associated with pain [2].  Pain and in particular musculoskeletal pain is common in the older population,  affecting around half of community-dwelling older adults [3]. With this in mind imagine our surprise to note that recent (inter)national guidelines do not recognise pain as an important risk factor for falls [4-5].

So we conducted a systematic review of current studies to establish if pain is associated with an increased risk of falls [6].  We found 21 studies that met the inclusion criteria. Results show that more than half of older adults (50.5%) classified as having pain reported experiencing a fall over a 12 month period compared to 25.7% of older adults without pain.  Next we pooled the available data from 14 studies (including over 17,000 older adults) and found that pain was significantly associated with approximately a 56% increased odds of falling.  In order to provide clinicians with more specific information concerning the link between pain and falls, we also looked at specific sites and aspects of pain. Foot pain and chronic pain were particularly associated with falls (approximately 138% and 80% increased odds for falls respectively).  In our analysis we included studies that measured falls in the past (retrospectively) since this is commonly used in clinical practice and is a reliable indicator of future falls [4]. However, in such studies uncertainties may arise as to whether pain caused the fall or the fall caused the pain. In order to avoid the latter we excluded studies that reported pain that was caused by a previous fall and analysed the data separately for falls measured prospectively (with 4,674 older adults) and retrospectively (with 13,012 older adults). When doing this we found the odds of falling were 71% when falls were monitored prospectively and 43% when measured retrospectively.  This difference is likely to due to the fact that recalling falls in the past is often less accurate than prospective measurement.

Our results demonstrate that compared to those without pain, older adults experiencing pain are more likely to have fallen in the last year and to fall again in the future.  More specifically, the risk of falls is particularly high for those with foot pain and those with chronic pain.  We believe our results have important clinical implications and recommend that clinicians working with an older adult at risk of falls, or having recently experienced a fall should assess their pain.  They may seek to employ interventions to manage pain, effects of which should be a future research priority since pain and falls are both highly prevalent and problematic concerns in the older population.  We recommend pain clinicians working with older adults to actively consider their patients’ risk of falls by for instance enquiring about their patients’ history of falls over the past 12 months.  If they identify an older adult with a history of falls, they could refer them to their local falls service and send along with them a comprehensive pain assessment with a short note informing them that pain is a risk factor for falls!

Brendon Stubbs

Brendon StubbsBrendon is a PhD student at the University of Greenwich, London and is currently investigating the association between chronic musculoskeletal pain and falls.  Brendon qualified as a physiotherapist in 2003 and helped set up a falls and osteoporosis screening service in 2005 and was actively involved in falls prevention in hospital and community settings until 2009.  Brendon is currently in full time research and in addition to the topic of the PhD is interested in reducing the physical health disparity in people with severe mental illness.

Laura Eggermont

Laura EggermontLaura is an assistant professor at the VU University in Amsterdam and a senior lecturer at the Leiden University Medical Center in Leiden, The Netherlands. With a background in clinical neuropsychology, she finished her PhD concerning the effects of non-pharmacological interventions on cognition and behaviour in older nursing home residents with dementia. Her current research focus lies on the maintenance of independent living of the general older adult population; her studies examining factors that determine this ability such as mobility, pain, falls and cognitive impairment.

References

[1] World Health Organisation (2007) WHO Global Report on Falls Prevention in Older Age.  WHO Library Cataloguing-in-Publication Data, ISBN 978 92 4 156353 6.

[2] Leveille SG, Ling S, Hochberg MC, Resnick HE, Bandeen-Roche KJ, Won A, & Guralnik JM (2001). Widespread musculoskeletal pain and the progression of disability in older disabled women. Annals of internal medicine, 135 (12), 1038-46 PMID: 11747382

[3] Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P, & British Geriatric Society (2013). Guidance on the management of pain in older people. Age and ageing, 42 Suppl 1 PMID: 23420266

[4] American Geriatrics Society and British Geriatrics Society, Panel on Prevention of Falls in Older Persons, Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011 Jan;59(1):148-57. doi: 10.1111/j.1532-5415.2010.03234.

[5] NICE The assessment and prevention of falls in older people Clinical guidelines, CG161 – Issued: June 2013

[6] Stubbs B, Binnekade T, Eggermont L, Sepehry AA, Patchay S, & Schofield P (2014). Pain and the risk for falls in community-dwelling older adults: systematic review and meta-analysis. Archives of physical medicine and rehabilitation, 95 (1), 175-2147483647 PMID: 24036161