Preliminary Characterization of Age and Chronic Low Back Pain Effects on Multimodal Pain Sensitivity: A Comparison Study in Older Adults with and Without Chronic Low Back Pain.

Though pain sensitivity impairments contribute to chronic pain in younger adults, it is unclear if pain hypersensitivity manifests with aging and is heightened in the geriatric chronic low back pain population. The cross-sectional study preliminarily addressed this gap by measuring pain sensitivity in older adults with chronic low back pain (n = 25) as well as pain-free sex-matched older (n = 25) and younger adults (n = 25). Pain sensitivity was quantified by 8 distinct measures that were subdivided as static (ie, pressure pain thresholds, heat pain thresholds, fixed mechanical pain, and fixed cold pain) and dynamic pain sensitivity (ie, mechanical temporal summation, thermal ramp and hold, heat pain aftersensations, and conditioned pain modulation). Test-retest reliability values for pain sensitivity ranged from moderate to excellent (intraclass correlation coefficients ≥ .500; p's < .05). The main effect for the group was significant (partial η2 = .413, P < .001), revealing between-group differences in pain sensitivity on 5 out of 8 tests (p's ≤ .043). Predominantly, both older adult groups demonstrated increased pain facilitation and decreased pain inhibition during dynamic pain sensitivity testing compared to pain-free younger adults (p's ≤ .044). Despite qualitative differences, static and dynamic pain sensitivity responses were statistically similar between older adults with and without chronic LBP (p's > .05). Findings suggest pain sensitivity can be reliably measured in older adults and that pain hypersensitivity develops with chronological aging, providing partial support for the theory that pain hypersensitivity may impact geriatric chronic pain populations. Further study is needed to more definitively parse out whether pain hypersensitivity is comparatively heightened in older adults with chronic LBP beyond the influence of chronological aging. PERSPECTIVE: This article establishes that surrogate measures of centrally mediated pain sensitization are heightened with aging. Impaired endogenous pain modulation may influence chronic pain development, maintenance, treatment efficacy, and/or ensuing disability, necessitating research to comprehensively characterize how pain hypersensitivity contributes to geriatric chronic pain conditions.

Through the Lens of Movement-Evoked Pain: A Theoretical Framework of the "Pain-Movement Interface" to Guide Research and Clinical Care for Musculoskeletal Pain Conditions.

Over 120 million Americans report experiencing pain in the past 3 months. Among these individuals, 50 million report chronic pain and 17 million report pain that limits daily life or work activities on most days (ie, high-impact chronic pain). Musculoskeletal pain conditions in particular are a major contributor to global disability, health care costs, and poor quality of life. Movement-evoked pain (MEP) is an important and distinct component of the musculoskeletal pain experience and represents an emerging area of study in pain and rehabilitation fields. This focus article proposes the "Pain-Movement Interface" as a theoretical framework of MEP that highlights the interface between MEP, pain interference, and activity engagement. The goal of the framework is to expand knowledge about MEP by guiding scientific inquiry into MEP-specific pathways to disability, high-risk clinical phenotypes, and underlying individual influences that may serve as treatment targets. This framework reinforces the dynamic nature of MEP within the context of activity engagement, participation in life and social roles, and the broader pain experience. Recommendations for MEP evaluation, encompassing the spectrum from high standardization to high patient specificity, and MEP-targeted treatments are provided. Overall, the proposed framework and recommendations reflect the current state of science in this emerging area of study and are intended to support future efforts to optimize musculoskeletal pain management and enhance patient outcomes. PERSPECTIVE: Movement-evoked pain (MEP) is a distinct component of the musculoskeletal pain experience and emerging research area. This article introduces the "Pain-Movement Interface" as a theoretical framework of MEP, highlighting the interface between MEP, pain interference, and activity engagement. Evaluating and treating MEP could improve rehabilitation approaches and enhance patient outcomes.

Hip-focused physical therapy versus spine-focused physical therapy for older adults with chronic low back pain at risk for mobility decline (MASH): a multicentre, single-masked, randomised controlled trial.

BACKGROUND: Previously, we identified a population of older adults with chronic low back pain, hip pain, and hip muscle weakness who had worse 12-month low back pain and functional outcomes than age-matched adults with only low back pain, indicating an increased risk for future mobility decline. We sought to determine whether tailored, hip-focused physical therapy reduced pain and functional limitations in this high-risk population compared with non-tailored, spine-focused physical therapy. METHODS: We did a multicentre, single-masked, randomised controlled trial at three research-based sites in the USA. We recruited older adults (aged 60-85 years) with hip pain and weakness who reported moderate low back pain intensity at least half the days in the last 6 months. Patients were randomly assigned to hip-focused physical therapy or spine-focused physical therapy using permuted blocks with random block size, stratified by site and sex (ie, male or female). The primary outcomes were self-reported disability using the Quebec Back Pain Disability Scale (QBPDS) and performance-based 10-Meter Walk Test (10MWT) at 8 weeks. All analyses were done in the intention-to-treat population. Adverse events were collected by study staff via a possible adverse event reporting form and then adjudicated by site investigators. This trial was registered with ClinicalTrials.gov, NCT04009837. FINDINGS: Between Nov 1, 2019, and April 30, 2022, 184 participants were randomly assigned to receive hip-focused (n=91) or spine-focused physical therapy (n=93) interventions. The mean age was 70·7 (SD 6·2) years. 121 (66%) of 184 participants were women, 63 (34%) were men, and 149 (81%) were White. At 8 weeks, the mean between-group difference on the QBPDS was 4·0 (95% CI 0·5 to 7·5), favouring hip-focused physical therapy. Both groups had similar, clinically meaningful gait speed improvements (10MWT) at 8 weeks (mean difference 0·004 m/s [95% CI -0·044 to 0·052]). No serious adverse events were related to study participation. INTERPRETATION: Tailored hip-focused physical therapy demonstrated greater improvements in low back pain-related disability at 8 weeks. However, both hip-focused physical therapy and spine-focused physical therapy produced clinically meaningful improvements in disability and function for this high-risk population at 6 months. These findings warrant further investigation before clinical implementation. FUNDING: US National Institute on Aging of the National Institutes of Health.

If You Build It, Will They Come? Patient and Provider Use of a Novel Hybrid Telehealth Care Pathway for Low Back Pain.

OBJECTIVE: The purpose of this study was to describe the referrals and use of a hybrid care model for low back pain that includes on-site care by physical therapists, physical activity training, and psychologically informed practice (PiP) delivered by telehealth in the Improving Veteran Access to Integrated Management of Low Back Pain (AIM-Back) trial. METHODS: Data were collected from November 2020 through February 2023 from 5 Veteran Health Administration clinics participating in AIM-Back, a multisite, cluster-randomized embedded pragmatic trial. The authors extracted data from the Veteran Health Administration Corporate Data Warehouse to describe referral and enrollment metrics, telehealth use (eg, distribution of physical activity and PiP calls), and treatments used by physical therapists and telehealth providers. RESULTS: Seven hundred one veterans were referred to the AIM-Back trial with 422 enrolling in the program (consult-to-enrollment rate = 60.2%). After travel restrictions were lifted, site visits resulted in a significant increase in referrals and a number of new referring providers. At initial evaluation by on-site physical therapists, 92.2% of veterans received pain modulation (eg, transcutaneous electrical nerve stimulation, manual therapy). Over 81% of enrollees completed at least 1 telehealth physical activity call, with a mean of 2.8 (SD = 2.0) calls out of 6. Of the 167 veterans who screened as medium to high risk of persistent disability, 74.9% completed at least 1 PiP call, with a mean of 2.5 (SD = 2.0) calls out of 6. Of those who completed at least 1 PiP call (n = 125), 100% received communication strategies, 97.6% received pain coping skills training, 89.6% received activity-based treatments, and 99.2% received education in a home program. CONCLUSION: In implementing a hybrid care pathway for low back pain, the authors observed consistency in the delivery of core components (ie, pain modulation, use of physical activity training, and risk stratification to PiP), notable variability in telehealth calls, high use of PiP components, and increased referrals with tailored provider engagement. IMPACT: These findings describe variability occurring within a hybrid care pathway and can inform future implementation efforts.

Examining Psychological Factors as Contributors to Pain, Disability, and Physical Function in Geriatric Chronic Low Back Pain: A Prospective Analysis of the Delaware Spine Studies Cohort.

In younger populations, risk factors from psychologically-focused theoretical models have become accepted as primary drivers behind the persistence of low back pain (LBP), but these risk factors have not been thoroughly assessed in older adult populations (60-85 years). To address this knowledge gap, we sought to examine longitudinal associations between both general and pain-related psychological risk factors and future pain intensity, LBP-related disability, and physical function (gait speed) outcomes in older adults with chronic LBP (n = 250). Questionnaires for general (ie, depressive symptoms) and pain-related psychological risk factors (ie, fear-avoidance beliefs, pain catastrophizing, and kinesiophobia) were collected at baseline. Questionnaire values were entered into principal component analysis to yield a combined psychological component score. LBP intensity (pain thermometers), LBP-related disability (Quebec Back Pain Disability Scale), and gait speed were measured at baseline and 12-month follow-up. Multiple linear regression was used to examine adjusted associations between baseline psychological component scores and each prospective outcome. The baseline psychological component score failed to independently predict 12-month LBP-related disability and gait speed after adjustment for baseline outcomes. Though the psychological component score was associated with 12-month LBP intensity after adjusting for baseline LBP intensity, this association diminished with full adjustment for other baseline characteristics. Cumulatively, general and pain-related psychological risk factors did not independently predict longitudinal pain, disability, and physical function outcomes in this cohort. Compared to younger populations with this condition, general and pain-related psychological risk factors may have less influence on the maintenance of chronic LBP in older adults. PERSPECTIVE: This article failed to establish consistent independent relationships between psychological factors and worse longitudinal pain, disability, and physical function outcomes in older adults with chronic LBP. The findings highlight a need to determine other age-specific biopsychosocial risk factors that may impact the maintenance of chronic pain in this patient population.

Associations Between Management Pathway and Opioid Prescriptions for Patients Entering the Emergency Department With Neck and Back Pain.

Objective: To determine associations between post-emergency department (ED) management pathways and downstream opioid prescriptions in patients seeking care for incident neck and/or back pain. Patients and Methods: We identified patients seeking first-time ED care for neck and/or back pain from January 1, 2013, through November 6, 2017. We reported demographic characteristics and opioid prescriptions across management pathways using descriptive statistics and assessed the relative risk of any opioid prescription 12 months post-ED visit among 5 different post-ED management pathways using Poisson regression adjusted for patient demographic characteristics. Results: Within 12 months after the index ED visit, 58.0% (n=10,949) were prescribed an opioid, with most patients prescribed an opioid within the first week (average daily morphine milligram equivalents of 6.8 mg (SD 9.6 mg). The morphine milligram equivalents decreased to 0.7 mg (SD 8.2 mg) by week 4 and remained consistently less than 1 mg between week 4 and 12 months. Compared with the ED to primary care provider pathway, the relative risk of opioid prescription between 7 days and 12 months after the index ED visit was similar for the ED to physical therapy pathway, higher for both the ED to hospital admission or repeat ED visit pathway (30% increase; relative risk (RR), 1.3; 95% CI, 1.17-1.44) and the ED to specialist pathway (19% increase; RR, 1.19; 95% CI, 1.07-1.33), and lower in the ED with no follow-up visits pathway (41% decrease; RR, 0.59; 95% CI, 0.54-0.65). Conclusion: In general, more conservative care was associated with lower opioid prescription rates, and escalated care was associated with higher opioid prescription rates.

Circulating Inflammatory Biomarkers Predict Pain Change Following Exercise-Induced Shoulder Injury: Findings From the Biopsychosocial Influence on Shoulder Pain Preclinical Trial.

Shoulder pain is a highly prevalent musculoskeletal condition that frequently leads to suboptimal clinical outcomes. This study tested the extent to which circulating inflammatory biomarkers are associated with reports of shoulder pain and upper-extremity disability for a high-risk genetic by psychological subgroup (catechol-O-methyltransferase [COMT] variation by pain catastrophizing [PCS]). Pain-free adults meeting high-risk COMT × PCS subgroup criteria completed an exercise-induced muscle injury protocol. Thirteen biomarkers were collected and analyzed from plasma 48 hours after muscle injury. Shoulder pain intensity and disability (Quick-DASH) were reported at 48 and 96 hours to calculate change scores. Using an extreme sampling technique, 88 participants were included in this analysis. After controlling for age, sex, and BMI, there were moderate positive associations between higher c-reactive protein (CRP; ߈ = .62; 95% confidence interval [CI] = -.03, 1.26), interleukin-6 (IL-6; ߈ = 3.13; CI = -.11, 6.38), and interleukin-10 (IL-10; ߈ = 2.51; CI = -.30, 5.32); and greater pain reduction from 48 to 96 hours post exercise muscle injury. Using an exploratory multivariable model to predict pain changes from 48 to 96 hours, we found participants with higher IL-10 were less likely to experience a high increase in pain (߈ = -10.77; CI = -21.25, -2.69). Study findings suggest CRP, IL-6, and IL-10 are related to shoulder pain change for a preclinical high-risk COMT × PCS subgroup. Future studies will translate to clinical shoulder pain and decipher the complex and seemingly pleiotropic interplay between inflammatory biomarkers and shoulder pain change. PERSPECTIVE: In a preclinical high-risk COMT × PCS subgroup, 3 circulating inflammatory biomarkers (CRP, IL-6, and IL-10) were moderately associated with pain improvement following exercise-induced muscle injury.

The Psychologically Informed Practice Consultation Roadmap: A Clinical Implementation Strategy.

Psychologically informed practice (PiP) includes a special focus on psychosocial obstacles to recovery, but research trials have revealed significant difficulties in implementing PiP outside of research environments. Qualitative studies have identified problems of both competence and confidence in tackling the psychosocial aspects of care, with a tendency to prefer dealing with the more mechanical aspects of care. In PiP, the distinction between assessment and management is not clear-cut. Analysis of the problem is part of the intervention, and guided self-management begins with the initial detective work by the patient, who is encouraged to develop successful and relevant behavior change. This requires a different style and focus of communication that some clinicians find difficult to enact. In this Perspective, the PiP Consultation Roadmap is offered as a guide for clinical implementation to establish a therapeutic relationship, develop patient-centered communication, and guide effective pain self-management. These strategies are illustrated through the metaphor of the patient learning to drive, with the therapist as a driving instructor and the patient as a student driver. For convenience, the Roadmap is depicted in 7 stages. Each stage represents aspects of the clinical consultation in a recommended order, although the Roadmap should be viewed as a general guide with a degree of flexibility to accommodate individual differences and optimize PiP interventions. It is anticipated that the experienced PiP clinician will find it progressively easier to implement the Roadmap as the building blocks and style of consultation become more familiar.

Psychologically Informed Practice: The Importance of Communication in Clinical Implementation.

There has been increasing interest in the secondary prevention of chronic pain and pain-associated disability over the past 3 decades. In 2011, psychologically informed practice (PiP) was suggested as a framework for managing persistent and recurrent pain, and, since then, it has underpinned the development of stratified care linking risk identification (screening). Although PiP research trials have demonstrated clinical and economic advantage over usual care, pragmatic studies have been less successful, and qualitative studies have identified implementation difficulties in both system delivery and individual clinical management. Effort has been put into the development of screening tools, the development of training, and the assessment of outcomes; however, the nature of the consultation has remained relatively unexplored. In this Perspective, a review of the nature of clinical consultations and the clinician-patient relationship is followed by reflections on the nature of communication and the outcome of training courses. Consideration is given to the optimization of communication, including the use of standardized patient-reported measures and the role of the therapist in facilitating adaptive behavior change. Several challenges in implementing a PiP approach in day-to-day practice are then considered. Following brief consideration of the impact of recent developments in health care, the Perspective concludes with a brief introduction to the PiP Consultation Roadmap (the subject of a companion paper), the use of which is suggested as a way of structuring the consultation with the flexibility required for a patient-centered approach to guided self-management of chronic pain conditions.

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

OBJECTIVES: Low back pain (LBP) is highly prevalent and disabling for older adults. Movement-evoked pain is an emerging measure that may help to predict disability; but is not currently a part of geriatric LBP clinical care. This study tested the safety and feasibility of a new Movement-Evoked Provocation Test for Low Back Pain in Older Adults (MEPLO). We also compared associations between movement-evoked pain via 2 different scoring methods and disability-associated outcomes. MATERIALS AND METHODS: Thirty-nine older adults with persistent LBP provided baseline recalled and resting pain ratings, self-reported physical function, and usual gait speed. Participants then completed MEPLO, involving 4 tasks essential for functional independence: chair rises, trunk rotation, reaching, and walking. Movement-evoked pain was then quantified using the traditional change score (delta) method of pain premovement to postmovement; and also, a new aggregate method that combines pain ratings after the 4 tasks. RESULTS: No safety or feasibility issues were identified. Compared with the delta score, the aggregate score was more strongly associated with self-reported physical function (beta: -0.495 vs. -0.090) and usual gait speed (beta: -0.450 vs. -0.053). Similarly, the aggregate score was more strongly associated with self-reported physical function than recalled and resting pain (beta: -0.470, -0.283, and 0.136, respectively). DISCUSSION: This study shows the safety and feasibility of testing movement-evoked pain in older adults with persistent LBP, and its potential superiority to traditional pain measures. Future studies must validate these findings and test the extent to which MEPLO is implementable to change with geriatric LBP standard of care.

Construct validity of movement-evoked pain operational definitions in older adults with chronic low back pain.

OBJECTIVE: Movement-evoked pain (MeP) may predispose the geriatric chronic low back pain (LBP) population to health decline. As there are differing operational definitions for MeP, the question remains as to whether these different definitions have similar associations with health outcomes in older adults with chronic LBP. DESIGN: Cross-sectional analysis of an observational study. SETTING: Clinical research laboratory. SUBJECTS: 226 older adults with chronic LBP. METHODS: This secondary analysis used baseline data from a prospective cohort study (n = 250). LBP intensity was collected before and after the repeated chair rise test, stair climbing test, and 6-minute walk test; MeP change scores (ie, sum of pretest pain subtracted from posttest pain) and aggregated posttest pain (ie, sum of posttest pain) variables were calculated. LBP-related disability and self-efficacy were measured by the Quebec Back Pain Disability Scale (QBPDS) and Low Back Activity Confidence Scale (LOBACS), respectively. Physical function was measured with the Health ABC Performance Battery. Robust regression with HC3 standard errors was used to evaluate adjusted associations between both MeP variables and disability, self-efficacy, and physical function. RESULTS: Greater aggregated posttest MeP was independently associated with worse disability (b = 0.593, t = 2.913, P = .004), self-efficacy (b = -0.870, t = -3.110, P = .002), and physical function (b = -0.017, t = -2.007, P = .039). MeP change scores were not associated with any outcome (all P > .050). CONCLUSIONS: Aggregate posttest MeP was linked to poorer health outcomes in older adults with chronic LBP, but MeP change scores were not. Future studies should consider that the construct validity of MeP paradigms partially depends on the chosen operational definition.

Movement-Evoked Pain Versus Widespread Pain: A Longitudinal Comparison in Older Adults With Chronic Low Back Pain From the Delaware Spine Studies.

It is currently unknown which pain-related factors contribute to long-term disability and poorer perceived health among older adults with chronic low back pain (LBP). This investigation sought to examine the unique influence of movement-evoked pain (MeP) and widespread pain (WP) on longitudinal health outcomes (ie, gait speed, perceived disability, and self-efficacy) in 250 older adults with chronic LBP. MeP was elicited with 3 standardized functional tests, while presence of WP was derived from the McGill Pain Map. Robust regression with HC3 standard errors was used to examine associations between these baseline pain variables and health outcomes at 12-month follow-up. Covariates for these models included age, sex, body mass index, resting and recall LBP intensity, LBP duration, depression, pain catastrophizing, and baseline outcome (eg, baseline gait speed). Greater MeP was independently associated with worse 12-month LBP-related disability (b = .384, t = 2.013, P = .046) and poorer self-efficacy (b = -.562, t = -2.074, P = .039); but not gait speed (P > .05). In contrast, WP and resting and recall LBP intensity were not associated with any prospective health outcome after adjustment (all P > .05). Compared to WP and resting and recall LBP intensity, MeP is most strongly related to longitudinal health outcomes in older adults with chronic LBP. PERSPECTIVE: This article establishes novel independent associations between MeP and worse perceived disability and self-efficacy at 12-months in older adults with chronic LBP. MeP likely has biopsychosocial underpinnings and consequences and may therefore be an important determinant of health outcomes in LBP and other geriatric chronic pain populations.

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.

Classification of older adults who underwent lumbar-related surgery using pre-operative biopsychosocial predictors and relationships with surgical recovery: An observational study conducted in the United States.

Lumbar surgery is a commonly prescribed intervention for low back pain but poses higher risks and worse outcomes for older adults. Identifying clinical phenotypes based on biopsychosocial factors may help identify older adults who are at greatest risk for poor postoperative recovery. This study aimed to (a) classify older adults who underwent lumbar surgery based on preoperative biopsychosocial factors, and (b) quantify the association between preoperative biopsychosocial classifications and 3 and 12 months postoperative improvement outcomes. Latent class analysis was used to identify biopsychosocial classifications in 10,283 individuals aged ≥60 from the Quality Outcomes Database (the United States, 2021-2018). Logistic regression models measured the association between biopsychosocial classifications and 3 and 12 months postoperative outcomes (back/leg pain intensity, disability and quality of life), adjusting for covariates. Three classes were identified based on 19 a priori biopsychosocial factors and were characterised as 'high-risk' (15%), 'physical-/social health-risk' (44%) and 'low-risk' (41%). The high-risk class demonstrated increased odds of failing to recover post-operatively compared to the other classes. Similarly, the physical-/social-risk class demonstrated increased odds of failing to recover in all outcomes and time points compared to the low-risk class. Biopsychosocial factors with higher prevalence in the high versus low-risk class were depression (92.5% vs. 10.6%), multiple morbidities (55.3% vs. 25.7%) and obesity (59.5% vs. 37.2%). This study introduces novel non-recovery phenotypes for older adults undergoing lumbar surgery and may lead to the development of tailored interventions to improve clinical care and outcomes for this population.

A Standardized Assessment of Movement-evoked Pain Ratings Is Associated With Functional Outcomes in Older Adults With Chronic Low Back Pain.

OBJECTIVE: Despite high prevalence estimates, chronic low back pain (CLBP) remains poorly understood among older adults. Movement-evoked pain (MeP) is an understudied factor in this population that may importantly contribute to disability. This study investigated whether a novel MeP paradigm contributed to self-reported and performance-based function in older adults with CLBP. MATERIALS AND METHODS: This secondary analysis includes baseline data from 230 older adults with CLBP in the context of a prospective cohort study. The Repeated Chair Rise Test, Six Minute Walk Test, and Stair Climbing Test were used to elicit pain posttest LBP ratings were aggregated to yield the MeP variable. Self-reported and performance-based function were measured by the Late Life Function and Disability Index (LLFDI) scaled function score and Timed Up-and-Go Test (TUG), respectively. Robust regression with HC3 standard errors was used to model adjusted associations between MeP and both functional outcomes; age, sex, body mass index, and pain characteristics (ie, intensity, quality, and duration) were utilized as covariates. RESULTS: MeP was present in 81.3% of participants, with an average rating of 5.09 (SD=5.4). Greater aggregated posttest MeP was associated with decreased LLFDI scores (b=-0.30, t=-2.81, P=0.005) and poorer TUG performance (b=0.081, t=2.35, P=0.020), independent of covariates. LBP intensity, quality and duration were not associated with the LLFDI or TUG, (all P>0.05). DISCUSSION: Aggregated posttest MeP independently contributed to worse self-reported and performance-based function among older adults with CLBP. To understand long-term consequences of MeP, future studies should examine longitudinal associations between MeP and function in this population.

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

OBJECTIVES: Despite its impact, individual factors associated with persistent low back pain (LBP) remain poorly understood. This study investigated static and dynamic pain sensitivity in adults with persistent LBP versus pain-free controls; and investigated associations between pain sensitivity and 3 clinical pain measures: recalled, resting, and movement-evoked pain (MEP). MATERIALS AND METHODS: A lifespan sample of 60 adults with persistent LBP and 30 age-matched/sex-matched controls completed 4 laboratory sessions. Static pain sensitivity (pressure pain threshold [PPT], heat pain threshold) and dynamic pain sensitivity (heat pain aftersensations [AS], temporal summation [TS] of second heat pain) were measured. Demographic and clinical factors collected were education, global cognition, and perceived health. Resting and recalled pain were measured via questionnaire, and MEP via the Back Performance Scale. RESULTS: LBP participants demonstrated lower PPT remotely (hand; F1,84=5.34, P=0.024) and locally (low back; F1,84=9.55, P=0.003) and also had higher AS (F1,84=6.01, P=0.016). Neither static nor dynamic pain sensitivity were associated with recalled pain (P>0.05). However, static pain sensitivity (local PPT) explained an additional 9% variance in resting pain, while dynamic pain sensitivity (AS, TS) explained an additional 10% to 12% variance in MEP. DISCUSSION: This study characterized pain sensitivity measures among individuals with persistent LBP and suggests static pain sensitivity plays a larger role in resting pain while dynamic pain sensitivity plays a larger role in MEP. Future studies will confirm these relationships and elucidate the extent to which changes in static or dynamic pain sensitivity predict or mediate clinical pain among adults with persistent LBP.

Stakeholder Engagement in Pragmatic Clinical Trials: Emphasizing Relationships to Improve Pain Management Delivery and Outcomes.

BACKGROUND: The NIH-DOD-VA Pain Management Collaboratory (PMC) supports 11 pragmatic clinical trials (PCTs) on nonpharmacological approaches to management of pain and co-occurring conditions in U.S. military and veteran health organizations. The Stakeholder Engagement Work Group is supported by a separately funded Coordinating Center and was formed with the goal of developing respectful and productive partnerships that will maximize the ability to generate trustworthy, internally valid findings directly relevant to veterans and military service members with pain, front-line primary care clinicians and health care teams, and health system leaders. The Stakeholder Engagement Work Group provides a forum to promote success of the PCTs in which principal investigators and/or their designees discuss various stakeholder engagement strategies, address challenges, and share experiences. Herein, we communicate features of meaningful stakeholder engagement in the design and implementation of pain management pragmatic trials, across the PMC. DESIGN: Our collective experiences suggest that an optimal stakeholder-engaged research project involves understanding the following: i) Who are research stakeholders in PMC trials? ii) How do investigators ensure that stakeholders represent the interests of a study's target treatment population, including individuals from underrepresented groups?, and iii) How can sustained stakeholder relationships help overcome implementation challenges over the course of a PCT? SUMMARY: Our experiences outline the role of stakeholders in pain research and may inform future pragmatic trial researchers regarding methods to engage stakeholders effectively.

Improving Veteran Access to Integrated Management of Back Pain (AIM-Back): Protocol for an Embedded Pragmatic Cluster-Randomized Trial.

BACKGROUND: Coordinated efforts between the National Institutes of Health, the Department of Defense, and the Department of Veterans Affairs have built the capacity for large-scale clinical research investigating the effectiveness of nonpharmacologic pain treatments. This is an encouraging development; however, what constitutes best practice for nonpharmacologic management of low back pain (LBP) is largely unknown. DESIGN: The Improving Veteran Access to Integrated Management of Back Pain (AIM-Back) trial is an embedded pragmatic cluster-randomized trial that will examine the effectiveness of two different care pathways for LBP. Sixteen primary care clinics will be randomized 1:1 to receive training in delivery of 1) an integrated sequenced-care pathway or 2) a coordinated pain navigator pathway. Primary outcomes are pain interference and physical function (Patient-Reported Outcomes Measurement Information System Short Form [PROMIS-SF]) collected in the electronic health record at 3 months (n=1,680). A subset of veteran participants (n=848) have consented to complete additional surveys at baseline and at 3, 6, and 12 months for supplementary pain and other measures. SUMMARY: AIM-Back care pathways will be tested for effectiveness, and treatment heterogeneity will be investigated to identify which veterans may respond best to a given pathway. Health care utilization patterns (including opioid use) will also be compared between care pathways. Therefore, the AIM-Back trial will provide important information that can inform the future delivery of nonpharmacologic treatment of LBP.