The clinical course of pain and function in older adults with a new primary care visit for back pain

Prior acupuncture experience among elderly participants enrolled in a clinical trial of acupuncture for chronic low back pain: Implications for future trials

Background

The effectiveness of acupuncture for chronic low back pain (cLBP) has not been studied specifically in the 65-and-older population. To inform the validity and generalizability of future acupuncture studies among older adults, we characterized elderly participants' prior experience with and views toward acupuncture and tested for clinical and sociodemographic differences between acupuncture-naïve and non-naïve participants.

Methods

Data for this study were collected during the baseline telephone interview from the participants enrolled in the Kaiser Permanente Northern California site of an NIH-funded, multicenter clinical trial of acupuncture for cLBP in older adults.

Results

Nearly two-thirds (65.6 %) of participants surveyed reported they had previously received acupuncture treatment with the vast majority seeking acupuncture treatment for pain-related issues (84.8 %). The majority of these participants reported relatively modest levels of exposure to acupuncture with most participants (63.1 %) reporting fewer than 10 treatment sessions over their lifetimes. There were no significant differences in age, sex, race, ethnicity, disability scores, income levels, or pain levels between the acupuncture-naïve and non-naïve groups.

Conclusion

Contextual consideration for prior acupuncture utilization rates is warranted and may be higher than expected or previously reported. We found few differences in baseline characteristics between participants who were acupuncture-naïve and those with prior acupuncture experience; thus, future pragmatic clinical trials might relax previous acupuncture-use considerations in their recruitment criteria. For trials focused on acupuncture-naive patients, it may be more feasible to expand the definition of "acupuncture-naive" based on lifetime acupuncture visits or time since last treatment.

Trial registration

The protocol was registered at clinicaltrials.gov (#NCT04982315).

Racial Differences in Movement-Related Appraisals and Pain Behaviors Among Adults With Chronic Low Back Pain

Research documents racial disparities in chronic low back pain (CLBP). Few studies have examined racial disparities in movement-related appraisals and no studies have examined anticipatory appraisals prior to or pain behaviors during functional activities among individuals with CLBP. This cross-sectional study examined racial differences in anticipatory appraisals of pain, concerns about harm, and anxiety, appraisals of pain and anxiety during movement, and observed pain behaviors during 3 activities of daily living (supine-to-standing bed task, sitting-to-standing chair task, floor-to-waist lifting task) in a sample (N = 126) of non-Hispanic Black (31.0%), Hispanic (30.2%), and non-Hispanic White (38.9%) individuals with CLBP. Hispanic participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed and chair tasks compared to non-Hispanic White participants. Hispanic participants reported more pain during the bed task and more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants reported more expected pain, concerns about harm, and pre-movement anxiety prior to the bed task and more pre-movement anxiety prior to the chair task compared to non-Hispanic White participants. Non-Hispanic Black participants reported more anxiety during the bed and chair tasks compared to non-Hispanic White participants. Non-Hispanic Black participants were observed to have significantly more verbalizations of pain during the bed task compared to non-Hispanic White participants. Current findings identify racial disparities in important cognitive-behavioral and fear-avoidance mechanisms of pain. Results indicate a need to revisit traditional theoretical and treatment models in CLBP, ensuring racial disparities in pain cognitions are considered. PERSPECTIVE: This study examined racial disparities in anticipatory and movement-related appraisals, and pain behaviors during activities of daily living among Non-Hispanic Black, Non-Hispanic White, and Hispanic individuals with CLBP. Racial disparities identified in the current study have potentially important theoretical implications surrounding cognitive-behavioral and fear-avoidance mechanisms of pain.

Voluntary postural sway control and mobility in adults with low back pain

Introduction

Low back pain (LBP) is associated with altered somatosensory perception, which is involved in both involuntary and voluntary control of posture. Currently, there is a lack of methods and tools for assessing somatosensory acuity in patients with LBP. The purpose of this study was (1) to assess the reliability of the sway discrimination apparatus (SwayDA) (2) to evaluate the differences in somatosensory acuity between patients with LBP and pain-free individuals, and (3) to examine relationships between somatosensory acuity, severity of LBP, and mobility in patients with LBP.

Methods

Twenty participants (10 patients with LBP and 10 matched asymptomatic controls) were recruited in a test-retest reliability test. Another 56 participants were recruited for this study with 28 individuals presenting with LBP and a further twenty-eight being asymptomatic. The SwayDA was custom-built to measure somatosensory perception during voluntary anterior-posterior (SwayDA-AP), medial-lateral to the dominant side (SwayDA-ML-D), and non-dominant side (SwayDA-ML-ND) postural sway control. Participants also completed mobility tests, including 10 times and 1-min sit-to-stand tests (10-STS, 1 m-STS). The area under the receiver operating characteristic curve (AUC) was calculated to quantify somatosensory acuity in discriminating different voluntary postural sway extents.

Results

The ICC (2.1) for the SwayDA-AP, SwayDA-ML-D, and SwayDA-ML-ND were 0.741, 0.717, and 0.805 with MDC95 0.071, 0.043, and 0.050. Patients with LBP demonstrated significantly lower SwayDA scores (tSwayDA-AP = -2.142, p = 0.037; tSwayDA-ML-D = -2.266, p = 0.027) than asymptomatic controls. The AUC values of the SwayDA-AP test were significantly correlated with ODI (rSwayDA-AP-ODI = -0.391, p = 0.039). Performances on the 1 m-STS and the 10-STS were significantly correlated with the AUC scores from all the SwayDA tests (-0.513 ≤ r ≤ 0.441, all p < 0.05).

Discussion

The SwayDA tests evaluated showed acceptable reliability in assessing somatosensory acuity during voluntary postural sway. Somatosensory acuity was diminished in patients with LBP compared to asymptomatic controls. In patients with LBP, lower somatosensory acuity was associated with increased LBP-related disability. Future research could focus on investigating the factors contributing to the decreased somatosensory perception and mobility in individuals with LBP.

Effects of exercise therapy on disability, mobility, and quality of life in the elderly with chronic low back pain: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Exercise is an effective treatment in chronic low back pain (CLBP), but there are few studies on CLBP in the elderly, and the intervention effect is controversial. We aimed to compare the efficacy of different exercises therapy on CLBP, dysfunction, quality of life, and mobility in the elderly.

METHODS

We searched Web of Science, MEDLINE, Cochrane Library, Chinese National Knowledge Infrastructure, EMBASE, and PubMed from the database inception till December 31, 2022. The publication languages were Chinese and English. Randomized controlled trials (RCTs) of exercise intervention in the elderly (≥ 60 years) with CLBP were included. Two reviewers independently extracted the data and evaluated them using the Revised Cochrane Risk of Bias Tool for Randomized Trials 2 (RoB2). The pooled effect sizes on different aspects of outcome measures were calculated.

RESULTS

Sixteen articles (18 RCTs) were included, comprising a total of 989 participants. The quality of included studies was relatively high. Meta-analysis results indicated that exercise therapy could improve visual analog scale (VAS) (WMD = - 1.75, 95% CI - 2.59, - 0.92, p < 0.05), Oswestry disability index (ODI) (WMD = - 9.42, 95% CI - 15.04, - 3.79, p < 0,005), short-form 36-item health survey physical composite summary (SF-36PCS) (WMD = 7.07, 95% CI 1.01, 13.14, p < 0.05), short-form 36-item health survey mental composite summary (SF-36MCS) (WMD = 7.88, 95% CI 0.09, 15.67, p < 0.05), and timed up and go test (TUG) (WMD = - 0.92, 95% CI - 2.22, 0.38, p < 0.005).

CONCLUSION

Exercise therapy effectively improved VAS, ODI, and SF-36 indexes in the elderly. Based on the subgroup, when designing the exercise therapy regimen, aerobics, strength, and mind-body exercise (≥ 12 weeks, ≥ 3 times/week, ≥ 60 min) should be considered carefully, to ensure the safety and effectiveness for the rehabilitation of CLBP patients. More high-quality trials are needed in future to confirm the effect of exercise on SF-36 and TUG indexes.

Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021

Background

Low back pain is highly prevalent and the main cause of years lived with disability (YLDs). We present the most up-to-date global, regional, and national data on prevalence and YLDs for low back pain from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021.

Methods

Population-based studies from 1980 to 2019 identified in a systematic review, international surveys, US medical claims data, and dataset contributions by collaborators were used to estimate the prevalence and YLDs for low back pain from 1990 to 2020, for 204 countries and territories. Low back pain was defined as pain between the 12th ribs and the gluteal folds that lasted a day or more; input data using alternative definitions were adjusted in a network meta-regression analysis. Nested Bayesian meta-regression models were used to estimate prevalence and YLDs by age, sex, year, and location. Prevalence was projected to 2050 by running a regression on prevalence rates using Socio-demographic Index as a predictor, then multiplying them by projected population estimates.

Findings

In 2020, low back pain affected 619 million (95% uncertainty interval 554-694) people globally, with a projection of 843 million (759-933) prevalent cases by 2050. In 2020, the global age-standardised rate of YLDs was 832 per 100 000 (578-1070). Between 1990 and 2020, age-standardised rates of prevalence and YLDs decreased by 10·4% (10·9-10·0) and 10·5% (11·1-10·0), respectively. A total of 38·8% (28·7-47·0) of YLDs were attributed to occupational factors, smoking, and high BMI.

Interpretation

Low back pain remains the leading cause of YLDs globally, and in 2020, there were more than half a billion prevalent cases of low back pain worldwide. While age-standardised rates have decreased modestly over the past three decades, it is projected that globally in 2050, more than 800 million people will have low back pain. Challenges persist in obtaining primary country-level data on low back pain, and there is an urgent need for more high-quality, primary, country-level data on both prevalence and severity distributions to improve accuracy and monitor change.

Funding

Bill and Melinda Gates Foundation.

Acupuncture for chronic low back pain in older adults: Design and protocol for the BackInAction pragmatic clinical trial

BACKGROUND

Back pain prevalence and burden increase with age; approximately one-third of U.S. adults 65 years of age and older experience lower back pain (LBP). For chronic low back pain (cLBP), typically defined as lasting three months or longer, many treatments for younger adults may be inappropriate for older adults given their greater prevalence of comorbidities with attendant polypharmacy. While acupuncture has been demonstrated to be safe and effective for cLBP in adults overall, few studies of acupuncture have either included or focused on adults ≥65 years old.

METHODS

The BackInAction study is a pragmatic, multi-site, three-arm, parallel-groups randomized controlled trial designed to test the effectiveness of acupuncture needling for improving back pain-related disability among 807 older adults ≥65 years old with cLBP. Participants are randomized to standard acupuncture (SA; up to 15 treatment sessions across 12 weeks), enhanced acupuncture (EA; SA during first 12 weeks and up to 6 additional sessions across the following 12 weeks), and usual medical care (UMC) alone. Participants are followed for 12 months with study outcomes assessed monthly with the primary outcome timepoint at 6 months.

DISCUSSION

The BackInAction study offers an opportunity to further understand the effectiveness, dose-dependence, and safety of acupuncture in a Medicare population. Additionally, study results may encourage broader adoption of more effective, safer, and more satisfactory options to the continuing over-reliance on opioid- and invasive medical treatments for cLBP among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04982315. Clinical trial registration date: July 29, 2021.

A Novel Movement-Evoked Pain Provocation Test for Older Adults With Persistent Low Back Pain: Safety, Feasibility, and Associations With Self-reported Physical Function and Usual Gait Speed

OBJECTIVES

Low back pain (LBP) is highly prevalent and disabling for older adults. Movement-evoked pain is an emerging measure that may help to predict disability; but is not currently a part of geriatric LBP clinical care. This study tested the safety and feasibility of a new Movement-Evoked Provocation Test for Low Back Pain in Older Adults (MEPLO). We also compared associations between movement-evoked pain via 2 different scoring methods and disability-associated outcomes.

MATERIALS AND METHODS

Thirty-nine older adults with persistent LBP provided baseline recalled and resting pain ratings, self-reported physical function, and usual gait speed. Participants then completed MEPLO, involving 4 tasks essential for functional independence: chair rises, trunk rotation, reaching, and walking. Movement-evoked pain was then quantified using the traditional change score (delta) method of pain premovement to postmovement; and also, a new aggregate method that combines pain ratings after the 4 tasks.

RESULTS

No safety or feasibility issues were identified. Compared with the delta score, the aggregate score was more strongly associated with self-reported physical function (beta: -0.495 vs. -0.090) and usual gait speed (beta: -0.450 vs. -0.053). Similarly, the aggregate score was more strongly associated with self-reported physical function than recalled and resting pain (beta: -0.470, -0.283, and 0.136, respectively).

DISCUSSION

This study shows the safety and feasibility of testing movement-evoked pain in older adults with persistent LBP, and its potential superiority to traditional pain measures. Future studies must validate these findings and test the extent to which MEPLO is implementable to change with geriatric LBP standard of care.

Australian emergency department care for older adults diagnosed with low back pain of lumbar spine origin: a retrospective analysis of electronic medical record system data (2016-2019)

BACKGROUND

In Australian emergency departments, 30% of all back pain presentations are for older adults. Relatively little is known about the care that this population receives during an emergency department stay, including admission to hospital. The aim of this study is to describe emergency department management of older adults diagnosed with a lumbar spine condition and to determine predictors of healthcare use in this population.

METHODS

A retrospective analysis of electronic medical record data of adults aged ≥ 65 years with a lumbar spine discharge diagnosis. Demographic, clinical care (date and time of presentation and discharge, length of stay in the emergency department, mode of arrival, triage category, re-presentations to the emergency department (within 48 h), discharge mode, the administration of pain-relieving medicines, lumbar imaging, and laboratory tests) and costs data were extracted from the electronic medical record system. Descriptive analyses and multilevel mixed-effects logistic regression models were performed.

RESULTS

Over the period January 2016 to December 2019 there were 4,093 presentations to emergency departments by older adults with a lumbar spine discharge diagnosis (82.0% were non-specific low back pain). Most were female (58.3%), 39.9% had some form of lumbar imaging, and 34.1% were admitted to hospital. The most administered pain medicines were opioid analgesics (67.1%), followed by paracetamol (63.9%) and NSAIDs (33.0%). Predictors of healthcare use and hospital inpatient admission were receiving a laboratory test and receiving any opioid. For the financial period 2019-20, the mean (SD) total cost of care per presentation was $5,629 ($11,982).

CONCLUSION

In the emergency department, more than two thirds of older adults with a lumbar spine condition received opioid analgesics. They often received imaging and laboratory tests, had high costs and were admitted to hospital. Alternative pathways of care are needed to support older adults with low back pain, to receive guideline-concordant emergency department care and have good health outcomes.

Risk factors for non-specific low back pain in older people: a systematic review with meta-analysis

PURPOSE

To conduct a systematic review about risk factors associated with non-specific low back pain (LBP) in older people.

METHODS

The study protocol was prospectively registered with Prospero (CRD42020191619). This systematic review with meta-analysis included cohort studies that investigated risk factors for LBP in older people. The following databases were searched up to 12 December 2020: MEDLINE (Ovid), Embase, CINAHL, SCOPUS and Web of Science. Two independent reviewers appraised methodological quality using the Critical Appraisal Checklist for Cohort Studies instrument.

RESULTS

We identified 3939 potentially relevant publications. After removing duplicates, screening title, and abstracts, we assessed 86 publications in full text. We included the remaining 11 publications for analysis. There is strong evidence that depressive symptoms are a risk of reporting future back pain onset (I² = 52,7%, Odds ratio 1.4, CI 1.28-1.53).

CONCLUSION

Depressive symptoms are a risk factor for LBP in older people. Due to the limitations of the literature, the role of some risk factors remains unclear. An additional high-quality prospective cohort is needed to better elucidate these relationships.

Factors impacting adherence to an exercise-based physical therapy program for individuals with low back pain

Background/Objective

Exercise-based rehabilitation is a conservative management approach for individuals with low back pain. However, adherence rates for conservative management are often low and the reasons for this are not well described. The objective of this study was to evaluate predictors of adherence and patient-reported reasons for non-adherence after ceasing a supervised exercise-based rehabilitation program in individuals with low back pain.

Design

Retrospective observational study.

Methods

Data was retrospectively analyzed from 5 rehabilitation clinics utilizing a standardized exercise-based rehabilitation program. Baseline demographics, diagnosis and symptom specific features, visit number, and discontinuation profiles were quantified for 2,243 patients who underwent the program.

Results

Forty-three percent (43%) of participants were adherent to the program, with the majority (31.7%) discontinuing treatment prior to completion due to logistic and accessibility issues. Another 13.2% discontinued prior to the prescribed duration due to clinically significant improvements in pain and/or disability without formal discharge evaluation, whereas 8.3% did not continue due to lack of improvement. Finally, 6.0% were discharged for related and unrelated medical reasons including surgery. Individuals diagnosed with disc pathology were most likely to be adherent to the program.

Limitations

This study was a retrospective chart review with missing data for some variables. Future studies with a prospective design would increase quality of evidence.

Conclusions

The majority of individuals prescribed an in-clinic exercise-based rehabilitation program are non-adherent. Patient diagnosis was the most important predictor of adherence. For those who were not adherent, important barriers include personal issues, insufficient insurance authorization and lack of geographic accessibility.

Paraspinal Muscle Health is Related to Fibrogenic, Adipogenic, and Myogenic Gene Expression in Patients with Lumbar Spine Pathology

BACKGROUND

Lumbar spine pathology is a common feature of lower back and/or lower extremity pain and is associated with observable degenerative changes in the lumbar paraspinal muscles that are associated with poor clinical prognosis. Despite the commonly observed phenotype of muscle degeneration in this patient population, its underlying molecular mechanisms are not well understood. The aim of this study was to investigate the relationships between groups of genes within the atrophic, myogenic, fibrogenic, adipogenic, and inflammatory pathways and multifidus muscle health in individuals undergoing surgery for lumbar spine pathology.

METHODS

Multifidus muscle biopsies were obtained from patients (n = 59) undergoing surgery for lumbar spine pathology to analyze 42 genes from relevant adipogenic/metabolic, atrophic, fibrogenic, inflammatory, and myogenic gene pathways using quantitative polymerase chain reaction. Multifidus muscle morphology was examined preoperatively in these patients at the level and side of biopsy using T2-weighted magnetic resonance imaging to determine whole muscle compartment area, lean muscle area, fat cross-sectional areas, and proportion of fat within the muscle compartment. These measures were used to investigate the relationships between gene expression patterns and muscle size and quality.

RESULTS

Relationships between gene expression and imaging revealed significant associations between decreased expression of adipogenic/metabolic gene (PPARD), increased expression of fibrogenic gene (COL3A1), and lower fat fraction on MRI (r = -0.346, p = 0.018, and r = 0.386, p = 0.047 respectively). Decreased expression of myogenic gene (mTOR) was related to greater lean muscle cross-sectional area (r = 0.388, p = 0.045).

CONCLUSION

Fibrogenic and adipogenic/metabolic genes were related to pre-operative muscle quality, and myogenic genes were related to pre-operative muscle size. These findings provide insight into molecular pathways associated with muscle health in the presence of lumbar spine pathology, establishing a foundation for future research that addresses how these changes impact outcomes in this patient population.

Association Between Psychosocial Parameters and Response to Chiropractic Care Among Older Adults With Chronic Low Back Pain: Secondary Analysis of a Randomized Clinical Trial

OBJECTIVES

The purpose of this study was to determine whether baseline self-efficacy, fear of pain with movement (kinesiophobia), or change in either were associated with clinically important improvement in disability among older adults with chronic low back pain after 12 weeks of chiropractic spinal manipulation (CSM) and exercise.

METHODS

This secondary analysis used randomized trial data from community-dwelling adults aged 65 years or older with chronic spinal disability who received non-pharmacological treatment of CSM and exercise. Those with ≥30% reduction in the Oswestry Disability Index (ODI) after 12 weeks of treatment were considered responders to care. Psychosocial measures included the Pain Self-Efficacy Questionnaire (PSEQ) and the Tampa Scale of Kinesiophobia (TSK). Logistic regression-assessed associations were between psychosocial, demographic, and low back predictors and 30% ODI improvement.

RESULTS

There were 176 community-dwelling older adults included in this analysis. Mean age was 71 years, 59.7% were women; 176 (96.7%) had complete data. Baseline disability (ODI = 26.1 ± 9.3) and back pain (5.0 ± 1.9, 0-10 scale) were moderate. Baseline PSEQ reflected higher self-efficacy (47.7 ± 7.8, 0-60 scale) with minimal kinesiophobia (TSK 34.3 ± 5.2, 17-68 scale). Seventy-two (40.9%) achieved 30% reduction in ODI (mean -5.4 ± 7.9) after 12 weeks of treatment. Mean self-efficacy improvement was clinically important (2.5 ± 6.5 points); kinesiophobia (-2.7 ± 4.4 points) and LBP (-1.6 points) also improved. Baseline PSEQ and percent improvement in PSEQ and TSK were associated with response to treatment in univariate regression analyses but not in multiple regression models that included low back predictors. LBP duration >4 years negatively impacted recovery.

CONCLUSIONS

Among this sample of older adults who received chiropractic manipulation and exercise, baseline self-efficacy and improvements in self-efficacy and kinesiophobia were individually associated with clinically important reductions in disability post-intervention, although not in adjusted models when LBP duration was included.

An Exploration of the Psychometric Properties of the PASS-20 in Older Adults with Chronic Pain: Preliminary Development and Validity

OBJECTIVES

The Pain Anxiety Symptoms Scale (PASS-20) is well validated in adults and younger populations, but not in older adults. This study aimed to analyze the psychometric properties of the PASS-20 in Spanish older adults who experience chronic pain.

METHODS

Participants were 111 older adults with chronic pain living in nursing homes (mean age = 83.36; SD = 6.53; 78.6% female). Face-to-face interviews were conducted which included assessment of pain anxiety (PASS-20), chronic pain acceptance (CPAQ), depression symptoms (GDS), catastrophizing beliefs (PCS), pain severity, and sociodemographic information. An Exploratory Structural Equation Modeling (ESEM) approach was used to refine the scale.

RESULTS

The final scale was composed of seven items, measuring two factors that could be labeled "Internal experiences" and "Escape/Avoidance behaviors". The two factors explained 60.98% of the total variance. PASS-7 version fit properly: χ²/df = 14.57/13, CMIN/df = 1.121, CFI = 0.99, RMSEA = 0.033, TLI = 0.98, GFI = 0.96, AGFI = 0.92. Good validity indices were found and acceptable reliability results in the scale and its subscales (Chronbach´s α; Internal Experiences = 0.70; Escape/Avoidance Behaviors= 0.73; Total Scale = 0.77).

CONCLUSIONS

The short version of the PASS-7 has good psychometric properties.

CLINICAL IMPLICATIONS

The brevity of the PASS-7 increases the feasibility of this instrument which could potentially be utilized in a variety of clinical settings and research studies with older people with chronic pain samples, specially institutionalized older adults.

The Flares of Low back pain with Activity Research Study (FLAReS): study protocol for a case-crossover study nested within a cohort study

BACKGROUND

Although it is generally accepted that physical activity and flares of low back pain (LBP) are related, evidence for the directionality of this association is mixed. The Flares of Low back pain with Activity Research Study (FLAReS) takes a novel approach to distinguish the short-term effects of specific physical activities on LBP flares from the cumulative effects of such activities, by conducting a longitudinal case-crossover study nested within a cohort study. The first aim is to estimate the short-term effects (≤ 24 h) of specific physical activities on LBP flares among Veterans in primary care in the Veterans Affairs healthcare system. The second aim is to estimate the cumulative effects of specific activities on LBP-related functional limitations at 1-year follow-up.

METHODS

Up to 550 adults of working age (18-65 years) seen for LBP in primary care complete up to 36 "Scheduled" surveys over 1-year follow-up, and also complete unscheduled "Flare Window" surveys after the onset of new flares. Each survey asks about current flares and other factors associated with LBP. Surveys also inquire about activity exposures over the 24 h, and 2 h, prior to the time of survey completion (during non-flare periods) or prior to the time of flare onset (during flares). Other questions evaluate the number, intensity, duration, and/or other characteristics of activity exposures. Other exposures include factors related to mood, lifestyle, exercise, concurrent treatments, and injuries. Some participants wear actigraphy devices for weeks 1-4 of the study. The first aim will examine associations between 10 specific activity categories and participant-reported flares over 1-year follow-up. The second aim will examine associations between the frequency of exposure to 10 activity categories over weeks 1-4 of follow-up and long-term functional limitations at 12 months. All analyses will use a biopsychosocial framework accounting for potential confounders and effect modifiers.

DISCUSSION

FLAReS will provide empirically derived estimates of both the short-term and cumulative effects of specific physical activities for Veterans with LBP, helping to better understand the role of physical activities in those with LBP.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04828330 , registered April 2, 2021.

Intravoxel incoherent motion imaging predicts exercise-based rehabilitation response in individuals with low back pain

Exercises to strengthen and stabilize the trunk musculature are a common conservative treatment strategy for low back pain (LBP), despite the possible presence of impairments in muscle activation in this population. Intravoxel incoherent motion (IVIM) MRI permits evaluation of activation-induced blood flow through diffusion-weighted images that are sensitized to microvascular blood flow. In the current study we aimed to evaluate IVIM signal changes after exercise in patients with LBP compared with pain-free healthy controls and determine if these changes were related to reductions in disability with a 12-week rehabilitation program. We hypothesize that the magnitude of changes in IVIM parameters in the lumbar extensor muscles will be smaller in patients with LBP compared with those without LBP, and that these magnitudes will be correlated with responsiveness to a 12-week, resistance-based exercise program. IVIM MR data for molecular diffusion (D), blood flow pseudodiffusion (D*) and perfusion fraction (f) were collected before and immediately after an ~ 3-min session of high-intensity lumbar extension resistance exercise in 16 healthy participants and 17 participants with LBP. Improvements in LBP-related disability after the 12-week, machine-based, high-intensity exercise rehabilitation program were measured in the LBP group. We observed a significant increase in all IVIM parameters (f, D*, D) in response to exercise (p < 0.0001) and an interaction of group-by-time for D (p = 0.016). Thresholds were identified using receiver operating characteristic (ROC) curves for diffusion and pseudodiffusion coefficients, which predicted a reduction in LBP-related disability in response to the 12-week, exercise-based rehabilitation program. Exercise was associated with an increase in (f), capillary blood flow-based pseudodiffusion (D*) and diffusion coefficient (D), regardless of the presence of LBP. Additionally, subgroup analysis identified patients who were not responsive to the acute exercise session, for whom, based on ROC analysis, there was no clinically significant change in disability following the 12-week program.

The Manual Therapy and Strengthening for the Hip (MASH) Trial: Protocol for a Multisite Randomized Trial of a Subgroup of Older Adults With Chronic Back and Hip Pain

OBJECTIVE

Chronic low back pain (CLBP) is a disabling and costly condition for older adults that is difficult to properly classify and treat. In a cohort study, a subgroup of older adults with CLBP who had elevated hip pain and hip muscle weakness was identified; this subgroup differentiated itself by being at higher risk for future mobility decline. The primary purpose of this clinical trial is to evaluate whether a hip-focused low back pain (LBP) treatment provides better disability and physical performance outcomes for this at-risk group compared with a spine-focused LBP treatment.

METHODS

This study is a multisite, single-blinded, randomized controlled, parallel arm, Phase II trial conducted across 3 clinical research sites. A total of 180 people aged between 60 and 85 years with CLBP and hip pain are being recruited. Participants undergo a comprehensive baseline assessment and are randomized into 1 of 2 intervention arms: hip-focused or spine-focused. They are treated twice weekly by a licensed physical therapist for 8 weeks and undergo follow-up assessments at 8 weeks and 6 months after randomization. Primary outcome measures include the Quebec Low Back Disability Scale and the 10-Meter Walk Test, which are measures of self-report and performance-based physical function, respectively.

IMPACT

This multicenter, randomized clinical trial will determine whether a hip-focused or spine-focused physical therapist intervention results in improved disability and physical performance for a subgroup of older adults with CLBP and hip pain who are at increased risk of mobility decline. This trial will help further the development of effective interventions for this subgroup of older adults with CLBP.

Adaptability and Resilience in Aging Adults (ARIAA): protocol for a pilot and feasibility study in chronic low back pain

Background

Chronic low back pain (cLBP) is the leading cause of disability among older adults and one of the top reasons for seeking healthcare, resulting in significant decrements in physical functioning. Because older adults are among the fastest growing cohorts in the USA, both the incidence and burden of cLBP are expected to increase considerably, rendering geriatric pain management a top health priority. Resilience is defined as a process allowing individuals to adapt and recover from adverse and stressful conditions, and it has been highlighted as a crucial factor in positive health-related functioning. While a growing body of literature supports the use of resilience-based interventions in chronic pain, research examining their effectiveness in older adults with cLBP remains limited. The primary aims of the study are to assess the feasibility and acceptability of a psychologically oriented resilience intervention among aging adults with cLBP.

Methods

In this article, we describe the rationale and design of the Adaptability and Resilience in Aging Adults (ARIAA) study, a single-arm intervention in which 60 participants (ages ≥ 60 years) with cLBP will be recruited to participate in a 7-week group-based program aimed at enhancing psychological resilience. Intervention sessions will target positive psychology concepts (e.g., positive affect, pain acceptance, hopeful thinking, pain self-efficacy) and cognitive behavioral techniques that have established benefits in pain management. Primary study outcomes include intervention feasibility and acceptability as measured by treatment engagement, intervention credibility and satisfaction, ability to meet recruitment and retention metrics, and the feasibility of questionnaire and home activity completion. Outcomes will be assessed at baseline, immediately at posttreatment, and at the 3-month follow-up period.

Discussion

This study will establish the feasibility and acceptability of a novel intervention aimed at enhancing positive, psychological functioning, and resilience in older adults with cLBP. Achievement of these aims will provide a rich platform for future intervention research targeting improvements in pain and disability among geriatric populations and will serve as a foundation for a fully powered trial to examine treatment efficacy of the proposed intervention.

Trial registration

Clinicaltrials.gov, identifier NCT04068922. Registered 28 August 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-021-00923-y.

Associations of Multiple Chronic Conditions With Physical Performance and Falls Among Older Adults With Back Pain: A Longitudinal, Population-based Study

OBJECTIVE

To determine the association of chronic conditions measured at baseline with physical performance and falls over time among older adults with back pain. We examined both number and type (depression, anxiety, arthritis) of chronic conditions.

DESIGN

Retrospective cohort study.

SETTING

National Health and Aging Trends Study.

PARTICIPANTS

A total of 2438 community-dwelling Medicare beneficiaries aged ≥65 years with bothersome back pain (N=2438). The sample was mostly female (62%; 95% confidence interval [CI], 59%-64%) and aged 65-74 years (56%; 95% CI, 53%-58%).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Short Physical Performance Battery (SPPB) (range, 0-12, lower indicates worse function) and recurrent falls measured annually over 6 years.

RESULTS

Multiple chronic conditions were highly prevalent (82%; 95% CI, 79%-84%) among those reporting back pain. Adjusted regressions using survey weights with Taylor series linearization method and containing interaction terms for comorbidity and time showed having 2-3 chronic conditions vs 0-1 was associated with lower SPPB scores, and differences grew over time (for example 0.61 points lower [95% CI, -0.88 to -0.34] and 1.22 points lower [95% CI, -1.76 to -0.67] in rounds 3 and 6, respectively). Having ≥4 chronic conditions was associated with lower SPPB scores at all time points vs 0-1 (point estimate range, -1.72 to -2.31). Arthritis alone; the combination of arthritis with depression; and the triad of arthritis, depression, and anxiety were associated with lower SPPB scores at all time points. Logistic regression models showed presence of 2-3 and ≥4 chronic conditions was associated with increased odds of recurrent falls in any given year (odds ratio, 1.91; 95% CI, 1.35-2.69 and odds ratio, 3.92; 95% CI, 2.81-5.46, respectively). Those with the triad of arthritis, depression, and anxiety had greater odds of recurrent falls vs none or 1 condition.

CONCLUSIONS

Among older adults with back pain, those with multiple chronic conditions, including co-occurrence of arthritis, depression, and anxiety, have greater risk for poor physical functioning and falls over time.

"If You Don't Keep Going, You're Gonna Die": Helplessness and Perseverance Among Older Adults Living With Chronic Low Back Pain

BACKGROUND AND OBJECTIVES

Chronic low back pain (CLBP) is the leading cause of disability worldwide and the most common pain complaint among the rapidly growing older adult population. As part of a larger qualitative study examining the lived experience of CLBP among older adults, the objective of the present study is to understand how older pain clinic patients experience helplessness and also how they foster perseverance amid treatment-resistant CLBP.

RESEARCH DESIGN AND METHODS

Using van Manen's phenomenological method, semistructured, in-depth, one-on-one interviews were conducted with 21 older pain clinic patients (aged 66-83) living with CLBP. Data were iteratively analyzed via line-by-line thematic coding.

RESULTS

Findings dually illustrate how participants were living a battle between helplessness and perseverance; the final thematic structure revealed 5 subthemes: (a) Feeling helpless because nothing works; (b) Feeling down and depressed; (c) Distantly wishing for an end; (d) Accepting the reality of my pain; and (e) The pain stays, I keep going.

DISCUSSION AND IMPLICATIONS

This study contributes a vivid illustration of older adults' CLBP illness experiences that are substantially underpinned by helplessness, depression, and a drive to continue thriving in old age. Practice implications include the need for clinic-based mood and suicide assessment.

Attitudes and beliefs of older adults with acute low back pain: 12-month results from the Brazilian cohort back complaints in the elders

BACKGROUND

Psychosocial factors have been identified as important predictors of onset, course and persistence of low back pain (LBP) in the general population.

OBJECTIVE

To identify factors associated with attitudes/beliefs in older adults with LBP throughout a 12-month follow-up.

METHODS

A longitudinal investigation was conducted with 500 participants aged ≥60 years reporting a new (acute) episode of nonspecific LBP. Data were obtained at baseline, 6-week, 3-, 6-, 9-, and 12-month interviews. The study variables were: [dependent] LBP-related attitudes/beliefs that were assessed by the Back Beliefs Questionnaire (BBQ); [independent] age; sex; LBP intensity 'at-the-present-time' of interview and 'over-the-past-week' before interview; LBP frequency; LBP-related treatments; disability; mobility; depressive symptoms; self-perceived recovery; expectation of pain improvement; and expectation for returning to activities. Data were analysed by multiple linear regression analysis.

RESULTS

At baseline, 85.7% of the participants were female, had mean age of 69.0 (6.3) years, mean BBQ score of 24.5 (6.5), and 79.6% reported pain complaints after an acute episode of LBP. After 12 months, participants maintained a mean BBQ score of 24.6 (6.6) and 63.3% still reported pain complaints after an acute episode of LBP at baseline. Multivariate analysis showed that disability, advancing age, poor expectation of pain improvement in 3 months, and mobility decline were significantly associated with worse BBQ scores during all follow-ups.

CONCLUSION

Ageing, hopelessness, and physical and functional impairment impact pain-related behaviours among older patients seeking healthcare due to acute LBP complaints. Their screening may assist in strategies to manage symptoms and prevent the persistence of pain.

Multi-Dimensional Impact of Chronic Low Back Pain among Underserved African American and Latino Older Adults

Chronic low back pain is one of the most common, poorly understood, and potentially disabling chronic pain conditions from which older adults suffer. The existing low back pain research has relied almost exclusively on White/Caucasian participant samples. This study examines the correlates of chronic low back pain among a sample of underserved urban African American and Latino older adults. Controlling for age, gender, race/ethnicity, education, living arrangement, and number of major chronic conditions, associations between low back pain and the following outcome variables are examined: (1) healthcare utilization, (2) health-related quality of life (HR-QoL) and self-rated quality of health; and (3) physical and mental health outcomes.

METHODS

We recruited nine hundred and five (905) African American and Latino older adults from the South Los Angeles community using convenience and snowball sampling. In addition to standard items that measure demographic variables, our survey included validated instruments to document HR-QoL health status, the Short-Form McGill Pain Questionnaire-2, Geriatric Depression Scale, sleep disorder, and healthcare access. Data analysis includes bivariate and 17 independent multivariate models.

RESULTS

Almost 55% and 48% of the Latino and African American older adults who participated in our study reported chronic low back pain. Our data revealed that having low back pain was associated with three categories of outcomes including: (1) a higher level of healthcare utilization measured by (i) physician visits, (ii) emergency department visits, (iii) number of Rx used, (iv) a higher level of medication complexity, (v) a lower level of adherence to medication regimens, and (vi) a lower level of satisfaction with medical care; (2) a lower level of HR-QoL and self-assessment of health measured by (i) physical health QoL, (ii) mental health QoL, and (iii) a lower level of self-rated health; and (3) worse physical and mental health outcomes measured by (i) a higher number of depressive symptoms, (ii) a higher level of pain, (iii) falls, (iv) sleep disorders, (v) and being overweight/obese.

DISCUSSION

Low back pain remains a public health concern and significantly impacts the quality of life, health care utilization, and health outcomes of underserved minority older adults. Multi-faceted and culturally sensitive interventional studies are needed to ensure the timely diagnosis and treatment of low back pain among underserved minority older adults. Many barriers and challenges that affect underserved African American and Latino older adults with low back pain simply cannot be addressed in over-crowded EDs. Our study contributes to and raises the awareness of healthcare providers and health policymakers on the necessity for prevention, early diagnosis, proper medical management, and rehabilitation policies to minimize the burdens associated with chronic low back pain among underserved older African American and Latino patients in an under-resourced community such as South Los Angeles.

Static and Dynamic Pain Sensitivity in Adults With Persistent Low Back Pain: Comparison to Healthy Controls and Associations With Movement-evoked Pain Versus Traditional Clinical Pain Measures

OBJECTIVES

Despite its impact, individual factors associated with persistent low back pain (LBP) remain poorly understood. This study investigated static and dynamic pain sensitivity in adults with persistent LBP versus pain-free controls; and investigated associations between pain sensitivity and 3 clinical pain measures: recalled, resting, and movement-evoked pain (MEP).

MATERIALS AND METHODS

A lifespan sample of 60 adults with persistent LBP and 30 age-matched/sex-matched controls completed 4 laboratory sessions. Static pain sensitivity (pressure pain threshold [PPT], heat pain threshold) and dynamic pain sensitivity (heat pain aftersensations [AS], temporal summation [TS] of second heat pain) were measured. Demographic and clinical factors collected were education, global cognition, and perceived health. Resting and recalled pain were measured via questionnaire, and MEP via the Back Performance Scale.

RESULTS

LBP participants demonstrated lower PPT remotely (hand; F1,84=5.34, P=0.024) and locally (low back; F1,84=9.55, P=0.003) and also had higher AS (F1,84=6.01, P=0.016). Neither static nor dynamic pain sensitivity were associated with recalled pain (P>0.05). However, static pain sensitivity (local PPT) explained an additional 9% variance in resting pain, while dynamic pain sensitivity (AS, TS) explained an additional 10% to 12% variance in MEP.

DISCUSSION

This study characterized pain sensitivity measures among individuals with persistent LBP and suggests static pain sensitivity plays a larger role in resting pain while dynamic pain sensitivity plays a larger role in MEP. Future studies will confirm these relationships and elucidate the extent to which changes in static or dynamic pain sensitivity predict or mediate clinical pain among adults with persistent LBP.

Developing clinical prediction models for nonrecovery in older patients seeking care for back pain: the back complaints in the elders prospective cohort study

ABSTRACT

Back pain is a leading cause of disability worldwide and is common in older adults. No clinical prediction models for poor long-term outcomes have been developed in older patients with back pain. This study aimed to develop and internally validate 3 clinical prediction models for nonrecovery in this population. A prospective cohort study in general practice was conducted (Back Complaints in the Elders, Netherlands), including 675 patients >55 years with a new episode of care for back pain. Three definitions of nonrecovery were used combining 6-month and 12-month follow-up data: (1) persistent back pain, (2) persistent disability, and (3) perceived nonrecovery. Sample size calculation resulted in a maximum of 14 candidate predictors that were selected from back pain prognostic literature and clinical experience. Multivariable logistic regression was used to develop the models (backward selection procedure). Models' performance was evaluated with explained variance (Nagelkerke's R2), calibration (Hosmer-Lemeshow test), and discrimination (area under the curve [AUC]) measures. The models were internally validated in 250 bootstrapped samples to correct for overoptimism. All 3 models displayed good overall performance during development and internal validation (ie, R2 > 30%; AUC > 0.77). The model predicting persistent disability performed best, showing good calibration, discrimination (AUC 0.86, 95% confidence interval 0.83-0.89; optimism-adjusted AUC 0.85), and explained variance (R2 49%, optimism-adjusted R2 46%). Common predictors in all models were: age, chronic duration, disability, a recent back pain episode, and patients' recovery expectations. Spinal morning stiffness and pain during spinal rotation were included in 2 of 3 models. These models should be externally validated before being used in a clinical primary care setting.

Acupuncture Intervention Protocol: Consensus Process for a Pragmatic Randomized Controlled Trial of Acupuncture for Management of Chronic Low Back Pain in Older Adults: An NIH HEAL Initiative Funded Project

Objective

The aim of this article is to describe the consensus process used to develop an acupuncture intervention protocol for an NIH-funded pragmatic randomized controlled trial (PRCT) of acupuncture for the management of chronic low back (cLBP) in older adults (BackInAction).

Background

CLBP is among leading causes of disability worldwide: almost 33% of US adults 65 and older experience LBP. Acupuncture is effective for cLBP but there is no specific data on older adults. The National Institutes for Health (NIH) funded a PRCT of acupuncture needling for this population. An essential trial milestone was development of a consensus intervention protocol.

Methods

An Acupuncture Advisory Panel (AAP) was formed with nine members: two physician-acupuncturists, six licensed acupuncturists representing diverse work backgrounds, and an acupuncture researcher. We used a modified Delphi process that included provision of acupuncture trial data, survey data describing how each expert treats cLBP, three conference calls, and between-call email discussion.

Results

Lively and professional discussions led to a consensus intervention protocol for the BackInAction trial that included steps/staging of care, recommendations for parameters of care session length, number of needle insertion sites, insertion depths, needle retention times, recommended types of needles, both local and distal areas of the body to be treated, acupuncture point options, auricular point options, self-care options, and minimum number of sessions considered ideal.

Conclusion

Using a modified Delphi process, an expert AAP created a consensus intervention protocol for the PRCT of acupuncture needling for cLBP in patients 65 and older.

Risk Factors for Recurrent L4-5 Disc Herniation After Percutaneous Endoscopic Transforaminal Discectomy: A Retrospective Analysis of 654 Cases

Background

Percutaneous endoscopic lumbar discectomy (PELD) is an increasingly applied minimally invasive procedure that has several advantages in the treatment of lumbar disc herniation (LDH). However, recurrent LDH (rLDH) has become a concerning postoperative complication. It remains difficult to establish a consensus and draw reliable conclusions regarding the risk factors for rLDH.

Purpose

This retrospective study aimed to investigate the risk factors associated with rLDH at the L4-5 level after percutaneous endoscopic transforaminal discectomy (PETD).

Methods

A total of 654 patients who underwent the PETD procedure at the L4-5 level from October 2013 to January 2020 were divided into a recurrence (R) group (n=46) and a nonrecurrence (N) group (n=608). Demographic and clinical data and imaging parameters were collected and analyzed using univariate and multiple regression analyses.

Results

The current study found a 7% rate of rLDH at the L4/5 level after successful PETD. Univariate analysis showed that older age, high BMI, diabetes mellitus history, smoking, large physical load intensity, moderate disc degeneration, small muscle-disc ratio (M/D), more fat infiltration, large sagittal range of motion (sROM), scoliosis, small disc height index (DHI), small intervertebral space angle (ISA), and small lumbar lordosis (LL) were potential risk factors (P < 0.10) for LDH recurrence after PETD at the L4-5 level. Multivariate analysis suggested that high BMI, large physical load intensity, moderate disc degeneration, small M/D, more fat infiltration, large sROM, small ISA, and small LL were independent significant risk factors for recurrence of LDH after PETD.

Conclusion

Consideration of disc degeneration, M/D, fat infiltration of the paravertebral muscles, sROM, ISA, LL, BMI, and physical load intensity prior to surgical intervention may contribute to the prevention of rLDH following PETD and lead to a more satisfactory operative outcome and the development of a reasonable rehabilitation program after discharge.

The Effectiveness of a Dyadic Pain Management Program for Community-Dwelling Older Adults with Chronic Pain: A Pilot Randomized Controlled Trial

Background: Chronic pain is a major health problem among older adults and their informal caregivers, which has negative effects on their physical and psychological status. The dyadic pain management program (DPMP) is provided to community-dwelling older adults and informal caregivers to help the dyads reduce pain symptoms, improve the quality of life, develop good exercise habits, as well as cope and break the vicious circle of pain. Methods: A pilot randomized controlled trial was designed and all the dyads were randomly divided into two groups: the DPMP group and control group. Dyads in the DPMP group participated in an 8-week DPMP (4-week face-to-face program and 4-week home-based program), whereas dyads in the control group received one page of simple pain-related information. Results: In total, 64 dyads participated in this study. For baseline comparisons, no significant differences were found between the two groups. After the interventions, the pain score was significantly reduced from 4.25 to 2.57 in the experimental group, respectively. In the repeated measures ANOVA, the differences in pain score (F = 107.787, p < 0.001, d = 0.777) was statistically significant for the group-by-time interaction. After the interventions, the experimental group participants demonstrated significantly higher pain self-efficacy compared with the control group (F = 80.535, p < 0.001, d = 0.722). Furthermore, the elderly increased exercise time significantly (F = 111.212, p < 0.001, d = 0.782) and reported developing good exercise habits. Conclusions: These results provide preliminary support for the effectiveness of a DPMP for relieving the symptoms of chronic pain among the elderly.

Caring for older veterans with chronic low back pain using a geriatric syndrome approach: Rationale and methods for the aging back clinics (ABC) trial

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.

Automatic Characterizations of Lumbar Multifidus Muscle and Intramuscular Fat with Fuzzy C-means based Quantization from Ultrasound Images

BACKGROUND

Low Back Pain (LBP) is a common disorder involving the muscles and bones and about half of the people experience LBP at some point of their lives. Since the social economic cost and the recurrence rate over the lifetime is very high, the treatment/rehabilitation of chronic LBP is important to physiotherapists, both for clinical and research purposes. Trunk muscles such as the lumbar multifidi is important in spinal functions and intramuscular fat is also important in understanding pain control and rehabilitations. However, the analysis of such muscles and related fat require many human interventions and thus suffers from the operator subjectivity especially when the ultrasonography is used due to its cost-effectiveness and no radioactive risk.

AIMS

In this paper, we propose a fully automatic computer vision based software to compute the thickness of the lumbar multifidi muscles and to analyze intramuscular fat distribution in that area.

METHODS

The proposed system applies various image processing algorithms to enhance the intensity contrast of the image and measure the thickness of the target muscle. Intermuscular fat analysis is done by Fuzzy C-Means (FCM) clustering based quantization.

RESULTS

In experiment using 50 DICOM format ultrasound images from 50 subjects, the proposed system shows very promising result in computing the thickness of lumbar multifidi.

CONCLUSION

The proposed system have minimal discrepancy(less than 0.2 cm) from human expert for 72% (36 out of 50 cases) of the given data. Also, FCM based intramuscular fat analysis looks better than conventional histogram analysis.

Short- or Long-Term Treatment of Spinal Disability in Older Adults With Manipulation and Exercise

OBJECTIVE

Back and neck pain are associated with disability and loss of independence in older adults. Whether long-term management using commonly recommended treatments is superior to shorter-term treatment is unknown. This randomized clinical trial compared short-term treatment (12 weeks) versus long-term management (36 weeks) of back- and neck-related disability in older adults using spinal manipulative therapy (SMT) combined with supervised rehabilitative exercises (SRE).

METHODS

Eligible participants were ages ≥65 years with back and neck disability for ≥12 weeks. Coprimary outcomes were changes in Oswestry Disability Index (ODI) and Neck Disability Index (NDI) scores after 36 weeks. An intent-to-treat approach used linear mixed-model analysis to detect between-group differences. Secondary analyses included other self-reported outcomes, adverse events, and objective functional measures.

RESULTS

A total of 182 participants were randomized. The short-term and long-term groups demonstrated significant improvements in back disability (ODI score -3.9 [95% confidence interval (95% CI) -5.8, -2.0] versus ODI score -6.3 [95% CI -8.2, -4.4]) and neck disability (NDI score -7.3 [95% CI -9.1, -5.5] versus NDI score -9.0 [95% CI -10.8, -7.2]) after 36 weeks, with no difference between groups (back ODI score 2.4 [95% CI -0.3, 5.1]; neck NDI score 1.7 [95% CI 0.8, 4.2]). The long-term management group experienced greater improvement in neck pain at week 36, in self-efficacy at weeks 36 and 52, and in functional ability, and balance.

CONCLUSION

For older adults with chronic back and neck disability, extending management with SMT and SRE from 12 to 36 weeks did not result in any additional important reduction in disability.

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults

Objective

To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions.

Methods

A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models.

Results

About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures.

Conclusions

New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.

T'ai Chi for Chronic Low Back Pain in Older Adults: A Feasibility Trial

Objectives: T'ai chi (TC) has been found effective for improving chronic low back pain (cLBP). However, such studies did not include adults over 65 years of age. This study was designed to evaluate the feasibility and acceptability of TC in this population compared with Health Education (HE) and with Usual Care (UC). Design: Feasibility randomized controlled trial. Settings/Location: Participants were recruited from Kaiser Permanente Washington and classes took place in a Kaiser facility. Patients: Adults 65 years of age and older with cLBP. Interventions: Twenty-eight participants were randomized to 12 weeks of TC followed by a 24-week tapered TC program, 12 were assigned to a 12-week HE intervention and 17 were assigned to UC only. Outcome Measures: Feasibility and acceptability were determined by recruitment, retention and 12-, 26-, and 52-week follow-up rates, instructor adherence to protocol, class attendance, TC home practice, class satisfaction, and adverse events. Results: Fifty-seven participants were enrolled in two cohorts of 28 and 29 during two 4-month recruitment periods. Questionnaire follow-up completion rates ranged between 88% and 93%. Two major class protocol deviations were noted in TC and none in HE. Sixty-two percent of TC participants versus 50% of HE participants attended at least 70% of the classes during the 12-week initial intervention period. Weekly rates of TC home practice were high among class attendees (median of 4.2 days) at 12 weeks, with fewer people practicing at 26 and 52 weeks. By 52 weeks, 70% of TC participants reported practicing the week before, with a median of 3 days per week and 15 min/session. TC participants rated the helpfulness of their classes significantly higher than did HE participants, but the groups were similarly likely to recommend the classes. Conclusion: The TC intervention is feasible in this population, while the HE group requires modifications in delivery.

Aging Back Clinics-a Geriatric Syndrome Approach to Treating Chronic Low Back Pain in Older Adults: Results of a Preliminary Randomized Controlled Trial

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.

A Review of the Development and Application of Generic Preference-Based Instruments with the Older Population

Older people (aged 65 years and over) are the fastest growing age cohort in the majority of developed countries, and the proportion of individuals defined as the oldest old (aged 80 years and over) living with physical frailty and cognitive impairment is rising. These population changes put increasing pressure on health and aged care services, thus it is important to assess the cost effectiveness of interventions targeted for older people across health and aged care sectors to identify interventions with the strongest capacity to enhance older peoples' quality of life and provide value for money. Cost-utility analysis (CUA) is a form of economic evaluation that typically uses preference-based instruments to measure and value health-related quality of life for the calculation of quality-adjusted life-years (QALYS) to enable comparisons of the cost effectiveness of different interventions. A variety of generic preference-based instruments have been used to measure older people's quality of life, including the Adult Social Care Outcomes Toolkit (ASCOT); Health Utility Index Mark 2 (HUI2); Health Utility Index Mark 3 (HUI3); Short-Form-6 Dimensions (SF-6D); Assessment of Quality of Life-6 dimensions (AQoL-6D); Assessment of Quality of Life-8 dimensions (AQoL-8D); Quality of Wellbeing Scale-Self-Administered (QWB-SA); 15 Dimensions (15D); EuroQol-5 dimensions (EQ-5D); and an older person specific preference-based instrument-the Investigating Choice Experiments Capability Measure for older people (ICECAP-O). This article reviews the development and application of these instruments within the older population and discusses the issues surrounding their use with this population. Areas for further research relating to the development and application of generic preference-based instruments with populations of older people are also highlighted.

Individual recovery expectations and prognosis of outcomes in non-specific low back pain: prognostic factor review

BACKGROUND

Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.

OBJECTIVES

To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.

SEARCH METHODS

The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.

SELECTION CRITERIA

We included low back pain prognosis studies from any setting assessing general, self-efficacy, and treatment expectations (measured dichotomously and continuously on a 0 - 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow-up.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta-analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.

MAIN RESULTS

We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty-five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation. Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate-quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta-analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low-quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta-analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow-up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta-analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta-analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow-up times closest to 12 months using adjusted data, is less certain, achieving very low- and low-quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.

AUTHORS' CONCLUSIONS

We found that individual recovery expectations are probably strongly associated with future work participation (moderate-quality evidence) and may be associated with clinically important recovery outcomes (low-quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.

Development of an Evaluative, Educational, and Communication-Facilitating App for Older Adults with Chronic Low Back Pain: Patient Perceptions of Usability and Utility

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.

Low Back Pain--Related Disability in Parkinson Disease: Impact on Functional Mobility, Physical Activity, and Quality of Life

BACKGROUND

People with Parkinson disease (PD) frequently experience low back pain (LBP), yet the impact of LBP on functional mobility, physical activity, and quality of life (QOL) has not been described in PD.

OBJECTIVE

The objectives of this study were to describe body positions and functional activities associated with LBP and to determine the relationships between LBP-related disability and PD motor sign severity, physical activity level, and QOL.

DESIGN

The study was a cross-sectional study.

METHODS

Thirty participants with idiopathic PD (mean age = 64.6 years [SD = 10.3]; 15 women) completed the Revised Oswestry Disability Questionnaire (RODQ), a measure of LBP-related disability. PD motor symptom severity was measured using the Movement Disorder Society-Unified Parkinson Disease Rating Scale Part III (MDS-UPRDS III). The Physical Activity Scale for the Elderly (PASE) was used to measure self-reported physical activity. The Parkinson Disease Questionnaire-39 (PDQ-39) was used to measure QOL. Descriptive statistics were used to characterize LBP intensity and LBP-related disability. Spearman correlations were used to determine relationships between the RODQ and the MDS-UPDRS III, PASE, and PDQ-39.

RESULTS

LBP was reported to be of at least moderate intensity by 63.3% of participants. LBP most frequently impaired standing, sleeping, lifting, and walking. The RODQ was significantly related to the MDS-UPDRS III (r = 0.38), PASE (r = -0.37), PDQ-39 summary index (r = 0.55), PDQ-39 mobility subdomain (r = 0.54), and PDQ-39 bodily pain subdomain (r = 0.44).

LIMITATIONS

Limitations included a small sample of people with mild to moderate PD severity, the fact that RODQ is a less frequently used measure of LBP-related disability, and the lack of a non-PD control group.

CONCLUSIONS

LBP affected walking, sleeping, standing, and lifting in this small sample of people with mild to moderate PD. Greater LBP-related disability was associated with greater motor sign severity, lower physical activity level, and lower QOL in people with PD.

The effect of high-intensity resistance exercise on lumbar musculature in patients with low back pain: a preliminary study

Background

Muscle atrophy and fatty infiltration of the lumbar extensors is associated with LBP. Exercise-based rehabilitation targets strengthening these muscles, but few studies show consistent changes in muscle quality with standard-of-care rehabilitation. The goal of this study was to assess the effect of high-intensity resistance exercise on lumbar extensor muscle size (cross sectional area) and quality (fat fraction) in individuals with low back pain (LBP).

Methods

Fourteen patients with LBP were recruited from a local rehabilitation clinic. Patients underwent MRI scanning before and after a standardized 10-week high-intensity machine-based, resistance exercise program. Patient pain, disability, anxiety/depression, satisfaction, strength, and range of motion was compared pre- and post-rehabilitation using analysis of covariance (covariates: age, gender). Exercise-induced changes in MRI, and patient functional outcome measures were correlated using Pearson’s correlation test.

Results

No significant differences were found in muscle size or fatty infiltration of the lumbar extensors over the course of rehabilitation (p > 0.31). However, patients reported reduced pain (p = 0.002) and were stronger (p = 0.03) at the conclusion of the program. Improvements in muscle size and quality for both multifidus and erector spinae correlated with improvements in disability, anxiety/depression, and strength.

Conclusion

While average muscle size and fatty infiltration levels did not change with high-intensity exercise, the results suggest that a subgroup of patients who demonstrate improvements in muscle health demonstrate the largest functional improvements. Future research is needed to identify which patients are most likely to respond to this type of treatment.

Associations of Race and Ethnicity With Patient-Reported Outcomes and Health Care Utilization Among Older Adults Initiating a New Episode of Care for Back Pain

STUDY DESIGN

Secondary analysis of the Back Pain Outcomes using Longitudinal Data (BOLD) cohort study.

OBJECTIVE

To characterize associations of self-reported race/ethnicity with back pain (BP) patient-reported outcomes (PROs) and health care utilization among older adults with a new episode of care for BP.

SUMMARY OF BACKGROUND DATA

No prior longitudinal studies have characterized associations between multiple race/ethnicity groups, and BP-related PROs and health care utilization in the United States.

METHODS

This study included 5117 participants ≥65 years from three US health care systems. The primary BP-related PROs were BP intensity and back-related functional limitations over 24 months. Health care utilization measures included common diagnostic tests and treatments related to BP (spine imaging, spine-related relative value units [RVUs], and total RVUs) over 24 months. Analyses were adjusted for multiple potential confounders including sociodemographics, clinical characteristics, and study site.

RESULTS

Baseline BP ratings were significantly higher for blacks vs. whites (5.8 vs. 5.0; P < 0.001). Participants in all race/ethnicity groups showed statistically significant, but modest improvements in BP over 24 months. Blacks and Hispanics did not have statistically significant improvement in BP-related functional limitations over time, unlike whites, Asians, and non-Hispanics; however, the magnitude of differences in improvement between groups was small. Blacks had less spine-related health care utilization over 24 months than whites (spine-related RVU ratio of means 0.66, 95% confidence interval [CI] 0.51-0.86). Hispanics had less spine-related health care utilization than non-Hispanics (spine-related RVU ratio of means 0.60; 95% CI 0.40-0.90).

CONCLUSION

Blacks and Hispanics had slightly less improvement in BP-related functional limitations over time, and less spine-related health care utilization, as compared to whites and non-Hispanics, respectively. Residual confounding may explain some of the association between race/ethnicity and health outcomes. Further studies are needed to understand the factors underlying these differences and which differences reflect disparities.

LEVEL OF EVIDENCE

3.

Living a Life Full of Pain: Older Pain Clinic Patients' Experience of Living With Chronic Low Back Pain

Chronic low back pain (CLBP) is older adults' most common pain complaint and is associated with many physical and psychosocial consequences, which have been quantitatively examined. However, little research has qualitatively examined the experience itself of CLBP in later life. Study objective was to understand older adults' lived CLBP experience. Guided by van Manen's phenomenological method, 21 pain clinic patients aged 66 to 83 completed semistructured interviews. Under the main theme "living a life full of pain," results are reflected in four existential subthemes: (a) Corporeality: The pain is relentless and constantly monitored, (b) Temporality: To live with pain is to live by pacing day and night, (c) Relationality: Pain creates limits that can be tested or obeyed, and (d) Spatiality: Manipulating the space around me to accommodate the pain. Findings improve understanding of the patient experience of late life CLBP and highlights the importance of empathy and patient-centeredness when treating older adults.

A longitudinal study of the influence of comorbidities and lifestyle factors on low back pain in older men

Older adults are largely under-represented in low back pain (LBP) research. In light of the ageing population, it is crucial to understand the influence of comorbidities and lifestyle factors on the risk and prognosis of LBP in older adults. The aims of this study were to describe the course of LBP in older men; to investigate whether comorbidities/lifestyle factors can predict the course of LBP in older men; to assess if comorbidities/lifestyle factors increase the risk of developing LBP in older men. The study sample comprised 1685 older men living in suburban Sydney, Australia. Low back pain, sociodemographic measures, lifestyle factors, and comorbidities were assessed. Of the 1012 men with LBP at baseline, 58% still reported having pain at the 24-month follow-up. Of those without pain at baseline (n = 673), 28% reported pain at follow-up. The odds of persistent pain at 24 months increased with each additional alcoholic drink/wk (odds ratio [OR] = 1.10, 95% confidence interval [CI]: 1.01-1.22; P = 0.03) and each additional unit of body mass index (OR = 1.28, 95% CI: 1.04-1.60; P = 0.02), but reduced for men who speak English at home (OR = 0.58, 95% CI: 0.35-0.96; P = 0.03). In older men, free of LBP at baseline (n = 673), for every additional comorbidity there was an increased risk of developing LBP (OR = 1.17, 95% CI: 1.00-1.37; P = 0.05). These results demonstrate the influence of lifestyle factors and comorbidities on LBP in older men and suggest that the consideration of these issues in management may improve outcomes.

Predictive Validity of the STarT Back Tool for Risk of Persistent Disabling Back Pain in a U.S. Primary Care Setting

OBJECTIVE

To examine the predictive validity of the Subgrouping for Targeted Treatment (STarT Back) tool for classifying people with back pain into categories of low, medium, and high risk of persistent disabling back pain in U.S. primary care.

DESIGN

Secondary analysis of data from participants receiving usual care in a randomized clinical trial.

SETTING

Primary care clinics.

PARTICIPANTS

Adults (N = 1109) ≥18 years of age with back pain. Those with specific causes of back pain (pregnancy, disc herniation, vertebral fracture, spinal stenosis) and work-related injuries were not included.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The original 9-item version of the STarT Back tool, administered at baseline, stratified patients by their risk (low, medium, high) of persistent disabling back pain (STarT Back risk group). Persistent disabling back pain was defined as Roland-Morris Disability Questionnaire scores of ≥7 at 6-month follow-up.

RESULTS

The STarT Back risk group was a significant predictor of persistent disabling back pain (P<.0001) at 6-month follow-up. The proportion of individuals with persistent disabling back pain at follow-up was 22% (95% confidence interval [CI] 18-25) in the low-risk group, 62% (95% CI 57-67) in the medium-risk group, and 80% (95% CI 75-85) in the high-risk group. The relative risk of persistent disabling back pain was 2.9 (95% CI 2.4-3.5) in the medium-risk group compared to the low-risk group, and 3.7 (95% CI 3.1-4.4) in the high-risk group.

CONCLUSIONS

The STarT Back risk groups successfully separated people with back pain into distinct categories of risk for persistent disabling back pain at 6-month follow-up in U.S. primary care. These results were very similar to those in the original STarT Back validation study. This validation study is a necessary first step toward identifying whether the entire STarT Back approach, including matched/targeted treatment, can be effectively used for primary care in the United States.

Predictors of Persistent Disability and Back Pain in Older Adults with a New Episode of Care for Back Pain

Objective

To identify predictors of persistent disability and back pain in older adults.

Design

Prospective cohort study.

Setting

Back pain outcomes using longitudinal data registry.

Subjects

Five thousand two hundred twenty adults age 65 years and older with a new primary care visit for back pain.

Methods

Baseline measurements included: demographics, health, and back pain characteristics. We abstracted imaging findings from 348 radiology reports. The primary outcomes were the Roland-Morris Disability Questionnaire (RMDQ) and back pain intensity. We defined persistent disability as RMDQ of 4/24 or higher at both six and 12 months and persistent back pain as pain 3/10 or higher at both six and 12 months.

Results

There were 2,498 of 4,143 (60.3%) participants with persistent disability, and 2,099 of 4,144 (50.7%) had persistent back pain. Adjusted analyses showed the following characteristics most strongly predictive of persistent disability and persistent back pain: sex, race, worse baseline clinical characteristics of back pain, leg pain, back-related disability and duration of symptoms, smoking, anxiety symptoms, depressive symptoms, a history of falls, greater number of comorbidities, knee osteoarthritis, wide-spread pain syndromes, and an index diagnosis of lumbar spinal stenosis. Within the imaging data subset, central spinal stenosis was not associated with disability or pain.

Conclusion

We found that many predictors in older adults were similar to those for younger populations.

Lumbopelvic Pain and Threats to Walking Ability in Well-Functioning Older Adults: Findings from the Baltimore Longitudinal Study of Aging

OBJECTIVES

To examine the potential contribution of severity of lumbopelvic pain (LPP) in well-functioning older adults to poorer walking efficiency, lack of endurance, slower gait speed, and decline in these mobility parameters over 1 to 5 years.

DESIGN

Longitudinal analysis of Baltimore Longitudinal Study of Aging data.

SETTING

National Institute on Aging, Clinical Research Unit, Baltimore, Maryland.

PARTICIPANTS

Well-functioning men and women aged 60 to 89 (N=878).

MEASUREMENTS

An interviewer-administered questionnaire was used to ascertain reported presence and severity of back and hip pain in the preceding 12 months and reported walking ability, including ease of walking a mile. Certified examiners assessed usual gait speed, the energetic cost of walking (oxygen consumption, mL per kg/m), and time taken to walk 400 m as quickly as possible. Covariates included sex, age, age-squared, race, height, weight, exercise, and smoking.

RESULTS

Overall, 31.4% had mild LPP, and 15.7% had moderate to severe LPP. In adjusted analyses, reported walking ability (p<.001), endurance walk performance (p=.007), and energetic cost of walking (p=.049) were worse with increasing LPP severity. Usual gait speed did not vary according to LPP (p=.31). Longitudinally, over an average 2.3 years, persons with new or sustained LPP had worse follow-up level, greater mean decline, and higher likelihood of meaningful decline in reported walking ability than persons free of LPP or whose LPP resolved. Walking performance did not differ according to LPP follow-up status.

CONCLUSION

LPP was common in well-functioning older adults and was associated with greater energetic cost of walking and poorer perceived and observed walking endurance. The longitudinal effect of LPP is unclear, but worsening perception of walking ability and its contribution to future mobility loss warrants further attention.

Associations Between Relative Value Units and Patient-Reported Back Pain and Disability

Objective: To describe associations between health care utilization measures and patient-reported outcomes (PROs). Method: Primary data were collected from patients ≥65 years with low back pain visits from 2011 to 2013. Six PROs of pain and functionality were collected 12 and 24 months after the index visits and total and spine-specific relative value units (RVUs) from electronic health records were tabulated over 1 year. We calculated correlation coefficients between RVUs and 12- and 24-month PROs and conducted linear regressions with each 12- and 24-month PRO as the outcome variables and RVUs as predictors of interest. Results: We observed very weak correlations between worse PROs at 12 and 24 months and greater 12-month utilization. In regression analyses, we observed slight associations between greater utilization and worse 12- and 24-month PROs. Discussion: We found that 12-month health care utilization is not strongly associated with PROs at 12 or 24 months.

Multifidi Muscle Characteristics and Physical Function Among Older Adults With and Without Chronic Low Back Pain

OBJECTIVE

To determine whether multifidi size, intramuscular fat, or both, are associated with self-reported and performance-based physical function in older adults with and without chronic low back pain (LBP).

DESIGN

Case-control study.

SETTING

Individuals participated in a standardized evaluation in a clinical laboratory and underwent magnetic resonance imaging (MRI) of the lumbar spine at a nearby facility.

PARTICIPANTS

A volunteer sample of community-dwelling older adults (N=106), aged 60 to 85 years, with (n=57) and without (n=49) chronic LBP were included in this secondary data analysis.

INTERVENTION

Average right-left L5 multifidi relative (ie, total) cross-sectional area (CSA), muscle-fat infiltration index (MFI) (ie, a measure of intramuscular fat), and relative muscle CSA (rmCSA) (ie, total CSA minus intramuscular fat CSA) were determined from MRIs. Linear regression modeling was performed with physical function measures as the dependent variables. Age, sex, and body mass index were entered as covariates. The main effects of L5 multifidi MFI and rmCSA, as well as their interaction with group assignment, were compared as independent variables.

MAIN OUTCOME MEASURES

Medical Outcomes Study 36-Item Short-Form Health Survey physical functioning subscale, timed Up and Go, gait speed, and fast stair descent performance.

RESULTS

Interaction terms between L5 multifidi MFI and group assignment were found to be significant contributors to the variance explained in all physical function measures (P≤.012). Neither the main effect nor the interaction with group assignment for L5 multifidi rmCSA significantly contributed to the variance explained in any of the physical function measures (P>.012).

CONCLUSIONS

Among older adults with chronic LBP of at least moderate intensity, L5 multifidi muscle composition, but not size, may help to explain physical function.

Identifying Treatment Effect Modifiers in the STarT Back Trial: A Secondary Analysis

Identification of patient characteristics influencing treatment outcomes is a top low back pain (LBP) research priority. Results from the STarT Back trial support the effectiveness of prognostic stratified care for LBP compared with current best care, however, patient characteristics associated with treatment response have not yet been explored. The purpose of this secondary analysis was to identify treatment effect modifiers within the STarT Back trial at 4-month follow-up (n = 688). Treatment response was dichotomized using back-specific physical disability measured using the Roland-Morris Disability Questionnaire (≥7). Candidate modifiers were identified using previous literature and evaluated using logistic regression with statistical interaction terms to provide preliminary evidence of treatment effect modification. Socioeconomic status (SES) was identified as an effect modifier for disability outcomes (odds ratio [OR] = 1.71, P = .028). High SES patients receiving prognostic stratified care were 2.5 times less likely to have a poor outcome compared with low SES patients receiving best current care (OR = .40, P = .006). Education level (OR = 1.33, P = .109) and number of pain medications (OR = .64, P = .140) met our criteria for effect modification with weaker evidence (.20 > P ≥ .05). These findings provide preliminary evidence for SES, education, and number of pain medications as treatment effect modifiers of prognostic stratified care delivered in the STarT Back Trial.

PERSPECTIVE

This analysis provides preliminary exploratory findings about the characteristics of patients who might least likely benefit from targeted treatment using prognostic stratified care for LBP.

Effect of Comorbid Knee and Hip Osteoarthritis on Longitudinal Clinical and Health Care Use Outcomes in Older Adults With New Visits for Back Pain

OBJECTIVE

To examine if a comorbid diagnosis of knee or hip osteoarthritis (OA) in older adults with new back pain visits is associated with long-term patient-reported outcomes and back-related health care use.

DESIGN

Prospective cohort study.

SETTING

Three integrated health systems forming the Back pain Outcomes using Longitudinal Data cohort.

PARTICIPANTS

Participants (N=5155) were older adults (≥65y) with a new visit for back pain and a complete electronic health record data.

INTERVENTIONS

Not applicable; we obtained OA diagnoses using diagnostic codes in the electronic health record 12 months prior to the new back pain visit.

MAIN OUTCOME MEASURES

The Roland-Morris Disability Questionnaire (RDQ) and the EuroQol-5D (EQ-5D) were key patient-reported outcomes. Health care use, measured by relative-value units (RVUs), was summed for the 12 months after the initial visit. We used linear mixed-effects models to model patient-reported outcomes. We also used generalized linear models to test the association between comorbid knee or hip OA and total back-related RVUs.

RESULTS

Of the 5155 participants, 368 (7.1%) had a comorbid knee OA diagnosis, and 94 (1.8%) had a hip OA diagnosis. Of the participants, 4711 (91.4%) had neither knee nor hip OA. In adjusted models, the 12-month RDQ score was 1.23 points higher (95% confidence interval [CI], 0.72-1.74) for patients with knee OA and 1.26 points higher (95% CI, 0.24-2.27) for those with hip OA than those without knee or hip OA, respectively. A lower EQ-5D score was found among participants with knee OA (.02 lower; 95% CI, -.04 to -.01) and hip OA diagnoses (.03 lower; 95% CI, -.05 to -.01) compared with those without knee or hip OA, respectively. Comorbid knee or hip OA was not significantly associated with total 12-month back-related resource use.

CONCLUSIONS

Comorbid knee or hip OA in older adults with a new back pain visit was associated with modestly worse long-term disability and health-related quality of life.