Geriatric Nursing 42 (2021) 460 466

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Geriatric Nursing
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Featured Article

Higher levels of physical activity buffered the negative effect of pain

severity on physical frailty in older Latinx adults
Zenong Yin, PhDa,*, Shiyu Li, MScb, William M. Land, PhDc, Sarah L. Ullevig, PhD, LRD, RDd,
Fernando Juarez Jr, MSca, Arthur E. Herna
ndez, PhD, NCSP, NCCe, Catherine Ortega, EdD, PTa,
Neela K. Patel, MD, MPH, CMDf, Maureen J. Simmonds, PhD, PTa
a
Department of Public Health, The University of Texas at San Antonio, United States
b
School of Nursing, UT Health San Antonio, United States
c
Department of Kinesiology, The University of Texas at San Antonio, United States
d
College for Health, Community and Policy, The University of Texas at San Antonio, United States
e
Dreeben School of Education, University of the Incarnate Word, United States
f
Glenn Biggs Institute for Alzheimer’s & Neurodegenerative Diseases, UT Health San Antonio, United States

A R T I C L E I N F O A B S T R A C T S

Article history: This cross-sectional study examined whether and to what extent physical activity (PA) mediated the effect of
Received 30 November 2020 chronic pain on physical frailty in a sample of predominantly older Latinx adults. Study participants were
Received in revised form 2 February 2021 118 community-dwelling older adults in southwest United States. Physical frailty was measured by a sum-
Accepted 4 February 2021
mary score of physical function tests. Pain severity and pain interference were measured by the Brief Pain
Available online 11 March 2021
Inventory. PA levels were defined as meeting the PA recommendation by 7-day accelerometry. Pain out-
comes and PA were associated with physical frailty, respectively. Hierarchical regression analysis revealed
Keywords: that PA mediated the relationship between pain severity and physical frailty. However, no mediation effect
Frailty of PA was found in the relationship between pain interference and physical frailty scores. Higher levels of PA
Physical activity buffered the negative effect of pain severity on physical frailty. Future studies should pay attention to PA pro-
Chronic pain motion to prevent the negative consequences of frailty in older minority adults.
Older adult
© 2021 Elsevier Inc. All rights reserved.

Introduction Frailty is the deterioration of the physiological function of multi-

Frailty has emerged as a major public health priority as well as a
health disparity that disproportionally affected vulnerable popula-
tions in the United States (U.S.) in recent decades. Among Americans
ages 65 or older, prevalence of frailty was 24.6% and 22.9% for His-
panics/Latinx and Blacks compared to 13.8% in Whites.1 Risk for
frailty is also higher for older adults who are low income, older age,
and female.1,2 An international review of 21 community-based stud-
ies reported that the prevalence of frailty in community-dwelling
adults aged 65 and older was approximately 10.7% (9.9% for physical
frailty and 13.6% for the broad phenotype of frailty) while 41.6% were
characterized as pre-frail.3 Frailty has been associated with increased
risk of mortality, low quality of life, physical disability, falls, hospitali-
zation and higher healthcare costs.4 There is an urgent call for imple-
mentation of frailty prevention programs to promote healthy aging.5
Abbreviations: ASA24, Automated Self-Administered Recall System; BMI, Body
Mass Index; BPI, Brief Pain Inventory; PA, Physical Activity
*Corresponding author.
E-mail address: Zenong.Yin@utsa.edu (Z. Yin).
ple systems in aging adults that coincides with increased vulnerabil-
ities to health disorders, loss of functional capacity, and decreased
quality of life.6 Clinical signs of frailty include declines in lean body
mass, poor physical function (declines in muscle strength, cardiore-
spiratory fitness, balance), compromised walking performance
(speed and endurance), low levels of activity, and a decline in cogni-
tive function.6 Assessment of frailty is usually based on narrowly
defined physical phenotype that includes fatigue, slowness, weak-
ness, low levels of physical activity (PA), and weight loss.6 Others
have defined frailty using a multidimensional phenotype model that
includes physiological, psychological and social dimensions as well as
physical impairment to explain the heterogeneous impact and out-
comes of specific health conditions, including frailty.7
One in three Americans experience some level of pain that affects
their quality of daily life, and activity level and this increases with
age.8 Epidemiological studies have consistently shown a close associ-
ation between chronic pain and frailty,9 while longitudinal studies
found that the onset of chronic pain preceded the development of
frailty in older adults10 perhaps because chronic pain frequently
compromises physical activity. Self-reported pain is also significantly

https://doi.org/10.1016/j.gerinurse.2021.02.004
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 Z. Yin et al. / Geriatric Nursing 42 (2021) 460 466
associated with increased risk for physical frailty after controlling for
age, education, comorbidities, and disability in Mexican Americans
aged 67 years or older over a period of 18 years.10 Furthermore, the
prevalence of chronic pain is higher and associated with increased
risk for frailty in older and underprivileged adults.11 In sum, the asso-
ciation between chronic pain and frailty is not surprising given that
chronic pain is not only a negative bio-psycho-social stressor but also
frequently limits physical activity. Older adults also have higher rates
of chronic diseases such as diabetes, heart disease, obesity, and
arthritis. These conditions add to the burden of ill health as they tend
to limit PA and may also be associated with the development of
chronic pain which may further limit physical activity.12 Finally, lim-
ited access to optimum health care as well as resources to address
challenges associated with the management of complex comorbid
conditions aggravate the impact of these conditions on overall health,
function and quality of life.5
PA has known physiological and psychological health protective
effects regardless of age, race/ethnicity, and health status. Normal
aging is associated with decline across physiological systems and
includes loss of muscle mass and strength and deterioration of bal-
ance and cardiorespiratory fitness13 which reduces physical mobility
and contributes to an overall reduction in PA. This reduction in PA
may further contribute to aging associated decline across physiologi-
cal systems. Frailty, however, results from more significant aging-
associated decline in reserve and function across multiple physiologi-
cal systems. Furthermore, physical inactivity (i.e., excessive sedentary
time)14 and poor nutrition (i.e., deficient intake of energy, protein and
vitamin D)15 increases loss of muscle mass and risk of frailty.
Epidemiological and intervention studies have demonstrated that
participation in regular PA (i.e.,
150 minutes of moderate and vigor-
ous physical activity (MVPA) a week) can prevent or at least ameliorate
decline in physical function and quality of life thereby reducing the
burden and costs of disease and disability in older adults.13 A robust
body of research supports the beneficial effects of PA on physical and
psychological function improving quality of life in older adults.16 Inter-
vention studies have also shown that for many individuals with
chronic pain, increasing PA can improve physical function and psycho-
logical mood (decreased levels of depression) without increasing pain
intensity.12 However, no study has examined whether levels of PA can
mediate the relationship between chronic pain and frailty in commu-
nity-dwelling older minority adults. Therefore, the purpose of this
cross-sectional study was to examine whether and PA level mediates
the relationship between chronic pain and physical frailty in a pre-
dominantly Latinx older adult sample.
Material and methods
Study design and sample
Study participants were members of a senior community center in
San Antonio, Texas which provided free health, social and recreational
services to adults aged 60 and older as well as their primary family
caregivers. Using a paper flyer, recruitment targeted adults enrolled in
fitness classes (e.g., table tennis, chair volleyball, Zumba, yoga, chair
weightlifting) and/or social/education programs (e.g., bingo, arts, craft,
and writing classes). The criteria of study eligibility were 1) age of
60 years or older, and 2) being physically active or inactive at least 6
months at the time of the study. The study excluded Individuals who
had a health condition (physical or psychological) or did not speak
English that prevented them from independently completing the study
measurements. Research staff screened all interested members for eli-
gibility. To be physically active, the participant reported participation
in a fitness class or PA
2 times a week for at least 6 months. All par-
ticipants completed written informed consent and received up to $30
gift card for participation in the study. The Institutional Review Board
461
[blinded for review] approved the study protocol. Once eligibility was
established, a research assistant explained the study procedures and
scheduled assessments.
Data collection and measurements
Data were collected in the senior community center during two
sessions over a 9-day period. In session 1, the participants completed
all measures, received a $10 gift card, and started wearing an acceler-
ometer for 7 days. In session 2, the participants returned the acceler-
ometers, completed a second dietary recall and received a $20 gift
card. Study participants received a text reminder one day before their
scheduled data collection session and additional reminders about
wearing the accelerometer and recording their food intake. Trained
research assistants performed the data collection.
Physical frailty
Three tests from the Simmonds Physical Performance Test Battery
measure the performance of fundamental tasks of daily function for
community-dwelling older adults.17 Specifically the five-time
repeated sit-to-stand (seconds) was a test of strength, balance, coor-
dination, movement speed and movement transition; the 50-foot
fast walk was used as a measure of gait speed (seconds/50) repre-
senting level of physical mobility and muscle strength of legs; and
the 6-minute distance walk (meters) was a test of walking endurance
as well as aerobic function. The test battery has well-established reli-
ability and validity for assessing physical function and physical frailty
in different populations.17
Chronic pain
The Brief Pain Inventory (BPI) was a self-report to measure pain
severity and impact on specific daily activities using a 0 to 10 rating
scale with established reliability and validity for the study popula-
tion.18,19 Average scores for pain intensity (4 questions) and pain inter-
ference/impact on mood and activity (7 questions) were calculated
following a published scoring algorithm. Cronbach’s alpha was .94 and
.95 for pain intensity and pain interference in the study sample.
Physical activity
The level of participation in PA was assessed by 7-day accelerome-
try. In test session 1, the participants were instructed to wear Acti-
graph wGT3X-BT monitors (ActiGraph, LLC, Pensacola, FL) on the non-
dominant wrist for 7 consecutive days, except for activities involving
water (i.e., bathing, swimming). Participants returned the accelerome-
ters during test session 2. Accelerometer data was collected at 30 Hz
using all three axes and then aggregated to 60-second epochs for proc-
essing.20 Non-wear time was defined as
90 consecutive minutes of
zero counts, with an allowance of up to two-minute time intervals
with nonzero counts provided there were no counts detected during
30-minute window up and downstream from that interval. Partici-
pants with at least 10 hours of wear time per day for a minimum of 3
valid days were included in the analyses. Based on the PA recommen-
dations for Americans,21 a participant was determined to be physically
active if she/he accumulated
150 minutes of moderate and vigorous
PA; otherwise she/he was determined to be physically inactive.21 Due
to non-compliance with the accelerometry protocol, 13% of the partici-
pants did not have a valid measure of PA. We replace the missed mea-
sure with their self-reported level of PA which was significantly
correlated to the accelerometry-based assessment (Chi-square
test = 5.23, df=1, p = .02 with continuity correction).
462 Z. Yin et al. / Geriatric Nursing 42 (2021) 460 466

Diet One-way F-test was used to examine differences in pain severity,

Dietary quality was evaluated based on food intake assessed by
two 24-hour dietary recalls using an automated self-reported 24HR
instrument (ASA24).22 Participants recalled everything they ate and
drank during the previous 24 hours, (including dietary supplements)
on a desktop computer in the senior center at test sessions 1 and 2. A
research assistant helped participants enter their dietary information
as needed. An index of quality of dietary intake was created by the
number of the 10 Dietary Reference Intakes met by the participants.
The participants provided demographic information (age, sex,
race/ethnicity, education, employment status, marital status, and par-
ticipation in government assistance programs) and health history.
We also measured participant’s height and weight without shoes and
with light clothing. Two measures were taken, and the average was
used. Body Mass Index (BMI) was calculated as average weight in
kilograms divided by average height in meters squared.
Statistical analysis
pain interference, and physical frailty scores between participants
categorized as inactive and active. To address the study question, a
hierarchical regression on physical frailty score was performed to
test the mediation effect of PA with pain severity and pain interfer-
ence as pridictor variable separately and physical frailty score as the
criterion variable. In step 1, the variables in the model included age,
gender, education, race/ethnicity, marital status, BMI, government
assistance status, and dietary quality. To increase parsimony, only
covariates with p value  0.25 were kept in the model. Pain severity
(or pain interference) score and PA levels were entered in the model
in step 2 and step 3 to test their main effect. In step 4, a two-way
interaction term between pain severity (or pain interference) and PA
levels was entered in the model. A significant interaction term
(change in R2) would indicate a mediation effect of PA levels on the
relation between pain severity (pain interference) and physical
frailty.23 The level of significance was set at p < .05. Data was exam-
ined for normal distribution before conducting the analysis. Data
were analyzed using SPSS-IBM version 25 (SPSS Inc., Chicago, IL,
USA).

A modified index of physical frailty was created using the sum of
the standardized scores of the physical performance measures (five-
time sit-to-stand, gait speed, and 6-minute walk distance). The
higher the score the higher the level of physical frailty. The three
measures represent levels of physical performance and are indepen-
dently or jointly associated with symptoms of frailty.17 The use of a
modified index score was necessary to address the question of the
study since it excluded measures of PA and energy expenditure that
are part of the Fried Frailty Index.6
Results
Results were from 118 participants with a valid measure of PA out
of 132 participants who were tested in the study. Table 1 displays the
characteristics of study participants and means and standard devia-
tions of the study measures. The participants were primarily minority
(65.25% Latinx, African American 5.93%, and Asian 9.32%), female
(86%) with a mean age of 71.07 years (SD = 6.58). While over 80% of
the participants had completed high school, 13.64% reported

Table 1
Characteristics of the study participants and mean (M) and standard deviation (SD) of study measures (n=118).

Variables All (n=118) Physically active Physically inactive Group Comparison

(n=50, 42.37%) (n=68, 57.63%)

Age, M (SD) 71.07 (6.58) 70.36 (5.93) 71.59 (7.01) n.s.

Female, n (%) 84 (71.2) 39 (78.00) 45 (66.18) n.s.
Weight (kg), M (SD) 75.64 (19.34) 72.85 (17.92) 77.72 (20.23) n.s.
Height (cm), M (SD) 159.58 (8.79) 159.37 (8.73) 159.74 (8.90) n.s.
Body Mass Index (kg/m2), M (SD) 29.11 (5.83) 28.46 (5.70) 29.59 (5.83) n.s.
Education, n (%) PA > PI
Elementary school 3 (2.54) 1 (2.00) 2 (2.94)
Middle school 17 (14.41) 5 (10.00) 12 (17.65)
High school 70 (59.32) 28 (56.00) 42 (61.76)
College/university 18 (15.25) 10 (20.00) 8 (11.76)
Graduate school 10 (8.47) 6 (12.00) 4 (5.88)
Race, n (%) n.s.
Hispanic/Latinx 77 (65.25) 29 (58.00) 48 (70.59)
White 23 (19.49) 12 (24.00) 11 (16.18)
African American 7 (5.93) 4 (8.00) 3 (4.41)
Asian 11 (9.32) 5 (10.00) 6 (8.82)
Received government assistance, n (%) 15 (13.64) 3 (6.00) 12 (17.65) PA < PI
Married, n (%) 51 (43.22) 24 (48.00) 27 (39.71) n.s.
High alcohol consumption, n (%) 8 (6.84) 3 (6.00) 5 (7.46) n.s.
Number of Recommended Dietary Intake Met, n (%) n.s.
1-2 21 (18.10) 7 (14.29) 14 (20.90)
3-4 69 (59.48) 32 (65.31) 37 (55.22)
5-6 23 (19.83) 8 (16.33) 15 (22.39)

7 3 (2.58) 2 (4.08) 1 (1.49)
Moderate and vigorous physical activity (minutes per day) 33.24 (28.96) 59.29 (26.96) 14.88 (10.10) PA > PI
Pain Severity Score, M (SD) 2.02 (2.33) 2.23 (2.51) 1.88 (2.20) n.s.
Pain Interference Score, M (SD) 1.47 (2.16) 1.45 (2.10) 1.49 (2.22) n.s.
Repeated Sit-to-Stand (seconds), M (SD) 12.36 (5.03) 11.22 (3.11) 13.21 (5.97) PA < PI
6-minute walk distance (feet), M (SD) 1526.82 (381.32) 1637.92 (272.93) 1441.35 (430.01) PA > PI
Gait Speed (sec/foot), M (SD) 0.25 (0.07) 0.23 (0.05) 0.26 (0.08) PA < PI
Frailty Index Score, M (SD) 1.36 (0.95) 1.11 (0.60) 1.54 (1.11) PA < PI
PA = physically active group; PI = physically inactive group; Total participants may not add up to 118 due to missing values; Group comparison was tested using univariate F-test for
continuous variables, contingency table (X2, Cramer’s V, or Somer’s D) for categorical or ordinal variables; p < .05, significant difference; n.s., no significant difference.
 Z. Yin et al. / Geriatric Nursing 42 (2021) 460 466 463

Table 2 resulted in the total model accounting for 40.4% of the variance (p <
Hierarchical regression model assessing effects of pain severity and physical activity on .0001; see Table 2) in physical frailty scores. Participants with higher lev-
physical frailty.
els of pain severity tended to have higher levels of physical frailty if they
Variables DR2 B (95% CI) b p were physically inactive, whereas the levels of physical frailty did not
change with higher levels of pain severity if the participants were physi-
Step 1 .245 .0001
Age .030 (.055 to .005) .209 .019 cally active. Fig. 1 depicts the interaction between PA and pain severity
Gender -.603 (-.253 to -.953) -.290 .001 on physical frailty.
Body Mass Index .043 (.072 to .014) .264 .004
Hispanic Race .479 (.906 to .052) .242 .028
Step 2 .083 .0001 Pain interference
Pain Severity .121 (.187 to .056) .299 .001 In the first step, the covariates accounted for 21.9% (p < .0001) of
Step 3 .045 .0001
the variance in the model. In the second step, the inclusion of pain
Physical Activity -.415 (-.120 to -.711) -.218 .006
Step 4.031.0001
interference significantly increased the amount of variance explained
Pain Severity x Physical -.149 (-.024 to -.274) -.309 .020 by 7.3% (p < .0001) in the model. Likewise, the inclusion of PA in step
Activity 3 raised the variance accounted for by 3.2% (p < .0001) in the model.
Total R2 = .404, Adjusted R2 = .349, F(10, 107) = 7.262, p < .0001 In the final step, inclusion of the interaction between PA and pain
DR2, change in adjusted R2; CI, confidence interval; Only covariates with p value  .25 interference was not significant (DR2=.004, p = .403; See Table 3).
were retained in the model in step 1.

receiving government assistance. Less than half of the participants
(42.37%) were in the physically active group.
A significant difference was observed in frailty scores such that
individuals classified as active had lower scores (M = 1.11, SD = .60)
than individuals classified as inactive (M = 1.54, SD = .1.11), F(117) = -
2.62, p < .01. No significant differences in pain severity (F(117) = -
.379, p >.05) and pain interference (F(117) = -.244, p > .05) were
found between active and inactive participants. Other significant dif-
ferences between the groups included levels of education, participa-
tion in government assistance programs, time in moderate and
vigorous physical activity, and physical performance levels that
favored the physically active group.
Mediation analyses
Pain intensity
In the first step, the covariates accounted for 24.5% (p < .0001) of the
variance in the model. In the second step, the inclusion of pain intensity
in the model increased the amount of variance explained by 8.3% (p <
.0001). Likewise, the inclusion of PA in step 3 raised the variance
accounted for by 4.5% (p < .0001). Finally, a significant interaction
between PA and pain intensity (DR2=.031, p < .034) in the fourth step
Discussion
Findings from this study demonstrated the mediating effect of PA
on the relationship between pain intensity and physical frailty in a
sample of older adults who were predominantly Latinx and other
racial/ethnic minority. Both levels of pain intensity and interference
as well as levels of PA are associated with physical frailty scores. A
higher level of PA only attenuates the influence of pain intensity but
not pain interference on the physical frailty suggesting that regular
PA can partially buffer the negative effect of pain on physical frailty
and well-being in older adults. Furthermore, the level of physical
activity in the inactive group was similar to that reported in a large
population-based study.24 Whilst the low levels of PA are a concern,
it does lend support to the generalizability of our results.
The findings from this study on the relationships among chronic
pain9 and PA25 with physical frailty are consistent with cross-sec-
tional and longitudinal studies in older adults. Pain is complex
because it is a symptom of many health conditions as well as being a
primary pathological health condition in itself.26 Pain, especially
chronic pain, has direct negative impacts on well-being and physical
activity levels, and this increases the vulnerability for many chronic
health conditions in older minority adults, including the increased
risk for frailty.27 Secondary effects of pain include a negative impact

Fig. 1. Moderating effect of physical activity on the relation between pain severity and physical frailty.
464 Z. Yin et al. / Geriatric Nursing 42 (2021) 460 466
Table 3
Hierarchical regression model assessing effects of pain interference and physical activ-
ity (PA) on physical frailty.
Variables DR2 B (95% CI)
Step 1 .266
Age .031 (.056 to .007)
Gender -.574 (-.226 to -.922)
Body Mass Index .041 (.070 to .013)
Hispanic Race .450 (.874 to .026)
Step 2 .073
Pain Interference .122 (.192 to .052)
Step 3 .032
Physical Activity -.352 (-.051 to -.654)
Step 4 .004
Pain Interference £ Physical -.060 (.081 to -.200)
Activity
Total R2 = .375, adjusted R2 = .310, F(11, 106) = 5.777, p < .0001.
DR2, change in adjusted R2, CI, confidence interval; Only covariates with p value  .25
were retained in the model in step 1.
on both mood (e.g., depression) and movement (daily PA). These sec-
ondary effects limit community activities and social engagement that
adds to the burden of chronic pain and may lead to a further down-
ward spiral of physical, psychological and social health and well-
being.27
In contrast and in general, PA has directly positive impacts on
health and well-being and a protective or buffering effect against
many chronic health conditions such as frailty in older adults. PA has
measurable, systemic and beneficial effects across all physical (e.g.,
musculoskeletal, cardiovascular systems) and psychological (e.g.,
cognitive and emotional functions) domains that enable social-envi-
ronmental engagement (e.g., social participation and community
activities). For example, PA helps maintaining muscle mass, bone
mineral density, and joint flexibility which consequently enhance
performance of physical tasks. Higher levels of physical performance
enable physiological and temporal movement efficiencies, i.e., indi-
viduals are able to complete tasks in less time and with relatively less
effort/fatigue and thus have greater reserve capacity, better overall
health status and a slower progression to frailty as older adults.28
Higher levels of physical performance (strength, coordination and
balance) also reduce the risk of falls and the subsequent fear of fur-
ther falls which is a barrier to PA in older adults.
The results of our study clearly show differences in physical per-
formance levels between individuals who were physically active
compared to those who were not. The results also suggest that, given
no difference in mean pain severity levels between physically active
and inactive groups in these community dwelling older adults, pain
severity did not directly influence PA level nor did PA level aggravate
pain severity albeit the mean level of pain severity score was rela-
tively low. This is an important point with clinical implications
because it suggests that PA can generally be encouraged without too
much worry about aggravating pain. PA clearly had a significant
effect on physical function. For example, the physically inactive group
had an average six-time sit-to-stand time of 13.21 seconds. Relatively
slow performance time (cut-off score 13.6 seconds) is score associ-
ated with an risk of increased disability and mortality29 and lower
than 15 seconds, the cut-off score which identifies older adults at risk
for recurrent falls.30 There were 16% of physically active and 23.9% of
physically inactive participants who scored below 15 seconds. The
differential physical performance levels between groups occurred
despite there being no overall group difference in reported pain
severity. However, it must be recognized that although the effect of
pain on PA activity and physical performance did not differ between
groups, there may well have been some impact based on pain loca-
tion and specific physical performance tasks. Although our sample
size precluded analysis of the impact of pain location on specific task
performance, common sense suggests that this would be true. For
example, knee pain will have a greater negative impact on walking
speed and sit-to-stand times than on forward reach distance for bal-
b p ance. In contrast, shoulder pain will likely impact forward reach dis-
tance to a greater extent but have little impact on walking speed or
.0001
.219 .014 sit-to-stand times. Movement speed as a component of physical func-
-.276 .001 tion and has been consistently shown to be a strong predictor of out-
.254 .005 come across health conditions (e.g. cancer, chronic pain) as well as in
.227 .038
the older adults (Simmonds et al). This is not too surprising. The
.0001
.278 .001
capacity to move and complete basic physical tasks relatively quickly,
.0001 safely and efficiently has important implications. Generalized psy-
-.185 .022 chomotor slowing and stiffening occurs with healthy aging and is
.0001 accentuated in those aging with a health condition. As noted earlier,
-.096 .403
slow movements are relatively costly in terms of the time taken to
complete a task as well as in the greater level of perceived effort asso-
ciated with that task be it walking or rising from a chair. For some
individuals including minority populations the relatively high cost in
effort and time may act as a barrier to PA, contributing to further
physical compromise and reductions in PA. Studies that have exam-
ined a treatment approach aiming to increase movement speed (e.g.,
brisk walking) have demonstrated acute improvements across a
range of both physical and cognitive performance tasks.31 Notewor-
thy is the fact that self-selected preferred speed of walking increased
following a brisk walking intervention. It is plausible that focusing
attention on positive movement efficiencies as well as the physical
and mental (cognitive and emotional) health benefits of PA which
may decrease the risk of frailty, may encourage older adults to
increase their levels of PA. This is particularly important in those
with pain who are at higher of frailty
Although it is widely recognized that PA and nutritional status
play important roles in the variations of vulnerability to frailty,32 the
mechanism of the mediation effect of PA on the relationship between
chronic pain and frailty remains unclear. A number of studies have
shown that PA has direct positive effects on psychological mood as
well as on cognitive function in the aging population.33 Enhanced
physical capacity and psychological function enables social and com-
munity engagement.34 This PA-induced improvement in mood, social
engagement and support may reduce the impact of pain as a negative
stressor thereby further reducing the risk of frailty.35 Advanced aging
has also been associated with the decline in secretion of growth hor-
mone (GH) and levels of insulin-like growth factor-I (IGF-I) which
contribute to the loss of muscle mass and physical function, and onset
of frailty.36 While the age-related decline in IGF-1 is related to a
lower level of PA,37 some evidence suggests that aerobic and resis-
tance training can increase the levels of IGF-1 in older adults.38 Addi-
tionally, lower levels of the GH and IGF-1 is linked to hyperalgesia
and clinical pain syndromes.39
It is not clear why PA mediated the relation between pain severity
and physical frailty but not the relation between pain interference
and physical frailty. However, it should be noted that pain, and pain
interference are different constructs (albeit they may be associated).
Most likely the differential result is based in part on the fact that a
different array of bio-psychosocial factors influences pain severity
compared to those that influence the magnitude of interference by
pain on mood and function. For example, it is well known that PA can
positively modify cortisol levels which may alleviate the perceived
severity of pain.40
Older adults are among the least active population groups
with only one third meeting the PA recommendations and over a
third being physical inactive. 41 The prevalence of physical inac-
tivity was highest among individuals with Latinx and Blacks race/
ethnicity, higher age, and chronic diseases.42 Since the prevalence
of chronic pain remains high in older Latinx and other minority
adults, innovative and balanced approaches are necessary to
address the age-related decline in PA, and alleviate harmful
 Z. Yin et al. / Geriatric Nursing 42 (2021) 460 466
effects of chronic pain on the quality of life. Hence, the promotion
of PA must take into consideration of characteristics of pain expe-
rience in the older Latinx adults and resources and support from
their family and community.43 For example, Latinx prefer group-
based activities with a focus on social interaction. 44 Simple appli-
cation of the recommendations and strategies developed for the
general population can be counterproductive, 43 since the barriers
and motivators for PA can be different for older Latinx adults than
other population groups.
There are several limitations that may hinder the validity and gen-
eralizability of the study findings. First, findings from this study should
be interpreted with caution since we used a cross-sectional study
design which is not indicative of causality. However, the relationships
investigated in the study have been indirectly substantiated by previ-
ous longitudinal and experimental studies.45 Second, we used a modi-
fied index of physical frailty that focused exclusively on the physical
functions of lower extremity to allow the examination of the effects of
PA on the relationship between chronic pain and physical frailty in a
cross-sectional study. The study needs to be replicated in a prospective
study using Fried’s physical frailty index.6 Third, the sample size of the
study was small. To increase study sample size, we used self-reported
PA in 13% of the participants to replace missed accelerometry-based
assessment of PA status. Self-reported PA has been typically used in
frailty studies in the past. Finally, the scores of pain intensity and pain
interference were relatively low in the study sample compared to
studies with chronic pain population and might have masked the mag-
nitude of relation between pain and frailty. Future research needs to
replicate the finding in a large sample with chronic pain.
Conclusions
Being physically active was associated with a protective effect on
declining physical frailty among older adults experiencing high levels
of severity of pain. It is noteworthy to note that the majority of partic-
ipants in this study of community dwelling older adults were from
minority racial/ethnic backgrounds, a generally understudied group.
Findings from the study provides evidence in support of the develop-
ment of healthy aging programs which may prevent or mitigate the
negative consequences of frailty in older minority adults. Future
studies should pay special attention to the promotion of PA in older
adults with chronic pain to improve function, quality of life and
reduce healthcare costs that can reduce health disparity in the aging
population.
Funding
This work was supported by Center for Research to Advance Com-
munity Health (ReACH), UT Health San Antonio, San Antonio, Texas.
Conflicts of Interest
None declared.
Acknowledgements
Our heartfelt appreciation goes to the seniors at Alicia Trevino
Lopez Senior One-Stop Center, San Antonio, Texas who have partici-
pated in our study. We thank Mr. Gerrod Allen and Ms. Hetal Nayak
for their support and coordination with data collection. Finally, we
want to thank our research staff, undergraduate intern students, and
graduate assistants for their hard work and contribution to the study.
465
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