Physical, Emotional, and Social Impacts of Restricting Back Pain in Older Adults: A Qualitative Study

Abstract

Objective. Back pain is the most common type of pain reported by older adults, yet current management strategies often do not address the multi-dimensional impacts on older adults who face unique challenges as compared with younger populations. The objective of this qualitative study was to assess the physical, psychological, and social impacts of back pain (severe enough to restrict activity, hereafter referred to as restricting back pain) on older adults.

Design. This was a qualitative study using semi-structured interviews and focus groups.

Setting and Patients. This study was comprised of a diverse sample of 93 community-living older adults (median age 83) with restricting back pain.

Methods. We used a semi-structured guide in 23 interviews and 16 focus groups to discuss the various ways that restricting back pain impacted participants. Transcripts were analyzed in an iterative process to develop thematic categories.

Results. Restricting back pain affected participants physically (inability to execute routine tasks, disruption of sleep and exercise), psychologically (feelings of sadness and irritability, fears about worsening health, loss of hope towards recovery or pain relief), and socially (experiences of isolation, inability to pursue hobbies).

Conclusions. These data inform which outcomes should be measured in studies evaluating treatments for older adults with restricting back pain.

Introduction

Back pain is the second most common complaint for which patients visit a primary care doctor’s office [1–3] and the most common type of musculoskeletal pain reported by older adults [4–6]. In the United States, more than $100 billion is spent on back pain annually [7], and these estimates will likely increase as our population ages [8]. We lack clinical guidelines for back pain in older adults. Guidelines for back pain in younger populations fail to account for multiple comorbid conditions [9], poly-pharmacy, frailty, and fragmented social support systems [10]—all issues that contribute to decision-making complexities in older populations [9,10]. Chronic back pain in older adults has been described as a syndrome; the complexity stems from the multiple contributors responsible for the back pain experience [11,12]. Because the pain experience, values, and priorities may be different among older adults as compared with younger adults [13–18], it is important to assess the impacts specifically on this growing population.

Clinical pain assessment and management strategies have traditionally focused on measuring and reducing the intensity or frequency of pain [19]. While the numeric rating scale (NRS) improves documentation of pain, measurement of the NRS alone has not been shown to improve clinical outcomes, perhaps because it fails to account for pain impact and patient preferences for treatments [20]. Pain intensity is a uni-dimensional measure, yet outcomes should be measured using multi-dimensional scales, just as management efforts need to be multi-dimensional in nature. The recognition of the need for a multi-dimensional approach to pain management is not new, dating back to the 1970s [21–23]. The fields of behavioral medicine and health psychology have conceptualized the interdependence of multiple impacts that individuals experience as a result of physical disease [24]. Perhaps the most well-known and widely-accepted of these, the biopsychosocial model, describes how pain is experienced physically, psychologically, and socially, and how these factors can modulate or exacerbate the clinical presentation of disease [22–25].

Research that incorporates the biopsychosocial model is particularly timely and relevant. The 2014 publication from the NIH Task Force on Research Standards for Chronic Low Back Pain [26] emphasized the importance of incorporating a biopsychosocial model of chronic pain, stratifying back pain by its impact rather than attempting classification solely by pathophysiology, and reporting data on multiple domains using a minimum dataset. However, the NIH Research Task Force acknowledged uncertainty regarding the generalizability of their recommendations/suggestions for older adults with back pain, largely due to a paucity of prior research in this population. Most research conducted to date has focused on younger patients with chronic pain, and we cannot assume that these findings apply equally to older adults with back pain [16–18,27,28]. The current research is timely in addressing this ambiguity for three reasons: first, older adults are a rapidly growing subpopulation [29]; second, back pain is the most common type of pain reported by older adults [3,30]; and third, older adults are often excluded from clinical trials [31].

We are learning more about the experience of back pain among older adults, although much remains to be learned [17,32,33]. Using monthly data collected over 13 years, our prior work shows a strong independent association between restricting back pain and subsequent mobility disability in older adults [34]. While we were able to gain a better understanding of the impact of restricting back pain, from a quantitative standpoint, we were eager to complement these results with the older adults’ experience, in their own words, with this phenomenon. Our team has published qualitative results from interviews and focus groups reporting how ageism, negative attitudes, and competing co-morbidities can hinder older adults from seeking care for their restricting back pain [35]. Another publication from our group described illness representation of restricting back pain in the framework of self-regulatory theory [36]; however, this population was mostly non-Hispanic white older adults. This research seeks to contribute additional data about the multi-dimensional impacts of restricting back pain from the perspective of a diverse, older adult population. Qualitative methods can provide a thorough understanding of older adults’ perspectives by allowing them to elaborate on their experiences, rather than focusing solely on quantified outcomes [35–37]. Elucidating older adults’ experiences with back pain, and their perceptions of its impact will inform which outcomes are most relevant to assess in this population.

Methods

Our qualitative research strategy consisted of multiple data collection techniques and samples [38–42] to assess the experiences among older adults (age ≥ 65 years) with restricting back pain (defined as back pain severe enough to restrict activity) [43]. This research builds on previous work with primarily older white women [36] by purposively sampling more racially diverse older adults who experienced restricting back pain during the past 3 months. Restricting back pain is clinically meaningful because it requires that the pain exceeds a threshold of severity beyond the occasional ache and pain.

Participant recruitment started with a sample drawn from the Precipitating Events Project (PEP), a longitudinal study of non-disabled community-living persons of age 70 and older [36,44]. PEP participants who had reported restricting back pain in the previous 3 months were considered eligible for potential inclusion in our study. We extended recruitment beyond PEP to older adults in the Connecticut community (mostly white). As part of our strategy to include a more racially diverse sample, we then recruited participants from New York City (mostly non-white). The principal investigator networked with New York City senior center directors who facilitated recruitment of participants, using a process that successfully recruited for other chronic pain studies [45–47], with the listed eligibility criteria. We excluded participants who were non-English speaking or unable to participate actively in either an in-person interview or focus group.

We used two qualitative data collection strategies: semi-structured in-depth interviews, and focus groups. The principal investigator, with formal training in qualitative interviewing skills, facilitated the interviews and focus groups. In-depth interviews (N = 23) were conducted in participants’ homes, with each interview lasting an average of 45 minutes. Next, the principal investigator recruited participants for focus groups to assess whether patterns in findings from the individual interviews were also reflected in a larger, more diverse sample. Focus groups can facilitate dynamic discussions and allow members to reflect on others’ diverse attitudes and experiences, revealing areas of agreement and difference [48]. The research team recruited participants from New York City senior centers that primarily served black and Hispanic clients. These focus groups were intended to increase the racial/ethnic diversity of the sample and verify consistency or identify discrepancies in emerging themes.

Of the 16 focus groups, seven were conducted in Connecticut and nine in New York City. Each group included three to seven participants and lasted between 30–60 minutes. Both Connecticut and New York City participants were 65 years of age or older, community-living, and reported restricting back pain during the last 3 months. Researchers concluded data collection once focus groups no longer produced unique findings related to the various impacts of restricting back pain, i.e., reached thematic saturation.

The interview guide included open-ended questions that asked participants to comment on the various ways that back pain impacted their lives, physically (“How does your back pain affect you physically?” “What makes it better/worse?”), emotionally (“What, if anything, about your back pain worries you?” “How does the back pain affect you emotionally?”), socially (“How does your back pain affect your relationships with family, friends, and care-providers?”), and personally (“What is most concerning to you about your back pain?” “Does back pain impact your quality of life?”). The semi-structured interview and focus group guides included the same general topics (Appendix A).

Data Analysis

Interviews and focus groups were audio recorded, subsequently transcribed verbatim, and then analyzed in NVivo 9.0 (QSR International, Melbourne, AUS). The research team, with experience in qualitative data analysis, first analyzed six transcripts using inductive thematic analysis to identify themes and to develop a coding scheme. Initial codes included, for example, physical, psychological, and social impacts of restricting back pain, self-management strategies, experiences with providers, and attitudes toward medication. Codes were then re-evaluated and revised in an iterative process to categorize emergent themes including statements about impact on relationships with family members, hobbies, and physical functioning. Coding concordance among team members was verified by selecting and reviewing four interview transcripts at random by the principal investigator. Where discrepancies in coding existed, the team discussed the analysis until consensus was achieved. The research team developed the final coding scheme and code definitions based on the analysis of these initial six transcripts, and created a qualitative codebook that served as a guide for all coders and subsequent coding activities. Two coders analyzed each transcript in a matrix ensuring that all coders were paired evenly across transcripts for parallel analysis. Researchers met regularly to review coding consistency [39,40] and discrepancies were discussed until consensus was reached.

All data were de-identified prior to analysis. This study was approved by the Yale University and UT Southwestern Medical Center’s Institutional Review Boards.

Results

The Connecticut focus groups revealed a high level of thematic consistency with the PEP one-on-one interviews. The final analysis of data following the nine New York City focus groups (with diverse older adults) determined that no new themes had emerged from these groups as compared with the Connecticut participants, suggesting consistency between the two locations.

Ninety-three individuals participated in 16 focus groups (N = 70) and 23 interviews (Table 1). Of the 93, 63 (68%) were female, the median age was 83 years, 16 (17%) did not complete high school, and more than half lived alone. The Connecticut focus groups and individually interviewed participants were composed primarily of non-Hispanic whites, whereas seven of the nine focus groups in NYC were composed predominately of black and/or Hispanic participants. Over half of the participants (N = 51, 55%) reported episodes of restricting back pain for 10 years or longer, and an additional quarter (N = 24, 26%) reported restricting back pain during the prior 5–10 years. Seventy-six (82%) of the participants had previously used or were currently using an oral pain medication (including both prescribed and over the counter), 18 (19%) had tried topical therapies (e.g., tiger balm, capsaicin, Bengay™), 69 (74%) reported using a combination of non-pharmacologic strategies (e.g., physical therapy, yoga, and exercise), and 54 (58%) reported using hot/cold modalities to alleviate pain symptoms (e.g., ice pack, heating pad).

Table 1.

Interview and focus group participant characteristics

	Interviews	Focus groups
Number of participants	N = 23 (25%)	N = 70 (75%)
Age
< 80 years	0 (0%)	36 (52%)
80–84 years	7 (30)	11 (16%)
≥ 85 years	16 (70%)	20 (29%)
Gender
Female	13 (57%)	50 (71%)
Male	10 (43%)	20 (29%)
Ethnicity
Hispanic	0 (0%)	8 (11%)
Non-Hispanic	23 (100%)	57 (81%)
Unknown	0 (0%)	5 (7%)
Race
African American/black	2 (9%)	26 (37%)
Caucasian/white	21 (91%)	36 (51%)
Other/multiracial	0 (0%)	7 (10%)
Unknown	0 (0%)	1 (1%)
Education level
Did not complete high school	5 (22%)	11 (16%)
Living arrangements
Living alone	12 (52%)	37 (53%)

Analysis of the data revealed that restricting back pain negatively impacts participants physically (inability to carry out routine tasks, disruption of healthy levels of sleep and exercise), emotionally (feelings of anxiety, sadness/depression and irritability, fears about worsening conditions, loss of hope toward recovery or pain relief), and socially (experiences of isolation, inability to engage in hobbies).

Physical Impact

As older adults attempt to maintain daily routines and household tasks, many described how restricting back pain prevented them from engaging in routine activities of daily living such as cleaning and walking, or feeling motivated to do activities that they had formerly enjoyed.

• “It’s stopped me from walking normally, whereas before I walked with a normal gait. I’ve been slowing down to a crawl.” (NYC focus group participant)

• “Well, I don't like to bake anymore because standing for any length of time bothers me. I just can't stand there that long working.” (PEP interview participant)

For many, the restricting back pain translates into an inability to carry out specific housework chores.

• “I find that making the bed, bending over, is when I get pain in my back. And it takes me forever to get it made … I really can’t do, like vacuuming … I can’t even use that. It’s just, my back is really painful.” (PEP interview participant)

• “My back pains when I mop the floor—oh, my God! I can’t mop no more. I get two aspirin … then I have to sit down.” (NYC focus group participant)

Some participants shared that their restricting back pain not only impacts daytime activities, but also prevents healthy/restful sleep.

• “I always sleep on my back. If I sleep on my side, I can barely walk when I get up in the morning and I hate sleeping on my back. It’s not my usual posture but I have to do it because then when I get out of bed, I can walk.” (CT focus group participant)

• “First of all, I don’t sleep all night. I go to bed early and I get a couple hours of sleep and the rest of the night I’m awake up and down with my [back] pain.” (PEP interview participant)

Multiple participants mentioned how restricting back pain negatively affects their independence because of its impact on their physical functioning.

• “Well, I don't like being limited. Naturally. I like to be active. And I like to be independent.” (PEP interview participant)

• “Whether it’s coming from the back or it’s just very, very sore and, it makes me stop and ask somebody else to do something for me. And that’s very, very aggravating.” (PEP interview participant)

The physical impact of restricting back pain was not only discussed in terms of daily chores and reduction in daily activity, but also in the will and desire to perform these tasks. Several participants shared their belief that back pain “saps your strength” leaving them not only unable but disinterested in these activities.

• “[The pain] didn’t limit my activities the way it does now. I just don’t feel like doing anything. I don’t have the energy. I force myself.” (PEP interview participant)

• “You have no desire to do anything. And your feeling is you’re not capable of doing anything. It knocks me out … Some days I don’t even read. I don’t know whether I could or not, but I just don’t feel like it.” (PEP interview participant)

Several participants felt that they were mentally capable but physically restricted from being more active.

• “It’s very debilitating both mentally and physically because I’m not able to do what I want to do. My head says yes and my body says no.” (PEP interview participant)

• “Now I have a saying: I can do the talk, I can’t do the walk.” (PEP interview participant)

Psychological Impact

When asked if back pain affects them emotionally, most participants shared feelings of frustration, anxiety, and sadness.

Participants relayed their experiences with being quick to anger when they are in pain, and how this affects friends and family.

• “Well I’m sour and maybe I’m nasty, I get mean. My temper goes up and I don’t want to talk [to] anybody, just leave me alone. Let me die in peace or die in pain or whatever. Just don’t bother me.” (PEP interview participant)

• “ … I get crabby when everything hurts too much …  I give people kind of those sharp answers, short and swift.” (PEP interview participant)

Participants who shared feelings about the impact of their restricting back pain often related that they had fears about whether the back pain would get worse over time.

• “Fear appears. Is this going to get worse to the point that I can’t be mobile at all?” (CT focus group participant)

• “Well, I do worry about it. Yes I do … . Because someday, I figure I may be laid up and wouldn’t be able to do anything.” (PEP interview participant)

Several participants expressed feelings of sadness because of a diminished quality of life that they attributed to living with restricting back pain. These impacts have a compounding effect, in which physical impact leads to social isolation, which in turn could worsen/lead to depression.

• “I think my situation is pretty mild but the fact that I have pain every day, I find depressing.” (CT focus group participant)

• “It has ruined my life … I can’t … I don’t go anywhere alone anymore … ” (NYC focus group participant)

• “I talk to my daughter sometimes and say, I hope soon this will be over … sometimes people say, ‘Oh don’t talk like that. You’re going to be around for a long time.’ But you don’t want to be around for a long time when, you don’t have a quality of life. You really don’t. I don’t.” (PEP interview participant)

Social Impact and Social Isolation

A majority of participants discussed the link between restricting back pain and their social life, including relationships with their friends and family. Sometimes, pain forced them to avoid certain settings and activities, causing them to miss out on important social functions.

• “I’m miserable. Because I’m invited someplace, you know and I don’t know if I can go all the time … if I have to go to my sister’s 90th birthday party, I didn’t know where I was going or how many stairs I had to climb and so I didn’t go!” (PEP interview participant)

• “We have a niece and nephew who invite us all the time to join big functions, and I can’t do it anymore. I don’t want to be in that position where I have to sit for a long time … It becomes uncomfortable. You don’t want to leave a group of people you love constantly like that.” (CT focus group participant)

Participants discussed social isolation generally and related that restricting back pain had changed their social behavior.

• “Well, I’m not as open as I used to be. I’m not. I don’t get out there and talk with everybody. I usually stay in my house; I don’t go out that much.” (PEP interview participant)

• “I don’t see people and I’m a people person. I try to get out as much as I feel I could do it but I still have to come back and take care of myself.” (PEP interview participant)

For others restricting back pain not only brings social isolation, but also the loss of an experience or a hobby that used to be enjoyable: “I don’t do the things that I used to love doing.”

• “I can’t do much walking. Not long-term walking. We used to go on bus trips … I had to stop doing that because it wasn’t a pleasure going on a trip anymore because of the pain.” (PEP interview participant)

• “It’s a writing group upstairs that I used to go to and we wrote poetry and little stories. I used to love to participate in that and … . I can’t stand the pain of sitting in a group … if I take the pills or something to help, then I can’t concentrate.” (PEP interview participant)

Discussion

This research addresses an important gap in the literature by qualitatively describing the multi-dimensional impacts of restricting back pain in a diverse sample of older adults. Our findings reveal insights about what matters to older adults living with restricting back pain. For example, social isolation was identified as an important consequence of living with restricting back pain in this older adult sample; however, this is an outcome not typically associated with back pain in younger adults and is not routinely assessed. Our results underscore the necessity of measuring the appropriate outcomes in research and in clinical practice. Further, by focusing on impacts and outcomes of importance to older adults with restricting back pain, researchers may develop interventions that are age-appropriate, relevant and of importance to older adults with this common condition.

A large body of literature suggests that assessing and managing chronic back pain in older adults poses unique challenges, including the presence of multi-morbidity, polypharmacy, physical frailty and/or cognitive impairment [12,49–51]. More recently, an emerging body of literature indicates that older adults may also have unique treatment goals, expectations about the patient-provider relationship, and priorities for quality of life as compared to younger individuals with chronic back pain [32,52–54]. The literature also suggests that clinical outcomes most commonly used by providers to gauge treatment success may not align with patients’ goals [55]. In a study of older adults with spinal stenosis, participants were asked to rate the specific items of the Roland-Morris Disability Questionnaire (one of the most commonly used back pain specific disability measures) based on importance (to warrant treatment with an epidural steroid injection) [56]. Surprisingly, participants rated only 10 of the 24 items on this scale as important enough to warrant intervention for their spinal stenosis symptoms [56]. Although difficulty exercising and participating in hobbies or leisure activities were among the most highly rated problems, they are typically not assessed and not considered in clinical encounters [56]. Likewise, older adults in our study describe the diverse impacts of back pain that disrupt their quality of life in ways that may not be adequately recognized by providers, including feelings of isolation and depression resulting from an inability to engage in previously enjoyed hobbies and social activities, and fears of physical deterioration.

Our findings are consistent with existing research indicating that pain is experienced along multiple domains [57] and is currently insufficiently assessed using uni-dimensional outcome assessments (such as NRS alone) [20] or addressed by uni-dimensional or biomedical-only treatments [12,28]. Various instruments have been used to measure other patient-reported outcomes (PRO) related to pain, including depression and function [58–62]. Since the NIH developed PROMIS (Patient Reported Outcomes Measurement Information System) in 2004, these instruments have been utilized and psychometrically validated across a large sample of individuals with various chronic diseases. PROMIS includes item banks on various domains (physical, psychological, and social) identified by older adults with restricting back pain in our research, although not necessarily validated in this distinct sub-population. Ultimately, our research confirms specific biopsychosocial impacts related to restricting back pain as identified by older adults, and PROMIS has state of the science measurement of all of the relevant domains [63]. Future research is needed to determine whether back pain specific PROMIS instruments are necessary and how these compare with existing validated instruments that capture similar constructs/domains.

Along with measuring outcomes that capture the biopsychosocial impacts of restricting back pain in older adults, researchers are developing and adapting multi-component interventions that will address these outcomes. Despite highlighting the need to utilize multi-component interventions to effectively manage chronic back pain, the NIH Task Force on Research Standards for Chronic Low Back Pain Report [26] did not identify how an intervention might address the specific needs of unique populations such as older adults. A recent Cochrane systematic review found that patients with chronic low back pain benefitted more from coordinated multi-domain biopsychosocial interventions delivered by multi-disciplinary provider teams than by usual care or physical treatment alone [64], and it recommended ongoing research with older adults to develop, test, and implement multi-disciplinary, multi-component interventions and innovative approaches to management [12,65,66]. If multi-component interventions seek to target different domains, the outcomes assessed must capture the relevant and appropriate domains for older populations.

While belonging to a minority group has been associated with under-treatment of pain [14,15], the bulk of back pain research has focused exclusively on non-Hispanic whites [47]. We specifically broadened our sample to enroll a greater proportion of racial/ethnic minorities; our study team was surprised that no new themes emerged from the focus groups. Complementing a previous study from our group, focused mostly on older white women [36], the research presented here enhances our understanding of how diverse populations experience back pain outside of the clinical setting by including older adults recruited from the community. Our qualitative research is hypothesis-generating, so generalizing our findings to other populations (for example, non-English speakers) should be done cautiously. Importantly, we recognize that qualitative research methods are not suited to making quantitative inferences about similarities or differences between groups in our study. Future research should focus on specific coping mechanisms (including spirituality and religion) in an older diverse sample and how these influence the experience and outcomes of restricting back pain.

This study has several limitations. While Hispanic/Latino participants were included in the focus groups, these were conducted in English only, preventing exclusively Spanish-speaking members of the community centers in New York City from participating in the research. Non-English speaking older adults of different race/ethnicities may have a different lived experience of restricting back pain than those who speak English [15]. The discussion guide (Appendix A) and methodology used in this research do not allow us to make generalizations about racial/ethnic groups. Like the community-living older adult population at large, our sample included a greater proportion of women. Extrapolations of our findings should be done with caution given the limited geographic representation of our sample (urban northeastern United States). We also acknowledge that there are socio-economic and other variables that were not assessed that likely contribute to various impacts of and experiences with restricting back pain. The focus groups included older adults with restricting back pain within the past 3 months who were ambulatory enough to travel to a senior center. We were not able to capture/document the experience of restricting back pain from participants who were non-ambulatory and/or home-bound. Therefore, the focus group sample likely experienced pain that was more manageable at the time of the focus group. We know that those who attend senior centers are usually unique as they seek out and are able to engage in community activities. We also know that many senior center clients attend for the purposes of meals, reflecting potentially lower socio-economic status (and associated food insecurity). Despite this, we found consistent results with interviews in participants’ homes and those from the focus groups in senior centers.

Conclusions

This research enhances our understanding of the physical, psychological, and social impacts of back pain specifically among older adults, in their words, based on what is most meaningful to them. These data suggest that clinicians and researchers should be assessing diverse outcome domains that capture the most meaningful dimensions of the back pain experience for older adults.

Appendix A: Back Pain Discussion Guide

To begin our discussion I would like you to:

1. Think back to the last time you had back pain. Can you tell me what happens when you get back pain?

   1. Probes:
      1. When was the last time you had it?
      2. How long does it last? Hours? Days? Months?
      3. Does it come and go?
      4. Is it constant?
      5. Does it come suddenly or gradually?
      6. Where is it located?
      7. Is it sharp or dull?
      8. Does it “travel” anywhere?
      9. Confirmatory question from screening criteria: Did it cause you to cut down on usual activities? Why, or why not?
2. Have you had more than one episode of back pain? If yes,

   1. When did you first develop back pain?
   2. Are you pain-free in between back pain episodes?
   3. How often do you get back pain?
   4. Are the episodes of back pain the same or different each time?

3. Does back pain impact your quality of life? If yes, how?

4. How did the back pain affect you? (understand how it impacts independence/functionality)

   1. Probes:
      1. Did it stop you from doing anything?
      2. What is your day like if you don’t have back pain?
      3. What is your day like if you do have back pain?
      4. Does your back pain affect your sleep? Do you take any medication for sleep?

5. What is most concerning (bothers you most) about your back pain?

6. What, if anything, about your back pain worries you?

7. What do you think will happen over the next year or two with your back pain? If response is “what does that mean? Follow up with “it can mean anything that you think is important, but, for example, do you think it will get better or worse? Why? … ”

8. How important is it to you to have your back pain treated?

9. What are your goals for managing your back pain?

10. What do you think makes the back pain worse? When is it worst?

11. When the pain is bad, what do you think makes the pain better? Is there anything you do to lessen your back pain? When is it the best?

    1. Probes:
       1. What has been most helpful to you?
12. What do you think causes your back pain? (etiology or precipitating events)

    1. Probes:
       1. Trauma (e.g., fall, MVA)
       2. Cancer?
       3. Infection?
       4. Certain movements or activities
       5. Arthritis of the back?
       6. Vertebral fracture?
       7. Muscle strain?
       8. Old age (does subject perceive back pain as normal aging)?
13. Tell me about what you do to care for your back pain?

    1. What treatments (including medications, non-Rx, coping mechanisms) are you using or have you used for your back pain?
    2. Probes:
       1. Medications (including OTC, herbal, natural substances)
       2. Exercise, water aerobics
       3. Physical therapy
       4. Yoga, Tai Chi, meditation
       5. Acupuncture
       6. Hot/cold (heat pads), massage therapy
       7. Reading books/educating yourself
       8. Religion or spirituality?

14. Have you had surgery on your back? If yes, when and was it helpful?

15. Do you have any other medical conditions? If yes,

    1. How does your back pain compare or rank with these other conditions?

16. Does your back pain affect you physically? If yes, how?

    1. Do you use a cane or walker? For back pain?

17. Does your back pain affect you emotionally? If yes, how?

18. Does your back pain affect your relationships (friends, spouse, family, care-providers)?

19. Do you talk with your friends or family about your back pain?

20. Do you think that back pain is a normal part of aging? Can you tell me more?

21. In addition to back pain, do you have other sources of pain?

    1. If yes, where?
    2. How does your back pain affect these other pains?
    3. How does the other pain affect your back pain?

22. Is there a role for your doctor in managing your back pain? If yes, what is it?

23. Do you tell your doctor about your back pain?

    1. What type of doctor do you tell about your back pain?

24. What has your doctor told you about your back pain?

    1. Do you wish you knew more about back pain?

25. What can your doctor do better to help you with your back pain?