Best Practice & Research Clinical Rheumatology xxx (2017) 1e9

Contents lists available at ScienceDirect

Best Practice & Research Clinical

Rheumatology
journal homepage: www.elsevierhealth.com/berh

Chronic musculoskeletal pain and its impact on

older people
Fiona M. Blyth a, b, *, Naomi Noguchi a, c
a
Centre for Education and Research on Ageing, Concord Hospital, University of Sydney, Australia
b
Concord Clinical School, University of Sydney, Australia
c
School of Public Health, University of Sydney, Australia

a b s t r a c t
Keywords:
Musculoskeletal pain Musculoskeletal conditions are the leading cause of disability
Older people worldwide and also have a large impact on many other aspects of
Epidemiologic studies older people's health such as low physical activity level, poor
mobility, frailty, depression, cognitive impairment, falls and poor
sleep quality. Clustering of musculoskeletal pain with other pain
conditions is also common, and the number of pain sites is an
important prognostic factor. While musculoskeletal pain is usually
nociceptive in origin, older people with musculoskeletal conditions
may also experience neuropathic pain and central pain syndromes.
Musculoskeletal burden of disease is increasing because of rapid
ageing of populations, especially in developing countries. Interac-
tion of musculoskeletal pain with co-existing conditions, including
other types of pain, needs to be studied in longitudinal studies to
identify modifiable targets for intervention. Additionally, potential
impacts of musculoskeletal pain and prognostic factors need to be
investigated in developing countries where evidence is scarce.
© 2017 Elsevier Ltd. All rights reserved.

Introduction and background

In this chapter, we explore the burden of chronic musculoskeletal pain in older populations. Chronic
musculoskeletal pain is defined using the proposed ICD-11 classification system as ‘persistent or

* Corresponding author. Centre for Education and Research on Ageing Concord Hospital, Hospital Rd, Concord, 2139 NSW,
Australia.
E-mail address: fiona.blyth@sydney.edu.au (F.M. Blyth).

https://doi.org/10.1016/j.berh.2017.10.004
1521-6942/© 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
2 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9

recurrent pain that arises as part of a disease process directly affecting bone(s), joint(s),muscle(s), or
related soft tissue(s)’ [1]. This chapter focuses on chronic musculoskeletal pain in community-dwelling
older people as a distinct entity. While chronic musculoskeletal pain as described here is nociceptive in
type, older people may also experience neuropathic pain, functional pain conditions where pain is
perceived in the musculoskeletal system or other types of chronic pain. Population studies have also
shown that some people experience chronic pain that has mixed features of both nociceptive and
neuropathic pain conditions [2].

Overview of the global burden of musculoskeletal pain

Global burden of disease (GBD) studies have been conducted since 1990, with the aim of assessing
the relative contributions of individual diseases, injuries and risk factors to the population, and societal
burden of death and disability [3]. GBD 2010 was notable for having the most detailed assessment of
the contribution of musculoskeletal conditions to the GBD [4]. Within the broader grouping of
musculoskeletal conditions, low back pain emerged as the leading cause of disability globally, in both
developed and developing countries. Neck pain, osteoarthritis, rheumatoid arthritis and gout were also
important global causes of disability. There is consensus that the major drivers of this burden relate to
the increasing size and ageing of populations around the world [5].

Global trends in population ageing

The prevalence of common musculoskeletal conditions is strongly age related. In both developed
and developing countries, there are consistent trends of population ageing over time. The rate at which
ageing is occurring is faster in developing countries than in developed countries. It has been predicted
that by 2050, there will be five times more people aged 40 and over in developing countries than in
developed countries [6]. Given the importance of musculoskeletal pain with regard to functional status
in older age groups (see section ‘Impact of musculoskeletal pain in older people’), this may have
profound implications for future disability burden.

Changes in life expectancy and healthy years of life

GBD 2013 examined changes in life expectancy at birth and healthy life expectancy at birth from
1990 to 2013 [7]. The principal finding was that gains in overall life expectancy were not matched by
gains in healthy life expectancy, driven by a global reduction in years of life lost to disease and an
increase in disability (and to a much lesser extent mortality) with major contributions from muscu-
loskeletal disorders, neurological disorders, and mental and substance use disorders.

Ageing

Overview of the epidemiology of normal ageing and its variability

A number of epidemiological studies have explored determinants of successful ageing. A systematic

review that investigated operational definitions of successful ageing found that most definitions of
successful ageing included physiological constructs (e.g. physical and cognitive function) [8]. In
addition, most definitions also considered engagement constructs (e.g. involvement in voluntary work)
and/or well-being constructs (e.g. life satisfaction). Personal resources (e.g. resilience) and extrinsic
factors (e.g. finances) were included in some definitions.
Physical functioning is frequently used as an outcome measure because it is a key determinant of
the ability to live independently. Physical functioning may be measured subjectively using self-report
measures of limitations or disability in daily activities, which are influenced by each person's living
environment and his or her physical ability. Compared to limitations in daily activities, physical per-
formance tests are sometimes considered a more objective and robust indicator of physical functioning
under standardised conditions and have been widely used in epidemiological studies on ageing. Both

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9 3

types of measures (subjective and objective) can be used together to explore common and individual
aspects of physical functioning.
There is considerable heterogeneity in physical functioning in older age. The Health and Retirement
Study has reported walking speed, grip strength and balance (ability to maintain tandem stance) in
community-dwelling men and women aged 80 and over [9]. Although the average performance in all
these tests was shown to decline across age groups, a wide variation was observed even within the
oldest old population of 80 years and over: walking speed ranged from 0.1 m/s to 2.0 m/s; grip strength
from 3.5 kg to 98.5 kg; while some participants could hold full tandem stance for 30 s, 21% could not
hold semi-tandem stance for even 10 s.
It is clear that when considering the health status and healthcare needs of older adults with chronic
musculoskeletal pain, we should not base our decisions on chronological age alone. There is a wide
variation in physical functioning, and other dimensions of health such as cognitive function and social
engagement need to be taken into consideration.

Unique features of ageing

In this section, key concepts of older people's health will be introduced to highlight unique features
of ageing.
First, it is common for older people to have multiple medical conditions or multimorbidity. Mul-
timorbidity is not centred around any particular disease but rather considers the overall disease burden
in an individual as a whole. A systematic review reported that the prevalence of multimorbidity
defined as having two or more diseases ranged from 55% to 98% in studies of older people aged 60 and
over [10]. Although the variation may be explained by different methods to ascertain diseases across
studies (e.g. self-report, GP records) and there has been no consensus on what diseases should be
assessed for multimorbidity, the data shows that a majority of older people have two or more diseases.
Although having multiple diseases is highly prevalent in older age and many people are living well
with chronic medical conditions, multimorbidity has been associated with adverse outcomes such as
disability and death at population level [10].
Geriatric syndromes are common and distinctive conditions among older people that are at the core
of geriatric care provision. Isaacs, a British physician, described these conditions as the Giants of Ge-
riatrics in 1975 [11]. These original syndromes included immobility, instability (falls), incontinence and
intellectual incapacity (dementia and delirium), which he believed were the fundamental causes of
most other health problems in older people. Later, further additions to the geriatric syndromes have
been suggested by other researchers, including frailty, pressure ulcers, depression, dizziness and even
pain. All of these indeed are central to healthcare provision to older people.
Frailty is a state of having limited physiological reserves because of decline across multiple systems,
creating vulnerability to additional stressors. As mentioned above, frailty is often considered a component
of the geriatric syndromes. There are two major models of frailty: Fried's frailty is a syndrome of wasting
where frailty was defined as meeting three of five criteria (weight loss, weak grip strength, exhaustion,
slow walking speed and physical inactivity) [12], whereas Rockwood's accumulation of deficits model
calculates the frailty index as a proportion of abnormalities in a set of health conditions assessed (e.g. if 30
health conditions are assessed and eight abnormalities are found, frailty index is calculated as 8/30 ¼ 0.27)
[13]. Frailty defined by both of the two definitions has been shown to predict adverse outcomes such as
hospitalisation, disability and death [12,13], and this may have implications for clinical decision-making
regarding the use of interventions that have adverse effects or those with only long-term effects.
In summary, there are many different dimensions to ageing such as multimorbidity, geriatric syn-
dromes, frailty and disability. Ageing is a dynamic process where these factors interact with each other
and result in further decline beyond their simple sum. In addition, psychosocial factors and behaviour
can either inflate or mitigate these effects, contributing to the heterogeneity of the ageing process.

Overview of pain and ageing

Age-related changes in peripheral and central pain processing have been described as a reduction in
the functional capacity of the ‘pain system’ to respond to challenges [14]. Ageing is associated with

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
4 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9

structural and functional changes in the parts of the peripheral and the central nervous system that are
involved in nociception, pain modulation and pain expression. Evidence suggests that neural, immune
and humoural systems are involved in these age-related changes [15]. Psychophysical studies of pain in
older people have provided at times conflicting results regarding pain thresholds, which may vary
depending on stimulus type, site and duration. However, there are consistent findings that older people
may experience prolonged periods of hyperalgesia following sustained peripheral afferent stimulation,
and this prolongation of pain puts them at risk of a range of adverse outcomes associated with pain [14].
Pain and cognition interrelate in a range of areas, including cognitive influences on pain processing
and modulation, cognitive effects of treatments, effect of cognitive state on pain assessment and
treatment and the effect of pain on cognitive processes [16]. New longitudinal findings from the na-
tionally representative US Health and Retirement Survey have shown that reporting persistent pain
was associated with a 9.2% more rapid objectively measured memory decline over time compared to
participants not reporting persistent pain [17]. The specific challenges of pain expression and assess-
ment in people with cognitive impairment has been limited the extent to which specific conditions
(such as chronic musculoskeletal pain) have been studied in cognitively impaired populations. A recent
review of pain and cognition highlighted the evidence that pain can interfere with attentional, exec-
utive and general cognitive functioning [18]. It is likely that a part of the relationship between
musculoskeletal pain and disability onset in older people involves this pathway.

Overview of the epidemiology of musculoskeletal pain in older people in the context of multimorbidity and
geriatric syndromes

As discussed in the section ‘Overview of the global burden of musculoskeletal pain’, musculo-
skeletal conditions are the leading contributors to disability worldwide. In addition to musculoskeletal
pain contributing to disability, it has also been associated with a number of conditions in older people
such as low physical activity level, poor mobility, frailty, depression, cognitive impairment, falls and
poor sleep quality [19e24].
Many of these associated problems may stem from and lead to reduced physical activity. A sys-
tematic review found that older people with musculoskeletal pain are less physically active than those
without musculoskeletal pain; physical activity was determined through a number of different mea-
sures, and the standardised summary estimate was 20% reduction compared to controls without
musculoskeletal pain [19]. As older people with musculoskeletal pain can have higher levels of fear of
pain and fear of falling [25], they may limit activities that exacerbate their pain or that may cause falls.
Other studies suggest a direct effect of the severity of musculoskeletal pain on mobility limitations.
A cross-sectional study in older people investigated the association between musculoskeletal pain and
mobility limitation [20]. This study showed that people with moderate to severe intensity pain are 1.8
times more likely to have mobility limitations, and this was not wholly attributable to reductions in
physical activity or muscle weakness.
Reduced activity level may also lead to social isolation or reduced social involvement, and it has
therefore been hypothesised that this may result in depression. The English Longitudinal Study of Ageing
found that the relationship between pain (not specific to musculoskeletal pain but likely to be the
contributing cause) and depression is bidirectional: those with pain were 1.5 times more likely to develop
depression and those with depression were 1.5 times more likely to develop pain during follow-up [21].
They also identified older age, poor vision and poor mobility to be shared risk factors for developing both
pain and depression. To stop the cyclical worsening between pain and depression, secondary prevention of
the two conditions and treatment of the shared risk factors may both be important.
The Boston Maintenance of Balance, Independent Living, Intellect and Zest in the Elderly (MOBI-
LIZE) study is a longitudinal population-based study of fall risk factors in community-living older
people, and they have identified cognitive function, falls and sleep quality to be associated with pain.
The association between pain (not limited musculoskeletal pain) and cognitive impairment was
determined using cross-sectional data. Memory and executive functioning in particular were found to
be impaired in older people with pain [22]. The associations were attenuated after adjusting for chronic
conditions, behaviour and psychiatric medication use. This is consistent with hypothesised mecha-
nisms such as the association between pain and cognitive function being through the effect of

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9 5

analgesics to treat pain or the apparent cognitive impairment being a presentation of depression. It has
also been hypothesised that attention overload by pain causes cognitive impairment. Falls were
assessed longitudinally in association with musculoskeletal pain in the MOBILIZE study using the 13-
item joint pain questionnaire [23]. High pain intensity, having multiple pain sites and pain interference
were all associated with 50% increase in fall rate. Another cross-sectional finding from the MOBILIZE
study is that older people with either widespread or other multisite musculoskeletal pain are twice as
likely to report difficulties in initiating sleep, staying asleep or sleeping longer than usual [24].
Additionally, a recently published multi-country study in home care recipients in Europe and
Canada found that a majority of people with osteoarthritis and having pain, also had other geriatric
syndromes such as urinary incontinence, disability and falls, and they had a mean number of 3.2
chronic diseases [26]. This may be a typical phenotype of an older patient with musculoskeletal pain,
and it is important to consider the broader picture of patients with musculoskeletal pain when
assessing and making clinical decisions.
Frailty and pain were examined in the Concord Health and Ageing in Men Project [27]. In this study,
older men with intrusive pain (predominantly due to low back pain and major joints) were 1.7 times
more likely to have frailty after adjusting for risk factors of frailty in a cross-sectional analysis. A recent
latent class analysis study using longitudinal data from the Health and Retirement Study has shown
that persistent pain co-occurred with other frailty components over time in a syndromic manner.
Worse outcomes (including death and disability) were found using the frailty definition that included
persistent pain compared with the standard definition [28].
Clustering of musculoskeletal pain with different types of pains and clustering of pain with non-
pain co-morbidities are also common. A Norwegian study of general population reported that only
16.8% of responders had localised musculoskeletal pain, whereas 53% had pain in two or more sites
[29]. Multiple pain sites are a robust prognostic indicator for poorer outcomes, as will be discussed in
the next section [30].
Multiple-site musculoskeletal pain can also occur in the context of generalised musculoskeletal pain
syndromes that occur along a continuum of number of pain sites and include chronic widespread pain
(CWP) and fibromyalgia syndrome (FMS) [31]. These syndromes, more common in women than in
men, tend to have relatively early onset in adult populations; the prevalence of CWP typically peaks in
middle age, with prevalence estimates ranging from 4.2% to 13.3%, but remains elevated into older age
groups, while the prevalence of FMS ranges from 2% to 8% of the adult population depending on the
diagnostic criteria [32]. Distinctive features of FMS include evidence of central dysregulation of pain
processing resulting in pain amplification, overlap with other chronic pain conditions (e.g. irritable
bowel syndrome and chronic regional pain syndrome) and a constellation of other features including
sleep disruption, fatigue and distress [33,34].
Musculoskeletal conditions feature prominently in studies examining the common patterns of
multimorbidity at population level. In a cross-sectional analysis of the New Zealand National Health
Survey, Dominick et al. also found that the sum of general co-morbidities not related to pain increased
the likelihood of reporting chronic pain, in addition to specific contributions from co-morbidities
known to cause pain [35]. This conforms to the theory discussed in the previous section that multi-
ple conditions interact with each other, sometimes yielding a synergistic effect.
Some of the above studies are cross-sectional studies that do not indicate causality in a particular
direction, but many of the associations are likely to be bidirectional, as suggested in Dominick and
Blyth's model of the development of chronic pain (Fig. 1) [36].

Impact of musculoskeletal pain in older people

Longitudinal epidemiological studies of musculoskeletal pain in older people

Because musculoskeletal pain is a leading contributor to disability, epidemiological studies have

sought to identify a subgroup of patients who are likely to have persistent pain or develop disability. In

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
6 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9

Fig. 1. Life-course influences on the development of chronic pain [36]. Adapted from Dominick C and Blyth FM. Epidemiology of Pain
and Non-Pain Co-morbidities in Pain Co-morbidities: Understanding the Complex Patient. Gamberadino and Jensen (eds) IASP Press
(Seattle) 2012 and reproduced with permission from IASP Press.

this section, longitudinal studies of prognostic factors for musculoskeletal pain in older people will be
discussed.
A systematic review of prognostic factors related to musculoskeletal pain revealed that most studies
were conducted in younger adults and either focused on acute pain to look at short-term outcomes or
did not differentiate acute and chronic pain [30]. In the included studies, they found widespread pain,
high functional disability, somatisation, high pain intensity and chronicity of pain to be prognostic
factors of adverse outcomes.
To replicate the findings from the older version of the above systematic review, Mallen et al. con-
ducted a cohort study in older patients presenting to general practitioners for musculoskeletal pain
[37]. A set of brief point-of-care prognostic indicators that consist of five items (duration of present
pain episode, current pain intensity, pain interference with daily activities, multiple site pain and
depression) was recorded by general practitioners. Pain intensity at follow-up time points was
determined using a self-administered questionnaire. In this population, they confirmed that chronicity
of pain of greater than 3 months, pain interference with daily activities and presence of multiple-site
pain predicted persistent pain at 6 months and at 3 years.
Using the Boston MOBILIZE study data in community-living older people, Eggermont et al.
compared different dimensions of musculoskeletal pain (pain intensity, number of pain areas and
interference with activities) as predictors of disability [38]. Disability measures that were examined as
outcomes included mobility performance tests (Short Physical Performance Battery), self-reported
mobility, activities of daily living and instrumental activities of daily living. Number of pain sites (no
pain, single-site pain, multi-site pain and widespread pain) was found to be a better predictor of all of
the disability measures than pain intensity and interference with activities.
Similarly, the longitudinal study by Shah et al. (2011) demonstrated a dose-response relationship
between number of painful joint sites in the year prior to baseline and incident severe mobility

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9 7

disability (measured using gait speed) in their study of community-dwelling older clergymen [39].
Similar dose-response relationships between the number of painful joint sites and incident disability
have also been shown in oldest old Danish people aged 90 and over [40].
We found no longitudinal study about predictors of functional outcomes in developing countries.
The same prognostic factors may apply as were found in developed countries but it is also possible that
there are unique ones in developing countries that will be important to identify.

Implications and future directions

As the global population is ageing rapidly, particularly in resource-limited countries, preservation of

functional independence and quality of life into old age is a global imperative. Musculoskeletal burden
of disease is the leading cause of disability in older age groups around the world, and through its impact
on physical activity and many other aspects of health as discussed in this paper, musculoskeletal
burden has the potential to limit gains in healthy life expectancy. Musculoskeletal conditions are the
leading cause of chronic pain burden in populations, and systematic approaches understanding this
through research and translation into policy and action are required [5]. Prevention and control of the
population burden of chronic musculoskeletal pain ultimately requires a whole of life approach [36].

Research implications

Research into prevention of chronic musculoskeletal pain in older people can be divided into
reducing the overall occurrence of musculoskeletal conditions within the population and minimising
the progression from acute musculoskeletal pain to chronic musculoskeletal pain (e.g. following
injury). Given the evidence of patterning of musculoskeletal pain with other chronic conditions in
multimorbidity clusters, research to identify common risk factors and shared etiological pathways for
these conditions is a priority [41]. Studies of chronic musculoskeletal pain in older people need to take
a consistent and systematic approach to characterising the health state of older people so that other
factors associated with health burden and disability are captured.
First, co-morbid chronic and other diseases, geriatric syndromes, frailty and polypharmacy should
be taken into account to estimate the relative contribution of chronic musculoskeletal pain to disability,
loss of functional independence and poor quality of life. Longitudinal studies are needed to examine
the interrelationships between chronic musculoskeletal pain and other common problems of older
people (e.g. sleep problems and falls) e how they develop and change over time and the nature of the
interrelationships as to whether they moderate or amplify chronic musculoskeletal pain. From this,
modifiable targets for intervention can be identified and form the basis of pragmatic randomised
controlled trials (where the modifiable factors are at the person level) or other types of intervention
studies for factors at a meso- or macro-level (e.g. educational interventions for clinicians or health
system-wide interventions).
Second, systematic approaches to identifying and classifying all contributors to the pain burden are
required. Chronic musculoskeletal pain, while generally understood to be nociceptive in origin, may co-
exist with related neuropathic pain conditions (e.g. radicular pain) or unrelated neuropathic pain
conditions that are common in older populations (e.g. shingles). It is important to understand the
contribution of musculoskeletal pain and its interactive effects with other types of pain, particularly in
older people.
Finally, basic epidemiological data on chronic musculoskeletal pain conditions are still lacking for
many developing countries such as data on the potential impact of chronic musculoskeletal pain on
disability and functional independence. This is a priority area for research, and ongoing efforts are
required to ensure that validated translated versions of brief and robust measures of pain are included
for use in general health surveys in developing countries.

Policy implications

Policies that support optimal musculoskeletal health need to be seen in the broader context of
population-level approaches to healthy ageing. The WHO's World Report on Ageing and Health [6]

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
8 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9

acknowledges the heterogeneity of the ageing process and focuses on functioning rather than diseases
or co-morbidity. They propose a whole of life public health framework that uses the trajectories of
intrinsic and functional capacities to define three phases of ageing: high and stable capacity, declining
capacity and significant loss of capacity. This framework identifies three domains of action (health
services, care needs and environment) to address each of the three phases. Briggs et al. have identified
key areas to address to reduce the burden of musculoskeletal conditions in older adults, including
better translation of evidence-based interventions into policy and practice according to Models of Care
for developed country settings [5]. In developing countries, an approach based on health systems
strengthening has been articulated [42]. From a different perspective, frameworks for the prevention
and control of chronic pain [43,44] can also contribute to the development of an integrated policy
agenda for the control of chronic musculoskeletal pain in older people.

Practice points

- In older people with musculoskeletal pain, geriatric syndromes and co-morbidities often co-
exist.
- Older people with musculoskeletal pain have more frailty, depression and cognitive decline
than people without pain.
- Older people with chronic musculoskeletal pain that is predominantly nociceptive may also
have other types of pain.
- Number of pain sites is an important prognostic factor for functional status in older people
- Assessment of chronic musculoskeletal pain must consider the potential interactive effects
on multiple domains of functioning.

Research agenda

- Interaction of musculoskeletal pain with co-existing conditions including other types of pain
need to be studied in longitudinal studies to identify modifiable targets for intervention.
- The potential impact of musculoskeletal pain needs to be investigated in developing coun-
tries where evidence is scarce.

Conflict of interest statement

The authors have no conflicts of interest to disclose. This research did not receive any specific grant
from funding agencies in the public, commercial or not-for-profit sectors.

References

[1] Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain 2015;156(6):1003e7.
[2] Torrance N, Smith BH, Bennett MI, Lee AJ. The epidemiology of chronic pain of predominantly neuropathic origin. Results
from a general population survey. J Pain 2006;7(4):281e9.
[3] World Health Organization. About the Global Burden of Disease project. Available from: http://www.who.int/healthinfo/
global_burden_disease/about/en/.
[4] Murray CJL, Vos T, Lozano R, et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions,
1990e2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2197e223.
[5] Briggs AM, Cross MJ, Hoy DG, et al. Musculoskeletal health conditions represent a global threat to healthy aging: a report
for the 2015 World Health Organization World Report on Ageing and Health. Gerontologist 2016;56(Suppl. 2):S243e55.
[6] World Health Organization. World report on ageing and health. Geneva: World Health Organization; 2015.
[7] Murray CJL, Barber RM, Foreman KJ, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306
diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990e2013: quantifying the epidemiological
transition. Lancet 2015;386(10009):2145e91.

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004
 F.M. Blyth, N. Noguchi / Best Practice & Research Clinical Rheumatology xxx (2017) 1e9 9

[8] Cosco TD, Prina AM, Perales J, et al. Operational definitions of successful aging: a systematic review. Int Psychogeriatr 2014;
26(3):373e81.
[9] Ailshire JC, Cummins EM. Physical and biological indicators of health and functioning in U.S. oldest old. Annu Rev Gerontol
2013;33:193e215.
[10] Marengoni A, Angleman S, Melis R, et al. Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev
2011;10(4):430e9.
[11] Isaacs B. The challenge of geriatric medicine. Oxford: Oxford University Press; 1992.
[12] Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;
56(3):M146e56.
[13] Rockwood K, Mitnitski A, Song X, et al. Long-term risks of death and institutionalization of elderly people in relation to
deficit accumulation at age 70. J Am Geriatr Soc 2006;54(6):975e9.
[14] Gibson SJ, Farrell M. A review of age differences in the neurophysiology of nociception and the perceptual experience of
pain. Clin J Pain 2004;20(4):227e39.
[15] Yezierski RP. The effects of age on pain sensitivity: preclinical studies. Pain Med 2012;13(2):S27e36.
[16] Kreitler SN, Niv D. Cognitive impairment in chronic pain. Pain Clin Updat 2007;15(4):1e4.
[17] Whitlock EL, Diaz-Ramirez LG, Glymour MM, et al. Association between persistent pain and memory decline and dementia
in a longitudinal cohort of elders. JAMA Intern Med 2017;177(8):1146e53.
[18] Moriarty O, McGuire BE, Finn DP. The effect of pain on cognitive function: a review of clinical and preclinical research. Prog
Neurobiol 2011;93(3):385e404.
[19] Stubbs B, Binnekade TT, Soundy A, et al. Are older adults with chronic musculoskeletal pain less active than older adults
without pain? A systematic review and meta-analysis. Pain Med 2013;14(9):1316e31.
[20] Karttunen N, Lihavainen K, Sipila S, et al. Musculoskeletal pain and use of analgesics in relation to mobility limitation
among community-dwelling persons aged 75 years and older. Eur J Pain 2012;16(1):140e9.
[21] Chou KL. Reciprocal relationship between pain and depression in older adults: evidence from the English longitudinal
study of ageing. J Affect Disord 2007;102(1):115e23.
[22] van der Leeuw G, Eggermont LH, Shi L, et al. Pain and cognitive function among older adults living in the community.
J Gerontol A Biol Sci Med Sci 2016;71(3):398e405.
[23] Leveille SG, Jones RN, Kiely DK, et al. Chronic musculoskeletal pain and the occurrence of falls in an older population.
JAMA 2009;302(20):2214e21.
[24] Chen Q, Hayman LL, Shmerling RH, et al. Characteristics of chronic pain associated with sleep difficulty in older adults: the
Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly (MOBILIZE) Boston study. J Am Geriatr Soc
2011;59(8):1385e92.
[25] Martin RR, Hadjistavropoulos T, McCreary DR. Fear of pain and fear of falling among younger and older adults with
musculoskeletal pain conditions. Pain Res Manag 2005;10(4):211e8.
[26] Vetrano DL, Foebel AD, Marengoni A, et al. Chronic diseases and geriatric syndromes: the different weight of comorbidity.
Eur J Intern Med 2016;27:62e7.
[27] Blyth FM, Rochat S, Cumming RG, et al. Pain, frailty and comorbidity on older men: the CHAMP study. Pain 2008;140(1):
224e30.
[28] Lohman MC, Whiteman KL, Greenberg RL, Bruce ML. Incorporating persistent pain in phenotypic frailty measurement and
prediction of adverse health outcomes. J Grontol A Biol Sci Med Sci 2017;72(2):216e22.
[29] Kamaleri Y, Natvig B, Ihlebaek CM, et al. Number of pain sites is associated with demographic, lifestyle, and health-related
factors in the general population. Eur J Pain 2008;12(6):742e8.
[30] Artus M, Campbell P, Mallen CD, et al. Generic prognostic factors for musculoskeletal pain in primary care: a systematic
review. BMJ Open 2017;7(1), e012901.
[31] Moura ~o AF, Blyth FM, Branco JC. Generalised musculoskeletal pain syndromes. Best Prac Res Clin Rheumatol 2010;24(6):
829e40.
[32] Clauw DJ. Fibromyalgia: a clinical review. JAMA 2014;311(15):1547e55.
[33] Arnold LM, Choy E, Clauw DJ, et al. Fibromyalgia and chronic pain syndromes: a white paper detailing current challenges
in the field. Clin J Pain 2016;32(9):737e46.
[34] Sluka KA, Clauw DJ. Neurobiology of fibromyalgia and chronic widespread pain. Neuroscience 2016;338:114e29.
[35] Dominick CH, Blyth FM, Nicholas MK. Unpacking the burden: understanding the relationships between chronic pain and
comorbidity in the general population. Pain 2012;153(2):293e304.
[36] Dominick CB, Blyth FM. Epidemiology of pain and non-pain comorbidities. In: Pain comorbidities: understanding and
treating the complex patient. Seattle, USA: IASP Press; 2012.
[37] Mallen CD, Thomas E, Belcher J, et al. Point-of-care prognosis for common musculoskeletal pain in older adults. JAMA
Intern Med 2013;173(12):1119e25.
[38] Eggermont LHP, Leveille SG, Shi L, et al. Pain characteristics associated with the onset of disability in older adults: the
maintenance of balance, independent living, Intellect, and zest in the elderly Boston study. J Am Geriatr Soc 2014;62(6):
1007e16.
[39] Shah RC, Buchman AS, Boyle PA, et al. Musculoskeletal pain is associated with incident mobility disability in community-
dwelling elders. J Gerontol A Biol Sci Med Sci 2011;66(1):82e8.
[40] Ma €nty M, Thinggaard M, Christensen K, Avlund K. Musculoskeletal pain and physical functioning in the oldest old:
musculoskeletal pain and physical functioning. Eur J Pain 2014;18(4):522e9.
[41] Valderas JM. Defining comorbidity: implications for understanding health and health services. Ann Fam Med 2009;7(4):
357e63.
[42] Geere J-A, Barrero LH, Meggitt B, et al. A time for action: opportunities for preventing the growing burden and disability
from musculoskeletal conditions in low- and middle-income countries. Best Pract Res Clin Rheumatol 2014;28(3):377e93.
[43] Blyth FM, Van der Windt DA, Croft PR. Chronic disabling pain a significant public health problem. Am J Prev Med 2015;
49(1):98e101.
[44] Rice AS, Smith BH, Blyth FM. Pain and the global burden of disease. Pain 2016;157(4):791e6.

Please cite this article in press as: Blyth FM, Noguchi N, Chronic musculoskeletal pain and its impact on
older people, Best Practice & Research Clinical Rheumatology (2017), https://doi.org/10.1016/
j.berh.2017.10.004