Preinjury Frailty Predicts 1-Year Mortality in Older Adults With Traumatic Spine Fractures.

BACKGROUND AND OBJECTIVES: Nearly 30% of older adults presenting with isolated spine fractures will die within 1 year. Attempts to ameliorate this alarming statistic are hindered by our inability to identify relevant risk factors. The primary objective of this study was to develop a prediction model that identifies feasible targets to limit 1-year mortality. METHODS: This retrospective cohort study included 703 older adults (65 years or older) admitted to a level I trauma center with isolated spine fractures, without neural deficit, from January 2013 to January 2018. Multivariable analysis was used to select for independently significant patient demographics, frailty variables, injury metrics, and management decisions to incorporate into distinct logistic regression models predicting 1-year mortality. Variables were considered significant, if P < .05. RESULTS: Of the 703 older adults, 199 (28.3%) died after hospital discharge, but within 1 year of index trauma. Risk Analysis Index (RAI; odds ratio [OR]: 1.116; 95% CI: 1.087-1.149; P < .001) and ambulation requiring a cane (OR: 2.601; 95% CI: 1.151-5.799; P = .02) or walker (OR: 4.942; 95% CI: 2.698-9.196; P < .001), ie, frailty variables, were associated with increased odds of 1-year mortality. Spine trauma scales were not associated with 1-year mortality. Longer hospital stays (OR: 1.112; 95% CI: 1.034-1.196; P = .004) and nursing home discharge (OR: 3.881; 95% CI: 2.070-7.378; P < .001) were associated with increased odds, while discharge to rehab (OR: 0.361; 95% CI: 0.155-0.799; P = .014) decreased 1-year mortality odds. A "preinjury" regression model incorporating Risk Analysis Index and ambulation status resulted in an area under receiver operating characteristic curve (AUROCC) of 0.914 (95% CI: 0.863-0.965). A "postinjury" model incorporating Glasgow Coma Scale, hospital stay duration, and discharge disposition resulted in AUROCC of 0.746 (95% CI: 0.642-0.849). Combining elements of the preinjury and postinjury models into an "integrated model" produced an AUROCC of 0.908 (95% CI: 0.852-0.965). CONCLUSION: Preinjury frailty measures are most strongly associated with 1-year mortality outcomes in older adults with isolated spine fractures. Incorporating injury metrics or management decisions did not enhance predictive accuracy. Further work is needed to understand how targeting frailty may reduce mortality.

Trends of Low Back Pain Research in Older and Working-Age Adults from 1993 to 2023: A Bibliometric Analysis.

Although the number of publications focusing on low back pain in older adults (LBP-O) and working-age adults (LBP-W) has been growing for decades, comparative research trends in these two populations, which may help to guide future investigation, have not been rigorously explored. This analysis aimed to describe publication patterns and trends of research targeting LBP-O and LBP-W over the last three decades. Peer-reviewed LBP-O and LBP-W articles published between 1993 and 2023 were retrieved from the Web of Science, which provided the details of annual publication volume, and prominent journals/countries/institutions. The relationship between the annual publication volumes and years was analyzed by Spearman correlation analysis. The hot topics and emerging trends were analyzed by VOSviewer and CiteSpace, respectively. A total of 4217 LBP-O-related and 50,559 LBP-W-related documents were included. The annual publication volumes of LBP-O and LBP-W articles increased over the years (r=0.995 to 0.998, p<0.001). The United States had the highest number of prominent institutions publishing relevant articles. The most prolific journal for LBP-O (5.4%) and LBP-W-related (6.1%) papers is the journal "Spine". Cognitive behavioral therapy, intervertebral disc (IVD) degeneration, physiotherapy, physical activity, and walking were the recent hot topics and physical activity was an emerging trend in LBP-O, while surgery and IVD degeneration (also a hot topic) were emerging trends in LBP-W. This study highlights the paucity of LBP-O-related research in the past. The United States and the journal Spine stand out in LBP research. The research trend of physical activity in LBP-O is consistent with the recognized importance of physical activity for older adults in general, and for managing LBP-O in particular. Conversely, the emerging trends of surgery and intervertebral disc degeneration in LBP-W research highlight a focus on the biomedical model of LBP despite LBP being a biopsychosocial condition.

Insomnia symptoms and postoperative healthcare utilization in veterans undergoing decompressive laminectomy for lumbar spinal stenosis.

Study Objectives: Lumbar spinal stenosis is an age-related spine condition that contributes to pain and disability. Decompressive laminectomy (DL) is regularly performed to alleviate symptoms. Insomnia symptoms are common among people living with chronic pain and may affect key DL outcomes, such as healthcare utilization. We examined associations of insomnia symptom severity with post-DL healthcare utilization in veterans with lumbar spinal stenosis. Methods: Veterans (N = 200) with lumbar spinal stenosis undergoing DL were recruited into a prospective cohort study and self-reported insomnia symptom severity on the Insomnia Severity Index prior to DL. Post-DL, veterans reported on pain and non-pain-related monthly healthcare office visits, emergency room visits, hospitalizations, and mental health visits for 1 year. Incident rate ratios (IRRs) obtained via negative binomial regression evaluated associations of insomnia symptom severity with healthcare utilization rates. Results: Approximately 51% of participants endorsed insomnia symptoms of at least mild severity. Participants who reported at least mild insomnia symptoms had more healthcare office visits (IRR = 1.23, p = .04), general mental health visits (IRR = 3.98, p < .0001), and pain-related mental health visits (IRR = 9.55, p = .01) than those without insomnia symptoms. Adjusting for covariates, rates of mental health visits, overall (IRR = 3.13, p = .001) and pain-related (IRR = 6.93, p = .02), remained statistically significantly higher. Conclusions: Insomnia symptoms are associated with postoperative healthcare utilization lending support for future work to examine the value of assessing and intervening on insomnia symptoms prelaminectomy.

Prevalence, Impact, and Trajectories of Sleep Disturbance in Cardiac Rehabilitation: A NARRATIVE REVIEW AND SUGGESTIONS FOR EVALUATION AND TREATMENT.

OBJECTIVE: The aim of this review was to summarize literature examining the prevalence, impact, and trajectories of sleep disturbance in cardiac rehabilitation (CR) patients and discuss how CR programs may incorporate targeted evaluation and interventions to promote sleep health. REVIEW METHODS: A narrative review of literature allowed for an examination of the prevalence of sleep disturbance in CR patients, the effects of sleep disturbance on CR outcomes, and trajectories of sleep disturbance in CR. SUMMARY: Sleep disturbance is prevalent in CR patient populations and is related to clinical and functional outcomes. Sleep may be an important biobehavioral process to target in CR to improve important patient outcomes and achieve secondary prevention goals.

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.

Partnering to cope with pain: A pilot study of a caregiver-assisted pain coping skills intervention for patients with cognitive impairment and dementia.

OBJECTIVE: To develop a new caregiver-assisted pain coping skills training protocol specifically tailored for community-dwelling persons with cognitive impairment and pain, and assess its feasibility and acceptability. METHOD: In Phase I, we conducted interviews with 10 patient-caregiver dyads to gather feedback about intervention content and delivery. Phase II was a single-arm pilot test to evaluate the intervention's feasibility and acceptability. Dyads in the pilot study (n = 11) completed baseline surveys, received five intervention sessions, and then completed post-intervention surveys. Analyses focused on feasibility and acceptability. RESULTS: Dyads responded positively to the pain coping skills presented in the interviews; their feedback was used to refine the intervention. Findings from the pilot study suggested that the intervention was feasible and acceptable. 69% of eligible dyads consented, 82% completed all five intervention sessions, and 100% completed the post-treatment assessment. Caregivers reported high satisfaction ratings. They also reported using the pain coping skills on a regular basis, and that they found most of the skills helpful and easy to use. SIGNIFICANCE OF RESULTS: These preliminary findings suggest that a caregiver-assisted pain coping skills intervention is feasible and acceptable, and that it may be a promising approach to managing pain in patients with cognitive impairment.

Classification of Geriatric Low Back Pain Based on Hip Characteristics With a 12-Month Longitudinal Exploration of Clinical Outcomes: Findings From Delaware Spine Studies.

OBJECTIVE: The purpose of this study is to identify geriatric chronic low back pain (LBP) subgroups based on the presence of potentially modifiable hip impairments, using Latent Variable Mixture Modeling (LVMM), and to examine the prospective relationship between these subgroups and key outcomes over time. METHODS: Baseline, 3-month, 6-month, and 12-month data were collected from a prospective cohort of 250 community-dwelling older adults with chronic LBP. Comprehensive hip (symptoms, strength, range of motion, and flexibility), LBP (intensity and disability), and mobility function (gait speed and 6-Minute Walk Test) examinations were performed at each timepoint. Baseline hip measures were included in LVMM; observed classes/subgroups were compared longitudinally on LBP and mobility function outcomes using mixed models. RESULTS: Regarding LVMM, a model with 3 classes/subgroup fit best. Broadly speaking, subgroups were differentiated best by hip strength and symptom presence: subgroup 1 = strong and nonsymptomatic, subgroup 2 = weak and nonsymptomatic, and subgroup 3 = weak and symptomatic (WS). Regarding longitudinal mixed models, all subgroups improved in most outcomes over time. Specifically, over 12 months, the nonsymptomatic subgroups had lower LBP intensity and disability levels compared with the WS subgroup, whereas the strong and nonsymptomatic subgroup had better mobility function than the 2 "weak" subgroups. CONCLUSION: These subgroup classifications may help in tailoring specific interventions in future trials. Special attention should be given to the WS subgroup given their consistently poor LBP and mobility function outcomes. IMPACT: Among older adults with chronic low back pain, there are 3 hip subgroups: "strong and nonsymptomatic," "weak and nonsymptomatic," and "weak and symptomatic." People in these subgroups demonstrate different outcomes and require different treatment; proper identification will result in tailored interventions designed to benefit individual patients. In particular, people in the WS subgroup deserve special attention, because their outcomes are consistently poorer than those in the other subgroups.

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.

Validating Goal Attainment in Veterans Undergoing Decompressive Laminectomy: A Preliminary Study.

OBJECTIVE: Although decompressive laminectomy (DL) for lumbar spinal stenosis (LSS) is a common procedure among older adults, it is unclear whether surgical definitions of success translate into patient-defined success. Using goal attainment scaling (GAS) to compare goal achievement between individuals, we investigated the relationship between surgical-defined functional recovery and achievement of personalized goals in patients who underwent DL for LSS. PARTICIPANTS: Twenty-eight community-dwelling veterans scheduled to undergo DL. METHODS: Participants were interviewed over the phone to set 1-year post-DL goals within 30 days before undergoing DL. Brigham Spinal Stenosis (BSS) score, comorbidities, cognitive function, and psychological factors also were assessed. GAS and BSS were repeated 1 year after DL. GAS scores were transformed into GAS-T scores (T-score transformation) to standardize achievement between patients and GAS-T change scores to compare study variables. RESULTS: Seventeen of 28 participants had successful DL outcomes by BSS standards, though none of the participants achieved all of their GAS goals, with follow-up GAS-T scores averaging 44.5 ± 16.8. All three BSS scales positively correlated with GAS-T change scores: severity change r = 0.52, P = 0.005; physical function change r = 0.51, P = 0.006; and satisfaction r = 0.70, P < 0.001. Covariate analysis revealed a negative correlation between GAS-T change score and fear-avoidance beliefs: r = -0.41, P = -0.029. CONCLUSION: There was congruent validity between GAS and the BSS in older veterans undergoing DL for LSS. Given the need for patient-centered care in older adults, future investigations exploring GAS in larger studies that target additional pain conditions and include participants with greater demographic diversity are warranted.

How to Teach Medical Students About Pain and Dementia: E-Learning, Experiential Learning, or Both?

OBJECTIVE: Pain management in persons with mild to moderate dementia poses unique challenges because of altered pain modulation and the tendency of some individuals to perseverate. We aimed to test the impact of an e-learning module about pain in communicative people with dementia on third-year medical students who had or had not completed an experiential geriatrics course. DESIGN: Analysis of pre- to postlearning changes and comparison of the same across the student group. SETTING: University of Pittsburgh School of Medicine and Saint Louis University School of Medicine. SUBJECTS: One hundred four University of Pittsburgh and 57 Saint Louis University medical students. METHODS: University of Pittsburgh students were randomized to view either the pain and dementia module or a control module on pain during a five-day geriatrics course. Saint Louis University students were asked to complete either of the two modules without the context of a geriatrics course. A 10-item multiple choice knowledge test and three-item attitudes and confidence questionnaires were administered before viewing the module and up to seven days later. RESULTS: Knowledge increase was significantly greater among students who viewed the dementia module while participating in the geriatrics course than among students who viewed the module without engaging in the course (P < 0.001). The modules did not improve attitudes in any group, while student confidence improved in all groups. CONCLUSIONS: Medical students exposed to e-learning or experiential learning demonstrated improved confidence in evaluating and managing pain in patients with dementia. Those exposed to both educational methods also significantly improved their knowledge.

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.

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.

Pain Catastrophizing and Arthritis Self-Efficacy as Mediators of Sleep Disturbance and Osteoarthritis Symptom Severity.

OBJECTIVE: Sleep and pain-related experiences are consistently associated, but the pathways linking these experiences are not well understood. We evaluated whether pain catastrophizing and arthritis self-efficacy mediate the association between sleep disturbance and osteoarthritis (OA) symptom severity in patients with knee OA. METHODS: We analyzed cross-sectional baseline data collected from Veterans Affairs (VA) patients enrolled in a clinical trial examining the effectiveness of a positive psychology intervention in managing pain from knee OA. Participants indicated how often in the past two weeks they were bothered by trouble falling asleep, staying asleep, or sleeping too much. We used validated scales to assess the primary outcome (OA symptom severity) and potential mediators (arthritis self-efficacy and pain catastrophizing). To test the proposed mediation model, we used parallel multiple mediation analyses with bootstrapping, controlling for sociodemographic and clinical characteristics with bivariate associations with OA symptom severity. RESULTS: The sample included 517 patients (Mage = 64 years, 72.9% male, 52.2% African American). On average, participants reported experiencing sleep disturbance at least several days in the past two weeks (M = 1.41, SD = 1.18) and reported moderate OA symptom severity (M = 48.22, SD = 16.36). More frequent sleep disturbance was associated with higher OA symptom severity directly (b = 3.08, P <0.001) and indirectly, through higher pain catastrophizing (b = 0.60, 95% confidence interval [CI] = 0.20 to 1.11) and lower arthritis self-efficacy (b = 0.84, 95% CI = 0.42 to 1.42). CONCLUSIONS: Pain catastrophizing and arthritis self-efficacy partially mediated the association between sleep disturbance and OA symptom severity. Behavioral interventions that address pain catastrophizing and/or self-efficacy may buffer the association between sleep disturbance and OA symptom severity.

Opioid Exposure Negatively Affects Antidepressant Response to Venlafaxine in Older Adults with Chronic Low Back Pain and Depression.

OBJECTIVE: Serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly co-prescribed with opioids for chronic pain. The purpose of this study was to describe pain and mood response to venlafaxine among older adults with chronic low back pain (CLBP) and depression relative to opioid exposure. DESIGN: Secondary analyses were collected from a randomized clinical trial testing a stepped-care approach to comorbid pain and depression in older patients: the Addressing Depression and Pain Together study (ADAPT: 2010-2016). SETTING: University-based late-life mental health research clinic. SUBJECTS: Two hundred twenty-seven adults aged 65+ years with CLBP and depression. METHODS: Participants received six weeks of lower-dose venlafaxine (≤150 mg/d). Pain and depression were measured each week. Response for both pain and depression at the end of six weeks was defined by a ≥30% improvement on a 0-20 numeric rating scale for low back pain and a Patient Health Questionnaire-9 score ≤5. Opioid exposure was analyzed as prescribed (yes or no) and by morphine equivalent dosing (MED). RESULTS: Patients co-prescribed an opioid were less likely to report a pain response to venlafaxine. MED was negatively correlated with pain response. Depression response was not impacted. CONCLUSIONS: Opioids are negatively associated with older adults' early analgesic response to lower-dose venlafaxine. These findings suggest that clinicians may wish to consider either nonopioid or alternative antidepressant approaches to pain management in these complex patients. It is reassuring that opioids do not prevent depression response. Future research should examine both longer duration of treatment and a wider range of doses.

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.

Improving Patient Reported Outcomes and Preventing Depression and Anxiety in Older Adults With Knee Osteoarthritis: Results of a Sequenced Multiple Assignment Randomized Trial (SMART) Study.

OBJECTIVE: Older adults with knee osteoarthritis (OA) and comorbid subsyndromal depressive symptoms are at elevated risk for incidental major depression or anxiety disorders. Using an indicated prevention paradigm, the authors conducted a sequenced multiple assignment randomized trial (SMART) to: 1) evaluate the effect of cognitive behavioral therapy (CBT) and physical therapy (PT), together with the temporal ordering of these interventions, on patient-reported global impression of change (P-GIC), mood, anxiety, and pain; and 2) compare the strategies' impact on incidence of common psychiatric disorders over 12-months. METHODS: This intervention development trial compared four adaptive strategies delivered in two stages (each up to 8 weeks), contrasted with enhanced usual care (EUC). The strategies were CBT followed by an increased dose of CBT (CBT-CBT), CBT followed by PT (CBT-PT), PT followed by an increased dose of PT (PT-PT), and PT followed by CBT (PT-CBT). Participants (n = 99) were aged 60 years and older and met clinical criteria for knee OA and subthreshold depression. Response was defined as at least "much better" on the P-GIC. Participants were assessed quarterly for 12 months for incidence of psychiatric disorders. RESULTS: Stage 1 response was higher for PT (47.5%) compared to CBT (20.5%). Non-responders receiving an additional dose of the same intervention experienced a response rate of 73%, higher than for switching to a different intervention. All strategies were superior to EUC (5%). Although not powered to detect effects on disorders, neither intervention strategy nor response status affected 12-month incidence of depression and anxiety disorders. CONCLUSION: As response rates were similar for PT-PT and CBT-CBT, it may be dose and not type of these interventions that are necessary for clinical benefit. For non-responders, this finding may guide providers to stay the clinical course for up to 12 weeks before switching. These results support future trials of SMART designs in late-life depression prevention.

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.

Managing Acute Pain and Opioid Risks Following Wisdom Teeth Extraction: An Illustrative Case.

Introduction: The opioid epidemic has awakened educators to the insufficiency of training in the areas of pain management and substance use disorders within the curricula of health sciences schools. The University of Pittsburgh Center of Excellence in Pain Education created an online educational module focusing on factors contributing to the opioid epidemic and the role of robust interprofessional communication in avoiding common practitioner errors. Methods: The 1-hour module created by an interprofessional team comprised a pretest, video presentation featuring case vignettes, posttest, and learner satisfaction survey. The content of the module focused on four core concepts: (1) managing acute perioperative pain, (2) maximizing opioid safety, and (3) identifying and (4) managing suspected opioid abuse and diversion. Results: Data were obtained from 250 dental, pharmacy, and nursing students from the University of Pittsburgh who completed the module as part of their respective profession-specific curricula. Results collapsed across the three school-specific implementations indicated an average increase in knowledge test scores from pre- to posttest (Z = -8.82, p < .001). In addition, the learner satisfaction data revealed an overall positive response to the module, with students commenting that they enjoyed the module and felt it provided them with a valuable learning experience. Discussion: Learner outcomes and feedback suggest that our interprofessional team was successful in creating an effective learning module applicable to several health care professions, namely, pharmacy, dentistry, and nursing. Future studies might address the application of the knowledge gained to actual patient care.

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.

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.