moreover , restrictions of physical functioning among 
 older adults are very important1 , 2 .
spinal pain is the most common of all 
 chronic pain disorders . in a previous study ,
including back and 
 neck pain , spinal pain negatively affects mobility and aerobic capacity of the elderly . 

chronic diseases and pain in aging can also saliently affect the balance ability of older 
 adults4 .
physical functioning including 
 balance ability and aerobic capacity is important for the activities of daily living and 
 static and dynamic posture .
chronic diseases and aging may affect physical functioning5 , 6 . 
 musculoskeletal disorders may occur due to many reasons that affect sensorial and motor 
 control systems and may affect functional capacity negatively . with aging , musculoskeletal 
 capacity is reduced , which results in loss of muscle mass and strength . a decrease in 
 aerobic capacity and
physical activity levels can cause changes in gait and balance7 , 8 . in 
 addition
, chronic musculoskeletal pain negatively affects emotional status and activities of 
 daily living ( adl)9 , 10 .
the aim of this study was to show the impact of chronic musculoskeletal pain of the spinal 
 column and lower extremities on physical functioning , emotional status , and independency in 
 older adults .
the study sample consisted of two hundred and fifty - eight independent older adults who were 
 randomly selected from volunteers .
the exclusion criteria were  being dependent in daily living activities ,  having a cognitive impairment ,  having a neurological diseases such as stroke , parkinson disease , multiple sclerosis or 
 spinal cord injuries .
the study was approved by the ethics committee for non - invasive clinical research of 
 pamukkale university denizli , turkey ( 2012/16 - 03 ) .
sociodemographic data including age , gender , marital status , and education level were 
 recorded through a face to face interview with a physiotherapist .
body mass index ( bmi ) was calculated for each older adults to define their obesity 
 level .
we asked the older adults who reported musculoskeletal pain to indicate the localization on 
 their pain on a body diagram . only the older adults who reported spinal or lower extremity 
 pain
the six - minute walk test ( 6mwt ) was used to evaluate aerobic capacity .
the 6mwt was 
 performed in a 30-m - long corridor , and the participants were instructed to walk as fast as 
 possible without running .
they could stop walking if they felt any discomfort , fatigue , or 
 shortness of breath .
the timed up and go ( tug ) test was used to evaluate dynamic balance .
the tug test as 
 described by podsiadlo and richardson is a simple timed test used to qualify functional 
 mobility11 . in the tug test , 
 participants were asked to stand up from a standard chair with a seat height of between 40 
 and 50  cm , walk a 3-m distance at a normal pace , turn , walk back to the chair , and sit down . 

go  and ended when the 
 participant s back touched the backrest of the chair , with a shorter time indicating better 
 balance ability12 .
the yesavage geriatric depression scale ( gds ) was used to detect depressive symptoms in 
 order to describe emotional status .
this scale was developed as a self - report measure for 
 depression in older adults .
since this version proved both time - consuming and 
 difficult for some patients to complete , a 15-item version was developed .
the sensitivity 
 and specificity of the gds-15 have been assessed in a general elderly population13 .
the 
 turkish internal validity of the gds was confirmed by aktrk et al14 . for the 15-item short form gds ,
04 points is normal , 59 
 points indicates mild depression , and 1015 points indicates more severe depression .
the lawton - brody instrumental activities of daily living scale ( iadl ) was used to evaluate 
 independency in daily living activities .
the iadl scale measures complex functional 
 activities of ability including using a telephone , handling finances , self - administration 
 medication , use of transportation , shopping , housekeeping , laundry , and cooking .
one point 
 was awarded if a patient required little / no help in performing a task , and no points were 
 awarded if significant / total help was required . for the lawton - brody iadl ,
08 points is 
 evaluated as dependent , 916 points is evaluated as semi - dependant , and 1724 points is 
 evaluated as independent
the data were analyzed using the statistical package for social science ( spss , chicago , 
 il , usa ) version 16.0 software for windows . to evaluate sociodemographic variables , 

descriptive statistical methods were used [ mean  standard deviation ( sd ) and frequencies 
 ( count and percentage ) ] . to compare the two groups ,
the data were analyzed using the statistical package for social science ( spss , chicago , 
 il , usa ) version 16.0 software for windows . to evaluate sociodemographic variables , 

descriptive statistical methods were used [ mean  standard deviation ( sd ) and frequencies 
 ( count and percentage ) ] . to compare the two groups , the independent samples t - test was 
 used .
table 1table 1 . baseline characteristics of participants with spinal and lower extremity 
 painspinal pain(group i)lower ext .
pain(group ii)n ( % ) mean ( sd)n ( % ) mean ( sd)total 130 ( 100 ) 82 ( 100 ) gendermale 63 ( 48.4)41 ( 31.5 ) female 67 ( 51.5 ) 41 ( 31.5 ) bmi score27.45 ( 3.95 ) 28.14 ( 4.35)marital statussingle 41 ( 31.5 ) 33 ( 40.2)married 89 ( 68.4 ) 49 ( 59.7 ) chronic illnessno 16 ( 12.3 ) 6 ( 7.3 ) yes 114 ( 87.6 ) 76 ( 92.6 ) body mass index ( bmi , kilograms per square meter ) 30 , sd : standard deviation , 
 * significant shows the baseline data of the groups .
spinal pain was reported by 61.3% of the participants ( neck and 
 lower back ; n=130 ) , and 38.7% reported pain in the lower extremities ( n=82 ) .
the mean age of 
 the participants was 71.98  5.86  years ; 131 ( 50.4% ) were male , and 127 ( 48.8% ) female .
the 
 mean vas score during activities was 5.061.89  cm for group i and 5.44 2.24  cm for group 
 ii .
no differences between the two groups in terms of the vas score were found ( p>0.05 ) 
 ( table 2table 2 .
pain(group ii)(n=130)(n=82)mean ( sd)mean ( sd)vas ( cm ) 5.06 ( 1.89 ) 5.44 ( 2.24)tug ( sn ) 24.37 ( 16.49 ) 24.24 ( 11.31)6mwt ( m ) 363.73 ( 278.66 ) 284.17 ( 195.78 ) * * gds - score 6.04 ( 3.63)7.12 ( 4.01)**iadl - score 9.20 ( 4.99)10.76 ( 5.68)***the independent samples t - test was used .
sd , standard deviation ; vas , visuel analog 
 scale ; tug : timed up and go test ; gds , geriatric depression scale ; iadl , instrumented 
 activities of daily living . * * significant ) . body mass index ( bmi , kilograms per square meter ) 30 , sd : standard deviation , 
 * significant * the independent samples t - test was used .
sd , standard deviation ; vas , visuel analog 
 scale ; tug : timed up and go test ; gds , geriatric depression scale ; iadl , instrumented 
 activities of daily living . * * significant table 2 also shows the tug , 6mwt , gds , and iadl 
 results .
except for the tug scores , all outcome measurements showed significant differences 
 between the groups .
namely , the participants in group ii ( with lower limb pain ) had a lower 
 score in terms of aerobic capacity than those in group i ( p=0.027 ) .
although the two groups 
 had scores below the cutoff point for the gds , group ii had a higher score than group i 
 ( p=0.045 ) .
the two groups had more or less the 
 same scores in terms of the iadl ( p=0.036 ) .
so , all participants in both groups were 
 semi - dependent according to the iadl scores .
the partial correlation coeffidents in the spinal pain ( group i ) ( after 
 correcting for age and gender)control variablesage and gender1 2 31 - 6mwt2- gds0.090 3-iadl0.142 0.3126mwt , 6 minute walk test ; gds , geriatric depression scale ; iadl , instrumental 
 activities of daily living ; * significant and 4table 4 .
the partial correlation coeffidents in the lower extremity pain ( group ii ) 
 ( after correcting for age and gender)control variablesage and gender1231 - 6mwt2-gds0.088 3-iadl0.025 0.420 6mwt , 6 minute walk test ; gds , geriatric depression scale ; iadl , instrumental 
 activities of daily living ; * significant show that there were significant inverse correlations between the gds and iadl 
 scores .
6mwt , 6 minute walk test ; gds , geriatric depression scale ; iadl , instrumental 
 activities of daily living ; * significant 6mwt , 6 minute walk test ; gds , geriatric depression scale ; iadl , instrumental 
 activities of daily living ; * significant
most of the older adults this study complained of 
 musculoskeletal pain in their spinal column and lower extremity .
the same complaints can also be found in the literature . moreover , helme and gibson , dawson 
 et al . , and robin et al .
reported that lower extremity pain including hip , knee , and foot 
 pain are very common15,16,17 . in our study , 
 we studied 258 older adults who reported musculoskeletal pain in their spinal column and 
 lower extremities ( n=212 ; 82.1% ) . in this descriptive and comparative study
the results showed that lower extremity pain affected functioning , 
 especially physical functioning , in older adults more than spinal pain .
in addition to this , 
 the results obtained from the 6mwt also showed that the older adults with lower extremity 
 pain had the worst aerobic capacity compared with those with spinal pain . that is , our 
 results showed that chronic musculoskeletal pain in the lower extremity led to a decreased 
 aerobic capacity18,19,20,21,22,23 . on the other hand ,
the older adults evaluated in this study showed decreased independency 
 in daily living activities .
the same results can be found 
 in the literature24 , 25 . since depressive symptoms are common during aging , we also detected depressive symptoms in 
 our study .
although there 
 have been some finding indicating that chronic musculoskeletal pain increases depressive 
 symptoms in older adults , our results did not support this idea26 , 27 .
the results obtained in this study also supported the inverse relation between depressive 
 symptoms and independency in daily living activities .
this show that increased depressive 
 symptoms led to decreased independency in daily living activities .
this is not an unexpected 
 result , as it has been reported in previous related literature9 , 25 , 26
. the limitations of this study are as follows : ( 1 ) the sample size was too small to make a general comment .
( 2 ) we studied older adults with spinal or lower extremity pain , but we could not compare 
 our sample with older adults without pain . despite to the limitations mentioned above , the study has a major strength : this study is 
 the first one showing the effects of pain localization in older adults completed in 
 turkey . keeping in mind the limitations of the present study , we plan to perform further research 
 with a larger sample size so we will be able to make general comments with regard to this 
 field . in conclusion ,
the results of this study indicate that evaluation and relief of chronic 
 musculoskeletal pain are vital in geriatric rehabilitation programs . for this reason ,
health 
 providers , including physiotherapists , ergotherapists , medical doctors , and nurses , should 
 consider chronic musculoskeletal pain in older adults .
in particular , physiotherapists and 
 ergotherapists should focus on chronic lower extremity pain to improve physical functioning 
 and aerobic capacity of older adults to make them more mobile and improve their aerobic 
 capacity .
   [ purpose ] the aim of this study was to show the impact of chronic musculoskeletal pain 
 of the spinal column and lower extremities on physical functioning , emotional status , and 
 independency in older adults . [ subjects ] in this cross - sectional study , 258 older adults 
 ( mean age , 71.985.86  years , 50.8% males , 49.2% females ) living in their own residences 
 were evaluated . 
 [ methods ] pain intensity was analyzed using a visual analogue scale . 
 
 physical functioning was evaluated with the timed up and go test ( tug ) and a six - minute 
 walk test . 
 the geriatric depression scale was used to determine emotional status . 
 the 
 independency in daily living of the participants was evaluated using the lawton brody iadl 
 scale . 
 all participants were divided into two groups in accordance with the pain 
 localization : the ( 1 ) spinal pain and ( 2 ) lower extremity pain groups . 
 [ results ] when the 
 pain scores were compared , no significant differences between the two groups were found . 
 
 the same results were found in terms of tug scores . 
 the spinal pain group had higher 
 scores in terms of aerobic capacity than the lower extremity pain group . 
 [ conclusion ] the 
 results indicate that chronic musculoskeletal pain in the lower extremities decreased 
 aerobic capacity much more than spinal pain in older adults . 
INTRODUCTION
SUBJECTS AND METHODS
Statistical analysis
RESULTS
DISCUSSION