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Active Rehabilitation Should Be First-line Treatment for Older Patients’ Back Pain

After age 70 years, spine degeneration, pain thresholds and inflammatory mediators increase.

By Susan M. Rapp

Because patients over age 70 years have a greater incidence of comorbidities and variable responses to certain therapies, controlling their back pain requires special knowledge and superior coordination skills on the part of health care providers, a spine and sports rehabilitation specialist from the Rehabilitation Institute of Chicago said.

At the North American Spine Society 24th Annual Meeting, Joshua D. Rittenberg, MD, reviewed the challenges that managing pre- and postoperative spine pain in older patients presents — from diagnosing the real source of pain to balancing medications.

“We have a lot of problems in terms of how we are going to manage these patients because there have been problems identified with assessing pain, especially those who have cognitive deficits,” said Rittenberg, medical director of the Interventional Spine Program at the institute and assistant professor in the Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine.

With numerous pain generators and structures in the spine, accurately diagnosing the cause of back pain in patients older than 70 years is difficult, but essential, he said.

Spine pain control in the elderly uses many of the same approaches for the general population: Physical Therapy, injections and prescription medications.

Rehabilitation: A start

The goal of pain control is improving how patients feel with as little risk as possible to their well-being.

“Rehabilitation is really a good starting point,” according to Rittenberg. “This will help improve function, prevent deconditioning and it can provide tools for that patient to self-manage their symptoms so they are not really dependent on coming into the medical system each time they have this pain,” he said.

Rittenberg discussed such passive modalities as ice and heat applications, transcutaneous electrical nerve stimulation (TENS) and bracing, noting they play a limited role in pain management in this population.

His patients have better results when prescribed treatments involving movement, core strengthening, general conditioning and aerobic exercises. Increased lumbar stabilization, balance and neuromuscular control are the benefits. All of these treatments are integral parts of a comprehensive Physical Therapy rehabilitation program.

For patients unable to progress with Physical Therapy, Rittenberg recommends interventional spine care, such as epidural steroid injections, radiofrequency neurotomy or facet or sacro-iliac joint injections used either as a treatment or diagnostic tool.


“Interventional spine care can be really helpful in this team approach to treating an older patient with pain,” he said, noting it is typically combined with other treatments.

Using pain medications in elderly patients has been associated with increased side effects and toxicities, polypharmacy problems and reduced efficacy. So he recommended that spine care practitioners follow the 2009 American Geriatrics Society clinical practice guidelines for pain, which include limiting routine use of NSAIDs.

“Frequent medication review is important,” including drug reconciliation, said Rittenberg, who avoids using opioids in his practice, especially long-acting medications.

“Pain control in older patients should be approached with systemic analgesics only after other options have not worked,” he added.


  • Rittenberg JD. Pain control in the elderly population. Presented at the North American Spine Society 24th Annual Meeting. Nov. 10-14, 2009. San Francisco.