1
|
Identifying biopsychosocial factors that impact decompressive laminectomy outcomes in veterans with lumbar spinal stenosis: a prospective cohort study. Pain 2021; 162:835-845. [PMID: 32925594 DOI: 10.1097/j.pain.0000000000002072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Abstract
ABSTRACT One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. The Brigham Spinal Stenosis (BSS) questionnaire was the main outcome. Brigham Spinal Stenosis scales (symptom severity, physical function [PF], and satisfaction [SAT]) were dichotomized as SAT < 2.42, symptom severity improvement ≥ 0.46, and PF improvement ≥ 0.42, and analyzed using logistic regression. Sixty-two percent improved in 2 of 3 BSS scales (ie, success). Baseline characteristics associated with an increased odds of success were-worse BSS PF (odds ratio [OR] 1.24 [1.08-1.42]), greater self-efficacy for PF (OR 1.30 [1.08-1.58]), lower self-efficacy for pain management (OR 0.80 [0.68-0.94]), less apparent leg length discrepancy (OR 0.71 [0.56-0.91]), greater self-reported alcohol problems (OR 1.53 [1.07-2.18]), greater treatment credibility (OR 1.31 [1.07-1.59]), and moderate or severe magnetic resonance imaging-identified central canal stenosis (OR 3.52 [1.06-11.6]) moderate, OR 5.76 [1.83-18.1] severe). Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.
Collapse
|
2
|
Caring for older veterans with chronic low back pain using a geriatric syndrome approach: Rationale and methods for the aging back clinics (ABC) trial. Contemp Clin Trials 2020; 95:106077. [PMID: 32593717 DOI: 10.1016/j.cct.2020.106077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/17/2020] [Accepted: 06/22/2020] [Indexed: 11/23/2022]
Abstract
The purpose of the ongoing trial is to improve care of older Veterans with chronic low back pain (CLBP, i.e., low back pain for ≥6 months on ≥ half the days). Current CLBP care is limited by being either overly spine-focused or non-specifically prescribed and both approaches frequently lead to suboptimal reduction in pain and improvement in function. Through prior studies we have laid the foundation for a patient-centered approach to care for older Veterans with CLBP in which the spine is a source of vulnerability but not the sole treatment target. The approach considers CLBP a geriatric syndrome, a final common pathway for the expression of multiple contributors rather than a disease of the spine. We describe here the rationale and design of a randomized controlled trial to test the efficacy of an older Veteran-centered approach to CLBP care in "Aging Back Clinics (ABCs)" compared with Usual Care (UC). Three hundred thirty Veterans age 65-89 with CLBP will be randomized to ABCs or UC and followed for 12 months after randomization. We will assess the impact of ABCs on our primary outcome of pain-associated disability with the Oswestry Disability Index at 6 and 12 months, and secondary outcomes of pain intensity, health-related quality of life, balance confidence, mobility and healthcare utilization. If shown efficacious, the approach tested in ABCs has the potential to transform the care of older adults with CLBP by improving the quality of life for millions, reducing morbidity and saving substantial healthcare costs.
Collapse
|
3
|
Back pain in adolescents with idiopathic scoliosis: the contribution of morphological and psychological factors. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1959-1971. [DOI: 10.1007/s00586-020-06489-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/25/2020] [Accepted: 05/31/2020] [Indexed: 01/13/2023]
|
4
|
Weiner DK, Gentili A, Rossi M, Coffey-Vega K, Rodriguez KL, Hruska KL, Hausmann L, Perera S. Aging Back Clinics-a Geriatric Syndrome Approach to Treating Chronic Low Back Pain in Older Adults: Results of a Preliminary Randomized Controlled Trial. PAIN MEDICINE 2020; 21:274-290. [PMID: 31503275 DOI: 10.1093/pm/pnz179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Treating chronic low back pain (CLBP) with spine-focused interventions is common, potentially dangerous, and often ineffective. This preliminary trial tests the feasibility and efficacy of caring for CLBP in older adults as a geriatric syndrome in Aging Back Clinics (ABC). DESIGN Randomized controlled trial. SETTING Outpatient clinics of two VA Medical Centers. SUBJECTS Fifty-five English-speaking veterans aged 60-89 with CLBP and no red flags for serious underlying illness, prior back surgery, dementia, impaired communication, or uncontrolled psychiatric illness. METHODS Participants were randomized to ABC care or usual care (UC) and followed for six months. ABC care included 1) a structured history and physical examination to identify pain contributors, 2) structured participant education, 3) collaborative decision-making, and 4) care guided by condition-specific algorithms. Primary outcomes were low back pain severity (0-10 current and seven-day average/worst pain) and pain-related disability (Roland Morris). Secondary outcomes included the SF-12 and health care utilization. RESULTS ABC participants experienced significantly greater reduction in seven-day average (-1.22 points, P = 0.023) and worst pain (-1.70 points, P = 0.003) and SF-12 interference with social activities (50.0 vs 11.5%, P = 0.0030) at six months. ABC participants were less likely to take muscle relaxants (16.7 vs 42.3%, P = 0.0481). Descriptively, UC participants were more likely to experience pain-related emergency room visits (45.8% vs 30.8%) and to be exposed to non-COX2 nonsteroidal anti-inflammatory drugs (73.1% vs 54.2%). CONCLUSIONS These preliminary data suggest that ABC care for older veterans with CLBP is feasible and may reduce pain and exposure to other potential morbidity.
Collapse
Affiliation(s)
- Debra K Weiner
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine (Geriatric Medicine), University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Anesthesiology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Angela Gentili
- Hunter Holmes McGuire VA Medical Center, Richmond, Pennsylvania.,Department of Medicine (Geriatric Medicine), Virginia Commonwealth University, Richmond, Virginia
| | - Michelle Rossi
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine (Geriatric Medicine), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Katherine Coffey-Vega
- Department of Medicine (Geriatric Medicine), University of Virginia, Charlottesville, Virginia
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kristina L Hruska
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Subashan Perera
- Department of Medicine (Geriatric Medicine), University of Pittsburgh, Pittsburgh, Pennsylvania.,Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
5
|
Madill ES, Samuels R, Newman DP, Boudreaux-Kelley M, Weiner DK. Development of an Evaluative, Educational, and Communication-Facilitating App for Older Adults with Chronic Low Back Pain: Patient Perceptions of Usability and Utility. PAIN MEDICINE 2019; 20:2120-2128. [PMID: 31329964 DOI: 10.1093/pm/pnz088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The purpose of this study is to examine the usability and utility of an office-based iPad app that we developed for older adults with chronic low back pain (CLBP). The app screens for conditions that contribute to back pain and pain interference and provides personalized education based on patient responses. It also facilitates patient-provider communication regarding treatment targets and expectations. METHODS Forty-six older adults (age ≥60 years) with CLBP were recruited from the Veterans Affairs and from the Pittsburgh community. Testing was split into two phases. Alpha testing (N = 15) was used to drive design changes to the app. Beta testing (N = 30, after one participant withdrew) used a structured questionnaire to evaluate the app's usability and utility. RESULTS The application was rated highly for usability and utility (9.6 and 8.9 out of 10, respectively). The majority of participants (82.1%) agreed that the app would help them communicate with their doctor and that it gave them useful information about potentially harmful or unnecessary interventions such as opioids and imaging (79.2% and 75.0%). Participants (age ≥60 years, mean age = 75.5 years) were able to successfully use the application without assistance and would be willing to do so in their primary care office. CONCLUSIONS We present the development of a CLBP app that screens for pain contributors and provides personalized education based on patient responses. Such an app could be employed in a variety of clinical settings to help educate patients about their CLBP and to curtail unnecessary interventions. Patient outcomes are being tested in an ongoing clinical trial.
Collapse
Affiliation(s)
- Evan S Madill
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rachel Samuels
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - David P Newman
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | - Debra K Weiner
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, Department of Medicine.,Department of Psychiatry.,Department of Anesthesiology.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
6
|
Jacobs ZG, Elnicki DM, Perera S, Weiner DK. An E-learning Module on Chronic Low Back Pain in Older Adults: Effect on Medical Resident Attitudes, Confidence, Knowledge, and Clinical Skills. PAIN MEDICINE 2019; 19:1112-1120. [PMID: 29315426 DOI: 10.1093/pm/pnx333] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective To determine 1) the feasibility of implementing an e-learning module on chronic low back pain (CLBP) in an older adult into an existing internal medicine residency curriculum and 2) the impact of this module on resident attitudes, confidence, knowledge, and clinical skills relating to CLBP. Methods Participants were assigned to complete either the online module (N = 73) or the Yale Office-based curriculum on CLBP (N = 70). Attitudes, confidence, and knowledge were evaluated pre- and postintervention via survey. A retrospective blinded chart review of resident clinic encounters was conducted, wherein diagnosis codes and physical exam documentation were rated as basic or advanced. Results There was no improvement in overall knowledge scores in either group (60% average on both metrics). There were tendencies for greater improvements in the intervention group compared with controls for confidence in managing fibromyalgia (2.4 to 2.9 vs 2.5 to 2.5, P = 0.06) and leg length discrepancy (1.8 to 2.5 vs 1.5 to 1.9, P = 0.05). Those exposed to the online module also showed an increase in the percentage of physical exam documentation rated as advanced following the intervention (13% to 32%, P = 0.006), whereas the control group showed no change (14% to 12%, P = 0.68). Conclusions An online module on CLBP in the older adult was a feasible addition to an existing curriculum for internal medicine residents. The module positively and substantively impacted resident clinical behaviors, as evidenced by enhanced sophistication in physical exam documentation; it also was associated with improved confidence in certain aspects of chronic pain management.
Collapse
Affiliation(s)
| | | | | | - Debra K Weiner
- Division of Geriatric Medicine.,Department of Medicine.,Department of Psychiatry.,Department of Anesthesiology.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania.,VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
7
|
Carvalho do Nascimento PR, Ferreira ML, Poitras S, Bilodeau M. Exclusion of Older Adults from Ongoing Clinical Trials on Low Back Pain: A Review of the WHO Trial Registry Database. J Am Geriatr Soc 2018; 67:603-608. [DOI: 10.1111/jgs.15684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/04/2018] [Accepted: 10/06/2018] [Indexed: 12/25/2022]
Affiliation(s)
| | - Manuela Loureiro Ferreira
- Institute of Bone and Joint Research, The Kolling Institute/Sydney Medical School, The University of Sydney Sydney New South Wales Australia
| | - Stéphane Poitras
- School of Rehabilitation Sciences, University of Ottawa Ottawa Ontario Canada
| | - Martin Bilodeau
- School of Rehabilitation Sciences, University of Ottawa Ottawa Ontario Canada
- Bruyère Research Institute Ottawa Ontario Canada
- School of Human Kinetics, University of Ottawa Ottawa Ontario Canada
| |
Collapse
|
8
|
Weiner DK, Marcum Z, Rodriguez E. Deconstructing Chronic Low Back Pain in Older Adults: Summary Recommendations. PAIN MEDICINE 2018; 17:2238-2246. [PMID: 28025358 DOI: 10.1093/pm/pnw267] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Debra K Weiner
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania .,Division of Geriatric Medicine, Department of Medicine.,Department of Psychiatry.,Department of Anesthesiology.,Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Zachary Marcum
- School of Pharmacy, University of Washington, Seattle, Washington, USA
| | | |
Collapse
|
9
|
Weiner DK, Gentili A, Coffey-Vega K, Morone N, Rossi M, Perera S. Biopsychosocial Profiles and Functional Correlates in Older Adults with Chronic Low Back Pain: A Preliminary Study. PAIN MEDICINE 2018; 20:1300-1310. [DOI: 10.1093/pm/pny065] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Abstract
Objective
To describe key peripheral and central nervous system (CNS) conditions in a group of older adults with chronic low back pain (CLBP) and their association with pain severity and self-reported and performance-based physical function.
Design
Cross-sectional.
Setting
Outpatient VA clinics.
Subjects
Forty-seven community-dwelling veterans with CLBP (age 68.0 ± 6.5 years, range = 60–88 years, 12.8% female, 66% white) participated.
Methods
Data were collected on peripheral pain generators—body mass index, American College of Rheumatology hip osteoarthritis criteria, neurogenic claudication (i.e., spinal stenosis), sacroiliac joint (SIJ) pain, myofascial pain, leg length discrepancy (LLD), and iliotibial band pain; and CNS pain generators—anxiety (GAD-7), depression (PHQ-9), insomnia (Insomnia Severity Index), maladaptive coping (Fear Avoidance Beliefs Questionnaire, Cognitive Strategies Questionnaire), and fibromyalgia (fibromyalgia survey). Outcomes were pain severity (0 to 10 scale, seven-day average and worst), self-reported pain interference (Roland Morris [RM] questionnaire), and gait speed.
Results
Approximately 96% had at least one peripheral CLBP contributor, 83% had at least one CNS contributor, and 80.9% had both peripheral and CNS contributors. Of the peripheral conditions, only SIJ pain and LLD were associated with outcomes. All of the CNS conditions and SIJ pain were related to RM score. Only depression/anxiety and LLD were associated with gait speed.
Conclusions
In this sample of older veterans, CLBP was a multifaceted condition. Both CNS and peripheral conditions were associated with self-reported and performance-based function. Additional investigation is required to determine the impact of treating these conditions on patient outcomes and health care utilization.
Collapse
Affiliation(s)
- Debra K Weiner
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine
- Department of Psychiatry
- Department of Anesthesiology
- Clinical and Translational Sciences Institute
| | - Angela Gentili
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA
| | | | - Natalia Morone
- Department of Medicine
- Clinical and Translational Sciences Institute
| | - Michelle Rossi
- Geriatric Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Medicine
| | - Subashan Perera
- Department of Medicine
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
10
|
CORR Insights ®: Moving Forward Through Consensus: A Modified Delphi Approach to Determine the Top Research Priorities in Orthopaedic Oncology. Clin Orthop Relat Res 2017; 475:3056-3059. [PMID: 28929405 PMCID: PMC5670072 DOI: 10.1007/s11999-017-5501-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/11/2017] [Indexed: 01/31/2023]
|