Deconstructing Chronic Low Back Pain in the Older Adult: Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part IV: Depression

Chronic Pain in Older Adults: A Neuroscience-Based Psychological Assessment and Treatment Approach

Chronic pain remains a serious healthcare challenge, particularly for older adults who suffer substantial disability and are susceptible to serious risks from pain medications and invasive procedures. Psychotherapy is a promising option for older adults with chronic pain, since it does not contribute to medical or surgical risks. However, standard psychotherapies for chronic pain, including cognitive-behavioral therapy (CBT), acceptance and commitment therapy, and mindfulness-based interventions, produce only modest and time-limited benefits for older adults. In this article, we describe a novel, evidence-based psychological assessment and treatment approach for older adults with chronic pain, including a detailed case example. The approach begins with reviewing patients' pain, psychosocial, and medical histories to elicit evidence of a subtype of chronic pain called centralized (primary, nociplastic, or psychophysiologic) pain, which is highly influenced and may even be caused by life stress, emotions, and alterations in brain function. Patients then undertake a novel psychotherapy approach called emotional awareness and expression therapy (EAET) that aims to reduce or eliminate centralized pain by resolving trauma and emotional conflicts and learning healthy communication of adaptive emotions. Our published preliminary clinical trial (n = 53) indicated that EAET produced statistically significant and large effect size advantages over CBT in pain reduction and marginally greater improvements in pain interference than CBT for older adults with chronic musculoskeletal pain. Geriatric mental healthcare providers may learn this assessment and treatment approach to benefit many of their patients with chronic pain.

A history of depression in patients attending a chronic pain management clinic in South Africa: A retrospective chart review

Background: Chronic pain and depression are closely related conditions, which commonly exist as comorbid disorders. Understanding the prevalence of depression in patients presenting with chronic pain is vital for effective pain management.Aim: Our study aimed to establish the prevalence of a history of depression in patients presenting with chronic pain to a chronic pain management clinic at a tertiary academic hospital and to describe the characteristics of patients with both conditions.Setting: Groote Schuur Hospital, Chronic Pain Management Clinic, Cape Town, South Africa.Method: A retrospective review of 665 medical charts of consecutive patients accessing the clinic over a 7-year period was conducted. Baseline, patient-centred data were collected.Results: Of the 665 charts, 623 were analysed. The median age of patients was 53 years. The prevalence of depression in patients presenting with chronic pain was 32%, three times higher than the national life-time prevalence in South Africa. The majority (77%) of patients with chronic pain and depression were female (p  0.01). Overall, 51% of the patients assessed were unemployed with low levels of education. The majority of our study patients had received a tricyclic antidepressant at some time prior to presentation.Conclusion: The high prevalence of a history of depression in patients presenting with chronic pain in our study, emphasises the importance of looking for and understanding the interrelation of the physiological, psychiatric, psychological and socio-economic factors that are common to both depression and chronic pain. Pain relief alone is insufficient to ensure optimal rehabilitation of these patients and integrating the management of their depression should improve patient outcomes and overall well-being.

Management of Chronic Low Back Pain and the Impact on Patients’ Personal and Professional Lives: Results From an International Patient Survey

Objective

Methods

Results

Conclusion

The Effectiveness of Cannabis and Cannabis Derivatives in Treating Lower Back Pain in the Aged Population: A Systematic Review

BACKGROUND/AIMS

Cannabis is increasingly used in the management of pain, though minimal research exists to support its use since approval. Reduction in stigma has led to a growing interest in pharmaceutical cannabinoids as a possible treatment for lower back pain (LBP). The objective of this review was to assess the role and efficacy of cannabis and its derivatives in the management of LBP and compile global data related to the role of cannabis in the management of LBP in an aging population.

METHODS

A systematic review was conducted using predetermined keywords by 3 independent researchers. Predetermined inclusion and exclusion criteria were applied, and 23 articles were selected for further analysis.

RESULTS

Studies identified both significant and insignificant impacts of cannabis on LBP. Contradicting evidence was noted on the role of cannabis in the management of anxiety and insomnia, 2 common comorbidities with LBP. The existing literature suggests that cannabis may be used in the management of LBP and comorbid symptoms.

CONCLUSIONS

Further research is needed to consider cannabis as an independent management option. There is a lack of evidence pertaining to the benefits of cannabis in an aged population, and thus, additional research is warranted to support its use in the aged population.

Prevalence and patterns of multimorbidity in Australian baby boomers: the Busselton healthy ageing study

BACKGROUND AND OBJECTIVE

Chronic medical conditions accumulate within individuals with age. However, knowledge concerning the trends, patterns and determinants of multimorbidity remains limited. This study assessed the prevalence and patterns of multimorbidity using extensive individual phenotyping in a general population of Australian middle-aged adults.

METHODS

Participants (n = 5029, 55% female), born between 1946 and 1964 and attending the cross-sectional phase of the Busselton Healthy Ageing Study (BHAS) between 2010 and 2015, were studied. Prevalence of 21 chronic conditions was estimated using clinical measurement, validated instrument scores and/or self-reported doctor-diagnosis. Non-random patterns of multimorbidity were explored using observed/expected (O/E) prevalence ratios and latent class analysis (LCA). Variables associated with numbers of conditions and class of multimorbidity were investigated.

RESULTS

The individual prevalence of 21 chronic conditions ranged from 2 to 54% and multimorbidity was common with 73% of the cohort having 2 or more chronic conditions. (mean ± SD 2.75 ± 1.84, median = 2.00, range 0-13). The prevalence of multimorbidity increased with age, obesity, physical inactivity, tobacco smoking and family history of asthma, diabetes, myocardial infarct or cancer. There were 13 pairs and 27 triplets of conditions identified with a prevalence > 1.5% and O/E > 1.5. Of the triplets, arthritis (> 50%), bowel disease (> 33%) and depression-anxiety (> 33%) were observed most commonly. LCA modelling identified 4 statistically and clinically distinct classes of multimorbidity labelled as: 1) "Healthy" (70%) with average of 1.95 conditions; 2) "Respiratory and Atopy" (11%, 3.65 conditions); 3) "Non-cardiometabolic" (14%, 4.77 conditions), and 4) "Cardiometabolic" (5%, 6.32 conditions). Predictors of multimorbidity class membership differed between classes and differed from predictors of number of co-occurring conditions.

CONCLUSION

Multimorbidity is common among middle-aged adults from a general population. Some conditions associated with ageing such as arthritis, bowel disease and depression-anxiety co-occur in clinically distinct patterns and at higher prevalence than expected by chance. These findings may inform further studies into shared biological and environmental causes of co-occurring conditions of ageing. Recognition of distinct patterns of multimorbidity may aid in a holistic approach to care management in individuals presenting with multiple chronic conditions, while also guiding health resource allocation in ageing populations.

Patients with Clinically Elevated Depressive Symptoms Report Improvements in Mood, Pain, and Functioning following Participation in Interdisciplinary Pain Rehabilitation

OBJECTIVE

Chronic pain and depression frequently co-occur and exacerbate one another; therefore, it is important to treat both conditions to improve patient outcomes. The current study evaluates an interdisciplinary pain rehabilitation program (IPRP) with respect to the following questions: 1) How do clinically elevated depressive symptoms impact pain-related treatment outcomes? and 2) To what extent does IPRP participation yield reliable and clinically significant change in depressed mood?

METHODS

Participants in this study included 425 adults who engaged in a 10-week IPRP and completed self-report measures of pain, mood, and functioning at intake and discharge. Participants were categorized into 4 groups based on self-reported depressive symptoms (PROMIS Depression): within normal limits (WNL; n = 121), Mild (n = 115), Moderate (n = 153), and Severe (n = 36).

RESULTS

Participants reported significant improvement in pain, pain-related life interference, health-related quality of life, pain catastrophizing, and depressed mood regardless of initial symptom level. In addition, 43.4% of patients with Mild, Moderate, or Severe depressed mood reported reliable and clinically significant improvement in depressive symptoms and 30.3% were in remission at the end of treatment.

CONCLUSIONS

These findings support the assertion that IPRPs represent an effective treatment for patients with comorbid chronic pain and depression and that participation is associated with improvement in both conditions.

Identifying biopsychosocial factors that impact decompressive laminectomy outcomes in veterans with lumbar spinal stenosis: a prospective cohort study

ABSTRACT

One in 3 patients with lumbar spinal stenosis undergoing decompressive laminectomy (DL) to alleviate neurogenic claudication do not experience substantial improvement. This prospective cohort study conducted in 193 Veterans aimed to identify key spinal and extraspinal factors that may contribute to a favorable DL outcome. Biopsychosocial factors evaluated pre-DL and 1 year post-DL were hip osteoarthritis, imaging-rated severity of spinal stenosis, scoliosis/kyphosis, leg length discrepancy, comorbidity, fibromyalgia, depression, anxiety, pain coping, social support, pain self-efficacy, sleep, opioid and nonopioid pain medications, smoking, and other substance use. The Brigham Spinal Stenosis (BSS) questionnaire was the main outcome. Brigham Spinal Stenosis scales (symptom severity, physical function [PF], and satisfaction [SAT]) were dichotomized as SAT < 2.42, symptom severity improvement ≥ 0.46, and PF improvement ≥ 0.42, and analyzed using logistic regression. Sixty-two percent improved in 2 of 3 BSS scales (ie, success). Baseline characteristics associated with an increased odds of success were-worse BSS PF (odds ratio [OR] 1.24 [1.08-1.42]), greater self-efficacy for PF (OR 1.30 [1.08-1.58]), lower self-efficacy for pain management (OR 0.80 [0.68-0.94]), less apparent leg length discrepancy (OR 0.71 [0.56-0.91]), greater self-reported alcohol problems (OR 1.53 [1.07-2.18]), greater treatment credibility (OR 1.31 [1.07-1.59]), and moderate or severe magnetic resonance imaging-identified central canal stenosis (OR 3.52 [1.06-11.6]) moderate, OR 5.76 [1.83-18.1] severe). Using opioids was associated with lower odds of significant functional improvement (OR 0.46 [0.23-0.93]). All P < 0.05. Key modifiable factors associated with DL success-self-efficacy, apparent leg length inequality, and opioids-require further investigation and evaluation of the impact of their treatment on DL outcomes.

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.

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.

Improved Psychosocial and Functional Outcomes and Reduced Opioid Usage Following Burst Spinal Cord Stimulation

Objective

Burst spinal cord stimulation (B‐SCS) has been shown to reduce neuronal firing in the anterior cingulate cortex through selective modulation of the medial pain pathway tract. This pain pathway communicates the affective component of pain processing. The purpose of this study was to assess the effect of B‐SCS on psychosocial functioning and its influence on pain and quality of life.

Materials and Methods

Eligible patients with chronic, intractable pain of the trunk, and/or lower limbs were enrolled. After a successful trial period, subjects received a permanent implant and returned for follow‐up at 6‐ and 12‐months.

Results

In total, 269 patients were enrolled at 22 centers. Trial success rate was 90%. Significant improvements in pain, physical, mental, and emotional functioning were observed from baseline to the 6‐ and 12‐month follow‐up (p < 0.001). Overall, patients had improved quality of life, became more active, and the negative impact of pain on daily life was decreasing. At one year, 81% of subjects were satisfied or very satisfied with their therapy. Subjects showing significant improvements on mental health outcomes reported enhanced pain relief and quality of life scores compared with subjects with continued impaired mental health at follow‐up. At one year, 89% of subjects who were taking opioids at baseline decreased or stayed at the same level of opioid use; 19% stopped taking any opioids. No unanticipated adverse events have been reported.

Conclusions

One‐year outcomes after B‐SCS show improvements across all evaluated psychological measures with the largest impact observed on catastrophizing and depression (the affective component of pain processing). These pain‐related beliefs and behaviors, and not pain intensity, have been shown to put patients at greatest risk of a poor prognosis and quality of life.

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.

Development of a Clinical Decision Aid for Chiropractic Management of Common Conditions Causing Low Back Pain in Veterans: Results of a Consensus Process

OBJECTIVE

The purpose of this study was to develop a clinical decision aid for chiropractic management of common conditions causing low back pain (LBP) in veterans receiving treatment in US Veterans Affairs (VA) health care facilities.

METHODS

A consensus study using an online, modified Delphi technique and Research Electronic Data Capture web application was conducted among VA doctors of chiropractic. Investigators reviewed the scientific literature pertaining to diagnosis and treatment of nonsurgical, neuromusculoskeletal LBP. Thirty seed statements summarizing evidence for chiropractic management, a graphical stepped management tool outlining diagnosis-informed treatment approaches, and support materials were then reviewed by an expert advisory committee. Email notifications invited 113 VA chiropractic clinicians to participate as Delphi panelists. Panelists rated the appropriateness of the seed statements and the stepped process on a 1-to-9 scale using the RAND/University of California, Los Angeles methodology. Statements were accepted when both the median rating and 80% of all ratings occurred within the highly appropriate range.

RESULTS

Thirty-nine panelists (74% male) with a mean (standard deviation) age of 46 (11) years and clinical experience of 17 (11) years participated in the study. Accepted statements addressed included (1) essential components of chiropractic care, (2) treatments for conditions causing or contributing to LBP, (3) spinal manipulation mechanisms, (4) descriptions and mechanisms of commonly used chiropractic interventions, and (5) a graphical stepped clinical management tool.

CONCLUSION

This study group produced a chiropractic clinical decision aid for LBP management, which can be used to support evidence-based care decisions for veterans with LBP.

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.

Use of Patient Health Questionnaire-2 scoring to predict patient satisfaction and return to work up to 1 year after lumbar fusion: a 2-year analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVE

The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a prospective, longitudinal, multicenter, quality-improvement collaborative. Using MSSIC, the authors sought to identify the relationship between a positive Patient Health Questionnaire-2 (PHQ-2) screening, which is predictive of depression, and patient satisfaction, return to work, and achieving Oswestry Disability Index (ODI) minimal clinically important difference (MCID) scores up to 2 years after lumbar fusion.

METHODS

Data from a total of 8585 lumbar fusion patients were analyzed. Patient satisfaction was measured by the North American Spine Society patient satisfaction index. A positive PHQ-2 score is one that is ≥ 3, which has an 82.9% sensitivity and 90.0% specificity in detecting major depressive disorder. Generalized estimating equation models were constructed; variables tested include age, sex, race, past medical history, severity of surgery, and preoperative opioid usage.

RESULTS

Multivariate analysis was performed. Patients with a positive PHQ-2 score (i.e., ≥ 3) were less likely to be satisfied after lumbar fusion at 90 days (relative risk [RR] 0.93, p < 0.001), 1 year (RR 0.92, p = 0.001), and 2 years (RR 0.92, p = 0.028). A positive PHQ-2 score was also associated with decreased likelihood of returning to work at 90 days (RR 0.76, p < 0.001), 1 year (RR 0.85, p = 0.001), and 2 years (RR 0.82, p = 0.031). A positive PHQ-2 score was predictive of failure to achieve an ODI MCID at 90 days (RR 1.07, p = 0.005) but not at 1 year or 2 years after lumbar fusion.

CONCLUSIONS

A multivariate analysis based on information from a large, multicenter, prospective database on lumbar fusion patients was performed. The authors found that a positive score (≥ 3) on the PHQ-2, which is a simple and accurate screening tool for depression, predicts an inability to return to work and worse satisfaction up to 2 years after lumbar fusion. Depression is a treatable condition, and so in the same way that patients are medically optimized before surgery to decrease postoperative morbidity, perhaps patients should have preoperative psychiatric optimization to improve postoperative functional outcomes.

An E-learning Module on Chronic Low Back Pain in Older Adults: Effect on Medical Resident Attitudes, Confidence, Knowledge, and Clinical Skills

Objective

To determine 1) the feasibility of implementing an e-learning module on chronic low back pain (CLBP) in an older adult into an existing internal medicine residency curriculum and 2) the impact of this module on resident attitudes, confidence, knowledge, and clinical skills relating to CLBP.

Methods

Participants were assigned to complete either the online module (N = 73) or the Yale Office-based curriculum on CLBP (N = 70). Attitudes, confidence, and knowledge were evaluated pre- and postintervention via survey. A retrospective blinded chart review of resident clinic encounters was conducted, wherein diagnosis codes and physical exam documentation were rated as basic or advanced.

Results

There was no improvement in overall knowledge scores in either group (60% average on both metrics). There were tendencies for greater improvements in the intervention group compared with controls for confidence in managing fibromyalgia (2.4 to 2.9 vs 2.5 to 2.5, P = 0.06) and leg length discrepancy (1.8 to 2.5 vs 1.5 to 1.9, P = 0.05). Those exposed to the online module also showed an increase in the percentage of physical exam documentation rated as advanced following the intervention (13% to 32%, P = 0.006), whereas the control group showed no change (14% to 12%, P = 0.68).

Conclusions

An online module on CLBP in the older adult was a feasible addition to an existing curriculum for internal medicine residents. The module positively and substantively impacted resident clinical behaviors, as evidenced by enhanced sophistication in physical exam documentation; it also was associated with improved confidence in certain aspects of chronic pain management.

Update on structured pain assessment for the documentation of diagnosis-independent symptoms and signs associated with pain

Concerning the diagnosis and therapy of pain syndromes, standardized descriptions similar to those used in the examination of psychopathological findings via the system produced by the AMDP ("Arbeitsgemeinschaft für Methodik und Dokumentation in der Psychiatrie", i. e., the working group establishing standardized methodology and documentation within psychiatry) are still lacking. Therefore, the authors of this article have founded a working group to establish standardized methodology and documentation for symptoms and signs associated with pain, although not at a diagnosis-specific level, in order to promote standardization in the documentation of pain and rating of the symptoms associated with a given set of medical results. This article presents a system for documenting the symptoms and signs associated with pain globally and independently of the diagnosis (Structured Pain Assessment System) with nomenclature that is inspired by the AMDP system. The objective of this working group is to develop documentation for a uniform multidimensional pain assessment (with defined terminology) that serves as a comparable and unified standard in the field.

Association of Statin Use with Increased Risk of Musculoskeletal Conditions: A Retrospective Cohort Study

INTRODUCTION

Musculoskeletal conditions, including osteoarthritis (OA), result in tremendous disability and cost. Statins are among the most commonly prescribed medications and their use for primary prevention in many otherwise healthy individuals, including those who are physically active, is increasing. There is conflicting evidence regarding the relationship of statin use and musculoskeletal conditions. Given the rising disability associated with musculoskeletal conditions, understanding predisposing factors, including medication-related exposures, deserves further attention.

OBJECTIVES

We examined the association between statin use and the risk of being diagnosed with non-traumatic arthropathies, use-related injury, and undergoing rehabilitation in a cohort with longitudinal follow-up.

METHODS

Patients enrolled in a regional military healthcare system between 2003 and 2012 were evaluated in this retrospective cohort study. A propensity score was generated to match statin-users and nonusers using 115 baseline characteristics. Outcomes included ICD-9 diagnoses codes for Agency for Healthcare Research and Quality disease categories of: non-traumatic arthropathies, use-related injury and undergoing rehabilitation. Primary analysis examined the outcomes in statin-users and nonusers after propensity score matching using conditional logistic regression analysis.

RESULTS

Initially, 60,455 patients were identified. We propensity score-matched 6728 statin users with 6728 nonusers (52 years of age, ~ 47% women). In the propensity score-matched cohort, non-traumatic arthropathies occurred in 59.8% of statin users and 56.0% of nonusers [odds ratio (OR) 1.17, 95% confidence interval (95% CI) 1.09-1.25] and use related injury occurred in 31.9% of statin users and 29.8% of nonusers (OR 1.11, 95% CI 1.03-1.19). There was no difference between statin users and nonusers undergoing rehabilitation (22.6% among statin users, 21.9% among nonusers, OR 1.04, 95% CI 0.96-1.13).

CONCLUSION

Statin use was associated with a significant increased risk of non-traumatic arthropathies and use-related injury. Our results provide additional data that can inform patient and clinician conversations about the benefits and risks of statin use.

Effect of Problem-Solving Therapy Versus Supportive Management in Older Adults with Low Back Pain and Depression While on Antidepressant Pharmacotherapy

OBJECTIVE

Testing stepped-care approaches that address both depression and low back pain are needed to optimize outcomes in older adults.

METHODS

This university-based late-life depression research center assessed 227 adults aged ≥ 60 years with chronic low back pain and depression. In Phase 1 participants received 6 weeks of low-dose venlafaxine (≤150 mg/day). Nonresponders were randomized to 10 weeks of high-dose venlafaxine (up to 300 mg/day) plus problem-solving therapy (PST) or high-dose venlafaxine with supportive management. Definition of response was 2 weeks of Patient Health Questionnaire-9 ≤ 5 and ≥30% pain reduction on a numeric rating scale. Function was measured with the Short Physical Performance Battery (SPPB) and Roland Morris Disability Questionnaire (RMDQ).

RESULTS

Of those who completed Phase 1 (N = 209), 78.5% (N = 164) were nonresponders and 139 proceeded to Phase 2, with 68 randomized to venlafaxine/PST and 71 randomized to venlafaxine/supportive management. Of those in venlafaxine/PST, 41.2% (28/68) responded, and of those in venlafaxine/supportive management, 39.4% (28/71) responded. Cumulative proportion responding over time did not differ across the two arms (hazard ratio: 1.07; 95% confidence interval: 0.63-1.80). We observed clinically significant improvements in physical performance (SPPB) and disability (RMDQ) across both Phase 1 and 2, independent of intervention. Over 12 months of follow-up there was no difference between groups for stability of depression, pain, or disability.

CONCLUSION

The combination of antidepressant pharmacotherapy and PST was not superior to antidepressant pharmacotherapy and supportive management. Clinically, the rates of response and stability of response over 1 year observed in both groups suggest that these approaches may have clinical utility in these chronically suffering patients.

Biopsychosocial Profiles and Functional Correlates in Older Adults with Chronic Low Back Pain: A Preliminary Study

Objective

To describe key peripheral and central nervous system (CNS) conditions in a group of older adults with chronic low back pain (CLBP) and their association with pain severity and self-reported and performance-based physical function.

Design

Cross-sectional.

Setting

Outpatient VA clinics.

Subjects

Forty-seven community-dwelling veterans with CLBP (age 68.0 ± 6.5 years, range = 60–88 years, 12.8% female, 66% white) participated.

Methods

Data were collected on peripheral pain generators—body mass index, American College of Rheumatology hip osteoarthritis criteria, neurogenic claudication (i.e., spinal stenosis), sacroiliac joint (SIJ) pain, myofascial pain, leg length discrepancy (LLD), and iliotibial band pain; and CNS pain generators—anxiety (GAD-7), depression (PHQ-9), insomnia (Insomnia Severity Index), maladaptive coping (Fear Avoidance Beliefs Questionnaire, Cognitive Strategies Questionnaire), and fibromyalgia (fibromyalgia survey). Outcomes were pain severity (0 to 10 scale, seven-day average and worst), self-reported pain interference (Roland Morris [RM] questionnaire), and gait speed.

Results

Approximately 96% had at least one peripheral CLBP contributor, 83% had at least one CNS contributor, and 80.9% had both peripheral and CNS contributors. Of the peripheral conditions, only SIJ pain and LLD were associated with outcomes. All of the CNS conditions and SIJ pain were related to RM score. Only depression/anxiety and LLD were associated with gait speed.

Conclusions

In this sample of older veterans, CLBP was a multifaceted condition. Both CNS and peripheral conditions were associated with self-reported and performance-based function. Additional investigation is required to determine the impact of treating these conditions on patient outcomes and health care utilization.

Sensory symptoms in low back pain-how do they matter?

OBJECTIVE

Successful treatment of chronic low back pain (LBP) is difficult in clinical practice and hard to measure in trials. One reason might be the use of insufficient outcome parameters. The aim was to investigate the importance of typical clinical characteristics of chronic LBP on QoL and functionality.

METHODS

A total of 51 patients with chronic LBP (19 with, 32 without radiculopathy) were investigated with different questionnaires.

RESULTS

Burdening symptoms differed in frequency, intensity and impairment of QoL and functionality between patients with and without radiculopathy and between the area of pain within the same patient, i.e. between back and leg. Symptoms of nerve affection such as prickling pain and numbness were rated higher in the area of radiating pain than on the back in radiculopathy, and typical neuropathic pain symptoms such as burning pain, prickling, spontaneous pain, and feeling of deep pressure and pain at the beginning of movement were rated with a higher impairment of QoL and functionality in patients with compared to those without radiculopathy. Furthermore, intensity, impairment of QoL, and functionality were not necessarily reported in association with one another: some patients were highly impaired in QoL or functionality, despite a moderate-to-low pain intensity, whereas others suffered from severe pain, but were less impaired in QoL or functionality.

CONCLUSION

Results suggest the consideration of impairment of QoL and functionality in addition to symptom intensity for treatment evaluation of chronic LBP. This can help to improve overall well-being of the patients and enhance efficacy in clinical pain trials and patient-centered treatment.

[The AMDS system for the documentation of symptoms and signs associated with pain]

The authors present a system for nomenclature and documentation of symptoms and signs associated with pain. The system was compiled in a staged process by the study group for methods and documentation of pain-associated symptoms and signs (Arbeitsgemeinschaft für Methodik und Dokumentation von Schmerzbefunden [AMDS]). The suggested items were elaborated from terms used in current national and international guidelines and classifications and in part integrated into superordinate terms. The items that were built up by this approach aim to reflect the broad spectrum of pain diseases. The items for the description of pain-associated symptoms and signs are divided into the areas of algesiomotor, psychoalgesiological and somatoalgesiological findings. The aim is the documentation of a multidimensional algesiological description of findings with defined terminology, which can serve as a comparable and unified standard, particularly in the field of pain assessment. The AMDS system should enable a systematic description of pain, which is a reliable foundation for diagnostics, therapy planning and expert case evaluation.

Epidemiology of Back Pain in Young and Middle-Aged Adults: A Longitudinal Population Cohort Survey From Age 27-50 Years

BACKGROUND

Back pain is extremely common and a huge burden for both individuals and health care services.

OBJECTIVE

The aim was to determine the prevalence and incidence of lumbar and cervical back pain over 23 years and to quantify associations with concomitant disorders.

METHODS

Data on lumbar and cervical back pain, and mental disorders from the Zurich study, collected between 1986 (age men: 27/women: 28 years) and 2008 (age 49/50) were analyzed. Epidemiological parameters were representative rates for the general population. Associations were quantified by odds ratios (ORs).

RESULTS

Of 499 subjects, 68.9% ever experienced lumbar pain and 60.7% ever experienced cervical back pain; the 23-year prevalences were 66.9% and 54.9% and the 23-year incidences 52.3% and 48.9% for lumbar and cervical back pain, respectively. Annual prevalences varied between 28.4% and 47.2% for lumbar and 18.3% and 54.7% for cervical back pain; the corresponding annual incidences varied by 5.8-13.3% (lumbar) and 7.8-12.6% (cervical). Lumbar back pain was significantly associated with cardiovascular disease (OR = 4.58), obesity (OR = 3.99), asthma spectrum (OR = 5.76), tranquillizer dependence (OR = 5.84), and other comorbidities (ORs = 1.47-3.27). Significant associations with cervical back pain were observed for specific phobia (OR = 5.10), panic attacks (OR = 4.79), and other comorbidities (ORs = 1.61-2.62).

CONCLUSIONS

This study contributes to the refinement of epidemiological data on lumbar and cervical back pain. Some associations with treatable disorders were high, which may offer hope for the indirect management of lumbar and cervical back pain.

Depression and chronic pain in the elderly: links and management challenges

Aging is an inevitable process and represents the accumulation of bodily alterations over time. Depression and chronic pain are highly prevalent in elderly populations. It is estimated that 13% of the elderly population will suffer simultaneously from the two conditions. Accumulating evidence suggests than neuroinflammation plays a critical role in the pathogenesis of both depression and chronic pain. Apart from the common pathophysiological mechanisms, however, the two entities have several clinical links. Their management is challenging for the pain physician; however, both pharmacologic and nonpharmacologic approaches are available and can be used when the two conditions are comorbid in the elderly patients.

Relationship of depression in participants with nonspecific acute or subacute low back pain and no-pain by age distribution

BACKGROUND AND PURPOSE

Nonspecific low back pain (LBP) is the most prevalent musculoskeletal condition in various age ranges and is associated with depression. The aim of this study was to determine the Beck Depression Inventory (BDI) scores in participants with nonspecific LBP and no-pain by age distribution.

METHODS

A case-control study was carried out following the Strengthening the Reporting of Observational Studies in Epidemiology criteria. A sample of 332 participants, divided into the following age categories: 19-24 (n=11), 25-39 (n=66), 40-64 (n=90), 65-79 (n=124), and ≥80 (n=41) years was recruited from domiciliary visits and an outpatient clinic. The BDI scores were self-reported in participants with nonspecific acute or subacute (≤3 months) LBP (n=166) and no-pain (n=166).

RESULTS

The BDI scores, mean ± standard deviation, showed statistically significant differences (p<0.001) between participants with nonspecific acute or subacute LBP (9.590±6.370) and no-pain (5.825±5.113). Significantly higher BDI scores were obtained from participants with nonspecific acute and subacute LBP in those aged 40-64 years (p<0.001; 9.140±6.074 vs 4.700±3.777) and 65-79 years (p<0.001; 10.672±6.126 vs 6.210±5.052). Differences were not significant in younger patients aged 19-24 (p=0.494; 5.000±2.646 vs 8.250±7.498), 25-39 (p=0.138; 5.440±5.245 vs 3.634±4.397), and in those aged ≥80 years (p=0.094; 13.625±6.1331 vs 10.440±5.591).

CONCLUSION

Participants with nonspecific acute and subacute LBP present higher BDI depression scores, influenced by age distribution. Specifically, patients in the age range from 40 to 80 years with LBP could require more psychological care in addition to any medical or physical therapy. Nevertheless, physical factors, different outcomes, and larger sample size should be considered in future studies.

Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment: Part XI: Dementia

OBJECTIVE : To present the 11th in a series of articles designed to deconstruct chronic low back pain (CLBP) in older adults. The series presents CLBP as a syndrome, a final common pathway for the expression of multiple contributors rather than a disease localized exclusively to the lumbosacral spine. Each article addresses one of 12 important contributions to pain and disability in older adults with CLBP. This article focuses on dementia.

METHODS

A modified Delphi technique was used to develop an algorithm for an approach to treatment for older adults living with CLBP and dementia. A panel of content experts on pain and cognition in older adults developed the algorithm through an iterative process. Though developed using resources available within Veterans Health Administration (VHA) facilities, the algorithm is applicable across all health care settings. A case taken from the clinical practice of one of the contributors demonstrates application of the algorithm.

RESULTS

We present an evidence-based algorithm and biopsychosocial rationale to guide providers evaluating CLBP in older adults who may have dementia. The algorithm considers both subtle and overt signs of dementia, dementia screening tools to use in practice, referrals to appropriate providers for a complete a workup for dementia, and clinical considerations for persons with dementia who report pain and/or exhibit pain behaviors. A case of an older adult with CLBP and dementia is presented that highlights how an approach that considers the impact of dementia on verbal and nonverbal pain behaviors may lead to more appropriate and successful pain management.

CONCLUSIONS

Comprehensive pain evaluation for older adults in general and for those with CLBP in particular requires both a medical and a biopsychosocial approach that includes assessment of cognitive function. A positive screen for dementia may help explain why reported pain severity does not improve with usual or standard-of-care pain management interventions. Pain reporting in a person with dementia does not always necessitate pain treatment. Pain reporting in a person with dementia who also displays signs of pain-associated suffering requires concerted pain management efforts targeted to improving function while avoiding harm in these vulnerable patients.Key Words. Dementia; Chronic Pain; Low Back Pain; Lumbar; Primary Care.

Advancing the Pain Agenda in the Veteran Population

The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.

Effect of depression and neuropathic pain using questionnaires on quality of life in patients with low back pain; cross-sectional retrospective study

PURPOSE

The present study investigated the percentage of low back pain (LBP) patients who have depressive symptoms and neuropathic pain and analyzed the effects of these on the quality of life (QOL) in these patients.

METHODS

Of the 650 new patients with LBP that visited the hospital between June 2012 and December 2013, 309 patients who completed questionnaires to assess LBP and QOL were included in the study. The questionnaire included demographic items, the self-rated depression scale (SDS)-Zung, the Japanese version of the PainDETECT questionnaire (PDQ-J), numerical pain rating scale (NRS), and QOL assessments. The patients were divided into two groups according to their SDS-Zung scores: a nondepressed group with SDS scores <40 and a depressed group with SDS-Zung scores ≥50.

RESULTS

One hundred twenty-five patients (40.5 %) were classified as nondepressed and 63 (20.4 %) as depressed. The mean PDQ-J score was higher in depressed patients than in nondepressed patients. The frequency of neuropathic pain was greater in depressed patients, with neuropathic pain observed in 17 of the 63 (27 %) depressed LBP patients and 11 of the 125 (9 %) nondepressed LBP patients. The SDS-Zung and PDQ-J scores of LBP patients were correlated significantly (r = 0.261, p < 0.001). Depressed patients had higher pain NRS scores and lower QOL scores compared with nondepressed patients.

CONCLUSIONS

Both the depressed patients and those with neuropathic LBP had a higher level of pain, greater pain-related disability, and poorer QOL compared with nondepressed patients. This is the first study to use the SDS-Zung and PDQ-J screening questionnaires to estimate the presence of neuropathic pain associated with depressive symptoms in LBP patients and to evaluate the impact of these on QOL.