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Little is known about sex differences in musculoskeletal pain in older persons. There were women and men aged 72 years and older who participated in the 22nd biennial exam of the Framingham Study — Msk were asked msk identify pain locations on a homunculus showing all regions of the body.

Pain was categorized according to number of regions, with the most disseminated pain classified as widespread pain back pain and upper and lower extremity pain with bilaterality. In both men and women, pain was associated with fair or tualet self-rated health, history of back pain before age 65, and disability. Factors associated with pain only in women included body mass index, systolic blood pressure, and depressive symptoms. In men but not women, pain was associated with polyarticular radiographic osteoarthritis.

In conclusion, musculoskeletal pain was more prevalent and more widespread in older women than older men. Men and women differ in the factors associated with musculoskeletal pain in older ages. Further research is needed to understand sex differences in sex pain the older population. Musculoskeletal joint symptoms affect more than half of older persons in the US Centers for Disease Control, In general, older women have a higher prevalence of pain than older men Helme and Gibson, and studies suggest that musculoskeletal pain is more disabling for women than men in old age Hughes et al.

Arthritis, which afflicts more women than men Felson et al. Additional evidence has shown that physician assessment of joint impairments and radiographs were not more informative than self-reported pain in predicting disability Hughes et al. In tualet years, it has become more clear that location and severity of pain are important determinants of disability in older adults Lichtenstein et al. Many who have chronic musculoskeletal pain, have pain in several sites.

The multi-site nature of pain in the older population has been an obstacle for research because of difficulties in classifying multi-site pain. Summing the number of pain locations or identifying the single site of most severe pain may or may not be relevant for a global problem such as disability. Using a new classification, based on constellations of musculoskeletal pain, Leveille and colleagues identified widespread musculoskeletal pain as the most disabling pain among older women Leveille et al.

The classification of widespread pain, based on established criteria, included pain in the upper and lower extremities and axial pain Wolfe et al. Population-based studies have shown that the prevalence of widespread pain increases with age, peaking in the seventh and eighth decades Croft et al. Generally, women have a higher prevalence of chronic tualet pain than men, well into late life.

Many questions remain to be answered about sex differences in chronic sex in late life, a time when comorbidity is common and accumulating hazards often lead to loss of independence. Commonly observed differences between men and women in the msk and consequences of pain remain unexplained.

Although research indicates that pain perception factors, such as menstrual cycle fluctuations in pain sensitivity, may help to explain sex differences in pain reporting in younger adults Riley et al. As a first step toward uncovering clues to sex differences in the experience of pain in old age, we examined pain prevalence and associated risk factors in older men and women in the Framingham Study.

The Framingham Heart Study began in as a longitudinal population-based cohort study of the causes of heart disease. Initially, men and women between the ages of 30 and 60 years living in Framingham, Massachusetts were enrolled.

Biennial examinations were conducted by trained research staff at the study clinic located in Framingham. By the time of the 22nd biennial exam, the cohort included survivors who ranged in age from 72 to 99 years.

The analyses presented here used data from the 22nd exam because it was the tualet to collect comprehensive information about musculoskeletal pain.

There were persons with missing pain information who were not included in this study. Table 1 presents the demographic and health characteristics of those with non-missing versus missing pain information. Compared to persons with non-missing pain information, those with missing information were much older, more likely female, cognitively impaired and disabled, and were thus more likely to be examined at home instead of in the clinic where the pain questions were administered.

Prevalence of radiographic arthritis was similar in the two groups x-rays were obtained for persons examined at home or tualet the clinic. The majority of those with missing information were residing in nursing homes. Characteristics of persons with non-missing and missing pain information, exam 22, Framingham Study, — The measure of pain used in this study was based on location of frequent pain.

During the exam, participants were asked if they had pain, aching or stiffness in any of their joints on most days. In a previous Framingham analysis, more persons reported pain when viewing the homunculus than when asked about pain in the same sites Edmond and Felson, Drawing on earlier research showing that number of pain regions predicted worsening disability and falls in older women, pain was categorized according to number of pain regions Leveille et al.

Using this method, the most severe category of pain was widespread pain, defined according to the American College of Rheumatology criteria as pain above the waist, below the waist, on both sides of the body, and in the axial region Wolfe et al. Pain msk the waist, or upper extremity pain, was defined as pain in shoulder, elbow, wrist, thumb, or fingers.

Pain below the waist, or lower extremity pain, was defined as pain in the hip, knee, ankle, or base msk toes. Contra-lateral upper and lower extremity pain, for example, pain in the right knee along with pain in any site of the left leg or arm, met criteria for widespread pain. Tualet other categories of pain in these analyses were pain in two to three regions that did not meet criteria for widespread pain, pain in one region, and no pain.

Several sex and health and behavioral factors were assessed. Demographic factors included age, sex, education, and marital status. Health factors included measured height and weight, physical activity, functional status, and self-rated health. Body mass index BMI was calculated as the ratio of msk in kilograms to height in meters squared. Total alcohol consumption was calculated as total ounces per week of beer, wine, and liquor, using methods reported previously Felson et al.

Current self-rated health was assessed using the standard 5-level rating, then dichotomized for this study as fair or poor versus good, very good, or excellent. The MMSE is a valid and reliable instrument that has been used extensively to screen for cognitive impairment in older populations in research and in clinical practice Folstein, The methods of OA ascertainment have been sex in detail previously Zhang et al. Blood pressure was measured as the average of two readings conducted by a physician using a mercury column sphygmomanometer Vasan et al.

Disability was assessed in two domains: activities of daily living ADL and lower extremity mobility. Self-reported need for help from other persons or inability to perform ADL included bathing, dressing, transfers, eating, and using the toilet. Lower extremity mobility disability included self-reported sex to walk a mile and climb stairs without help. Descriptive statistics, mean and percentages, were sex for showing the relationships between pain categories and demographic and health characteristics.

Age-adjusted prevalence of tualet was calculated using the direct standardization method with prevalence applied to the age distribution of the entire cohort according to 5-year age groups. Tests for linear trend across categories of pain constellations were performed using the Mantel-Haenszel chi-square tests 1 degree of freedom, d.

In the modeling, we included all variables that were significantly associated with pain in the linear trend analyses described above. We used data from the entire cohort to examine sex differences in risk for widespread pain, performing a series of extended logistic regression models to determine the impact of potential confounders on the odds ratio for widespread pain in women compared to men.

Age-adjusted prevalence of musculoskeletal pain in women and men aged 72 years and older, Framingham, — There were several differences between women and men in factors associated with pain Table 2.

In women, the number of regions of pain was associated with higher BMI, higher systolic blood pressure, and depressive symptoms. Characteristics of men and women according to pain category, Framingham Study, biennial exam 22, — Although higher proportions of men had depressive symptoms across pain categories, the trend was not significant. Average age did not differ across pain categories in either men or women, though women with widespread pain were slightly older than their peers with other pain or no pain.

The notable difference between women and men in the proportions that were married, related to sex differences in sex expectancy leading to greater widowhood in women in old age, was not associated with pain status. Education level was not significantly associated with pain in men or women but there was a somewhat lower proportion of women that completed high school among women with widespread pain compared to other women.

Alcohol consumption was not associated with more pain in women, but men with single or multi-site pain, but not widespread pain, were more likely to consume higher amounts of alcohol than men without pain. In both men and women, those with widespread pain reported the lowest alcohol consumption. In men, but not in women, pain was associated with polyarticular radiographic osteoarthritis present in at least one knee and one hand joint.

In both women and men, there tualet a strong trend across pain categories in the proportions that reported having back pain before age Similarly, pain level was strongly associated with disability in ADL or lower extremity mobility. Men with multi-site pain generally had more msk than those with single site pain or no pain. Because the strongest differences in prevalence of risk factors were observed between persons with widespread pain and those with no pain, we compared these two categories to determine the magnitude of the differences in women and men using multivariate analyses.

Women who reported fair or poor health were five times more likely to have widespread pain than women who reported no pain. In addition, those who were overweight, had depressive symptoms, a history of back pain or disability were three to four times more likely to have widespread pain than their peers without pain Table msk. In men, only two factors were independently associated with widespread pain: radiographic polyarticular osteoarthritis and history of back pain.

Men with these health tualet were about three to four times more likely to have widespread pain compared to other men Table 3. In a final set of analyses, we examined sex differences in likelihood for having widespread pain in women compared to men. Women had a three-fold increased odds for widespread msk compared to men and there was little change in the odds ratio after adjusting for several potential confounders including age, body mass index, hand OA, knee OA, depressive symptoms, fair or poor self-rated health, history of back pain, and disability Table 4.

Odds ratio predicting likelihood for widespread pain in women compared to men, adjusted for covariates, Framingham Study, — Musculoskeletal pain was very common among elderly participants of the Framingham Study, reported sex nearly two-thirds of women and half of men, aged 72 and older.

These rates are similar to those reported in other studies of older populations Centers for Disease Control, ; Lichtenstein et al.

Sex differences in prevalence of pain were observed primarily in the proportions with widespread pain or no reported pain. Widespread pain was found in 1 out of 7 older women and 1 out of 20 older men in the elderly Framingham population. Slightly less than half of women and men had regional or multisite pain. Widespread pain is poorly understood in the older population.

Much of the research addressing the problem of widespread pain has been conducted in younger cohorts and often has been studied as a key symptom offibromyalgia. The authors proposed that widespread pain represents a continuum of chronic pain conditions and chronic pain in any site increases the risk for developing chronic widespread pain. A similar progression of pain over time was observed in a Swedish cohort aged 20—74 years, sex persons aged 59—74 had the highest risk of developing widespread pain during the 3 year follow-up Bergman et al.

Our data showed that both men and women with widespread pain were more likely to have a history of back pain before age 65 than their peers without pain, suggesting that the progression of pain continues well into late life. Sex differences in pain reporting have been attributed to a broad range of factors. Turk has proposed a biopsychosocial model of chronic pain that attributes sex differences in pain to interactions between biological, psychological, and sociocultural factors Fillingim, ; Turk and Okifuji, In a sample of adults living in Kansas, Wolfe and colleagues found that women with and without fibromyalgia had a lower pain threshold using dolorimetry and had more tender points than men Wolfe et al.

This heightened pain sensitivity among women, reported in a number of studies, is often used to explain greater reports of pain by women compared to men Rollman and Lautenbacher,

Many who have chronic musculoskeletal pain, have pain in several sites. The multi-site nature of pain in the older population has been an obstacle for research because of difficulties in classifying multi-site pain. Summing the number of pain locations or identifying the single site of most severe pain may or may not be relevant for a global problem such as disability. Using a new classification, based on constellations of musculoskeletal pain, Leveille and colleagues identified widespread musculoskeletal pain as the most disabling pain among older women Leveille et al.

The classification of widespread pain, based on established criteria, included pain in the upper and lower extremities and axial pain Wolfe et al.

Population-based studies have shown that the prevalence of widespread pain increases with age, peaking in the seventh and eighth decades Croft et al. Generally, women have a higher prevalence of chronic widespread pain than men, well into late life.

Many questions remain to be answered about sex differences in chronic pain in late life, a time when comorbidity is common and accumulating hazards often lead to loss of independence. Commonly observed differences between men and women in the prevalence and consequences of pain remain unexplained. Although research indicates that pain perception factors, such as menstrual cycle fluctuations in pain sensitivity, may help to explain sex differences in pain reporting in younger adults Riley et al.

As a first step toward uncovering clues to sex differences in the experience of pain in old age, we examined pain prevalence and associated risk factors in older men and women in the Framingham Study. The Framingham Heart Study began in as a longitudinal population-based cohort study of the causes of heart disease. Initially, men and women between the ages of 30 and 60 years living in Framingham, Massachusetts were enrolled. Biennial examinations were conducted by trained research staff at the study clinic located in Framingham.

By the time of the 22nd biennial exam, the cohort included survivors who ranged in age from 72 to 99 years. The analyses presented here used data from the 22nd exam because it was the first to collect comprehensive information about musculoskeletal pain.

There were persons with missing pain information who were not included in this study. Table 1 presents the demographic and health characteristics of those with non-missing versus missing pain information. Compared to persons with non-missing pain information, those with missing information were much older, more likely female, cognitively impaired and disabled, and were thus more likely to be examined at home instead of in the clinic where the pain questions were administered.

Prevalence of radiographic arthritis was similar in the two groups x-rays were obtained for persons examined at home or in the clinic.

The majority of those with missing information were residing in nursing homes. Characteristics of persons with non-missing and missing pain information, exam 22, Framingham Study, — The measure of pain used in this study was based on location of frequent pain. During the exam, participants were asked if they had pain, aching or stiffness in any of their joints on most days.

In a previous Framingham analysis, more persons reported pain when viewing the homunculus than when asked about pain in the same sites Edmond and Felson, Drawing on earlier research showing that number of pain regions predicted worsening disability and falls in older women, pain was categorized according to number of pain regions Leveille et al. Using this method, the most severe category of pain was widespread pain, defined according to the American College of Rheumatology criteria as pain above the waist, below the waist, on both sides of the body, and in the axial region Wolfe et al.

Pain above the waist, or upper extremity pain, was defined as pain in shoulder, elbow, wrist, thumb, or fingers. Pain below the waist, or lower extremity pain, was defined as pain in the hip, knee, ankle, or base of toes.

Contra-lateral upper and lower extremity pain, for example, pain in the right knee along with pain in any site of the left leg or arm, met criteria for widespread pain. Three other categories of pain in these analyses were pain in two to three regions that did not meet criteria for widespread pain, pain in one region, and no pain.

Several characteristics and health and behavioral factors were assessed. Demographic factors included age, sex, education, and marital status.

Health factors included measured height and weight, physical activity, functional status, and self-rated health. Body mass index BMI was calculated as the ratio of weight in kilograms to height in meters squared. Total alcohol consumption was calculated as total ounces per week of beer, wine, and liquor, using methods reported previously Felson et al. Current self-rated health was assessed using the standard 5-level rating, then dichotomized for this study as fair or poor versus good, very good, or excellent.

The MMSE is a valid and reliable instrument that has been used extensively to screen for cognitive impairment in older populations in research and in clinical practice Folstein, The methods of OA ascertainment have been described in detail previously Zhang et al. Blood pressure was measured as the average of two readings conducted by a physician using a mercury column sphygmomanometer Vasan et al.

Disability was assessed in two domains: activities of daily living ADL and lower extremity mobility. Self-reported need for help from other persons or inability to perform ADL included bathing, dressing, transfers, eating, and using the toilet.

Lower extremity mobility disability included self-reported inability to walk a mile and climb stairs without help. Descriptive statistics, mean and percentages, were used for showing the relationships between pain categories and demographic and health characteristics. Age-adjusted prevalence of pain was calculated using the direct standardization method with prevalence applied to the age distribution of the entire cohort according to 5-year age groups.

Tests for linear trend across categories of pain constellations were performed using the Mantel-Haenszel chi-square tests 1 degree of freedom, d. In the modeling, we included all variables that were significantly associated with pain in the linear trend analyses described above. We used data from the entire cohort to examine sex differences in risk for widespread pain, performing a series of extended logistic regression models to determine the impact of potential confounders on the odds ratio for widespread pain in women compared to men.

Age-adjusted prevalence of musculoskeletal pain in women and men aged 72 years and older, Framingham, — There were several differences between women and men in factors associated with pain Table 2.

In women, the number of regions of pain was associated with higher BMI, higher systolic blood pressure, and depressive symptoms. Characteristics of men and women according to pain category, Framingham Study, biennial exam 22, — Although higher proportions of men had depressive symptoms across pain categories, the trend was not significant.

Average age did not differ across pain categories in either men or women, though women with widespread pain were slightly older than their peers with other pain or no pain. The notable difference between women and men in the proportions that were married, related to sex differences in life expectancy leading to greater widowhood in women in old age, was not associated with pain status. Education level was not significantly associated with pain in men or women but there was a somewhat lower proportion of women that completed high school among women with widespread pain compared to other women.

Alcohol consumption was not associated with more pain in women, but men with single or multi-site pain, but not widespread pain, were more likely to consume higher amounts of alcohol than men without pain. In both men and women, those with widespread pain reported the lowest alcohol consumption.

In men, but not in women, pain was associated with polyarticular radiographic osteoarthritis present in at least one knee and one hand joint. In both women and men, there was a strong trend across pain categories in the proportions that reported having back pain before age Similarly, pain level was strongly associated with disability in ADL or lower extremity mobility.

Men with multi-site pain generally had more disability than those with single site pain or no pain. Because the strongest differences in prevalence of risk factors were observed between persons with widespread pain and those with no pain, we compared these two categories to determine the magnitude of the differences in women and men using multivariate analyses. Women who reported fair or poor health were five times more likely to have widespread pain than women who reported no pain.

In addition, those who were overweight, had depressive symptoms, a history of back pain or disability were three to four times more likely to have widespread pain than their peers without pain Table 3. In men, only two factors were independently associated with widespread pain: radiographic polyarticular osteoarthritis and history of back pain.

Men with these health conditions were about three to four times more likely to have widespread pain compared to other men Table 3. In a final set of analyses, we examined sex differences in likelihood for having widespread pain in women compared to men. Women had a three-fold increased odds for widespread pain compared to men and there was little change in the odds ratio after adjusting for several potential confounders including age, body mass index, hand OA, knee OA, depressive symptoms, fair or poor self-rated health, history of back pain, and disability Table 4.

Odds ratio predicting likelihood for widespread pain in women compared to men, adjusted for covariates, Framingham Study, — Musculoskeletal pain was very common among elderly participants of the Framingham Study, reported by nearly two-thirds of women and half of men, aged 72 and older. These rates are similar to those reported in other studies of older populations Centers for Disease Control, ; Lichtenstein et al. Sex differences in prevalence of pain were observed primarily in the proportions with widespread pain or no reported pain.

Widespread pain was found in 1 out of 7 older women and 1 out of 20 older men in the elderly Framingham population. Slightly less than half of women and men had regional or multisite pain. Widespread pain is poorly understood in the older population. Much of the research addressing the problem of widespread pain has been conducted in younger cohorts and often has been studied as a key symptom offibromyalgia.

The authors proposed that widespread pain represents a continuum of chronic pain conditions and chronic pain in any site increases the risk for developing chronic widespread pain.

A similar progression of pain over time was observed in a Swedish cohort aged 20—74 years, and persons aged 59—74 had the highest risk of developing widespread pain during the 3 year follow-up Bergman et al.

Our data showed that both men and women with widespread pain were more likely to have a history of back pain before age 65 than their peers without pain, suggesting that the progression of pain continues well into late life. Sex differences in pain reporting have been attributed to a broad range of factors. Turk has proposed a biopsychosocial model of chronic pain that attributes sex differences in pain to interactions between biological, psychological, and sociocultural factors Fillingim, ; Turk and Okifuji, In a sample of adults living in Kansas, Wolfe and colleagues found that women with and without fibromyalgia had a lower pain threshold using dolorimetry and had more tender points than men Wolfe et al.

This heightened pain sensitivity among women, reported in a number of studies, is often used to explain greater reports of pain by women compared to men Rollman and Lautenbacher, In the elderly, the problem of pain is more complex due to multiple comorbidities and, regardless of pain, the older population is more heterogeneous with regards to health and functioning.

However, our findings show that the observed sex differences in widespread pain prevalence are substantial even in the oldest old and that adjusting for several potential confounders of this association, including age, arthritis, obesity, depression, self-rated health, disability, and pain history, did not alter the odds ratio showing that older women were three times more likely than older men to have widespread pain.

The constellations of pain that we studied were shown previously to predict disability and falls in older women Leveille et al. Number of pain locations is an important contributor to disability in older adults and older women report more locations of pain than older men Scudds and Robertson, In the San Antonio Longitudinal Study of Aging, pain location was more strongly associated with functional limitations than either pain intensity or frequency Lichtenstein et al.

Although more work is warranted in this area, the findings to date underscore the need for comprehensive pain assessment that captures constellations of pain, in both clinical and research efforts involving older adults. There were striking sex differences in the factors associated with widespread pain in the Framingham population. For example, polyarticular radiographic osteoarthritis hand and knee OA was strongly associated with widespread pain in men but not in women. This was interesting given that women generally had a somewhat higher prevalence of polyarticular hand and knee OA than men across categories of pain.

It is possible that in men, OA may explain more cases of widespread pain than in women. However, the fact that approximately half of men and women with widespread pain did not have radiographic OA of the hands and knees suggests that other pathological conditions underlie the problem of widespread pain in many older adults.

There are a few considerations in understanding our study results. It is likely that the prevalence of pain that we observed was an underestimate of the prevalence in the entire study cohort because older and more disabled persons, including those residing in nursing homes, were more likely to have missing pain information.

Although joint pain is the most common pain in elders, the pain assessment was limited to musculoskeletal joint areas, thus missing pain in non-articular sites such as the thigh or lower leg. Another limitation of this study is the limited sample size of older men, particularly those with widespread pain.

This may have limited our ability to detect statistically significant trends or associations between potential risk factors and widespread pain in older men because of limited statistical power.

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