Not So Golden After All

The Complexities of Chronic Low Back Pain in Older Adulthood

Meredith L. Stensland, PhD, LMSW; Sara Sanders, PhD, MSW


Gerontologist. 2018;58(5):923-931. 

In This Article

Discussion and Implications

By phenomenologically investigating older pain clinic patients' CLBP, this study highlighted the complexities of being old and chronically in pain. Findings showed that CLBP destroys dreams for retirement and the future, complicates other age-related health conditions, creates stigma around the aging process, and generates fear for what the "golden years" will look like. Taken cumulatively, CLBP may be understood as the source of many losses, creating an intense grief experience for older adults and shaping how they see growing old.

The results of this study confirm that chronic pain creates a variety of losses (Gatchel, Adams, Polatin, & Kishino, 2002; Worzer, Kishino, & Gatchel, 2009). As Sofaer-Bennett and colleagues (2007) found, the older adults in our study experienced significant loss by way of decreased physical functioning, resulting in restricted recreational and leisure time activities. This, in turn, drastically impacted the quality of their retirements, leading to disappointment, disillusionment, and a longing for prepain functionality. Individuals in this study had been employed for decades and had long envisioned a rewarding, fulfilling retirement period, and the reality of their CLBP led to grieving this unrealized dream. Their current situation was not as they had envisioned and hoped for, and narratives revealed a degree of anticipatory grief, whereby they feared the future and what further decline and losses it would entail. This is a major distinction from younger individuals with CLBP, in which there tends to be a "… perception of a meaningful future. Participants talked about the possibility of working again or an improved social life" (Snelgrove, Edwards, S., & Liossi, 2013, p. 131).

Research on younger adults with chronic pain tends to feature the chronic pain itself as the one and only pertinent health concern. By contrast, as illustrated in this study, CLBP among older adults must be viewed in the larger context of the likely multiple comorbid health conditions present. Having multiple chronic conditions in older adulthood is increasingly prevalent (Freid, Bernstein, & Bush, 2012). Though Higgins, Madjar, & Walton (2004) note multiple sources of pain and some comorbid conditions among participants, the interplay between the two was not described. Among the phenomenological studies on younger and middle-aged adults specifically with CLBP, little is mentioned with regard to comorbid conditions and their role in the CLBP experience, focusing instead on the CLBP exclusively. Thus, this study provides insight into how the experiences of older CLBP sufferers diverge from their younger counterparts. In this sense, late-life CLBP is not just a loss of a pain-free existence, it is also an exacerbation of lost global health. Findings highlight the grief-inducing nature of CLBP in older adulthood. Bereavement theories, particularly ambiguous loss theory (Boss & Couden, 2002) may provide clinicians with a framework for understanding older pain clinic patients' experiences of stigma, invisible suffering, and gradual loss.

Our findings relating to stigma support and expand previous knowledge about the stigmatization of individuals with chronic pain (Cohen, Quintner, Buchanan, Nielsen, & Guy, 2011; Holloway, Sofaer-Bennett, & Walker, 2007). Previous phenomenological findings related to CLBP stigmatization include facing disbelief by others (Holloway et al., 2007), malingering for reasons of financial benefit (Walker, Holloway, & Sofaer, 1999), and the concept of a "pain career" (Holloway, Sofaer, & Walker, 2000). This study offers an interesting perspective on pain related stigma, depicting older adults' stigma as tied largely specifically to their age and frailty. They explained being treated "like they were senile," detecting stigma surrounding use of a cane, and being labeled disabled. While Parsons, Godfrey, and Jester (2009) noted that older adults with osteoarthritis of the hip and knee thought other people viewed them negatively, the negativity involved being perceived as unable to manage their pain, not ageist stigma. Thus, findings point to age-specific experiences of stigma, in addition to being questioned and invalidated by health care providers. It is important to note, too, that many individuals incorrectly believe chronic pain is a normal aspect of aging, including older adults themselves (e.g., Sanders, Donovan, & Dieppe, 2002), which is some ways may reflect internalized stereotyping. As CLBP forced the older adults to let go of dreams and plans, the stigma of debility was further reinforced and embodied into how they viewed themselves and how they felt society judged them.

Several limitations of the study may be noted, which are also detailed elsewhere (Stensland & Sanders, Under review). First, the use of nonprobability convenience sampling prevents large-scale generalizability to the larger older pain clinic patient population. Second, the sample was racially and ethnically lacking in diversity, which hinders our ability to gain insight into the experiences of diverse older adults, who tend to fare worse on pain outcomes in comparison to Caucasian individuals. Third, the immersion of the researcher in interview approaches involves inherent variations from interview to interview with regard to probing, questioning, and general interacting, which has the potential to influence to some degree participant responses, nonetheless generating powerful, deep narratives as intended. Fourth, interpretive methodologies such as phenomenology strongly emphasize the consciousness, thereby operating under the assumption that participants have sufficient insight into their thoughts, speech, and action. The phenomenological interview arguably results in little insight into unconscious thought processes and internalized cultural norms that likely operate in participants' experiences.

This study has important implications for how health care providers and allied professions approach pain management for older adults with CLBP. First, as van Manen (2014) notes, the phenomenological understanding achieved by this study allows practitioners to "… nurture a measure of thoughtfulness and tact in the practice of our professions…" (van Manen, 2014, p. 31). Professionals must remain always cognizant of the complexity introduced by having chronic pain on top of multiple chronic conditions, highlighting the need for exceptionally coordinated care across specialties and between providers. Second, professionals such as social workers, psychologists, and mental health counselors should strive to more systematically assess grief reactions and design psychosocial treatments to address pain-related losses. Third, the fact that participants felt misunderstood and stigmatized emphasizes the importance of unconditional positive regard in clinical contexts. Lastly, given its treatment resistant nature, helping older adults with CLBP set realistic expectations of their aging process is essential, particularly given the monumental impact it has on retirement and late life functioning.