Impairment in Activities of Daily Living and Related Factors in Older Adults with Severe Lumbar Spinal Stenosis before Hospitalization

Daigo Ishizuka; Susumu Nozaki; Hiroshi Minezaki; Tsuyoshi Ota; Yasuyoshi Asakawa

doi:10.4235/agmr.24.0128

Ann Geriatr Med Res > Volume 29(1); 2025 > Article

Ishizuka, Nozaki, Minezaki, Ota, and Asakawa: Impairment in Activities of Daily Living and Related Factors in Older Adults with Severe Lumbar Spinal Stenosis before Hospitalization

Original Article

Annals of Geriatric Medicine and Research 2025;29(1):83-90.

Published online: November 19, 2024

DOI: https://doi.org/10.4235/agmr.24.0128

Impairment in Activities of Daily Living and Related Factors in Older Adults with Severe Lumbar Spinal Stenosis before Hospitalization

Daigo Ishizuka^1,²

, Susumu Nozaki^1,³, Hiroshi Minezaki⁴, Tsuyoshi Ota⁴, Yasuyoshi Asakawa¹

¹Department of Physical Therapy, Graduate School of Human Health Sciences, Tokyo Metropolitan University, Tokyo, Japan

²Department of Physical Therapy, Faculty of Rehabilitation Science, Faculty of Health Sciences, University of Human Sciences, Saitama, Japan

³Nissay Seirei Health and Welfare Foundation, Matsudo Nissay Seirei Clinic, Chiba, Japan

⁴Department of Rehabilitation Medicine, Saitama Saiseikai Kawaguchi General Hospital, Saitama Branch of Saiseikai Foundation, Saitama, Japan

Corresponding Author: Daigo Ishizuka, MS Department of Physical Therapy, Faculty of Rehabilitation Science, Faculty of Health Sciences, University of Human Sciences, 354-3 Shinshoji Kuruwa, Iwatsuki-ku, Saitama 339-8555, Japan
E-mail: daigo_ishizuka@human.ac.jp

Received August 2, 2024 Revised October 3, 2024 Accepted November 13, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

Lumbar spinal stenosis (LSS) impairs activities of daily living (ADL) in older adults. Factors associated with ADL impairment in LSS have not been identified. This study aimed to ascertain the pre-admission living conditions in older adults with LSS and investigate the factors associated with impairment in ADL.

Methods

A total of 261 community-dwelling older adults aged ≥65 years with LSS, scheduled for surgery were included. The Oswestry Disability Index (ODI) was used to assess ADL impairment. The Life-Space Assessment was used to assess the extent and frequency of outings. Pain, numbness, continuous walking distance, and health-related quality of life as psychosomatic functions. Falls self-efficacy and the degree of social isolation were assessed as social life status. Factors associated with ADL impairment were examined using multiple logistic regression analysis.

Results

Significant differences were found in psychosomatic functioning, living space, and falls self-efficacy depending on the presence or absence of ADL impairment. The ODI sub-components showed a stronger degree of impairment in pain intensity, walking, standing, and social life. There were significant differences in the frequency of going outside the home and inside the neighborhood, ADL impairment was shown to affect the frequency of outings within close proximity to their lives. Numbness was associated with ADL impairment (odds ratio=1.2; 95% confidence interval 1.1–1.4).

Conclusion

Assessing the degree of numbness is important in predicting ADL impairment in older adults with LSS. Additionally, assessing the living conditions and taking an appropriate approach before admission can help prevent ADL impairment.

Key Words: Spinal stenosis, Activities of daily living, Aged

INTRODUCTION

Lumbar spinal stenosis (LSS) is a degenerative disease that is common in the older adults and is characterized by narrowing of the spinal canal and nerve compression.^1,²⁾ With the aging population, the prevalence of LSS and the number of spinal surgeries are increasing.^1,^3-⁵⁾ LSS patients often experience lower limb pain, difficulty walking, reduced health-related quality of life (HRQOL), and risk of falls.^6-¹¹⁾ These factors are expected to be associated with reduced ability to perform activities of daily living (ADL). In patients with LSS, prolonged neurological symptoms are associated with poor prognosis.¹²⁾ For elderly individuals, reduced mobility can significantly impact ADL limitations, and persistent ADL impairment limits social participation, increases the risk of requiring long-term care, and increases mortality.¹³⁾

Although several studies have examined ADL impairment in postoperative LSS^14,¹⁵⁾ and ADL impairment with associated living conditions in older adults,^16-¹⁹⁾ few studies have examined these factors in critically ill older adults awaiting surgery. Therefore, the living conditions and ADL impairment patterns in older LSS patients awaiting surgery remain unclear. Decline in ADL is believed to lead to the need for nursing care and disruption of daily life.

This study aims to investigate the pre-admission living conditions of older adults with LSS and identify factors associated with ADL impairment, with the objective to aid informed preoperative assessment, develop management strategies for preventing ADL deterioration during surgical waiting periods, and optimize postoperative rehabilitation efficiency.

MATERIALS AND METHODS

Inclusion and Exclusion Criteria

This study included community-dwelling older adults aged 65 years or older who were diagnosed with LSS and scheduled for surgery at a specialized spine hospital. The diagnosis was made by a spine specialist. The exclusion criteria were patients with gait disorder due to lower extremity fractures, hemiparesis, or neuromuscular disorders, or patients with the limitation of daily activities due to heart failure.

Participants

Outpatients at a general hospital under the care of a spine and spinal cord disease specialist were recruited between October 1, 2021 and September 30, 2023. During the data collection period, 422 participants met the inclusion criteria, of whom 161 were excluded as they were unable to complete the questionnaire. Finally, 261 participants completed the questionnaire and were included in the study.

Ethical Considerations

Participants were fully informed of the purpose and content of the study, and written informed consent was obtained before participation. The study was approved by the Research Ethics Committees of the Arakawa Campus of Tokyo Metropolitan University (Approval No. 21050) and Saiseikai Kawaguchi General Hospital (Approval No. 2021-20) and conformed to the Declaration of Helsinki.

Data Collection

Data were collected using a questionnaire, and basic information was collected from the electronic medical records. Basic information included age, sex, care insurance status, body mass index (BMI), and medical history. Care insurance status is the indicator of care required in older adults as applied in the public long-term care insurance system. It is classified into seven levels according to the level of independence with higher grade requiring greater support and increased out-of-pocket expenses: support 1–2, care 1–5.²⁰⁾ Originally, it was designed as care 1–5, but in 2005, support 1–2 was added. In this study, only the presence or absence of care certification was investigated. A BMI of 27.5 kg/m² or more was defined as overweight, whereas a BMI of less than 18.5 kg/m² was defined as underweight.

Physical Function

A visual analog scale (VAS) was used to assess the degree of back pain, leg pain, and numbness. The ability to walk 100 m continuously was also investigated using the questionnaire.

HRQOL

HRQOL was assessed using the Short Form-8 (SF-8) Health Survey, a measure of HRQOL developed by Quality Metric Inc. that has been shown to be reliable and valid using the widely used SF-36.^21,²²⁾ In this study, the Physical Component Summary (PCS) was calculated using a scoring program SF-8 Health Survey Standard version (4 weeks recall). The PCS is an indicator for the overall assessment of physical health status, which is calculated from the sub-scores and is therefore called the summary score.

Assessment of ADL Impairment

The degree of ADL impairment was assessed using the ODI, a reliable and valid scale for assessing the degree of impairment in ADL due to low back pain.^23-²⁵⁾ The ODI consists of 10 sections—pain intensity, personal care, lifting objects, walking, sitting, standing, sleeping, sexual life, social life, and traveling in a vehicle. In this study, sexual life were excluded due to national characteristics. The score for each section ranged from 0 to 5 with higher scores indicating increased severity of injury.

The ODI scores were calculated by dividing the score obtained for each section by the total possible score of 50 and expressing it as a percentage. If there were sections with no answers, the total score was divided by the number of sections multiplied by five and subtracted from 50, with values ranging from 0 to 100. In the present study, ODI scores of 40 or more were considered severe,²³⁾ indicating impairment in ADL.

Life Space Assessment

The life space and frequency of outings were assessed using the Life-Space Assessment (LSA), a questionnaire developed by Baker et al.¹⁹⁾ to investigate the extent and frequency of outings in older adults living in the community in a simplified manner. This questionnaire is reliable and valid.²⁶⁾ The LSA score is calculated from a range of activities, frequency of the activities, and degree of independence during the past month. The activity range is divided into five categories: inside the home, outside the home, inside the neighborhood (within 800 m), inside the town (>800 m and ≤16 km), and outside the town (>16 km). The final score was calculated as the sum of the scores for each activity range. In this study, comparisons were made in four categories, excluding inside the home.

Falls Self-efficacy

Falls self-efficacy was assessed using the modified Falls Efficacy Scale (mFES). The mFES is a modified version of the original Falls Efficacy Scale that is reliable and valid.^27-²⁹⁾

Assessment of Social Aspects

The Lubben Social Network Scale short version (LSNS-6) was used to assess the degree of social isolation. The LSNS-6 is used worldwide and is reliable and valid.^30,³¹⁾

Statistical Analysis

All statistical analysis were performed using IBM SPSS Statistics version 27 (IBM Corporation, Armonk, NY, USA), with a statistical significance level of 5%. Normality of all data was assessed using the Shapiro-Wilk test.

Analysis 1: Differences in Each Item according to the Presence or Absence of ADL Impairment

The mean and standard deviation or percentage of each item according to the presence or absence of ADL impairment were calculated, and the Mann–Whitney U test or chi-square test was used according to the distribution of the differences in each item according to the presence or absence of ADL impairment.

Analysis 2: Characteristics of Disability in ODI Sub-items

Median and interquartile range were calculated for the ODI sub-items for each group with and without ADL impairment. The Mann-Whitney U test was performed on all sub-items to compare the differences between the two groups.

Analysis 3: Characteristics of ADL Impairment by Frequency of Outings to Each Life-Space

Based on the LSA assessment form, the frequency of outings in percentage (every day, 4–6 times a week, 1–3 times a week, and less than once a week) was assessed for each living space (outside the home, inside the neighborhood, inside the town, and outside the town). The chi-square test was used to compare ADL impairments and the frequency of going outdoors at each life-space level. The significance level for multiple comparisons was adjusted using Bonferroni correction (p<0.008).

Analysis 4: Factors Associated with ADL impairment

In Model 1, the independent variables were physical and mental function (back pain, leg pain, numbness, continuous walking distance, PCS, mFES). All of these factors were added as independent variables in Model 2, in addition to basic information (age, sex, and care insurance status). The dependent variable in both models was the presence or absence of ADL impairment. Analysis was carried out using multiple logistic regression analysis with the forced entry method. The Hosmer–Lemeshow test and discriminant accuracy were calculated to assess the goodness of fit of the model. A posterior power analysis was performed in Model 2.

RESULTS

Analysis 1: Differences in Each Item according to the Presence or Absence of ADL Impairment

Table 1 shows the characteristics of the participants according to the presence or absence of ADL impairment. Significant differences were found in back pain (p<0.001), leg pain (p<0.001), numbness (p<0.001), continuous walking distance (p<0.001), PCS (p<0.001), ODI (p<0.001), LSA (p=0.008), and mFES (p=0.018).

Analysis 2: Characteristics of impairment in ODI Sub-items

Table 2 shows the median and interquartile ranges of the ODI sub-items. Analysis results showed significant differences in all ODI sub-items (p<0.001). The items of higher median (interquartile range) in the ADL impairment group were: Question 1 (pain intensity), 3 (2–4); Question 3 (lifting objects), 3 (2–3); Question 4 (walking), 3 (3–4); Question 6 (standing), 4 (3–4); and Question 9 (social life), 3 (3–4); Question 10 (getting around in a vehicle), 3 (2–5). The items with median values more than 2 apart from the no ADL impairment group were Question 3, 4, 6, 9, and 10.

Analysis 3: Characteristics of ADL Impairment by Frequency of Outings to Each Life-Space

Table 3 shows ADL impairment and the frequency of outings organized by living space. Significant differences were found outside the home (p<0.001), inside the neighborhood (p=0.010), inside the town (p<0.001), and outside the town (p<0.001).

Multiple comparisons of life-space showed significant differences between outings every day and 4–6, 1–3, or <1 time a week for outside the home; between every day and 4–6 times a week, and 4–6 times a week and 1–3 or <1 time a week for inside the neighborhood; between every day and 1–3 or <1 time a week, and 4–6 times a week and 1–3 or <1 time a week for inside the town; between every day and 1–3 or <1 time a week, 4–6 times a week and 1–3 or <1 time a week, and 1–3 times a week and <1 time a week for outside the town.

Analysis 4: Factors Associated with ADL impairment

The results of this analysis are shown in Table 4. In Model 1, only numbness was associated with ADL impairment (odds ratio [OR]=1.2; p<0.001), and a similar trend was observed in Model 2 (OR=1.2; p<0.001). The Hosmer-Lemeshow test and discriminant hit rates for Model 1 were p=0.398 and 52.2%, respectively, and for Model 2 were p=0.244 and 62.1%. A post-hoc power analysis was conducted using G*Power with the following parameters: OR=1.2, α=0.05, total sample size=261, and R² other X=0.144 (based on Nagelkerke R² from our analysis). The calculated power was 0.41 in Model 2.

DISCUSSION

In this study, significant differences were found between patients with and without ADL impairment in terms of psychosomatic function, living space, and falls self-efficacy. Regarding older adults living in the community, previous study has reported that physical and mental function declines with age³²⁾ lead to ADL impairment and decreased frequency of outings.^17,¹⁸⁾ However, in this study, there were no significant differences by age between participants with and without ADL impairment. This might be because the effect of LSS on ADL impairment was greater than that of age. Additionally, previous research has shown that older men living in the community go out more frequently than do older women.^16,³³⁾ However, no significant differences were found with respect to ADL impairment between male and female in the present study. In other words, the ADL impairments of older adults living in the community with LSS are characterized differently from those of the overall community-dwelling seniors. Some studies have reported that ADL limitation and reduced frequency of outings occur at the same time.^16,¹⁸⁾ In a previous study, ADL impairment significantly decreased the frequency of outings outside the home, inside the neighborhood, and inside the town.¹⁸⁾ Similarly, in the present study, ADL impairment was associated with a significant decrease in the frequency of outings.

The multivariate models showed that preoperative numbness was associated with preoperative ADL impairment, and similar results were obtained after adjusting for confounding factors. Diabetic numbness is known to affect ADL,^34,³⁵⁾ and a similar association was demonstrated for LSS in this study. Previous studies on LSS have focused mainly on postoperative numbness and gait disturbance,¹⁵⁾ with limited reports examining the association between preoperative numbness and ADL. In these studies, preoperative numbness has been reported as a poor prognostic factor after surgery.³⁶⁾ Based on the present results, it is suggested that the maintenance or reduction of preoperative numbness may have a broad-ranging impact not only on the maintenance of preoperative ADL, but also on improving postoperative prognosis. Furthermore, since the degree of numbness can be assessed more conveniently than preoperative ADL impairment, the evaluation of the degree of numbness in severe lumbar spinal stenosis and treatment of numbness have become more significant. Persistent ADL impairment is associated with an increased risk of physical frailty and death, increased risk of falls,^37,³⁸⁾ reduced cognitive function,^39,⁴⁰⁾ decreased quality of life, decreased psychological health, and loneliness,^41,⁴²⁾ increased burden of caregiving, and increased use of care services.^43,⁴⁴⁾ Therefore, the management of numbness is important for older adults who were the participants of this study.

It is essential to support patients with numbness to prevent them from becoming inactive, and intervention before hospitalization is considered necessary to maintain a high level of independence in life. These approaches include pharmacotherapy, therapeutic exercise, and manual therapy to reduce numbness.^45-⁴⁷⁾ Epidural injections are considered effective for short-term symptomatic improvement and can temporarily improve symptoms of neuropathic claudication.⁴⁶⁾ In addition, strengthening and improving flexibility of the trunk through exercise therapy and postural improvement can be expected to reduce numbness.⁴⁷⁾ However, owing to the nature of the disease, which causes organic changes in the lumbar spinal cord, the extent to which numbness can be reduced is limited. Thus, it is necessary to consider the use of welfare equipment like canes and walkers, and care services for such patients during the waiting period before surgery. In summary, greater attention to preoperative assessment of the degree of numbness may lead to more effective medical treatment in severe LSS.

This study has some limitations. First, this was a cross-sectional survey. Accordingly, it was not possible to derive a causal relationship between ADL impairment, living space, and the frequency of outings. Second, the study focused on a specific population of community-dwelling older adults with severe LSS who were scheduled for surgery, which limits its generalizability to community-dwelling older adults in general and to individuals with mild LSS. Furthermore, magnetic resonance images were not investigated, and other factors including medical history may have influenced the results. In addition, numbness was extracted as a characteristic factor in the multivariate analysis, but a detailed investigation of the quality of numbness and its association with intermittent claudication has not been conducted. The goodness-of-fit discriminant accuracy of the model in this analysis was insufficient; therefore, caution must be taken when interpreting the results. Future studies should examine the relationship between LSS severity, ADL, and living space in more detail through longitudinal surveys, as well as investigate the actual degree of post-operative ADL impairment and related factors while considering preoperative characteristics and related factors.

In conclusion, physical and mental function differed in older adults with LSS depending on the presence or absence of ADL impairment. ADL was particularly impaired in increased pain intensity, walking, standing, and social life roles, affecting the frequency of outings, with numbness being extracted as a related factor. The findings from this study suggests that assessing the degree of numbness is an effective method of predicting ADL impairment in older adults with LSS. In addition, it is important to understand the living condition of each patient before hospital admission to prevent ADL impairment.

ACKNOWLEDGMENTS

We would like to express our sincere gratitude to the staff at Saiseikai Kawaguchi General Hospital for their invaluable cooperation in data collection for this study.

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

FUNDING

None.

AUTHOR CONTRIBUTIONS

Conceptualization, DI, HM, TO, YA; Data curation, DI, SN, YA; Methodology, DI, HM, TO, YA; Project administration, DI, HM, TO; Writing–original draft, DI; Writing–review & editing, SN, HM, TO, YA.

Table 1.

Characteristics of the participants according to ADL impairment

	Total (n=261)	With ADL impairment (n=146)	Without ADL impairment (n=115)	p-value
Basic information
Age (y)	76.2±6.0	76.6±6.2	75.6±5.7	0.119^a)
Male patients	153 (58.6)	83 (62.9)	53 (46.1)	0.683^b)
Female patients	108 (41.4)	49 (37.1)	62 (53.9)
Care insurance status	43 (16.5)	27 (15.6)	16 (12.2)	0.216^b)
Overweight	41 (15.7)	22 (15.1)	19 (16.5)	0.419^b)
Underweight	12 (4.6)	4 (2.7)	8 (7.0)	0.372^b)
Medical history
Lumbar spine surgery	48 (18.4)	27 (18.5)	21 (18.2)	0.955^b)
Stroke	18 (6.9)	14 (9.7)	4 (3.4)	0.028^b)
Neuromuscular disease	13 (5.0)	10 (6.9)	3 (2.6)	0.114^b)
Heart disease	51 (19.5)	27 (18.6)	24 (20.7)	0.667^b)
Cancer	28 (10.7)	14 (9.7)	14 (12.1)	0.532^b)
Respiratory disease	29 (11.1)	21 (14.5)	8 (6.9)	0.051^b)
Renal impairment	18 (6.9)	10 (6.9)	8 (6.9)	1.00^b)
Diabetes	47 (18.0)	29 (20.0)	18 (15.5)	0.334^b)
Joint disease	42 (16.1)	29 (20.0)	13 (11.2)	0.053^b)
Fracture	32 (12.3)	20 (13.8)	12 (10.3)	0.388^b)
Cervical and thoracic spine disorders	31 (11.9)	23 (15.9)	8 (6.9)	0.027^b)
Psychosomatic function
Lumbar pain	5.1±2.9	6.2±2.5	3.6±2.8	<0.001^a)
Leg pain	6.2±2.7	7.0±2.4	5.2±2.8	<0.001^a)
Numbness	5.6±3.1	6.1±3.0	4.9±3.0	<0.001^a)
Continuous walking distance (<100 m)	145 (60.9)	94 (68.6)	51 (50.5)	<0.001^b)
PCS	35.7±7.3	32.7±6.2	39.5±6.9	<0.001^a)
ODI	42.3±16.7	54.0±10.7	27.4±9.6	<0.001^a)
Social living conditions
LSA	59.8±33.3	55.1±33.9	65.8±31.6	0.008^a)
mFES	100±22.7	96.3±22.8	105.5±21.6	0.018^a)
LSNS-6	13±6.4	12.7±6.9	13.4±5.8	0.256^a)

Values are presented as mean±standard deviation or number (%).

ADL, activities of daily living; PCS, Physical Component Summary; ODI, Oswestry Disability Index; LSA, Life-Space Assessment; mFES, modified Fall Efficacy Scale; LSNS-6, Lubben Social Network Scale short version.

^a)Mann–Whitney U test.

^b)Chi-square test.

Table 2.

Results of the sub-items of the Oswestry Disability Index

		Total	With ADL impairment	Without ADL impairment	p-value
Question 1	Pain intensity	2 (1–3)	3 (2–4)	2 (1–3)	<0.001
Question 2	Personal care (e.g., washing and dressing)	1 (1–2)	2 (1–2)	1 (0–1)	<0.001
Question 3	Lifting objects	1 (0–3)	3 (2–3)	1 (0–2)	<0.001
Question 4	Walking	2 (1–3)	3 (3–4)	1 (0–2)	<0.001
Question 5	Sitting	1 (0–2)	2 (1–2)	1 (0–1)	<0.001
Question 6	Standing	3 (2–4)	4 (3–4)	2 (1–3)	<0.001
Question 7	Sleeping	0 (0–1)	1 (0–3)	0 (0–1)	<0.001
Question 9	Social life (socializing outside work)	2 (1–3)	3 (3–4)	1 (0–2)	<0.001
Question 10	Getting around in a vehicle	2 (1–3)	3 (2–5)	1 (0–2)	<0.001

Values are presented as median (interquartile range).

Table 3.

Characteristics of ADL impairment by frequency of outings to each life-space

	Every day	4–6 times/week	1–3 times/week	<1 time/week	p-value
Outside the home	81 (55.5)^a,b,c)	19 (13.0)	22 (15.1)	24 (16.4)	<0.001
Inside the neighborhood	44 (30.1)^a)	20 (13.7)^d,e)	45 (30.8)	37 (25.3)	0.01
Inside the town	25 (17.1)^b,c)	21 (14.4)^d,e)	44 (30.1)	56 (38.4)	<0.001
Outside the town	14 (9.6)^b,c)	15 (10.3)^d,e)	36 (24.7)^f)	81 (55.5)	<0.001

Values are presented as number (%).

ADL, activities of daily living.

^a)Significant difference between every day and 4–6 times a week.

^b)Significant difference between every day and 1–3 times a week.

^c)Significant difference between every day and <1 time a week.

^d)Significant difference between 4–6 times a week and 1–3 times a week.

^e)Significant difference between 4–6 times a week and <1 time a week.

^f)Significant difference between 1–3 times a week and <1 time a week.

Table 4.

Factors associated with ADL impairment

	Model 1 (crude)	Model 2 (adjusted)
	OR (95% CI)	OR (95% CI)
Basic information
Age	-	1.0 (0.9–1.1)
Male sex	-	1.0 (0.5–1.6)
Care insurance status	-	0.8 (0.7–1.2)
Psychosomatic function
Lumbar pain	0.9 (0.8–1.1)	0.9 (0.9–1.1)
Leg pain	1.0 (0.9–1.2)	1.0 (0.9–1.2)
Numbness	1.2 (1.1–1.4)^*	1.2 (1.1–1.4)^*
Continuous walking distance	1.1 (0.6–2.1)	1.0 (0.5–1.9)
PCS	1.0 (0.9–1.1)	1.0 (0.9–1.0)
mFES	1.0 (0.9–1.1)	1.0 (0.9–1.0)

ADL, activities of daily living; PCS, Physical Component Summary; mFES, modified Fall Efficacy Scale; OR, odds ratio; CI, confidence interval.

^*p<0.001.

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