Testing New Models of Care for Chronic Low Back Pain

The origins and mechanisms of the experience of pain is a complex field of study. An individual’s experience of pain is quite subjective in nature. Mitigating pain, be it acute or chronic, through various interventions of surgery, pharmacotherapy, physical therapy, and other methods is big business to the tune of tens of billions of dollars a year in the United States alone.

“Educating individuals about what contributes to their back pain is crucially important.I believe a big part of what drives excessive use of health care resources for this patient population is a lack of information,or inaccurately provided information.”
-Debra K. Weiner, MD

Chronic low back pain (CLBP) in older adults is all too common. Roughly a third of older adults (65+) experience low back pain, and an estimated three-quarters of those individuals suffer from CLBP. The effects of poorly controlled CLBP are well documented. However, many therapies and systems fail to deal with complex chronic low back pain effectively, leaving individuals in distress with reduced quality of life and susceptible to other conditions, such as anxiety and depression.

Debra K. Weiner, MD, has spent decades researching the causes and complexities of pain and chronic pain in the older adult, with significant recent efforts to address the need for a more rigorous and complete understanding of CLBP. Much of this research has manifested in a 12-part series of papers in the journal Pain Medicine, published under the heading Deconstructing Chronic Low Back Pain in the Older Adult: Shifting the Paradigm From the Spine to the Person.

“Chronic low back pain is a complex syndrome, one that usually presents or is expressed through many contributing factors, some of which lie not in the spine itself but outside the lumbar region. We may not be able to cure chronic low back pain, but we can do a much better job in treating chronic low back pain if we thoroughly evaluate and manage its multiple contributors,” says Dr. Weiner.

Dr. Weiner and colleagues’ research sets down an interrelated set of 12 algorithms for the assessment, diagnosis, and treatment of chronic low back pain. The scope of the research touches many common conditions that older adults experience, and that either individually, or in some aggregate, along with degenerative changes of the lumbar spine, can contribute to or otherwise manifest as an individual’s experience of chronic low back pain. Dr. Weiner and colleagues have identified and developed recommendations for evaluating and treating as contributors to CLBP and pain-associated disability the following conditions:

• Hip Osteoarthritis
• Myofascial Pain
• Lumbar Spinal Stenosis
• Sacroiliac Joint Syndrome
• Lateral Hip/Thigh Pain Syndrome
• Leg Length Discrepancy
• Insomnia
• Fibromyalgia
• Depression
• Anxiety
• Maladaptive Coping
• Dementia

While there may be other contributing factors, the commonality of these 12 conditions should be evaluated routinely as potential contributors to pain and disability. While each of the 12 contributing factors is discussed in detail in separate papers, Dr. Weiner indicates that the body of work is meant to be used in tandem, as a single assessment tool, with each aspect coming into play, or not, as the case may be, during patient evaluation and subsequent ongoing management.

Clinical Trials Testing the New Treatment Paradigm

With funding from the VA Office of Research and Development, Dr. Weiner is leading a new multicenter clinical trial to test the efficacy of this new paradigm in the care of chronic low back pain with a cohort of older veterans who will be enrolled from three VA sites across the United States (Pittsburgh, Dallas, Richmond).

“We completed a small, 50-person pilot trial with six-months follow-up, and we are in the process of writing up the results. The bottom line is that the results showed promise when comparing pain and function measures between our whole-person centered care approach versus the standard imaging-directed usual care,” says Dr. Weiner.

The new trial will randomize 330 older veterans into either the Aging Back Clinics model or usual care. Participants, regardless of the study arm, will all undergo the same comprehensive assessment that collects data based on the NIH minimum data set for CLBP. “The main outcomes we are interested in are pain and function, but we are collecting baseline measures on an extensive array of constructs, such as pain medications, gait speed, and many more.”