Objective: It is critical to identify modifiable factors associated with functional recovery from hip fracture. The authors examined the association between pain intensity and two functional endpoints—instrumental activities of daily living and social activity participation—after hip fracture. Method: A total of 270 cognitively intact, community-dwelling persons older than 65 who underwent surgical hip fracture repair in New Haven, Connecticut, were followed for 12 months. Results: Pain intensity was strongly negatively associated with both instrumental and social functioning (p values < .001). Increases in pain intensity between 6 and 12 months were also associated with concurrent decreases in function (p values < .001). These relationships were partly explained by depressive symptoms and a marker of physical ability—gait speed. Discussion: Interventions to control pain may enhance functional status after hip fracture; however, pain relief must be maintained to sustain recovery. Attention to the complex relationships among pain, depressive symptoms, and physical impairments should inform intervention development.
AGS Panel on Chronic Pain in Older Persons. (1998). The management of chronic pain in older persons. Geriatrics, 53(Suppl. 3), S8-S24.
2.
Andersen, R. E., Crespo, C. J., Ling, S. M., Bathon, J. M., & Bartlett, S. J. (1999). Prevalence of significant knee pain among older Americans: Results from the Third National Health and Nutrition Examination Survey. Journal of the American Geriatrics Society, 47, 1435-1438.
3.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.
4.
Blessed, G., Tomlinson, B. E., & Roth, M. (1968). The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. British Journal of Psychiatry, 114(512), 797-811.
5.
Cornoni-Huntley, J., Brock, D. B., Ostfeld, A. M., Taylor, J. O., & Wallace, R. B. (1986). Established populations for epidemiologic studies of the elderly: Resource data book(86-2443). Washington, DC: National Institute on Aging.
6.
Craik, R. L. (1994). Disability following hip fracture. Physical Therapy, 74, 387-398.
7.
Cree, M., Carriere, K. C., Soskolne, C. L., & Suarez-Almazor, M. (2001). Functional dependence after hip fracture. American Journal of Physical Medicine and Rehabilitation, 80, 736-743.
8.
Cronbach, J. L., & Furby, L. (1970). How we should measure “change”—or should we?Psychological Bulletin, 74(1), 68-80.
9.
Cummings, S. R., Phillips, S. L., Wheat, M. E., Black, D., Goosby, E., Wlodarczyk, D., et al. (1988). Recovery of function after hip fracture. The role of social supports. Journal of the American Geriatrics Society, 36, 801-806.
10.
Feldt, K. S., & Oh, H. L. (2000). Pain and hip fracture outcomes for older adults. Orthopedic Nursing, 19(6), 35-44.
11.
Ferrell, B. A. (1991). Pain management in elderly people. Journal of the American Geriatrics Society, 39(1), 64-73.
12.
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189-198.
13.
Fox, K. M., Hawkes, W. G., Hebel, J. R., Felsenthal, G., Clark, M., Zimmerman, S. I., et al. (1998). Mobility after hip fracture predicts health outcomes. Journal of the American Geriatrics Society, 46(2), 169-173.
14.
Gill, T. M., Williams, C. S., & Tinetti, M. E. (1995). Assessing risk for the onset of functional dependence among older adults: The role of physical performance. Journal of the American Geriatrics Society, 43, 603-609.
15.
Guralnik, J. M., Branch, L. G., Cummings, S. R., & Curb, J. D. (1989). Physical performance measures in aging research. Journal of Gerontology: Medical Sciences, 44(5), M141-M146.
16.
Guralnik, J. M., Ferrucci, L., Simonsick, E. M., Salive, M. E., & Wallace, R. B. (1995). Lower extremity function in persons over the age of 70 years as a predictor of subsequent disability. New England Journal of Medicine, 332, 556-561.
17.
Guralnik, J. M., Seeman, T. E., Tinetti, M. E., Nevitt, M. C., & Berkman, L. F. (1994). Validation and use of performance measures of functioning in a non-disabled older population: MacArthur studies of successful aging. Aging, 6, 410-419.
18.
Hagglund, K. J., Haley, W. E., Reveille, J. D., & Alarcon, G. S. (1989). Predicting individual differences in pain and functional impairment among patients with rheumatoid arthritis. Arthritis and Rheumatism, 32, 851-858.
19.
Herr, K. A., & Mobily, P. R. (1991). Complexities of pain assessment in the elderly. Clinical considerations. Journal of Gerontological Nursing, 17(4), 12-19.
20.
Herr, K. A., & Mobily, P. R. (1993). Comparison of selected pain assessment tools for use with the elderly. Applied Nursing Research, 6(1), 39-46.
21.
Heruti, R. J., Lusky, A., Barell, V., Ohry, A., & Adunsky, A. (1999). Cognitive status at admission: Does it affect the rehabilitation outcome of elderly patients with hip fracture?Archives of Physical Medicine and Rehabilitation, 80, 432-436.
22.
Hudson, J. I., Kenzora, J. E., Hebel, J. R., Gardner, J. F., Scherlis, L., Epstein, R. S., et al. (1998). Eight-year outcome associated with clinical options in the management of femoral neck fractures. Clinical Orthopaedics and Related Research,348, 59-66.
23.
Jensen, M. P., & Karoly, P. (1992). Self-report scales and procedures for assessing pain in adults. In D. C. Turk & R. Melzack (Eds.),Handbook of pain assessment (pp. 135-151). New York: Guilford.
24.
Jette, A. M., Harris, B. A., Cleary, P. D., & Campion, E. W. (1987). Functional recovery after hip fracture. Archives of Physical Medicine and Rehabilitation, 68, 735-740.
25.
Joint Commission on Accreditation of Healthcare Organizations. (2000). Joint Commission on Accreditation of Healthcare Organizations pain standards for 2001. Retrieved January 4, 2001, from http://www.jcaho.org/standard/pm.html
26.
Keefe, F. J., & Bonk, V. (1999). Psychosocial assessment of pain in patients having rheumatic diseases. Rheumatic Diseases Clinics of North America, 25(1), 81-103.
27.
Kenzora, J. E., Magaziner, J., Hudson, J., Hebel, J. R., Young, Y., Hawkes, W., et al. (1998). Outcome after hemiarthroplasty for femoral neck fractures in the elderly. Clinical Orthopaedics and Related Research,348, 51-58.
28.
Kohout, F. J., Berkman, L. F., Evans, D. A., & Cornoni-Huntley, J. (1993). Two shorter forms of the CES-D (Center for Epidemiological Studies Depression) depression symptoms index. Journal of Aging and Health, 5, 179-193.
29.
Lamb, S. E., Guralnik, J. M., Buchner, D. M., Ferrucci, L. M., Hochberg, M. C., Simonsick, E. M., et al. (2000). Factors that modify the association between knee pain and mobility limitation in older women: The Women’s Health and Aging Study. Annals of the Rheumatic Diseases, 59, 331-337.
30.
Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9(3), 179-186.
31.
Leveille, S. G., Ling, S., Hochberg, M. C., Resnick, H. E., Bandeen-Roche, K. J., Won, A., et al. (2001). Widespread musculoskeletal pain and the progression of disability in older disabled women. Annals of Internal Medicine, 135, 1038-1046.
32.
Magaziner, J., Hawkes, W., Hebel, J. R., Zimmerman, S. I., Fox, K. M., Dolan, M., et al. (2000). Recovery from hip fracture in eight areas of function. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55, M498-M507.
33.
Magaziner, J., Simonsick, E. M., Kashner, T. M., Hebel, J. R., & Kenzora, J. E. (1990). Predictors of functional recovery one year following hospital discharge for hip fracture: A prospective study. Journal of Gerontology: Medical Sciences, 45(3), M101-M107.
34.
Maldonado, G., & Greenland, S. (1993). Simulation study of confounder-selection strategies. American Journal of Epidemiology, 138, 923-936.
35.
Marottoli, R. A., Berkman, L. F., & Cooney, L. M., Jr. (1992). Decline in physical function following hip fracture. Journal of the American Geriatrics Society, 40, 861-866.
36.
Michel, J. P., Hoffmeyer, P., Klopfenstein, C., Bruchez, M., Grab, B., & d’Epinay, C. L. (2000). Prognosis of functional recovery 1 year after hip fracture: Typical patient profiles through cluster analysis. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55, M508-M515.
37.
Morrison, R. S., Magaziner, J., McLaughlin, M. A., Orosz, G., Silberzweig, S. B., Koval, K. J., et al. (2003). The impact of post-operative pain on outcomes following hip fracture. Pain, 103, 303-311.
38.
Morrison, R. S., & Siu, A. L. (2000). A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. Journal of Pain and Symptom Management, 19, 240-248.
39.
Mossey, J. M., Mutran, E., Knott, K., & Craik, R. (1989). Determinants of recovery 12 months after hip fracture: The importance of psychosocial factors. American Journal of Public Health, 79, 279-286.
40.
Mutran, E. J., Reitzes, D. C., Mossey, J., & Fernandez, M. E. (1995). Social support, depression, and recovery of walking ability following hip fracture surgery. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 50, S354-S361.
41.
Norton, R., Butler, M., Robinson, E., Lee-Joe, T., & Campbell, A. J. (2000). Declines in physical functioning attributable to hip fracture among older people: A follow-up study of case control participants. Disability and Rehabilitation, 22, 345-351.
42.
Office of Technology Assessment. (1994). Hip fracture outcomes in people age 50 and over— Background paper (OTA-BP-H-120). Washington, DC: Government Printing Office.
43.
Parmelee, P. A. (1994). Assessment of pain in the elderly. Annual Review of Gerontology and Geriatrics, 14, 281-301.
44.
Parmelee, P. A., Katz, I. R., & Lawton, M. P. (1991). The relation of pain to depression among institutionalized aged. Journal of Gerontology: Psychological Sciences, 46(1), P15-P21.
45.
Penninx, B. W., Leveille, S., Ferrucci, L., van Eijk, J. T., & Guralnik, J. M. (1999). Exploring the effect of depression on physical disability: Longitudinal evidence from the established populations for epidemiologic studies of the elderly. American Journal of Public Health, 89, 1346-1352.
46.
Phillips, D. M. (2000). JCAHO pain management standards are unveiled. Joint Commission on Accreditation of Healthcare Organizations. Journal of the American Medical Association, 284, 428-429.
47.
Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.
48.
Ray, N. F., Chan, J. K., Thamer, M., & Melton, L. J., III. (1997). Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: Report from the National Osteoporosis Foundation. Journal of Bone and Mineral Research, 12(1), 24-35.
49.
Roberto, K. A. (1997). Chronic pain in the lives of older women. Journal of the American Medical Womens Association, 52(3), 127-131.
50.
Rosner, B. (1979). The analysis of longitudinal data in epidemiologic studies. Journal of Chronic Diseases, 32(1-2), 163-173.
51.
Scudds, R. J., & Robertson, J. M. (1998). Empirical evidence of the association between the presence of musculoskeletal pain and physical disability in community-dwelling senior citizens. Pain, 75, 229-235.
52.
Scudds, R. J., & Robertson, J. M. (2000). Pain factors associated with physical disability in a sample of community-dwelling senior citizens. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55, M393-M399.
53.
Seeman, T. E. (1996). Social ties and health: The benefits of social integration. Annals of Epidemiology, 6, 442-451.
54.
Seeman, T. E., Charpentier, P. A., Berkman, L. F., Tinetti, M. E., Guralnik, J. M., Albert, M., et al. (1994). Predicting changes in physical performance in a high-functioning elderly cohort: MacArthur studies of successful aging. Journal of Gerontology: Medical Sciences, 49(3), M97-M108.
55.
Stevens, J. A., Hasbrouck, L. M., Durant, T. M., Dellinger, A. M., Batabyal, P. K., Crosby, A. E., et al. (1999). Surveillance for injuries and violence among older adults. MMWR CDC Surveillance Summaries, 48(8), 27-50.
56.
Summers, M. N., Haley, W. E., Reveille, J. D., & Alarcon, G. S. (1988). Radiographic assessment and psychologic variables as predictors of pain and functional impairment in osteoarthritis of the knee or hip. Arthritis and Rheumatism, 31, 204-209.
57.
Thorngren, K. G., Ceder, L., & Svensson, K. (1993). Predicting results of rehabilitation after hip fracture. A ten-year follow-up study. Clinical Orthopaedics and Related Research, 287, 76-81.
58.
Tinetti, M. E., Baker, D. I., Gottschalk, M., Garrett, P., McGeary, S., Pollack, D., et al. (1997). Systematic home-based physical and functional therapy for older persons after hip fracture. Archives of Physical Medicine and Rehabilitation, 78, 1237-1247.
59.
Tinetti, M. E., Baker, D. I., Gottschalk, M., Williams, C. S., Pollack, D., Garrett, P., et al. (1999). Home-based multicomponent rehabilitation program for older persons after hip fracture: A randomized trial. Archives of Physical Medicine and Rehabilitation, 80, 916-922.
60.
Turk, D. C. (1999). The role of psychological factors in chronic pain. Acta Anaesthesiologica Scandinavica, 43, 885-888.
61.
Visser, M., Harris, T. B., Fox, K. M., Hawkes, W., Hebel, J. R., Yahiro, J. Y., et al. (2000). Change in muscle mass and muscle strength after a hip fracture: Relationship to mobility recovery. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55, M434-M440.
62.
Waddell, G. (1987). 1987 Volvo award in clinical sciences. A new clinical model for the treatment of low-back pain. Spine, 12, 632-644.
63.
Williamson, G. M., & Schulz, R. (1992). Pain, activity restriction, and symptoms of depression among community-residing elderly adults. Journal of Gerontology: Psychological Sciences, 47, P367-P372.
64.
Wolinsky, F. D., Callahan, C. M., Fitzgerald, J. F., & Johnson, R. J. (1993). Changes in functional status and the risks of subsequent nursing home placement and death. Journal of Gerontology: Social Sciences,48(3), S94-S101.
65.
Wolinsky, F. D., Fitzgerald, J. F., & Stump, T. E. (1997). The effect of hip fracture on mortality, hospitalization, and functional status: A prospective study. American Journal of Public Health, 87, 398-403.
66.
Woo, J., Ho, S. C., Lau, J., & Leung, P. C. (1994). Musculoskeletal complaints and associated consequences in elderly Chinese aged 70 years and over. Journal of Rheumatology, 21, 1927-1931.
67.
Zuckerman, J. D. (1996). Hip fracture. New England Journal of Medicine, 334, 1519-1525.
