Older adult’s experience of chronic low back pain and its implications on their daily life: Study protocol of a systematic review of qualitative research

The average human life expectancy has increased significantly worldwide due to advances in medicine, health care delivery, and technologies over the recent years [1]. The The United Nations has estimated that the global population of people aged 60 or over will triple by 2050 [2]. The fast-growing aging population is accompanied by multiple health issues (e.g., musculoskeletal pain). It has been estimated that approximately 65 to 85% of older adults are suffering from musculoskeletal pain [3, 4].

Of various musculoskeletal pain, low back pain (LBP) is the most prevailing health condition in older adults that leads to functional limitations and disability [5‐7]. LBP is defined as pain or discomfort between the 12th rib and above the gluteal sulcus with or without radiating leg pain [8]. More than 17 million older adults in the USA suffer from at least one episode of LBP annually [9]. Similarly, multiple population-based studies have found that the prevalence of LBP (regardless of chronicity) among community-dwelling older adults in the last 12 months ranged from 13 to 50% [3, 10‐12]. Since the prevalence of chronic LBP increases with age [13‐15], many older adults experience chronic LBP that lasts for at least 3 months [16, 17]. It has been estimated that prevalence rates of chronic LBP in individuals aged 60 years or older were approximately 30% in different parts of the world [12, 18]. In the USA alone, over six million older adults experienced chronic LBP that significantly compromised their quality of life and physical function. [9]. Importantly, since chronic LBP is the major contributor of disability (including falls [19]) in older adults [20, 21], its negative impacts extend beyond the patients. Chronic LBP (like other chronic pain) imposes severe financial burden to caregivers and society [22] although the direct impact of LBP on work productivity in retired older adults appears minimal.

Older adults with LBP face unique age-related vulnerabilities. Compared to younger individuals, older adults are more sensitive to pain because of the compromised endogenous pain modulation processing [23, 24] and decreased pain thresholds [25]. Additionally, comorbidities in older adults (e.g., cognitive impairment [26], polypharmacy [27], and multisource pain generation [28]) may potentiate the debilitating effects of chronic LBP [29], reduce patients’ adherence to medical and therapeutic interventions, and/or cause contraindications to LBP treatments [30]. Since older adults may also need to face multiple age-related psychosocial comorbidities (e.g., bereavement from the loss of spouse or friends, financial constraints, depression and social isolation [31‐33]), these factors can negatively affect their LBP recovery, LBP-related disability, and attitudes/beliefs about pain [34].

Given the high prevalence of debilitating chronic LBP in older adults, designing and implementing proper age-related pain interventions has been suggested to be one of the priorities for educating healthcare professionals [35]. Although multidisciplinary chronic pain management approaches that incorporate the physician’s, nurse’s, and social worker’s perspectives have been recommended for treating older adults with chronic pain [36], patients’ perspective on their chronic LBP experiences is less emphasized in existing pain management guidelines [37]. Since chronic LBP can disrupt older adults’ life, as well as their family’s life and/or social relationships [36], it is paramount to look beyond medical treatments for these individuals so that more comprehensive approaches (e.g., the provision of supportive services or spouse participation) can be formulated to address age-related needs. For instance, a qualitative study interviewing a group of older adults with chronic pain living in rural Thailand revealed that these patients were more likely to adopt self-management programs when treatment for pain reduction or related information was more accessible, affordable, and acceptable [38]. Such information can inform the effective allocation of resources to meet patients’ needs.

While quantitative studies usually use theoretical-based self-reported questionnaires to evaluate the pain and function of older adults with chronic LBP [39], these studies are unable to determine the in-depth concerns or feeling of older adults with chronic LBP [40], which can explain patients’ behaviors and may better inform health and social policy for these patients. This limitation can be addressed by qualitative research. For instance, qualitative studies can provide insights into how age-related social roles can affect the older adults’ experiences with LBP. Therefore, a growing number of qualitative studies have been conducted to investigate the impacts of chronic LBP on various facets of life (e.g., coping strategies and social roles) in older adults residing in different settings [41‐46]. However, no systematic review of qualitative studies has ever been conducted, and we propose to utilize qualitative evidence synthesis (QES) to integrate these research findings. Since age, gender, social class, levels of education, culture, and living environments may have differential influences on the perceived impacts of chronic LBP in older adults, QES can be applied to re-interpret the conceptual data from primary studies [47] in order to deepen the understanding of how chronic LBP impacts the life experience of older adults. Furthermore, QES can enrich the relevance of findings from multiple qualitative studies, thereby broadening the perspectives [48] and enabling to inform healthcare policy or practice [49].

Given the above, the overarching objective of this systematic review of qualitative research is to synthesize and conceptualize daily life experience of older adults living with chronic LBP. It will pose two specific questions to the included studies:

Meta-synthesis is often used as an overarching umbrella term for describing different methods of qualitative evidence synthesis. Meta-ethnography [50], the approach used in the current review, is the most commonly cited method in health service research to synthesize findings from studies with a qualitative design. Our rationale for conducting a meta-ethnography, instead than for example a thematic analysis, is that it is an interpretative rather than an aggregate form of knowledge synthesis. Accordingly, it aims to develop a conceptual understanding of the phenomenon [50].

Since the current systematic review aims to encompass relevant qualitative research papers related to experiences of older adults with chronic LBP, it will be a comprehensive benchmark review paper in the field. The findings not only will provide an overview of all relevant qualitative research areas but also will identify research gaps for future studies and can be used as a foundation for developing adequate assessments and/or interventions for older adults with chronic LBP. Specifically, this review will significantly contribute to the holistic management of chronic LBP in older adults by (1) integrating and synthesizing existing qualitative research findings related to chronic LBP experiences of older adults residing in different settings; (2) providing an in-depth knowledge with regard to older adults’ experiences of living with chronic LBP and the implications on daily life; and (3) identifying potential unmet care needs of this population so that more effective person-centered healthcare and social interventions can be developed/implemented. The findings emerging from the proposed project will subsequently form the theoretical and empirical basis for designing a research program to investigate the effectiveness, adequacy, and feasibility of culturally competent interprofessional allied health interventions in improving the health and independence of living in older people with chronic LBP.