International Journal of

Environmental Research
and Public Health

Article
Association between Chronic Pain and Physical
Frailty in Community-Dwelling Older Adults
Yuki Nakai 1,2 , Hyuma Makizako 1, *, Ryoji Kiyama 1 , Kazutoshi Tomioka 2 ,
Yoshiaki Taniguchi 2 , Takuro Kubozono 3 , Toshihiro Takenaka 4 and Mitsuru Ohishi 3
1 Department of Physical Therapy, School of Health Sciences, Faculty of Medicine, Kagoshima University,
Kagoshima 890-8544, Japan; [email protected] (Y.N.);
[email protected] (R.K.)
2 Graduate School of Health Sciences, Kagoshima University, Kagoshima 890-8544, Japan;
[email protected] (K.T.); [email protected] (Y.T.)
3 Department of Cardiovascular Medicine and Hypertension, Graduate School of Medical and Dental
Sciences, Kagoshima University, Kagoshima 890-0075, Japan; [email protected] (T.K.);
[email protected] (M.O.)
4 Tarumizu Municipal Medical Center, Tarumizu Chuo Hospital, Kagoshima 891-2124, Japan;
[email protected]
* Correspondence: [email protected]; Tel.: +81-99-275-5111




Received: 6 March 2019; Accepted: 10 April 2019; Published: 13 April 2019


Abstract: This cross-sectional study investigated the association between chronic pain and physical
frailty in community-dwelling older adults. We analyzed data obtained from 323 older adults
(women: 74.6%) who participated in a community-based health check survey (the Tarumizu Study,
2017). Physical frailty was defined in terms of five parameters (exhaustion, slowness, weakness,
low physical activity, and weight loss). We assessed the prevalence of chronic low back and knee
pain using questionnaires. Participants whose pain had lasted ≥two months were considered to
have chronic pain. Among all participants, 138 (42.7%) had chronic pain, and 171 (53.0%) were
categorized as having physical frailty or pre-frailty. Logistic regression analysis showed that chronic
pain was significantly associated with the group combining frailty and pre-frailty (odds ratio 1.68,
95% confidence interval 1.03–2.76, p = 0.040) after adjustment for age, sex, body mass index, score on
the 15-item Geriatric Depression Scale, and medications. Comparing the proportions of chronic pain
among participants who responded to the sub-items, exhaustion (yes: 65.9%, no: 39.4%) demonstrated
a significant association (p < 0.001). Chronic pain could be associated with the group combining
frailty and pre-frailty and is particularly associated with exhaustion in community-dwelling older
adults. Therefore, there is a need for early intervention and consideration of the role of exhaustion
when devising interventions for physical frailty in older individuals with chronic pain.

Keywords: physical frailty; chronic pain; older individuals

1. Introduction
Frailty is a decline in physiological ability with aging [1]. Cellular defects accumulate with
age, creating a variety of disorders, including the loss of functional capacity [2]. Determinants of
frailty can be considered according to domains (physical, psychological, and social) [3]. Frailty has
multidimensional aspects, but its functional aspects are especially important in order to understand
it [4]. Older individuals with frailty have an increased risk of negative health outcomes, such as falling,
various disabilities, a lower quality of life, hospitalization, and mortality [1,5–8]. Therefore, early
identification and assessment of community-dwelling older individuals with frailty is required to
prevent progression to negative health states in an aging society.

Int. J. Environ. Res. Public Health 2019, 16, 1330; doi:10.3390/ijerph16081330 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019, 16, 1330 2 of 9

In a growing number of older adults, there is a heavy comorbidity burden and a high rate
of geriatric syndromes including chronic pain [9]. Chronic pain, which causes a rise in healthcare
costs and a deterioration in the quality of life, is a common symptom among community-dwelling
older adults [9–11]. Epidemiological studies reveal that the prevalence of chronic pain is high in
community-dwelling older adults [10,11]. For example, Liberman et al. reported a high rate of chronic
pain (55.2%) and geriatric syndromes (85.4%) as well as an association between them [9]. Previous
studies have also reported an association between chronic pain and limitations in the activities of daily
living [12,13] because of deterioration in physical functioning [12,14], poor psychological status [15,16],
and low physical activity levels [17,18]. Therefore, it is imperative to identify older adults with chronic
pain earlier and develop a means of preventing chronic pain in community-dwelling older adults.
It is known that chronic pain among community-dwelling older adults is a risk factor for worsening
frailty [19]. However, the relationships between the early stages of physical frailty and chronic pain
and the sub-items of physical frailty and chronic pain in older adults remain unclear.
Examining the cross-sectional relationship between physical frailty and chronic pain may provide
information that could be helpful in developing more effective strategies to prevent frailty from a
multidimensional perspective. In this study, we examined the effect of chronic pain as a risk factor for
the potential development of physical frailty, and investigated which components of frailty are more
relevant to chronic pain among community-dwelling older adults.

2. Materials and Methods

2.1. Participants
The current cross-sectional study used data from the Tarumizu Study 2017. Details of this study
have been reported previously [20]. Briefly, the Tarumizu Study 2017, which involved collaboration
between Kagoshima University (Faculty of Medicine), the Tarumizu city office, and Tarumizu Chuo
Hospital, was conducted in November and December 2017 as a community-based health check survey.
The participants of this study were selected from about 3810 older people over the age of 65 living
in Tarumizu, a city in Kagoshima Prefecture, Japan. They were recruited through local newspaper
advertisements and community campaigns. This was a health survey that is essentially based on the
city’s health examination; the criterion for inclusion was being able to walk on one’s own, while the
criterion for exclusion was having already received certification for long-term care. Informed consent
was obtained from all participants prior to their inclusion in the study, and the Ethics Committee of the
Faculty of Medicine, Kagoshima University approved the study protocol (Ref. No. 170103).

2.2. Physical Frailty

The status of physical frailty was based on the consisting of five components: exhaustion, slowness,
muscle weakness, low physical activity, and weight loss [1]. Exhaustion was defined when answering
“yes” to the next question from Kihon Checklist which is a self health checklist developed by the
Japanese Ministry of Health, Labor and Welfare [21]: “Have you ever felt tired for no reason in the last
two weeks?” Slowness was defined using (<1.0 m/s) as the normal walking speed cutoff value [22].
Weakness was defined using the maximum grip strength by different sex cutoff values (<26 kg for
men, <18 kg for women) [23]. Low physical activity level was defined by the following questions:
(1) “Do you do light exercise or sports for your health?” and (2) “Do you regularly exercise or sport?”
“No” participants in both questions were categorized into low activity levels [24]. Weight loss was
evaluated if participants answered “yes” to the following question, “Have you lost more than 2 kg
in the past six months?” [21]. Participants who did not have any of these characteristics were not
physically frail; physically pre-frail had one or two characteristics; and physically frail had three or
more characteristics [25,26].
Int. J. Environ. Res. Public Health 2019, 16, 1330 3 of 9

2.3. Chronic Pain

In this study, low back pain and knee pain were defined as chronic pain. These are the leading
causes of pain complaints due to functional limitations and disorders in the elderly in Japan and
other countries [27,28]. We assessed chronic pain by a face-to-face interview using the following four
questions: “Do you have low back pain at the present time?” (yes), “Has that pain endured more
than two months?” (yes), “Do you have knee pain at the present time?” (yes), and “Has that pain
endured more than two months?” (yes) [19,29,30]. Participants with either low back or knee pain, or
both lasting more than two months, formed the chronic pain group; those with neither low back nor
knee pain formed the non-pain group; and those with low back or knee pain for less than two months
formed the acute pain group.

2.4. Covariates
Age (years), sex, body mass index (BMI), responses on the 15-item Geriatric Depression Scale
(GDS-15) [24], and total medications used (number/day) were assessed and included as covariates.
Regarding these conditions and medications, doctors and nurses interviewed directly.

2.5. Statistical Analysis

The Mantel-Haenszel tests were used to compare the trends in sex and chronic pain in the groups
formed on the basis of physical frailty status (non-physically frail, pre-frail, and frail). A one-way
analysis of variance for continuous measures was performed to assess differences among frailty status
groups in age, BMI, GDS-15 scores, and the total number of prescribed medications.
The association between physical frailty and the prevalence of chronic pain was examined using
multivariate logistic regression analyses. Dependent variables were classified into two patterns: the
group combining physical frailty and pre-frailty, or physical frailty alone. The model in the multivariate
logistic regression analysis was adjusted for age, sex, BMI, GDS-15 score, and the number of prescribed
medications as covariates. The adjusted odds ratios (ORs) for incidents related to physical frailty were
estimated with 95% confidence intervals (95% CIs). The comparisons of the prevalence of physical
frailty sub-items in participants and of their chronic pain were made using chi-square tests. All analyses
were conducted using IBM SPSS Statistics 25.0 (IBM Japan, Tokyo, Japan). The level of statistical
significance was set at p < 0.05.

3. Results

3.1. Subsection Characteristics of Participants

A total of 452 older individuals were enrolled in the Tarumizu Study 2017; 380 of them participated
in a health check survey. The data from these 380 participants was eligible for the current investigation.
In this study, participants aged under 65 years (n = 1, the survey was undertaken before the
participant’s 65th birthday), with a history of diagnosis of dementia (n = 7), missing data on physical
frailty assessments (n = 2), no response to questions on pain (n = 1), and grip strength measures
for those with unsafe conditions (e.g., systolic blood pressure ≥ 180 mmHg) were excluded (n = 5).
Participants with acute pain were also excluded (n = 41). Finally, data from 323 community-dwelling
older adults (aged ≥ 65 years, mean age: 75.2 years, women: 74.6%) were analyzed (Figure 1).
Int. J. Environ. Res. Public Health 2019, 16, 1330 4 of 9
Int. J. Environ. Res. Public Health 2019, 16, x 4 of 9

Figure 1.Figure 1. Participant

Participant inclusioninclusion criteria
criteria flow flow diagram.
diagram.

The characteristics of the participants

The characteristics and the comparisons
of the participants among groups
and the comparisons divided
among by frailty
groups status
divided by frailty
are described in Table 1. Out of 323 participants, 152 (47.1%) were considered physically
status are described in Table 1. Out of 323 participants, 152 (47.1%) were considered physically non- non-frail,
152 (47.1%)
frail,were considered
152 (47.1%) werephysically
consideredpre-frail, 19 (5.9%)
physically were
pre-frail, considered
19 (5.9%) were physically
consideredfrail, and 138
physically frail, and
(42.7%) 138
met (42.7%)
the criteria
metfor
thechronic
criteriapain. Of the pain.
for chronic 152 non-frail participants,
Of the 152 52 (34.2%) had
non-frail participants, 52 chronic
(34.2%) pain;
had chronic
of the 152 pre-frail
pain; of theparticipants,
152 pre-frail76 (50.0%) had76
participants, chronic
(50.0%)pain;
hadand of thepain;
chronic 19 frail
andparticipants,
of the 19 frail10participants,
(52.6%) 10
had chronic pain.
(52.6%) Regarding
had frailtyRegarding
chronic pain. status, there was status,
frailty a significant
there difference in chronic
was a significant pain (p =in0.014).
difference chronic pain
There were significant
(p = 0.014). There differences in certain
were significant characteristics
differences of frailty
in certain status, such
characteristics as age
of frailty (p < 0.001),
status, such as age (p
GDS-15<score (p <GDS-15
0.001), 0.001), and prescribed
score medications
(p < 0.001), (p = 0.001),
and prescribed but no significant
medications differences
(p = 0.001), but in noBMI
significant
(p = 0.924) and sex (p
differences in = 0.226).
BMI (p = 0.924) and sex (p = 0.226).

Characteristics
Table 1. Table of the participants
1. Characteristics (mean ± (mean
of the participants SD or %).
± SD or %).

Total Non-Frailty
Total Pre-Frailty Pre-Frailty
Non-Frailty Frailty Frailty
Variable p*
Variable p*
(n = 323) (n = 152) (n = 152) (n = 19)
(n = 323) (n = 152) (n = 152) (n = 19)
Chronic pain, n (%) 138 (42.7) 52 (34.2) 76 (50.0) 10 (52.6) 0.014
Age,Chronic pain,
mean ± SD n (%)
(years) 75.2 ± 6.5 138 (42.7)
74.1 ± 5.8 52 (34.2)
75.4 ± 6.7 7681.9
(50.0)
± 7.1 10 (52.6)
<0.001 0.014
Women,
Age,nmean
(%) ± SD (years) 241 (74.6) 75.2 ±
115
6.5(75.7) 74.1109 (71.7)
± 5.8 75.417±(89.5)
6.7 0.226
81.9 ± 7.1 <0.001
BMI, mean ± SD (kg/m2 ) 23.5 ± 3.4 23.4 ± 3.2 23.5 ± 3.5 23.6 ± 4.2 0.924
Women,
GDS-15 n (%)± SD (points)
score mean 2.5 ± 2.5 241 (74.6)
2.0 ± 2.0 115 (75.7)
2.8 ± 2.5 1095.2
(71.7)
± 3.5 17 (89.5)
<0.001 0.226
Medications mean
BMI, mean ±±SDSD(kg/m
(number)
2) 3.7 ± 3.9 23.5 ±3.0
3.4± 3.4 23.4 4.1 ± 4.0
± 3.2 23.56.0± ±3.5
5.3 0.001
23.6 ± 4.2 0.924
SD,GDS-15
standard score
deviation;
mean BMI, body
± SD mass index; GDS-15,
(points) 15-item version
2.5 ± 2.5 of the Geriatric
2.0 ± 2.0 2.8 ± Depression
2.5 Scale.
5.2 ± 3.5 <0.001
* Mantel-Haenszel test for proportion trends and one-way analysis of variance for continuous measures.
Medications mean ± SD (number) 3.7 ± 3.9 3.0 ± 3.4 4.1 ± 4.0 6.0 ± 5.3 0.001
SD, standard
3.2. Associations deviation;
of Prevalence BMI,Pain
of Chronic bodyand
mass index; Frailty
Physical GDS-15, 15-item version of the Geriatric Depression
Scale. * Mantel-Haenszel test for proportion trends and one-way analysis of variance for continuous
The results of logistic regression analysis using a group combining frailty and pre-frailty
measures.
participants as dependent variables are shown in the following Table 2. In the crude models,
chronic 3.2.
painAssociations
was significantly associatedofwith
of Prevalence a group
Chronic combining
Pain frailty
and Physical and pre-frailty (OR 1.95, 95%
Frailty
CI 1.24–3.05, p = 0.004). In the adjusted models, which included age, sex, BMI, GDS-15 score, and the
The results
number of prescribed of logisticasregression
medications covariates,analysis
chronic using a group
pain (OR combining
1.68, 95% frailtyp =
CI 1.03–2.76, and pre-frailty
0.040)
and GDS-15 score (OR 1.17, 95% CI 1.06–1.30, p = 0.003) was associated with a group combining frailty chronic
participants as dependent variables are shown in the following Table 2. In the crude models,
pain was
and pre-frailty. significantly
The associated
results of logistic with aanalysis
regression group combining
using onlyfrailty and group
the frailty pre-frailty (OR 1.95, 95% CI
of participants
1.24–3.05,
as dependent p = 0.004).
variables In the in
are shown adjusted models,Chronic
the following. which included
pain wasage,not sex, BMI, GDS-15
associated with onlyscore,
theand the
number of prescribed medications as covariates, chronic pain (OR 1.68, 95% CI 1.03–2.76, p = 0.040)
and GDS-15 score (OR 1.17, 95% CI 1.06–1.30, p = 0.003) was associated with a group combining frailty
and pre-frailty. The results of logistic regression analysis using only the frailty group of participants
Int. J. Environ. Res. Public Health 2019, 16, x 5 of 9

as dependent
Int. J. Environ. Res.variables are
Public Health shown
2019, in
the following. Chronic pain was not associated with only5 of
16, 1330 the
9
frailty group in the crude models (OR 1.53, 95% CI 0.60–3.87) but also in the adjusted models
including covariates (OR 2.83, 95% CI 0.79–10.21). Age (OR 1.22, 95% CI 1.09–1.36, p = 0.001), GDS-15
frailty group
score (OR in the
1.50, 95%crude models (OR
CI 1.20–1.87, 1.53, 95%
p < 0.001), andCIthe
0.60–3.87)
numberbut also in the medications
of prescribed adjusted models(ORincluding
1.15, 95%
covariates (OR 2.83, 95% CI 0.79–10.21). Age (OR 1.22, 95% CI 1.09–1.36, p = 0.001),
CI 1.00–1.32, p = 0.047) were associated only with the frailty group in the adjusted models. GDS-15 score
(OR 1.50, 95% CI 1.20–1.87, p < 0.001), and the number of prescribed medications (OR 1.15, 95% CI
1.00–1.32, p = 0.047)
Table were associated
2. Logistic regressiononly withbetween
analysis the frailty group
chronic paininand
thephysical
adjusted models.
frailty status.

Dependent Value: Classification of Two Patterns of Physical Frailty Prevalence Rates

Independent Table 2. Logistic regression analysis between chronic pain and physical frailty status.
Non-Frailty & Pre-Frailty Non-Frailty
Variable
Independent vs Frailty
Dependent Value: Classification of Two Patterns of Physicalvs Pre-Frailty
Frailty & Frailty
Prevalence Rates
Variable Crude Non-Frailty & Pre-Frailty
Adjusted vs Frailty Crude Adjusted
Non-Frailty vs Pre-Frailty & Frailty
OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p
Crude Adjusted Crude Adjusted
Chronic pain 1.53 (0.60–3.87)
OR (95% CI) 0.371
p 2.83 (0.79–10.21)
OR (95% CI) 0.112
p 1.95 (1.24–3.05)
OR (95% CI) 0.004
p ** 1.68 (1.03–2.76)
OR (95% CI) 0.040
p *
Age
Chronic pain 1.53 (0.60–3.87) 0.371
1.22 (1.09–1.36)
2.83 (0.79–10.21)
0.001 **
0.112 1.95 (1.24–3.05) 0.004 **
1.03 (0.99–1.07)
1.68 (1.03–2.76)
0.176
0.040 *
Women
Age 2.151.22
(0.42–10.90)
(1.09–1.36) 0.358
0.001 ** 0.80(0.99–1.07)
1.03 (0.47–1.38) 0.176
0.428
BMI
Women 1.21 (1.00–1.46)
2.15 (0.42–10.90) 0.058
0.358 1.00(0.47–1.38)
0.80 (0.94–1.08) 0.428
0.938
BMI
GDS-15 1.501.21 (1.00–1.46) <0.001
(1.20–1.87) 0.058** 1.00
1.17(0.94–1.08)
(1.06–1.30) 0.938
0.003 **
GDS-15
Medications 1.151.50 (1.20–1.87)
(1.00–1.32) <0.001* **
0.047 1.17
1.06(1.06–1.30)
(1.00–1.14) 0.003 **
0.069
Medications 1.15 (1.00–1.32) 0.047 * 1.06 (1.00–1.14) 0.069
Note: OR, odds ratio; CI, confidence interval; BMI, body mass index; GDS-15, 15-item version of the
Note: OR, odds ratio; CI, confidence interval; BMI, body mass index; GDS-15, 15-item version of the Geriatric
Geriatric Depression
Depression Scale; the boldScale; theindicates
typeface bold typeface
statisticalindicates statistical
significance; significance;
** p < 0.01; ** p < 0.01;
* p < 0.05; adjusted * psex,
for age, < 0.05;
BMI,
GDS-15 score, and number of medications.
adjusted for age, sex, BMI, GDS-15 score, and number of medications.

Analysis of
Analysis of the
the prevalence
prevalence ofof chronic
chronic pain
pain inin participants
participants corresponding
corresponding to to the
the sub-items
sub-items that
that
determine frailty is represented in Figure 2. Exhaustion (yes: 65.9%, no: 39.4%) was
determine frailty is represented in Figure 2. Exhaustion (yes: 65.9%, no: 39.4%) was significantly significantly
associatedwith
associated withthe
theprevalence
prevalenceofofchronic pain(p(p<<0.001).
chronicpain 0.001). Slowness
Slowness(yes:
(yes: 52.4%,
52.4%, no:
no: 42.1%),
42.1%), weakness
weakness
(yes: 50.0%,
(yes: 50.0%, no:
no: 40.2%),
40.2%), low
low activity
activity (yes:
(yes: 44.6%,
44.6%, no:
no: 42.3%),
42.3%), and
and weight
weight loss
loss (yes:
(yes: 51.1%,
51.1%, no:
no: 41.4%)
41.4%)
were not significantly associated with the prevalence of chronic
were not significantly associated with the prevalence of chronic pain. pain.

70 **
60
Chronic pain （％）

50

40

30

20

10

0
Yes No Yes No Yes No Yes No Yes No
Exhaustion Slowness Weakness Low activity Weight loss
Figure 2. Association of the sub-items of physical frailty and presence of chronic pain. χ22 test for
Figure 2. Association of the sub-items of physical frailty and presence of chronic pain. χ test for
proportions; ** p < 0.01.
proportions; ** p < 0.01.
4. Discussion
4. Discussion
This cross-sectional study indicated that chronic pain in community-dwelling older adults could
This cross-sectional
be associated study
with the group indicatedfrailty
combining that chronic pain in community-dwelling
and pre-frailty. older with
That group was associated adults could
chronic
be associated with the group combining frailty and pre-frailty. That group was associated
pain even after the adjustment for potential covariates. Also, participants with exhaustion had with
a
significantly higher proportion of chronic pain.
Int. J. Environ. Res. Public Health 2019, 16, 1330 6 of 9

The development of an effective prevention strategy for frailty in community-dwelling older

adults is a pressing issue in a rapidly-aging society (e.g., Japan), as frailty has a negative effect on
health [1]. Chronic pain among community-dwelling older adults is a risk factor for worsening
frailty [19]. The prevalence of chronic pain in this study was almost the same as in a previous study
investigating Japanese adults [29], which reported that 1032 (39.3%) adults (mean age 57.7 years) out
of 2628 sampled had chronic pain. Makizako et al. investigated community-dwelling older adults
using the same definition of physical frailty as used in the present study, and reported that 56.5% of
older adults were frail or pre-frail [26]. Therefore, the present findings are consistent with previous
results, and are therefore credible. The previously mentioned prospective cohort study reported that
physical frailty, and even being pre-frail, strongly predicts an increased risk of disability in Japanese
older adults [26]. In the present study, the presence of chronic pain in the physically frail or pre-frail
groups was significantly higher than in the non-frail group. This may be explained by the fact that
chronic pain has profound effects on a number of health outcomes [31]. Chronic pain is associated
with and may be the origin of various health hazards, including depression and comorbidities that
exacerbate physical frailty. Also, in this study, an association between frailty and depression is
suggested. Thus, our findings suggest that interventions in chronic pain in the early stages of physical
frailty (mostly pre-frail status) may have something to do with preventing the risk of developing
disability in community-dwelling older adults.
Analysis of the prevalence of chronic pain and sub-items of frailty showed that exhaustion,
not other sub-items, was significantly associated with chronic pain. Many previous studies have
reported on the relationship between pain and physical function deterioration [12,14,32,33]. However,
in the present study, chronic pain was associated with exhaustion rather than with physical function.
Shega et al. [31] argued that older adults with persistent pain, lack of sleep, and poor nutrition may
experience a decrease in their physiological reserves, which increases the likelihood of falls and
cognitive dysfunction. Exhaustion may be related to sleep deprivation and nutritional status. This
may cause mental distress and also lose confidence. Then, they may express feelings that they cannot
fulfill their social roles sufficiently with families, friends and neighbors. This could lead to withdrawal
indoors and lead to a decline in physical activity as well. This suggests that in older adults, pre-frailty
or frailty is initially associated with exhaustion, and subsequently perhaps with a decline in physical
function. Among older adults, it is plausible that the multidimensional nature of chronic pain has an
impact on one’s physiological systems, reduces one’s physiological reserves, and decreases one’s ability
to maintain homeostasis [34]. Thus, there is a need for early intervention and consideration of the role
of exhaustion when devising interventions for physical frailty in older adults with chronic pain.
This study includes several limitations. First, while chronic pain was recognized as an important
aspect of physical frailty, the roles of the cognitive and psychological domains were not considered.
Also, other potential covariates, such as lifestyle, nutritional, and hormonal factors [35–37], that could
be related to exhaustion, were not considered. Second, we studied the relationship between chronic
pain and the prevalence of frailty using cross-sectional design, but statistical power was insufficient
due to the small number of participants. We need more prospective study with more participants.
Additionally, regarding the definition of pain, we asked questions about low back and knee pain,
but did not consider the degree of pain. The prevalence of low back and knee pain is high in Japan
and other countries [27,28], but other parts of the body and different degrees of pain may need to be
considered. We also need to consider other chronic pain cut-offs. In this study, registered 452 older
adults accounted for about 10% of the surveyed subjects in the city. Moreover, they were not randomly
selected. In this field, conducting longitudinal studies would accumulate valuable evidence.

5. Conclusions
Community-dwelling older adults with chronic pain were associated with the group combining
physical frailty and pre-frailty. In particular, exhaustion may be associated with the prevalence of chronic
pain. The maintenance of a patient’s physically non-frail status through interventions accounting for
Int. J. Environ. Res. Public Health 2019, 16, 1330 7 of 9

exhaustion can be a strategy for the maintenance of physical function among community-dwelling
older adults with chronic pain.

Author Contributions: Y.N. was responsible for study conceptualization and design, analysis and interpretation
of data, and writing the manuscript. H.M. contributed to study conceptualization and design, subject recruitment,
interpretation of data, and writing the manuscript. R.K., K.T., and Y.T. were instrumental in acquiring data and
preparing the manuscript. T.K., T.T. and M.O. helped with recruitment, interpreting the data, and preparing the
manuscript. All authors were involved in designing the study; all contributed to and approved the final manuscript.
Funding: This work was supported by AMED under Grant Number JP18dk0207027; Research Funding for
Longevity Sciences (29-42) from the National Center for Geriatrics and Gerontology (NCGG) and JSPS KAKENHI
(Grant-in-Aid for challenging Exploratory Research) Grant Number JP17K19870.
Acknowledgments: The authors thank Tarumizu Chuo Hospital for helping with arranging testers, medical
doctors, nurses, physical therapists, occupational therapists, and instructors. We also thank the Tarumizu city
office for its contributions to the study. Our sincere thanks goes out to all the participants in the study.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Fried, L.P. Frailty in Older Adults: Evidence for a Phenotype. J. Gerontol. Biol. Sci. Med. Sci. 2001, 56, 146–156.
[CrossRef]
2. Mitnitski, A.; Collerton, J.; Martin-Ruiz, C.; Jagger, C.; von Zglinicki, T.; Rockwood, K.; Kirkwood, T.B.L.
Age-related frailty and its association with biological markers of ageing. BMC Med. 2015, 13, 1–9. [CrossRef]
[PubMed]
3. Schols, J.M.G.A.; Gobbens, R.J.J.; van Assen, M.A.L.M.; Luijkx, K.G.; Wijnen-Sponselee, M.T. Determinants
of Frailty. J. Am. Med. Dir. Assoc. 2010, 11, 356–364.
4. Bernabei, R.; Marzetti, E.; Albaina, O.; Junius-Walker, U.; Wiese, B.; Soleymani, D.; Onder, G. The essence of
frailty: A systematic review and qualitative synthesis on frailty concepts and definitions. Eur. J. Intern. Med.
2018, 56, 3–10.
5. Tom, S.E.; Adachi, J.D.; Anderson, F.A.; Boonen, S.; Chapurlat, R.D.; Compston, J.E.; Cooper, C.; Gehlbach, S.H.;
Greenspan, S.L.; Hooven, F.H.; et al. Frailty and fracture, disability, and falls: A multiple country study from
the global longitudinal study of osteoporosis in women. J. Am. Geriatr. Soc. 2013, 61, 327–334. [CrossRef]
[PubMed]
6. Garre-Olmo, J.; Calvó-Perxas, L.; López-Pousa, S.; De Gracia Blanco, M.; Vilalta-Franch, J. Prevalence of
frailty phenotypes and risk of mortality in a community-dwelling elderly cohort. Age Ageing 2013, 42, 46–51.
[CrossRef] [PubMed]
7. Kojima, G.; Iliffe, S.; Jivraj, S.; Walters, K. Association between frailty and quality of life among community-
dwelling older people: A systematic review and meta-analysis. J. Epidemiol. Community Health 2016, 70,
716–721. [CrossRef]
8. Vermeiren, S.; Vella-Azzopardi, R.; Beckwée, D.; Habbig, A.K.; Scafoglieri, A.; Jansen, B.; Bautmans, I.;
Bautmans, I.; Verté, D.; Beyer, I.; et al. Frailty and the Prediction of Negative Health Outcomes: A Meta-Analysis.
J. Am. Med. Dir. Assoc. 2016, 17, 1163.e1–1163.e17. [CrossRef] [PubMed]
9. Peleg, R.; Press, Y.; Freud, T.; Liberman, O.; Keren, A. Chronic pain and geriatric syndromes in
community-dwelling patients aged ≥65 years. J. Pain Res. 2018, 11, 1171–1180.
10. Nakamura, M.; Nishiwaki, Y.; Ushida, T.; Toyama, Y. Prevalence and characteristics of chronic musculoskeletal
pain in Japan. J. Orthop. Sci. 2011, 16, 424–432. [CrossRef] [PubMed]
11. Hasegawa, M.; Yamazaki, S.; Kimura, M.; Nakano, K.; Yasumura, S. Community-based exercise program
reduces chronic knee pain in elderly Japanese women at high risk of requiring long-term care: A
non-randomized controlled trial. Geriatr. Gerontol. Int. 2013, 13, 167–174. [CrossRef]
12. Eggermont, L.H.P.; Penninx, B.W.J.H.; Jones, R.N.; Leveille, S.G. Depressive symptoms, chronic pain, and
falls in older community-dwelling adults: The mobilize Boston study. J. Am. Geriatr. Soc. 2012, 60, 230–237.
[CrossRef]
13. Buchman, A.S.; Shah, R.C.; Leurgans, S.E.; Boyle, P.A.; Wilson, R.S.; Bennett, D.A. Musculoskeletal pain and
incident disability in community-dwelling older adults. Arthritis Care Res. 2010, 62, 1287–1293. [CrossRef]
Int. J. Environ. Res. Public Health 2019, 16, 1330 8 of 9

14. Park, J.; Hughes, A.K. Nonpharmacological approaches to the management of chronic pain in community-
dwelling older adults: A review of empirical evidence. J. Am. Geriatr. Soc. 2012, 60, 555–568. [CrossRef]
15. Lihavainen, K.; Sipilä, S.; Rantanen, T.; Sihvonen, S.; Sulkava, R.; Hartikainen, S. Contribution of
musculoskeletal pain to postural balance in community-dwelling people aged 75 years and older. J. Gerontol.
Ser. Biol. Sci. Med. Sci. 2010, 65A, 990–996. [CrossRef] [PubMed]
16. Onder, G.; Landi, F.; Gambassi, G.; Liperoti, R.; Soldato, M.; Catananti, C.; Finne-Soveri, H.; Katona, C.;
Carpenter, I.; Bernabei, R. Association between pain and depression among older adults in Europe: Results
from the Aged in Home Care (AdHOC) project: A cross-sectional Study. J. Clin. Psych. 2005, 66, 982–988.
[CrossRef]
17. Eggermont, L.H.P.; Leveille, S.G.; Shi, L.; Kiely, D.K.; Shmerling, R.H.; Jones, R.N.; Guralnik, J.M.; Bean, J.F.
Pain characteristics associated with the onset of disability in older adults: The maintenance of balance,
independent living, intellect, and zest in the elderly boston study. J. Am. Geriatr. Soc. 2014, 62, 1007–1016.
[CrossRef]
18. Plooij, B.; Scherder, E.J.A.; Eggermont, L.H.P. Physical inactivity in aging and dementia: A review of its
relationship to pain. J. Clin. Nurs. 2012, 21, 3002–3008. [CrossRef]
19. McGreevy, K.; Bottros, M.M.; Raja, S.N. Preventing chronic pain following acute pain: Risk factors, preventive
strategies, and their efficacy. Eur. J. Pain Suppl. 2011, 5, 365–376. [CrossRef]
20. Makizako, H.; Kubozono, T.; Kiyama, R.; Takenaka, T.; Kuwahata, S.; Tabira, T.; Kanoya, T.; Horinouchi, K.;
Shimada, H.; Ohishi, M. Associations of social frailty with loss of muscle mass and muscle weakness among
community-dwelling older adults. Geriatr. Gerontol. Int. 2019, 19, 76–80. [CrossRef] [PubMed]
21. Fukutomi, E.; Okumiya, K.; Wada, T.; Sakamoto, R.; Ishimoto, Y.; Kimura, Y.; Chen, W.L.; Imai, H.; Kasahara, Y.;
Fujisawa, M.; et al. Relationships between each category of 25-item frailty risk assessment (Kihon Checklist)
and newly certified older adults under Long-Term Care Insurance: A 24-month follow-up study in a rural
community in Japan. Geriatr. Gerontol. Int. 2015, 15, 864–871. [CrossRef] [PubMed]
22. Salpakoski, A.; Portegijs, E.; Kallinen, M.; Sihvonen, S.; Kiviranta, I.; Alen, M.; Rantanen, T.; Sipil, S. Physical
inactivity and pain in older men and women with hip fracture history. Gerontology 2010, 57, 19–27. [CrossRef]
23. Wade, K.F.; Lee, D.M.; Mcbeth, J.; Ravindrarajah, R.; Gielen, E.; Pye, S.R.; Vanderschueren, D.; Pendleton, N.;
Finn, J.D.; Bartfai, G.; et al. Chronic widespread pain is associated with worsening frailty in European men.
Age Ageing 2016, 45, 268–274. [CrossRef]
24. Shimada, H.; Makizako, H.; Doi, T.; Yoshida, D.; Tsutsumimoto, K.; Anan, Y.; Uemura, K.; Ito, T.; Lee, S.;
Park, H.; et al. Combined Prevalence of Frailty and Mild Cognitive Impairment in a Population ofElderly
Japanese People. J. Am. Med. Dir. Assoc. 2013, 14, 518–524. [CrossRef]
25. Makizako, H.; Tsutsumimoto, K.; Nakakubo, S.; Hotta, R.; Makino, K.; Shimada, H.; Doi, T.; Lee, S. Social
Frailty Leads to the Development of Physical Frailty among Physically Non-Frail Adults: A Four-Year
Follow-Up Longitudinal Cohort Study. Int. J. Environ. Res. Pub. Health 2018, 15, 490. [CrossRef]
26. Makizako, H.; Shimada, H.; Doi, T.; Tsutsumimoto, K.; Suzuki, T. Impact of physical frailty on disability in
community-dwelling older adults: A prospective cohort study. BMJ Open 2015, 5, 1–9. [CrossRef]
27. Hirase, T.; Kataoka, H.; Inokuchi, S.; Nakano, J.; Sakamoto, J.; Okita, M. Factors associated with chronic
musculoskeletal pain in Japanese community-dwelling older adults. Medicine 2017, 96, e7069. [CrossRef]
28. Patel, K.V.; Guralnik, J.M.; Dansie, E.J.; Turk, D.C. Prevalence and impact of pain among older adults in the
United States: Findings from the 2011 National Health and Aging Trends Study. Pain 2013, 154, 2649–2657.
[CrossRef] [PubMed]
29. Knutson, G.A. Incidence of foot rotation, pelvic crest unleveling, and supine leg length alignment asymmetry
and their relationship to self-reported back pain. J. Manipul. Physiol. Ther. 2002, 25, 110E. [CrossRef]
30. Hirase, T.; Kataoka, H.; Inokuchi, S.; Nakano, J.; Sakamoto, J.; Okita, M. Effects of exercise training combined
with increased physical activity to prevent chronic pain in community-dwelling older adults: A preliminary
randomized controlled trial. Pain Res. Manag. 2018, 2018, 1–7. [CrossRef] [PubMed]
31. Hunt, I.M.; Silman, A.J.; Benjamin, S.; McBeth, J.; Macfarlane, G.J. The prevalence and associated features of
chronic widespread pain in the community using the “Manchester” definition of chronic widespread pain.
Rheumatology 1999, 38, 275–279. [CrossRef]
32. Yesavage, J.A. Geriatric Depression Scale. Psychopharmacol. Bull. 1988, 24, 709–711.
Int. J. Environ. Res. Public Health 2019, 16, 1330 9 of 9

33. Inoue, S.; Kobayashi, F.; Nishihara, M.; Arai, Y.-C.P.; Ikemoto, T.; Kawai, T.; Inoue, M.; Hasegawa, T.;
Ushida, T. Chronic Pain in the Japanese Community—Prevalence, Characteristics and Impact on Quality of
Life. PLoS ONE 2015, 10, e0129262. [CrossRef]
34. Zhu, K.; Devine, A.; Dick, I.M.; Prince, R.L. Association of back pain frequency with mortality, coronary
heart events, mobility, and quality of life in elderly women. Spine 2007, 32, 2012–2018. [CrossRef]
35. Isanejad, M.; Mursu, J.; Sirola, J.; Kröger, H.; Rikkonen, T.; Tuppurainen, M.; Erkkilä, A.T. Dietary protein
intake is associated with better physical function and muscle strength among elderly women. Br. J. Nutr.
2016, 115, 1281–1291. [CrossRef]
36. Oliveira, M.R.; Fogaça, K.C.; Leandro-Merhi, V.A. Nutritional status and functional capacity of hospitalized
elderly. Nutr. J. 2009, 8, 54. [CrossRef]
37. Frontera, W.R.; Ochala, J. Skeletal Muscle: A Brief Review of Structure and Function. Calcif. Tiss. Int. 2015,
96, 183–195. [CrossRef]

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).