Effects of aquarobics participation on back pain disability index, sleep disturbance, and subjective memory impairment in female older adults with chronic back pain

doi:10.21203/rs.3.rs-5027650/v1

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Effects of aquarobics participation on back pain disability index, sleep disturbance, and subjective memory impairment in female older adults with chronic back pain

https://doi.org/10.21203/rs.3.rs-5027650/v1

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Background

Pain is a notable risk factor for cognitive decline in older adults. Aims: This study aimed to evaluate the effect of an aquarobics exercise program on three critical health outcomes—back Pain Disability Index (BPDI), sleep disturbance (SD), and subjective memory impairment (SMI) —in female older adults with chronic low back pain. Methods: In total, 152 participants were recruited and randomly assigned to either the experimental group (n = 68), which participated in a structured aquarobics program for three months, or the control group (n = 84), which did not engage in any structured exercise intervention. Results: Participation in the aquarobics program resulted in a statistically significant reduction in BPDI scores, indicating a marked decrease in functional limitations associated with chronic back pain. Participants in the experimental group exhibited significant improvements in sleep quality and decreased subjective memory impairment, both of which were positively correlated with reduced BPDI. SEM analysis confirmed that improvements in BPDI mediated positive effects on sleep and memory, suggesting that physical pain alleviation contributes to enhanced cognitive and psychological well-being. Discussion: These findings underscore the potential of aquarobics as a viable non-pharmacological intervention for elderly women with chronic low back pain, offering comprehensive benefits beyond pain relief, including enhancements in sleep and cognitive function. Conclusions: Future research should explore the long-term sustainability of these benefits and consider the integration of aquarobics into broader rehabilitation and wellness programs for older adults.

Aquarobics

Back pain disability index (BPDI)

Sleep disturbance (SD)

Subjective memory impairment (SMI)

Chronic back pain

Female older adults

The number of patients with dementia worldwide is expected to increase from approximately 57.4 million in 2019 to approximately 152.8 million in 2050 due to population aging [1]. In 2021, for people aged 65 or older in South Korea, approximately 890,000 had dementia, with a prevalence rate of 10.4%. This number is estimated to reach 3.15 million by 2050 [2]. Cognitive decline spans a spectrum from mild impairment to dementia, which stems from various causes and underscores the critical need to prevent such decline [3, 4]. Previous studies have identified various contributors to cognitive decline including age, gender, education, socioeconomic status, living arrangements, daily activities, alcohol use, smoking, physical activity, obesity, depression, and chronic conditions such as hypertension and diabetes [5]. Collectively, these factors pose a substantial risk to older adults’ cognitive health.

Emerging research has highlighted pain as a notable risk factor for cognitive decline in older adults [6, 7]. Previous investigations have emphasized that pain is a potent predictor of cognitive health in the elderly. Chronic pain, particularly associated with musculoskeletal disorders, is a significant health issue affecting both men and women in older age groups. Studies have suggested that the prevalence of musculoskeletal pain in older adults ranges from 65–85% [8], with 36–70% of older adults experiencing back pain [9]. Research examining the correlation between chronic pain and cognitive function has revealed that individuals with chronic pain perform poorly on tests measuring memory, such as the digit span backward and immediate story recall tests [10]. Furthermore, chronic diffuse pain in adults aged 65 and older has been associated with a 43% and 29% increased risk of dementia and stroke, respectively [11].

The relationship between pain and sleep in patients with chronic back pain has been confirmed, and sleep disorders due to chronic back pain increase stress and anxiety, which affect the well-being of individuals [12]. Sleep disorders not only cause physical problems in the elderly but also affect memory and cognitive function and are a major predictor of dementia, worsening quality of life. Sleep problems in the elderly must be managed [13, 14]. Given these findings, back pain disorder caused by chronic back pain causes sleep disturbance and subjective memory impairment. Furthermore, sleep disturbance is inherent in the relationship between back pain and subjective memory impairment. Sleep disorders are not part of the normal aging process; however, their prevalence may increase with age. Therefore, factors associated with sleep disturbances—including substance abuse, chronic medical illnesses, psychiatric conditions, reduced physical activity, and changes in sleep habits that can be expected in older adults—must be identified [15]. Interventions must be initiated promptly, and more in-depth measures for subjective memory disorders should be presented.

Recently, various exercise methods and techniques have been proposed to treat and prevent back pain recurrence. Lumbar stabilization, slings, aquatic rehabilitation, and aerobic and resistance exercises have been reported effective [16]. Aquatic exercises have multiple elements suitable for exercise tailored to older adults and can be considered useful preventive approaches to elderly health. The relative density of the human body is lower than that of water. Therefore, when water enters, buoyancy occurs and the body becomes lighter [17]. Older adults with weak muscles and joints can easily improve their health and quality of life [18].

During exercise, water resistance, entanglement, and viscosity occur, improving muscle strength and stamina [19], and relieving pain accompanying knee and hip arthritis [20]. Given that the exercise involves moving rhythmically in water to music, it is easy to perform even for elderly people who do not know how to swim. Furthermore, since it is a group exercise, it can help relieve geriatric depression and loneliness and improve brain function [21].

Therefore, aquatic exercise can be tailored to the elderly and provide optimal conditions to relieve chronic back pain. The need for research on the relationship between aquatic exercise and elderly health is increasing, and opportunities for older people to participate in aquatic exercise are expanding.

The main purpose of this study was to determine the effect of aquarobics participation on each variable by measuring and comparing the differences in the back pain disability index, sleep disturbance, and subjective memory impairment before and after participation in both groups. The structural relationship among the variables was explored to determine the causal relationship among back pain disability index, sleep disturbance, and subjective memory impairment that appear through participation in aquarobics. The specific hypotheses of this study were as follows. First, participation in aquarobics will positively affect the back pain disability index, sleep quality, and cognition of female older adults with chronic back pain. Second, a causal relationship exists among back pain disability index, sleep disturbance, and subjective memory impairment according to aquarobics participation in female older adults with chronic pain.

Participants

The participants of this study were older adults individuals aged 65 years or older who had experienced back pain for more than one year for which they had not received medical treatment. Female older adults who agreed to participate in the study were selected based on the following criteria: no visual or hearing impairments; able to communicate effectively; and judged capable of completing exercise classes, since they were not included in the high-risk group because of medical or surgical conditions. Participants included those who participated in aquarobics programs at city/district sports clubs and private swimming pools in D City. The study comprised experimental (n = 79) and control (n = 89) groups. The control group participated in sedentary programs such as singing, musical instrument, calligraphy, Korean language, and art classes at welfare or community centers. However, 16 female older adults (11 from the experimental group and 5 from the control group) who received medication or were unable to participate regularly in classes from March to the end of May were excluded from the final analysis. Therefore, 152 participants(comprised experimental, n = 68; control, n = 84) were included in this study. The distribution of the study participants is presented in Table 1.

Research Design and Data Collection Procedure

This study was reviewed by C University's Bioethics Review Committee prior to data collection. Approved for exemption (No. 2-1046881-A-N-01-201707–HR-031-09-03) was implemented after receiving.

In this study, female older adults who regularly participated in exercise classes for three months were assessed before and after the intervention. A pre- and post-test control group design was employed, wherein female older adults in the exercise group (experimental and comparison groups) attended a sixty-minute session twice a week, for three months. To collect data, the researcher and an assistant researcher visited the swimming pool and gymnasium at the start and end of the exercise classes to administer surveys measuring the back pain disability index, sleep disturbance, and subjective memory impairment. Specifically, a consent form was attached to the questionnaire to confirm participation in this study. Six subjects who requested help because they had difficulty self-evaluating due to the large number of questions and reading problems had a research assistant answer each question after explaining it. It was carried out in this format.

Measurement Tools

The questionnaire contained six questions regarding sociodemographic factors. The back pain disability index (BPDI) used the Korean version of the Oswestry Back Pain Disability Index (ODI), revised to account for Korean cultural characteristics and validated for the Korean population [22]. It comprises ten items, excluding one question about sexual life, resulting in nine items scored on a Likert scale ranging from zero (no disability) to five (severe disability). The highest possible score was 45, and the functional disability score was calculated as a percentage. Higher scores indicated more severe disability.

To measure sleep disturbance (SD), the Korean Sleep Scale A, developed by Oh, Song, and Kim [23], was utilized. This tool consists of fifteen questions across four subfactors: sleep pattern, evaluation, outcome, and disturbance, rated on a four-point Likert scale. Positive questions were scored inversely, with higher scores indicating greater sleep disturbance.

To assess subjective memory impairment (SMI), the Korean version of the Memory Complaint Scale (KMCS) developed by Vale, Balieiro-Jr, and Silva-Filho[24] was used. The KMCS includes seven questions, with scores for each question ranging from zero to two. Higher scores indicate a greater degree of memory disorder.

Factor Analysis and Reliability Verification

To verify the reliability and validity of the measurement tools used in this study, the relationships between the items were examined using structural model theory. Confirmatory factor analysis (CFA) was conducted to evaluate the appropriateness of the structural model. The absolute fit indices used as model fit indicators were chi-square(χ²), Root Mean Square Residual(RMR), goodness-of-fit-index(GFI), Comparative Fit Index(CFI), and Root Mean Square Error of Apporoximation(RMSEA). The criteria were met for all three constructs being assessed in Table 2.

Data Analysis

The data collected in this study were analyzed using SPSS version 26.0 and Amos 26.0. A frequency analysis was performed to determine the general characteristics of the participants. Confirmatory factor and reliability analyses were conducted to verify the reliability and validity of the measurement tools.

Given the nature of the field research, where pre-measurements between the experimental and control groups differed significantly, a non-homogeneous control group design was applied. A covariate analysis (ANCOVA) was conducted with pre-measurement sets as covariates to control for these initial differences and examine the main effects. Additionally, multicollinearity was assessed through correlation analysis, and the inherent causal relationships among the variables were identified using structural equation modeling (SEM) with covariates.

Table 2

Confirmatory Factor Analysis Results of Measurement Variables
Factor		Question-naire	Standard load	Standard error	C.R.	AVE
Back Pain Disability Index		1	.726	.021	.939	.838
		2	.801	.041
		3	.761	.030
		4	.804	.010
		5	.724	.028
		6	.703	.039
		7	.608	.011
		8	.667	.020
		9	.734	.013
X² = 41.371, df = 19, GFI = .912, TLI = .925, CFI = .913, RMSEA = .069
Sleep Disturbance	Sleep pattern	1	.801	.021	.859	.803
		2	.811	.054
		3	.797	.031
		4	.705	.051
		5	.719	.070
		6	.783	.107
	Sleep assessment	1	.807	.213	.892	.843
		2	.799	.136
		3	.831	.105
		4	.697	.091
		5	.728	.020
	sleep results	1	.802	.091	.901	.891
	sleep results	2	.786	.075	.901	.891
	sleep-inhibiting factors	1	691	.165	.867	.811
	sleep-inhibiting factors	2	.795	.076	.867	.811
X2 = 50.639, df = 23, GFI = .931, TLI = .921, CFI = .914, RMSEA = .080
Subjective Memory Impairment		1	.694	.130	.910	.864
		2	.793	.015
		3	.809	.108
		4	.776	.064
		5	.789	.103
		6	.806	.067
		7	.826	.009
X2 = 48.976, df = 26, GFI = .932, TLI = .929, CFI = .926, RMSEA = .083

3.1. Effect of Participation in Aquarobics on Back Pain Disability Index (BPDI)

Table 3 and Fig. 1 show the pre-test and post-test BPDI scores of the experimental (participants) and control (non-participants) groups. BPDI decreased among aquarobics participants but not among non-participants. The changes differed significantly between the two groups (-2.8 and − 0.24). According to the results of covariate analysis(ANCOVA)—used to test the main effect of participation—was statistically significant (F = 331.517, df = 1, p < 0.001).

Table 3

Means and standard deviations of pre-test and post-test of back pain disability index(BPDI)
Group	N	Pre-test		Post-test
Group	N	M	SD	M	SD
Experimental group	68	31.37	2.91	28.57	1.97
Control group	84	33.64	3.89	33.88	3.64
Total	152	33.50	3.40	31.23	2.81

3.2. Effect of Participation in Aquarobics on Sleep Disturbance (SD)

Table 4 and Fig. 2 show the pre-test and post-test SD scores of the experimental (participants) and control (non-participants) groups. SD decreased among aquarobics participants but not among non-participants. The changes differed significantly between the two groups (-0.86 and 0.07). According to the results of covariate analysis(ANCOVA)—used to test the main effect of participation—was statistically significant (F = 21.310, df = 1, p < 0.001).

Table 4

Means and standard deviations of pre-test and post-test of sleep disturbance(SD)
Group	N	Pre-test		Post-test
Group	N	M	SD	M	SD
Experimental group	68	3.24	0.40	2.19	0.32
Control group	84	3.16	0.39	3.33	0.61
Total	152	3.20	0.40	2.76	0.47

3.3. Effect of Participation in Aquarobics on Subjective Memory Impairment (SMI)

Table 5 and Fig. 3 show the pre-test and post-test SMI scores of the experimental (participants) and control (non-participants) groups. SMI decreased among aquarobics participants but not among non-participants. The changes differed significantly between the two groups (-0.55 and 0.08). According to the results of covariate analysis(ANCOVA)—used to test the main effect of participation—was statistically significant (F = 28.617, df = 1, p < 0.001).

Table 5

Means and standard deviations of pre-test and post-test of subjective memory impairment(SMI)
Group	N	Pre-test		Post-test
Group	N	M	SD	M	SD
Experimental group	68	1.09	0.04	0.54	0.01
Control group	84	1.14	0.06	1.22	0.08
Total	152	1.12	0.05	0.88	0.05

3.4. Relationship Between BPDI, SD, and SMI Following Participation in Aquarobics

3.4.1. Correlation Between Factors

As a result of Pearson's product moment correlation analysis, it was confirmed that there was no problem with multicollinearity as there were no variables showing a correlation of more than 0.6(Table 6).

Table 6

Results of analysis on correlations between variables
Factor	1	2		3	4	5	6
Factor	BPDI	SD					SMI
BPDI(1)	1
sleep pattern (2)	.437*		1
sleep assessment (3)	.449*		.309**	1
sleep results (4)	.315**		.286**	.294**	1
sleep-inhibiting factors (5)	.438*		.364**	.299**	.104***	1
SMI (6)	.308**		.312**	.349**	.433*	.366**	1
p < .05, p < .01, **p < .001

3.4.2. Causal Relationships Between Variables

The results of the structural relationship analysis to investigate the relationship between BPDI, sleep disorders, and SMI in elderly women participating in aquarobics care were as follows

3.4.2.1 Verification of Model Fit

Table 7

shows that the results of the overall structural model verification indicated that the model fit indices were χ²=41.089, TLI = .941 (≥ 0.9), CFI = .938 (≥ 0.9), and RMSEA = .076 (≤ 0.05–0.1). These results demonstrate that the research model established in this study met all the criteria for acceptable fit.
Overall Index	χ2	χ2/ df(22)	sig	TLI	CFI	RMSEA
Research Model	41.089	1.868	.000	.941	.938	.076
Fit Index Standard		< 3.0	> 0.05	≥ 0.9	≥ 0.9	≤ 0.05 ~ 0.1

Table 7. Index of goodness fit test for the research model

3.4.2.2 Analysis of Interpersonal Relationships

Table 8 illustrates that the direct effects included the impacts of the BPDI due to participation in aquarobics on SD (β = 0.784), BPDI on SMI (β = 0.591), and SD on SMI (β = 0.396). The indirect effect was the impact of the BPDI due to participation in aquarobics on SMI through SD (0.784 ×0.396 = 0.310). The causal effect, which is the result of summing the direct and indirect effects, was relatively high at β = 2.081. Therefore, it was verified that the BPDI due to participation in aquarobics conditions directly impacted SD and SMI and indirectly impacted SMI through sleep disorders. This demonstrates a causal relationship between BPDI and participation in aquarobics conditions, SD, and SMI. The results of the analysis, conducted in line with the path verification of the research model, are illustrated in Fig. 4.

Table 8

Structural efficiency
Path	Direct effect	Indirect effect	Effect
BPDI → SD	.784	-	.784
BPDI → SMI	.591	-	.591
SD → SMI	.396	-	.391
BPDI → SD → SMI	-	.784×.396	.310
Total effect	1.771	.310	2.081

BPDI, back pain disability index; SD, sleep disturbance; SMI, subjective memory impairment

This study focused on participation in an aquarobics program as the most appropriate physical activity for female older adults with chronic back pain and analyzed the relationship between the BPDI, SD, and SMI. Participation in aquarobics positively impacted the reduction in BPDI, SD, and SMI, showing a significant causal relationship among these variables.

First, the finding that participation in aquarobics reduces the BPDI aligns with previous studies. Recent work suggests that the management of low back pain with exercise is associated with lower healthcare system costs and improvements in quality-adjusted life years compared to usual care for acute and chronic patients. Miyamoto et al. [25] investigated the effectiveness of the combination of 12 aquatic exercise sessions and pain neurophysiology education in 55 patients with Chronic low back pain(CLBP). These findings reveal a significant interaction between treatment conditions and pain intensity [26].

Yalfani et al. [27] evaluated the effect of a six-week aquatic exercise program on pain, disability, and function of the trunk and pelvic girdle muscles in twenty-four women with chronic low back pain. Another study on aquatic exercise programs for patients with back pain reported that subjective pain improved [27], while another study suggested significant improvements in pain, disability, and trunk muscles [28]. Previous research has also suggested that 12 weeks of aquatic exercise increases lumbar strength in middle-aged women with CLBP and improves lower back pain and body composition in men older adults with lower back pain [29]. Another study reported that pain decreased after aquatic exercise even in patients with arthritis and difficulties in daily life [30]. These previous studies and the present study suggest that aqua aerobics as part of aquatic exercise is an excellent rehabilitation method to reduce back pain in female older adults with chronic lower back pain.

Second, aquarobics participation was found to reduce SD in female older adults with chronic lower back pain. The few studies that have measured sleep outcomes from aquatic exercise suggest that it may produce greater benefits for sleep than land-based exercise [31–33] and have reported positive effects on sleep quality in patients with fibromyalgia performing aquarobics [34].

This decline in sleep quality among the older adults has prompted research into interventions such as aquarobics to address SDs, with findings suggesting that exercise is a crucial medium for producing positive effects. Furthermore, the effects of aquarobics on sleep quality have been observed, particularly in women. Elderly women participating in aquarobics experience significant improvements in sleep quality [35]. These improvements are attributed to the enjoyment and appropriate level of fatigue induced by the activity, which positively affect sleep quality. Ultimately, water-based activities promote blood circulation, reduce muscle tension, and induce relaxation due to the resistance, pressure, and eddy currents of water, which can foster positive thinking [36]. Underwater exercise is thus an effective medium for overcoming SDs by facilitating the recovery of mental function [37].

Third, participation in aquarobics is effective in reducing SMI in female older adults with chronic low back pain. Physical activities that can be incorporated into daily life are cost-effective for older adults and can sustainably enhance cognitive function [38]. A review of previous studies on the relationship between aquatic exercise and older adults’ cognition indicated that aquatic psychological exercise programs are effective in enhancing cognitive function in community-dwelling older adults [39]. Anecdotal evidence suggests that for those with dementia, water-based exercise has significant behavioral and psychological benefits, with reports suggesting reduced wandering and improved social interactions and sleeping patterns [40]. Underwater interval training was effective in improving brain nerve factors (IGF-1) and cognitive function in the older adults [41] supporting the findings of this study. Considering the findings of previous studies and the results of this study, aquarobics can be considered an active coping strategy that serves as a cognitive improvement program that positively influences the cognitive abilities of the elderly and reduces subjective memory impairment.

Finally, the causal relationship among the back pain disability index, SD, and SMI in aquarobics participants was measured, since appropriate physical activity in water can reduce the BPDI scores, which in turn alleviates SD, ultimately helping overcome SMI. Previous studies on cognitive function in the older adults have shown significant associations with health-related characteristics, such as exercise, and physical ailments, such as back pain and sleep [13, 14, 42]. The current study indicates that participation in aquarobics, an appropriate physical activity for older adults y individuals with chronic low back pain, significantly reduces BPDI scores, which in turn lowers SD and positively affects SMI. A causal relationship exists between the BPDI, SD, and SMI.

SDs caused by pain can lead to various complications, particularly cognitive impairment and functional disabilities, threatening the normal lives and health of healthy older adults individuals [43]. Many patients with chronic pain have sleep difficulties and report poor sleep quality [44]. Numerous studies have reported that pain disrupts sleep and that sleep deprivation and SD increase pain and affect cognitive function, indicating a strong correlation between pain and sleep [45]. SD has consistently been reported as a risk factor for cognitive impairment and is a major predictor of cognitive impairment [46]. Therefore, health-related characteristics, such as physical activity and sleep, must be identified to prevent cognitive decline in the older adults. Baker et al. [47] argued that cognitive function should be a key treatment goal for individuals experiencing chronic pain and that individualized approaches that consider pain and sleep quality related to cognitive function should be devised. Despite its importance, cognitive function enhancement has been overlooked in the interventions for elderly individuals experiencing low back pain despite its importance. Therefore, an integrated management program that includes screening and management of cognitive function, along with interventions to alleviate pain and improve sleep, is necessary for elderly individuals experiencing low back pain.

The conclusions derived from this study are as follows. First, participation in aquarobics by female older adults with chronic back pain positively affects the BPDI. In other words, participation in aquarobics conditions can be interpreted as an alleviation of back pain. Second, participation in aquarobics by female older adults with chronic back pain positively affected SD. This result can be interpreted as evidence that aquarobics is effective in improving sleep quality. Third, participation in aquarobics by elderly women with chronic back pain positively affected SMI, thus participation in aquarobics activities can enhance SMI. Finally, the BPDI resulting from participation in aquarobics by female older adults with chronic back pain had a positive causal relationship with SD and SMI.

Based on the results of this study, the following recommendations for future research are suggested. First, this study sampled female older adults with chronic low back pain who had experience participating in aquarobics. However, future studies should consider the differences in exercise function levels and demographic variables among female older adults with chronic low back pain. This would facilitate the application of individualized programs, thereby providing measures to improve the quality of life of the older adults. Second, the specific effects of aquarobics on sleep fragmentation caused by degenerative processes in female older adults have not been sufficiently studied. Therefore, follow-up studies should be conducted. Third, this study was conducted over a relatively short period, making it challenging to observe the full extent of changes resulting from aquarobics. We encourage further studies to carefully control these aspects to obtain more accurate results.

Funding Statement: This study was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (grant number NRF-2022S1A5C2A07090938).

Author Contributions: All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [MoonSook Lee] and [Jiyoun Kim]. The first draft of the manuscript was written by [MoonSook Lee] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Availability of Data and Materials: The original contributions presented in this study are further inquiries directed at the corresponding author.

Ethics Approval: Not applicable.

Conflicts of Interest: The author declares that they have no conflicts of interest to report regarding the present study.

Supplementary Materials: No supplementary material exists.

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Effects of aquarobics participation on back pain disability index, sleep disturbance, and subjective memory impairment in female older adults with chronic back pain

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Version 1

Abstract

Background

Figures

1. Introduction

2. Materials and Methods

3. Results

3.1. Effect of Participation in Aquarobics on Back Pain Disability Index (BPDI)

3.2. Effect of Participation in Aquarobics on Sleep Disturbance (SD)

3.3. Effect of Participation in Aquarobics on Subjective Memory Impairment (SMI)

3.4. Relationship Between BPDI, SD, and SMI Following Participation in Aquarobics

3.4.1. Correlation Between Factors

3.4.2. Causal Relationships Between Variables

3.4.2.1 Verification of Model Fit

3.4.2.2 Analysis of Interpersonal Relationships

4 Discussion

5 Conclusion and Suggestions

Declarations

References

Additional Declarations

Status:

Version 1