Mortality among older adults with osteoporotic vertebral fracture.

We evaluated whether older adults who received kyphoplasty had reduced risk of mortality compared to those who did not. In unmatched analyses, those receiving kyphoplasty were at reduced risk of death but after matching on age and medical complications, patients who received kyphoplasty were at increased risk of death. PURPOSE: In previous observational studies, kyphoplasty for treatment of osteoporotic vertebral fractures has been associated with decreased mortality compared to conservative management. The purpose of this research was to determine whether older adults who received kyphoplasty had reduced risk of mortality compared to matched patients who did not. METHODS: Retrospective cohort study of US Medicare enrollees with osteoporotic vertebral fractures between 2017-2019 comparing patients who underwent kyphoplasty to those who did not. We identified 2 control groups a priori: 1) non-augmented patients who met inclusion criteria (group 1); 2) propensity-matched patients on demographic and clinical variables (group 2). We then identified additional control groups using matching for medical complications (group 3) and age + comorbidities (group 4). We calculated hazard ratios (HRs) and 95% confidence intervals (95% CIs) associated with mortality. RESULTS: A total of 235,317 patients (mean (± standard deviation) age 81.1 ± 8.3 years; 85.8% female) were analyzed. In the primary analyses, those who received kyphoplasty were at reduced risk of death compared to those who did not: adjusted HR (95% CI) in group 1 = 0.84 (0.82, 0.87); and in group 2 = 0.88 (0.85, 0.91). However, in post hoc analyses, patients who received kyphoplasty were at increased risk of death: adjusted HR (95% CI) in group 3 = 1.32 (1.25, 1.41) and 1.81 (1.58, 2.09) in group 4. CONCLUSION: An apparent benefit of kyphoplasty on mortality among patients with vertebral fractures was not present after rigorous propensity matching, illustrating the importance of comparing similar individuals when evaluating observational data.

Risk Factors for Chronic Prescription Opioid Use in Multiple Sclerosis.

OBJECTIVE: To characterize patterns of prescription opioid use among individuals with multiple sclerosis (MS) and identify risk factors associated with chronic use. DESIGN: Retrospective longitudinal cohort study examining US Department of Veterans Affairs electronic medical record data of Veterans with MS. The annual prevalence of prescription opioid use by type (any, acute, chronic, incident chronic) was calculated for each study year (2015-2017). Multivariable logistic regression was used to identify demographics and medical, mental health, and substance use comorbidities in 2015-2016 associated with chronic prescription opioid use in 2017. SETTING: US Department of Veterans Affairs, Veteran's Health Administration. PARTICIPANTS: National sample of Veterans with MS (N=14,974). MAIN OUTCOME MEASURE: Chronic prescription opioid use (≥90 days). RESULTS: All types of prescription opioid use declined across the 3 study years (chronic opioid use prevalence=14.6%, 14.0%, and 12.2%, respectively). In multivariable logistic regression, prior chronic opioid use, history of pain condition, paraplegia or hemiplegia, post-traumatic stress disorder, and rural residence were associated with greater risk of chronic prescription opioid use. History of dementia and psychotic disorder were both associated with lower risk of chronic prescription opioid use. CONCLUSION: Despite reductions over time, chronic prescription opioid use remains common among a substantial minority of Veterans with MS and is associated with multiple biopsychosocial factors that are important for understanding risk for long-term use.

Predicting decompression surgery by applying multimodal deep learning to patients' structured and unstructured health data.

BACKGROUND: Low back pain (LBP) is a common condition made up of a variety of anatomic and clinical subtypes. Lumbar disc herniation (LDH) and lumbar spinal stenosis (LSS) are two subtypes highly associated with LBP. Patients with LDH/LSS are often started with non-surgical treatments and if those are not effective then go on to have decompression surgery. However, recommendation of surgery is complicated as the outcome may depend on the patient's health characteristics. We developed a deep learning (DL) model to predict decompression surgery for patients with LDH/LSS. MATERIALS AND METHOD: We used datasets of 8387 and 8620 patients from a prospective study that collected data from four healthcare systems to predict early (within 2 months) and late surgery (within 12 months after a 2 month gap), respectively. We developed a DL model to use patients' demographics, diagnosis and procedure codes, drug names, and diagnostic imaging reports to predict surgery. For each prediction task, we evaluated the model's performance using classical and generalizability evaluation. For classical evaluation, we split the data into training (80%) and testing (20%). For generalizability evaluation, we split the data based on the healthcare system. We used the area under the curve (AUC) to assess performance for each evaluation. We compared results to a benchmark model (i.e. LASSO logistic regression). RESULTS: For classical performance, the DL model outperformed the benchmark model for early surgery with an AUC of 0.725 compared to 0.597. For late surgery, the DL model outperformed the benchmark model with an AUC of 0.655 compared to 0.635. For generalizability performance, the DL model outperformed the benchmark model for early surgery. For late surgery, the benchmark model outperformed the DL model. CONCLUSIONS: For early surgery, the DL model was preferred for classical and generalizability evaluation. However, for late surgery, the benchmark and DL model had comparable performance. Depending on the prediction task, the balance of performance may shift between DL and a conventional ML method. As a result, thorough assessment is needed to quantify the value of DL, a relatively computationally expensive, time-consuming and less interpretable method.

Causal effects of psychosocial factors on chronic back pain: a bidirectional Mendelian randomisation study.

PURPOSE: Risk factors for chronic back pain (CBP) may share underlying genetic factors, making them difficult to study using conventional methods. We conducted a bi-directional Mendelian randomisation (MR) study to examine the causal effects of risk factors (education, smoking, alcohol consumption, physical activity, sleep and depression) on CBP and the causal effect of CBP on the same risk factors. METHODS: Genetic instruments for risk factors and CBP were obtained from the largest published genome-wide association studies (GWAS) of risk factor traits conducted in individuals of European ancestry. We used inverse weighted variance meta-analysis (IVW), Causal Analysis Using Summary Effect (CAUSE) and sensitivity analyses to examine evidence for causal associations. We interpreted exposure-outcome associations as being consistent with a causal relationship if results with IVW or CAUSE were statistically significant after accounting for multiple statistical testing (p < 0.003), and the direction and magnitude of effect estimates were concordant between IVW, CAUSE, and sensitivity analyses. RESULTS: We found evidence for statistically significant causal associations between greater education (OR per 4.2 years of schooling = 0.54), ever smoking (OR = 1.27), greater alcohol consumption (OR = 1.29 per consumption category increase) and major depressive disorder (OR = 1.41) and risk of CBP. Conversely, we found evidence for significant causal associations between CBP and greater alcohol consumption (OR = 1.19) and between CBP and smoking (OR = 1.21). Other relationships did not meet our pre-defined criteria for causal association. CONCLUSION: Fewer years of schooling, smoking, greater alcohol consumption, and major depressive disorder increase the risk of CBP. CBP increases the risk of greater alcohol consumption and smoking.

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.

The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study.

BACKGROUND: Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS. METHODS: This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation. DISCUSSION: This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials.

Effects of Including Epidemiologic Data in Lumbar Spine Imaging Reports on Prescribing Non-Opioid Medications for Pain.

BACKGROUND: Information on the prevalence of common imaging findings among patients without back pain in spine imaging reports might affect pain medication prescribing for patients with back pain. Prior research on inserting this text suggested a small reduction in opioid prescribing. OBJECTIVE: To evaluate the effect of epidemiologic information in spine imaging reports on non-opioid pain medication prescribing for primary care patients with back pain. DESIGN: Post hoc analysis of the Lumbar Imaging with Reporting of Epidemiology cluster-randomized trial. PARTICIPANTS: A total of 170,680 patients aged ≥ 18 years from four healthcare systems who received thoracolumbar, lumbar, or lumbosacral spine imaging from 2013 to 2016 and had not received a prescription for non-opioid pain medication in the preceding 120 days. INTERVENTION: Text of age- and modality-specific epidemiologic benchmarks indicating the prevalence of common findings in people without back pain inserted into thoracolumbar, lumbar, or lumbosacral spine imaging reports at intervention clinics. MAIN MEASURES: Primary outcomes: any non-opioid prescription within 90 days after index imaging, overall, and by sub-class (skeletal muscle relaxants, NSAIDs, gabapentinoids, tricyclic antidepressants, benzodiazepines, duloxetine). SECONDARY OUTCOMES: count of non-opioid prescriptions within 90 days, overall, and by sub-class. KEY RESULTS: The intervention was not associated with the likelihood of patients receiving at least one prescription for new non-opioid pain-related medications, overall (adjusted OR, 1.02; 95% CI, 0.97-1.08) or by sub-class. The intervention was not associated with the number of prescriptions for any non-opioid medication (adjusted incidence rate ratio [IRR], 1.02; 95% CI, 0.99-1.04). However, the intervention was associated with more new prescriptions for NSAIDs (IRR, 1.12) and tricyclic antidepressants (IRR, 1.11). CONCLUSIONS: Inserting epidemiologic text in spine imaging reports had no effect on whether new non-opioid pain-related medications were prescribed but was associated with the number of new prescriptions for certain non-opioid sub-classes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02015455.

Providing Epidemiological Data in Lumbar Spine Imaging Reports Did Not Affect Subsequent Utilization of Spine Procedures: Secondary Outcomes from a Stepped-Wedge Randomized Controlled Trial.

OBJECTIVE: To evaluate the effect of inserting epidemiological information into lumbar spine imaging reports on subsequent nonsurgical and surgical procedures involving the thoracolumbosacral spine and sacroiliac joints. DESIGN: Analysis of secondary outcomes from the Lumbar Imaging with Reporting of Epidemiology (LIRE) pragmatic stepped-wedge randomized trial. SETTING: Primary care clinics within four integrated health care systems in the United States. SUBJECTS: 238,886 patients ≥18 years of age who received lumbar diagnostic imaging between 2013 and 2016. METHODS: Clinics were randomized to receive text containing age- and modality-specific epidemiological benchmarks indicating the prevalence of common spine imaging findings in people without low back pain, inserted into lumbar spine imaging reports (the "LIRE intervention"). The study outcomes were receiving 1) any nonsurgical lumbosacral or sacroiliac spine procedure (lumbosacral epidural steroid injection, facet joint injection, or facet joint radiofrequency ablation; or sacroiliac joint injection) or 2) any surgical procedure involving the lumbar, sacral, or thoracic spine (decompression surgery or spinal fusion or other spine surgery). RESULTS: The LIRE intervention was not significantly associated with subsequent utilization of nonsurgical lumbosacral or sacroiliac spine procedures (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.93-1.09; P = 0.79) or any surgical procedure (OR = 0.99, 95 CI 0.91-1.07; P = 0.74) involving the lumbar, sacral, or thoracic spine. The intervention was also not significantly associated with any individual spine procedure. CONCLUSIONS: Inserting epidemiological text into spine imaging reports had no effect on nonsurgical or surgical procedure utilization among patients receiving lumbar diagnostic imaging.

Genome-wide meta-analysis of 158,000 individuals of European ancestry identifies three loci associated with chronic back pain.

Back pain is the #1 cause of years lived with disability worldwide, yet surprisingly little is known regarding the biology underlying this symptom. We conducted a genome-wide association study (GWAS) meta-analysis of chronic back pain (CBP). Adults of European ancestry were included from 15 cohorts in the Cohorts for Heart and Aging Research in Genomic Epidemiology (CHARGE) consortium, and from the UK Biobank interim data release. CBP cases were defined as those reporting back pain present for ≥3-6 months; non-cases were included as comparisons ("controls"). Each cohort conducted genotyping using commercially available arrays followed by imputation. GWAS used logistic regression models with additive genetic effects, adjusting for age, sex, study-specific covariates, and population substructure. The threshold for genome-wide significance in the fixed-effect inverse-variance weighted meta-analysis was p<5×10(-8). Suggestive (p<5×10(-7)) and genome-wide significant (p<5×10(-8)) variants were carried forward for replication or further investigation in the remaining UK Biobank participants not included in the discovery sample. The discovery sample comprised 158,025 individuals, including 29,531 CBP cases. A genome-wide significant association was found for the intronic variant rs12310519 in SOX5 (OR 1.08, p = 7.2×10(-10)). This was subsequently replicated in 283,752 UK Biobank participants not included in the discovery sample, including 50,915 cases (OR 1.06, p = 5.3×10(-11)), and exceeded genome-wide significance in joint meta-analysis (OR 1.07, p = 4.5×10(-19)). We found suggestive associations at three other loci in the discovery sample, two of which exceeded genome-wide significance in joint meta-analysis: an intergenic variant, rs7833174, located between CCDC26 and GSDMC (OR 1.05, p = 4.4×10(-13)), and an intronic variant, rs4384683, in DCC (OR 0.97, p = 2.4×10(-10)). In this first reported meta-analysis of GWAS for CBP, we identified and replicated a genetic locus associated with CBP (SOX5). We also identified 2 other loci that reached genome-wide significance in a 2-stage joint meta-analysis (CCDC26/GSDMC and DCC).

Forecasting Future Asthma Hospital Encounters of Patients With Asthma in an Academic Health Care System: Predictive Model Development and Secondary Analysis Study.

BACKGROUND: Asthma affects a large proportion of the population and leads to many hospital encounters involving both hospitalizations and emergency department visits every year. To lower the number of such encounters, many health care systems and health plans deploy predictive models to prospectively identify patients at high risk and offer them care management services for preventive care. However, the previous models do not have sufficient accuracy for serving this purpose well. Embracing the modeling strategy of examining many candidate features, we built a new machine learning model to forecast future asthma hospital encounters of patients with asthma at Intermountain Healthcare, a nonacademic health care system. This model is more accurate than the previously published models. However, it is unclear how well our modeling strategy generalizes to academic health care systems, whose patient composition differs from that of Intermountain Healthcare. OBJECTIVE: This study aims to evaluate the generalizability of our modeling strategy to the University of Washington Medicine (UWM), an academic health care system. METHODS: All adult patients with asthma who visited UWM facilities between 2011 and 2018 served as the patient cohort. We considered 234 candidate features. Through a secondary analysis of 82,888 UWM data instances from 2011 to 2018, we built a machine learning model to forecast asthma hospital encounters of patients with asthma in the subsequent 12 months. RESULTS: Our UWM model yielded an area under the receiver operating characteristic curve (AUC) of 0.902. When placing the cutoff point for making binary classification at the top 10% (1464/14,644) of patients with asthma with the largest forecasted risk, our UWM model yielded an accuracy of 90.6% (13,268/14,644), a sensitivity of 70.2% (153/218), and a specificity of 90.91% (13,115/14,426). CONCLUSIONS: Our modeling strategy showed excellent generalizability to the UWM, leading to a model with an AUC that is higher than all of the AUCs previously reported in the literature for forecasting asthma hospital encounters. After further optimization, our model could be used to facilitate the efficient and effective allocation of asthma care management resources to improve outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.5039.

ISSLS Prize in Clinical Science 2020. Examining causal effects of body mass index on back pain: a Mendelian randomization study.

PURPOSE: Measures of body fat accumulation are associated with back pain, but a causal association is unclear. We hypothesized that BMI would have causal effects on back pain. We conducted a two-sample Mendelian randomization (MR) study to assess the causal effect of body mass index (BMI) on the outcomes of (1) back pain and (2) chronic back pain (duration > 3 months). METHODS: We identified genetic instrumental variables for BMI (n = 60 variants) from a meta-analysis of genome-wide association studies (GWAS) conducted by the Genetic Investigation of ANthropometric Traits consortium in individuals of European ancestry (n = 322,154). We conducted GWAS of back pain and chronic back pain (n = 453,860) in a non-overlapping sample of individuals of European ancestry. We used inverse-variance weighted (IVW) meta-analysis as the primary method to estimate causal effects. RESULTS: The IVW analysis showed evidence supporting a causal association of BMI on back pain, with a 1-standard deviation (4.65 kg/m2) increase in BMI conferring 1.15 times the odds of back pain (95% confidence interval [CI]: 1.06-1.25, p = 0.001]; effects were directionally consistent in secondary analysis and sensitivity analyses. The IVW analysis supported a causal association of BMI on chronic back pain (OR 1.20 per 1 SD deviation increase in BMI [95% CI 1.09-1.32; p = 0.0002]), and effects were directionally consistent in secondary analysis and sensitivity analyses. CONCLUSION: In this first MR study of BMI and back pain, we found a significant causal effect of BMI on both back pain and chronic back pain. These slides can be retrieved under Electronic Supplementary Material.

Multi-site Pain Is Associated with Long-term Patient-Reported Outcomes in Older Adults with Persistent Back Pain.

OBJECTIVE: To estimate the prevalence of co-occurring pain sites among older adults with persistent back pain and associations of multisite pain with longitudinal outcomes. DESIGN: Secondary analysis of a cohort study. SETTING: Three integrated health systems in the United States. SUBJECTS: Eight hundred ninety-nine older adults with persistent back pain. METHODS: Participants reported pain in the following sites: stomach, arms/legs/joints, headaches, neck, pelvis/groin, and widespread pain. Over 18 months, we measured back-related disability (Roland Morris, scored 0-24), pain intensity (11-point numerical rating scale), health-related quality of life (EuroQol-5D [EQ-5D], utility from 0-1), and falls in the past three weeks. We used mixed-effects models to test the association of number and type of pain sites with each outcome. RESULTS: Nearly all (N = 839, 93%) respondents reported at least one additional pain site. There were 216 (24%) with one additional site and 623 (69%) with multiple additional sites. The most prevalent comorbid pain site was the arms/legs/joints (N = 801, 89.1%). Adjusted mixed-effects models showed that for every additional pain site, RMDQ worsened by 0.65 points (95% confidence interval [CI] = 0.43 to 0.86), back pain intensity increased by 0.14 points (95% CI = 0.07 to 0.22), EQ-5D worsened by 0.012 points (95% CI = -0.018 to -0.006), and the odds of falling increased by 27% (odds ratio = 1.27, 95% CI = 1.12 to 1.43). Some specific pain sites (extremity pain, widespread pain, and pelvis/groin pain) were associated with greater long-term disability. CONCLUSIONS: Multisite pain is common among older adults with persistent back pain. Number of pain sites was associated with all outcomes; individual pain sites were less consistently associated with 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.

Which Neuromuscular Attributes Are Associated With Changes in Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis?

OBJECTIVES: To identify neuromuscular attributes associated with mobility and changes in mobility over 2 years of follow-up among patients with and without symptomatic lumbar spinal stenosis (SLSS). DESIGN: Secondary analysis of a longitudinal cohort study. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Community-dwelling older adults ≥65 years with self-reported mobility limitations (N=430). SLSS was determined using self-reported symptoms of neurogenic claudication and imaging-detected lumbar spinal stenosis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Basic and advanced mobility as measured by the Late-Life Function and Disability Instrument (LLFDI). RESULTS: Among 430 community-dwelling older adults, 54 (13%) patients met criteria for SLSS, while 246 (57%) did not. On average LLFDI basic and advanced mobility scores decreased significantly from baseline through year 2 for participants with SLSS (basic: P=.04, 95% CI 0.18, 5.21; advanced P=.03, 95% CI 0.39, 7.84). Trunk extensor muscle endurance (trunk endurance) and leg strength were associated with baseline basic mobility (R2=0.27, P<.001) while leg strength and knee flexion range of motion (ROM) were associated with baseline advanced mobility among participants with SLSS (R2=0.47, P<.001). Among participants without SLSS trunk endurance, leg strength and ankle ROM were associated with baseline basic mobility (R2=0.38, P<.001), while trunk endurance, leg strength, leg strength asymmetry, and knee flexion ROM were associated with advanced mobility (R2=0.20, P<.001). Trunk endurance and leg strength were associated with change in basic mobility (R2=0.29, P<.001), while trunk endurance and knee flexion ROM were associated with change in advanced mobility (R2=0.42, P<.001) among participants with SLSS. Among participants without SLSS trunk endurance, leg strength, knee flexion ROM, and ankle ROM were associated with change in basic mobility (R2=0.22, P<.001), while trunk endurance, leg strength, and knee flexion ROM were associated with change in advanced mobility (R2=0.36, P<.001). CONCLUSIONS: Patients with SLSS experience greater impairment in the neuromuscular attributes: trunk endurance, leg strength, leg strength asymmetry, knee flexion and extension ROM, and ankle ROM compared to patients without SLSS. Differences exist in the neuromuscular attributes associated with mobility at baseline and decline in mobility over 2 years of follow-up for patients with and without SLSS. These findings may help guide rehabilitative care approaches for patients with SLSS.

Do medical conditions predispose to the development of chronic back pain? A longitudinal co-twin control study of middle-aged males with 11-year follow-up.

BACKGROUND: Poor general health predicts the transition to chronic back pain (CBP), but the role of specific medical conditions in the development of CBP is unclear. The study aim was to examine the association of medical conditions with the development of CBP ("incident CBP"), while controlling for familial factors, including genetics. METHODS: This was a longitudinal co-twin control study conducted in a nationwide United States sample from the Vietnam Era Twin Registry. The study sample included 3045 males without back problems at baseline, including 662 complete twin pairs, who were followed for 11 years. Baseline surveys inquired about self-reported medical conditions (arthritis, diabetes, hypertension, and coronary artery disease [CAD]). A medical comorbidity score was calculated based on the presence and/or treatment of 8 medical conditions. Covariates included age, race, and education. At 11-year follow-up, participants reported ever having had CBP. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated when considering twins as individuals, and in matched-pair co-twin control analyses adjusting for familial/genetic factors. RESULTS: Mean age at baseline was 51 years and 17% of participants developed CBP over the 11-year follow-up. Arthritis was significantly associated with incident CBP in individual-level analysis (OR 1.8 [95% CI 1.4-2.2]), but not within-pair analysis (OR 0.9 [95% CI 0.4-1.9]. CAD (OR 1.6 [95% CI 1.0-2.3]), hypertension (OR 1.3 [95% CI 1.0-1.5]), and the medical comorbidity score (OR 1.2 [95%CI 1.1-2.2]) were significantly associated with incident CBP in individual-level analyses; associations in within-pair analyses were of comparable magnitude, but not statistically significant. Diabetes was not associated with incident CBP. CONCLUSIONS: Arthritis, hypertension, CAD, and medical comorbidity score were associated with incident CBP in the current study. However, the association between arthritis and incident CBP was confounded by familial factors. This suggests that prevention or treatment of arthritis is unlikely to be useful for CBP prevention. Our findings cannot exclude the possibility of causal associations between CAD, hypertension, and medical comorbidities and incident CBP.

Using Natural Language Processing of Free-Text Radiology Reports to Identify Type 1 Modic Endplate Changes.

Electronic medical record (EMR) systems provide easy access to radiology reports and offer great potential to support quality improvement efforts and clinical research. Harnessing the full potential of the EMR requires scalable approaches such as natural language processing (NLP) to convert text into variables used for evaluation or analysis. Our goal was to determine the feasibility of using NLP to identify patients with Type 1 Modic endplate changes using clinical reports of magnetic resonance (MR) imaging examinations of the spine. Identifying patients with Type 1 Modic change who may be eligible for clinical trials is important as these findings may be important targets for intervention. Four annotators identified all reports that contained Type 1 Modic change, using N = 458 randomly selected lumbar spine MR reports. We then implemented a rule-based NLP algorithm in Java using regular expressions. The prevalence of Type 1 Modic change in the annotated dataset was 10%. Results were recall (sensitivity) 35/50 = 0.70 (95% confidence interval (C.I.) 0.52-0.82), specificity 404/408 = 0.99 (0.97-1.0), precision (positive predictive value) 35/39 = 0.90 (0.75-0.97), negative predictive value 404/419 = 0.96 (0.94-0.98), and F1-score 0.79 (0.43-1.0). Our evaluation shows the efficacy of rule-based NLP approach for identifying patients with Type 1 Modic change if the emphasis is on identifying only relevant cases with low concern regarding false negatives. As expected, our results show that specificity is higher than recall. This is due to the inherent difficulty of eliciting all possible keywords given the enormous variability of lumbar spine reporting, which decreases recall, while availability of good negation algorithms improves specificity.

Associations Between Traumatic Brain Injury History and Future Headache Severity in Veterans: A Longitudinal Study.

OBJECTIVE: To determine whether traumatic brain injury (TBI) history is associated with worse headache severity outcomes. DESIGN: Prospective cohort study. SETTING: Department of Veterans Affairs (VA) outpatient clinics. PARTICIPANTS: Veterans (N=2566) who completed a mail follow-up survey an average of 3 years after a comprehensive TBI evaluation (CTBIE). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The presence or absence of TBI, and TBI severity were evaluated by a trained clinician and classified according to VA/Department of Defense clinical practice guidelines. Headache severity was evaluated at both the baseline CTBIE assessment and 3-year follow-up using a 5-level headache score ranging from 0 ("none") to 4 ("very severe") based on headache-associated activity interference in the past 30 days. We examined associations of mild and moderate/severe TBI history, as compared to no TBI history, with headache severity in cross-sectional and longitudinal analyses, with and without adjustment for potential confounders. RESULTS: Mean headache severity scores were 2.4 at baseline and 2.3 at 3-year follow-up. Mild TBI was associated with greater headache severity in multivariate-adjusted cross-sectional analyses (ß [SE]=.61 [.07], P<.001), as compared with no TBI, but not in longitudinal analyses (ß [SE]=.09 [.07], P=.20). Moderate/severe TBI was significantly associated with greater headache severity in both cross-sectional (ß [SE]=.66 [.09], P<.001) and longitudinal analyses (ß [SE]=.18 [.09], P=.04). CONCLUSIONS: Headache outcomes are poor in veterans who receive VA TBI evaluations, irrespective of past TBI exposure, but significantly worse in those with a history of moderate/severe TBI. No association was found between mild TBI and future headache severity in veterans. Veterans with headache presenting for TBI evaluations, and particularly those with moderate/severe TBI, may benefit from further evaluation and treatment of headache.

Association of Neuromuscular Attributes With Performance-Based Mobility Among Community-Dwelling Older Adults With Symptomatic Lumbar Spinal Stenosis.

OBJECTIVES: To identify differences in health factors, neuromuscular attributes, and performance-based mobility among community-dwelling older adults with symptomatic lumbar spinal stenosis; and to determine which neuromuscular attributes are associated with performance-based measures of mobility. DESIGN: Cross-sectional; secondary data analysis of a cohort study. SETTING: Outpatient rehabilitation center. PARTICIPANTS: Community-dwelling adults aged ≥65 years with self-reported mobility limitations and symptomatic lumbar spinal stenosis (N=54). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Short Physical Performance Battery score, habitual gait speed, and chair stand test. RESULTS: Symptomatic lumbar spinal stenosis was classified using self-reported symptoms of neurogenic claudication and imaging. Among 430 community-dwelling older adults, 54 (13%) met criteria for symptomatic lumbar spinal stenosis. Compared with participants without symptomatic lumbar spinal stenosis, those with symptomatic lumbar spinal stenosis had more comorbidities, higher body mass index, greater pain, and less balance confidence. Participants with symptomatic lumbar spinal stenosis had greater impairment in trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion range of motion (ROM), knee extension ROM, and ankle ROM compared with participants without symptomatic lumbar spinal stenosis. Five neuromuscular attributes were associated with performance-based mobility among participants with symptomatic lumbar spinal stenosis: trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion ROM, and knee extension ROM asymmetry. CONCLUSIONS: Community-dwelling older adults with self-reported mobility limitations and symptomatic lumbar spinal stenosis exhibit poorer health characteristics, greater neuromuscular impairment, and worse mobility when compared with those without symptomatic lumbar spinal stenosis. Poorer trunk extensor muscle endurance, leg strength, leg strength asymmetry, knee flexion ROM, and knee extension ROM asymmetry were associated with performance-based mobility among participants with symptomatic lumbar spinal stenosis.

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.

Long-Term Effects of Repeated Injections of Local Anesthetic With or Without Corticosteroid for Lumbar Spinal Stenosis: A Randomized Trial.

OBJECTIVE: To determine the overall long-term effectiveness of treatment with epidural corticosteroid injections for lumbar central spinal stenosis and the effect of repeat injections, including crossover injections, on outcomes through 12 months. DESIGN: Multicenter, double-blind, randomized controlled trial comparing epidural injections of corticosteroid plus lidocaine versus lidocaine alone. SETTING: Sixteen clinical sites. PARTICIPANTS: Participants with imaging-confirmed lumbar central spinal stenosis (N=400). INTERVENTIONS: Participants were randomized to receive either epidural injections with corticosteroid plus lidocaine or lidocaine alone with the option of blinded crossover after 6 weeks to receive the alternate treatment. Participants could receive 1 to 2 injections from 0 to 6 weeks and up to 2 injections from 6 to 12 weeks. After 12 weeks, participants received usual care. MAIN OUTCOME MEASURES: Primary outcomes were the Roland-Morris Disability Questionnaire (RDQ) (range, 0-24, where higher scores indicate greater disability) and leg pain intensity (range, 0 [no pain] to 10 [pain as bad as you can imagine]). Secondary outcomes included opioid use, spine surgery, and crossover rates. RESULTS: At 12 months, both treatment groups maintained initial observed improvements, with no significant differences between groups on the RDQ (adjusted mean difference, -0.4; 95% confidence interval [CI], -1.6 to 0.9; P=.55), leg pain (adjusted mean difference, 0.1; 95% CI, -0.5 to 0.7; P=.75), opioid use (corticosteroid plus lidocaine: 41.4% vs lidocaine alone: 36.3%; P=.41), or spine surgery (corticosteroid plus lidocaine: 16.8% vs lidocaine alone: 11.8%; P=.22). Fewer participants randomized to corticosteroid plus lidocaine (30%, n=60) versus lidocaine alone (45%, n=90) crossed over after 6 weeks (P=.003). Among participants who crossed over at 6 weeks, the 6- to 12-week RDQ change did not differ between the 2 randomized treatment groups (adjusted mean difference, -1.0; 95% CI, -2.6 to 0.7; P=.24). In both groups, participants crossing over at 6 weeks had worse 12-month trajectories compared with participants who did not choose to crossover. CONCLUSIONS: For lumbar spinal stenosis symptoms, epidural injections of corticosteroid plus lidocaine offered no benefits from 6 weeks to 12 months beyond that of injections of lidocaine alone in terms of self-reported pain and function or reduction in use of opioids and spine surgery. In patients with improved pain and function 6 weeks after initial injection, these outcomes were maintained at 12 months. However, the trajectories of pain and function outcomes after 3 weeks did not differ by injectate type. Repeated injections of either type offered no additional long-term benefit if injections in the first 6 weeks did not improve pain.