**Transcript of Cyberseminar**

**Spotlight on Pain Management**

**Prevalence and Instance of Neck and Back Pain in the VA User Population**

**Presenter: Patsi Sinnott, PT, PhD, MPH**

**December 3, 2013**

*Host:*Good morning everyone.  This is Robin Masheb and I'm the new Director of the Education at the Prime Center.  We'll be hosting our monthly pain call entitled Spotlight on Pain Management.Today's session is Prevalence and Instance of Neck and Back Pain in the VA User Population.  I would like to introduce our presenters for today, Dr. Patsi Sinnott and Sharon Dally, who will be assisting with any technical questions.

*Automated Voice:*Someone has entered the conference.

*Host:*Patsi Sinnott is a member of the Pain Research Working Group and the Pain Research Network, consisting of the PIs and co-investigators of the three pain management Collaborative Research to Enhance and Advance Transformation and Excellence or CREATE projects.  She brings her expertise and experience using VA clinical and administrative databases for the study of pain management, including costs of care among Veterans receiving care in the Veterans Health Administration.Sharon Dally joined the Health Economics Resource Center at the VA Palo Alto Health Care in January 2012.  Her background is in data analysis and statistical computing.  Most recently she transferred from the VA Center for Health Care Evaluation where she worked on predictors and outcomes of treating bipolar disorder.We will be holding questions for the end of the talk.  At the end of the session there will be a feedback form to fill out immediately after.  Please stick around for just a minute or two to complete this form, as it is only about six or seven questions.

*[Pause 01:33-02:56]*

*Patsi Sinnott:* Hello.  Is somebody there?

*Operator:* Ah, yes.  This is the VANTS operator.  The call was actually placed in lecture *[distorted audio 03:03]*.

*Patsi Sinnott:* VANTS operator?  I'm the moderator.

*Patsi Sinnott:* Okay, so it looks like the call was placed into lecture without me calling in.  All of the presenter's lines were muted at that time.  I'm hoping that he unlectured it so that we would be able to talk.  Patsi, if you can get started.

*Patsi Sinnott:* Okay.  Can you hear me okay?

*Patsi Sinnott:* I can hear you.  I'll call into the operator and see if I can get this straightened out.

*Patsi Sinnott:* Hi there everyone.  Good morning.  Sorry for all this confusion.  My name is Patsi Sinnott.  I'm a health services researcher and health economist at the HERC, the Health Economics Resource Center.  Sharon Dally is joining me today to provide statistical and computational back up.  Today I'm going to talk about the incidents and prevalence of back pain in VA users and hopefully provide you with some background information about how this problem is impacting Veterans and the VHA.  My plan is to do some background *[distorted audio 04:26-* 0*4:40]*.

*Patsi Sinnott:*Well, we're hearing typing but we're not hearing Patsi.

*Patsi Sinnott:* Thank you.

*Patsi Sinnott:*For the audience, once again, please make sure your phones are muted.  You can use your mute button or star-six to mute your phone.  We're getting a lot of background noise and we are unable to hear.

*Patsi Sinnott:* Heidi, I was actually taken off for a minute by the advance operator.  Can you hear me now?

*Patsi Sinnott:*Yes.

*[Cross talk 05:10]*

*Speaker:* This is Bob.  I can hear you.

*Patsi Sinnott:* Okay Bob.  Thanks a lot.  So we're going to talk about prevalence, incidents, and the next steps.  I just want to emphasize we're talking about prevalence and incidents of VA users and not based on survey.Just a background, and I think people are pretty familiar, neck and back pain are pervasive.  Between 60 to 80 percent of the population will ever have back pain.  Twenty to seventy percent will have neck pain that interferes with their daily activities during their lifetime.There's very poor understanding at the origins or source of pain.  Back pain and neck pain are actually symptoms.  They're not physiologic entities, but a complex of these symptoms that are very hard to discriminate between.  There are a lot of anatomic structures that are at risk.  There is also an argument that there is a mental health predisposition to having neck and back pain.  Neck and back pain are highly recurrent and each recurrence is associated with increasing severity and disability.  Twenty to thirty percent of the population with neck pain report a recurrence within one year.  Of those with low back pain, 50 to 60 percent report recurrence in the year following their first episode.  Eighty-five percent of the population with low back pain will experience at least one reoccurrence during their lifetime.The duration of the first episode is highly associated with reoccurrence and each reoccurrence is marked by increasing severity and disability.  As you might expect, there's high health care utilization associated with both neck and back pain.There's evidence that both within the VA and the general population of increasing prevalence and rising costs.  Dana Freeburger reports a change from '92 to 2004, a prevalence in North Carolina of 3.9 percent to 10.6 percent.  We previously reported an annual increase of 4.8 percent from 2000 to 2008 in chronic low back pain, but little is known about the incidence of back pain, mostly because it's so difficult to identify a first event.Here's our first set of questions.  I think Heidi is supposed to—

*Patsi Sinnott:*Sorry.  I will pull up your first poll right now.

*Patsi Sinnott:* Great.  While you're doing that, I just want to express that back pain costs a lot of money and neck pain as well.  Here's the question.  What proportion of Veterans and general medical clinics report chronic neck or back pain?  We have some interests.  Clearly people don’t think it's a small amount.  The answer here is 25 percent.  Let's go to the next question.  What proportion of Veterans have reported back pain in the Veteran's Health Study?  I see people are very familiar with the Veteran's Health Study.  This is actually 52 percent by self report.  This is Selim and Kazis's paper. Then the third question is where does chronic low back pain rank in the prevalence in VA?  Again, this is a chronic problem and is it first?  Is it tenth?  Here we are.  People generally think it's a little higher than it is.  Well, we are *[fading voice]*.  It's actually eighth.  It's the eighth most prevalent chronic condition.  Back pain is also the second most often reported physical symptom in Veterans, with post-traumatic stress disorder.  Patients with low back pain score significantly higher on depression scales than Veterans without low back pain.  Combat Veterans with PTSD and combats from the Persian Gulf report more sematic complaints, including back pain, than non-combat Veterans and combat Veterans without PTSD.We have a very prevalent problem but there are few studies relatively about back or neck pain in the VA.  We have the reports I just mentioned on back pain and PTSD.  We also have one study about an association between lower extremity amputation and back pain, and back pain and diagnostic imaging, using bipolar magnets and post-op medications in patients with back pain.  Sarah Krein has a project, Veterans to Walk to Beat Back Pain, which was a clinical trial.  Let's see, so generally more information is needed.  We need to understand the natural history of back or neck pain and to understand the progression and regression from acute to chronic pain.  We need it for strategic program planning and particularly to manage these problems in such a large health care system.For me, my particular interest is in how patients with acute injuries end up having chronic neck and back problems, which of course feed into the very large population of Veterans with pain, the use of opioids, and other medications, and the overall demand on the health care system.  In my previous work this is an IIR funded by HSR&D.  We're doing an observational study with administrative data.  We're differentiating between neck and back pain.  This project is particularly and specific to look at acute, mechanical, or nonspecific spine pain, meaning there's no trauma, there's no cancer, no pregnancy-related problems.Our first step was to confirm which codes to use to look at this data.  Our review methods found inconsistent definitions of back and low back pain and inconsistent coding algorithms.  In other words, what kinds of problems should be included in list and not included in the list?  We set about to establish a standard methodology to identify patients with spine pain and really to update the algorithms that had been the basis for most of the work done since 1992 in the back pain port, which really was the original funding to identify, to create an algorithm to look at back pain in administrative data.Our objectives for this study are two describe the prevalence of neck and back pain among VHA users between 2002 and 2011.  Describe the incidents events for these VHA users, and to provide the context for understanding these patients with neck and back pain, and describe the physical and mental health co-morbidities of the patients.  All of this again will help understand what's happening with these patients, provide it the needed information to do strategic program planning, and really understand how patients with acute injuries end up with chronic problems.The data for this project is VA inpatient and outpatient files and Fee Basis files from fiscal year 2002—actually that's to 2012—DSS Outpatient National Data Extracts, and vital status file.  We use ICD codes available in each file, including DX Prime, VXLSF, DXF 1 through 13, and diagnosis 1 through 25.  We use data from fiscal year 12 data sets so that we can capture a full calendar year of calendar year 2011 because we wanted to report in calendar years.  We used OPAT and OPAT2 to identify patients whose only utilization was pharmacy.  This adds patients to the denominator.  That means all Veterans' treatment care, but not the count of prevalent or incident cases.We identified patients using ICD codes from the literature in our previous work and categorized these patients as either having no spine pain, back pain, neck pain, or nonspecific spinal pain.  These patients with nonspecific spinal pain had at least one diagnosis for—I'm sorry, one diagnosis code that is nonspecific to a spinal segment, or the anatomical segment, or had multiple or had diagnosis in multiple categories.Just to give you an idea of the ICD-9 codes, we pulled all of the codes from the spine segments of the ICD books.  You can see how we have categorized them as back, neck, or nonspecific in then the spinal segments.  For example, if you look at—I'm going to go over there—other types of scoliosis or scoliosis, this particular problem can be both in the thoracic spine and the lumbar spine.  That's why this ends up being nonspecific.  This next one, curvature of the spine associated with other conditions unspecified.  Again, this is a nonspecific area.Maybe I'll go back a little bit just to my picture in the beginning.  Sorry.  Just to remind people, this is the pelvis here.  Back down in here is the sacrum or coccyx, the lumbar spine, the thoracic spine, and then the cervical spine or the neck area—so neck, upper back or thoracic spine, lumbar spine, and then down here is the sacral spine and coccyx.  I apologize.  I'm going to move forward again.We have over 140 codes that we included in the list of cases that we identified from the data.  Then again, we defined—I wanted to be very specific, and particularly because of the previous work where people were so vague about what part of the spine they were talking about.  For example, in some studies, the back is considered the entire spine.  In some cases people refer to back as only low back, which is the lumber spine.  In this case, what we're doing is we're defining neck pain as cervical spine ICD codes where the cervical spine is specifically defined in the ICD codes.  Back pain includes all other spinal segments.  Nonspecific again is codes that refer to either a nonspecific area or patients who had encounters with both back and neck pain diagnosis.We excluded non-Veterans.  We excluded Fee Basis inpatient records where the duration of care was greater than ten years.  This is because Fee Basis providers usually bill monthly.  A bill for a period of more than ten years is almost certainly an error.  Only seven records were deleted using this criteria, and only the affected records were deleted.  The Veterans had other valid records we kept that *[inaudible 19:55]* in there.The prevalent cases are defined as those who presented for care with one of these diagnosis in the calendar year 2002 to 2011.  We categorized them by anatomy and then had produced the annual totals again for VHA users.Our incident cases are the first encounter for each Veteran following a two-year clean period.  Remember, we started in calendar year 2002.  The first encounter for each Veteran would occur in 2004.  A Veteran can have more than one incident event, in other words could have more than one event with a two-year clean period.  During the clean period, the Veteran also used VHA services in the preceding two years so that we know they hadn't gone completely away for other care.  We looked at change rates, compare prevalence to incidents, and then provide the demographics, comorbidities, and compare it to the general population.  Our results, here we show the demographics of the spine team cohort.  Again, average age is just—we have 1.3 million cases in calendar year '11.  The average age is 57 to 58 across all years.  We have 92 to 94 percent male and 3 to 5 percent of the population are homeless.Just to clarify, our age is calculated as of January 1st of each calendar year.  The sex from the vital status menu file and the source for homelessness status is the PTS main and bed section files and MPCDSE file.Our prevalence in VHA users for back pain is 10.8 percent in 2002 and 16.2 percent in 2011.  For neck pain is 1.6 in 2002 and 2.5 in 2011, and nonspecific 2.8 percent to 4.9 percent.  This is a 50 percent increase in percent of population seeking care for back pain, a 50 percent increase in the percent of population seeking care for neck pain, and a 75 percent increase in those seeking care for nonspecific or multiple sites—remember the nonspecific can be people who are seeking care for both neck and back pain.The comorbidities of this population come from the HERC chronic conditions file.  It shows that, again, here is our 1.3 million cases.  The arthritis seems to be going down.  Their heart disease prevalence is going down, but their headache is going up, their mental health comorbidities, increasing tobacco, nicotine dependence, increasing cannabis dependence and abuse, increasing depression and decreasing PTSD.  Our comparisons to all Veterans, we have a slightly younger and the same distribution, and our homelessness population is a bit higher than the all Veterans population.  In terms of their comorbidities, we have more patients with arthritis, more patients with headaches than almost twice as many patients with any drug dependence or abuse, and depression, and PTSD.  Again, these are the prevalent cases.Then we looked at incidents.  In 2004 we have a 4.9 percent incidence of Veterans seeking care for back pain.  Again, if we just look down here, the definitions again are down here, these are incident cases of patients seeking care.  They're having no spine pain.  Case encounters in the two years prior are receiving other care for VA.  In 2011 our incident cases, 5.4 percent for back pain.  In 2004, 1.1, in 2011, 1.2 percent.  The incidents of nonspecific spine pain is unchanged across these years.  This reflects an increase in ten percent in incidents of back pain over these seven years, ten percent increase in incidents of neck pain, and no change in the incidents of nonspecific spine pain.If we look at these comparisons, what you see here is the incidence rate for back pain compared to the prevalence.  You see that the incidence is fairly common but prevalence is rising.  The same is true with neck pain and the same is true with nonspecific.  These change rates are change rates for the incidents of back pain is 1.6 percent per year over the 2004 to 2011 time period, for neck pain is 1.46.  For prevalence however, your annual increase is 4.7 percent for back pain, and 4.6 percent for neck pain, and 6.8 percent for nonspecific or multi-segment pain.  This is compared to depression, which has a 3.8 percent increase, diabetes 4.4, and hypertension 4.1 percent.  This is 2002 to 2007 change rates.  You see that the prevalence rates are increasing rather remarkably.My question to you all is what does this mean?  What does this suggest for us?  Heidi's going to put up a whiteboard here.  We ask you to make a suggestion, what do you think this means?  What does this suggest?

*Patsi Sinnott:*  I just want to interrupt here Patsi, too.  Use the whiteboard at the top of the screen.  There you have some annotation tools.  There is a capital T.  If you click on that T and then go down to the screen, you'll be able to click and then type in free text down there.  You don't need to use the pencil tool.  Just click on the T and you'll be able to type.  Back to you Patsi.

*Moderator:*  Right, and then it won't actually show up until you hit enter.  Lots of OES entering VA care was undertreated PTSD and...

*[Pause 29:22- 29:36]*

*Patsi Sinnott:*  At this point, we don't know about the obesity.  Lots of OES with back injuries.  Remember, as the OES population come in, they are treated to be an incident case.  Their first encounter for back pain has to have a two-year clean period.  They're showing up first as an incident case and then as a prevalence case.  We need to utilize chiropractic acupuncture.  We need unconventional methods of treatment.  Chronification—I love that word—is important to study, yes.  I don't have the age group information right now. The question is, "Could you break down age groups to see if they are different?"  If you go back and look, the age group in the prevalent cases is slightly lower than the average age of the Veteran population of users.This suggestion that we need unconventional methods of treatment and we need to utilize modality, such as chiropractic acupuncture, these both suggest that whatever we're doing at this point is not successful in preventing chronification.  Is that what is being suggested here?  I would say we really need to understand what's happening at the acute injury.  We really need to understand the transition from acute to chronic injuries because we have this rising prevalence while the incidents of new cases is fairly constant.  We don’t know, at this point, how quickly Veterans are being treated from the time of the incident claim.  It doesn't look like we're preventing acute low back pain from becoming chronic.  Let's see.  The pain, substance abuse, MTBI—I'm sorry.  I don't know what MTBI means.  I would just like to emphasize that...  Let's see how crazy—hmm.  Question about step care.  I'm not going to be very good at this.  Chronification is a really important part of this.  We have this...  We don't know whether the gradual increase in access to chiropractic services in the VA is impacting that.  That's something that needs to be looked at.  Heidi, we can save all these comments, right?

*Speaker:*Well, I'm not actually able to turn it into a Word document or something, but we are recording the call.  I do have a video screen shot of this.  Yes, we do have all the information.

*Patsi Sinnott:*  Okay.  Anne, you suggested rising prevalence may also be driven by other interests such as disability claims.  That may be true but we don't know that.  Again, that's an important area to study.  We need to better treat the acute problem.  Access to PT for back school, yes.  We need to understand much better.  I think a lot of what you were mentioning is any acute—and I appreciate this because it is my particular interest is what's happening at the acute level is having an impact on long-term disability.  Then let's take this screen shot as the final one.  I can see it suggests there a bunch of physical therapists on this call because I can see PT comments coming through, which is great.  Can we go back to the presentation?  Do I just hit forward?

*Moderator:*  Nope.  Give me just a second and I will pull it back up.

*Patsi Sinnott:*  Okay.

*Moderator:*  As soon as it shows up on your screen it's all yours.

*Patsi Sinnott:*  Okie doke.  What our next steps for this project are to compare the VHA DOD clinical practice guideline for the management of back pain or sciatica in the primary care setting, compare the care patients with acute injuries are receiving to the clinical practice guidelines, and assess the incidence of guidelines, and assess influence of guideline concordant care on recovery.  Again, I just want to emphasize that we're talking about recovery, which we will define as receiving care for an acute injury within 90 days of the first *[distorted audio]* injury or the acute claim.  Then, while continuing to seek care from VA, they seek no further care for back or neck pain.  We're going to assess the influence of various therapies on recovery and then compare administrative data findings to chart review.There's just so much we can infer from looking at the administrative data results.  We will really need to go into charts to look at what is being done, whether or not the patients that we identify as being recovered are truly recovered, and identify the treatments that are having an influence.  That would include counseling services, collaborative care, step care, physical therapy, chiropractic and acupuncture, everything that we can identify, first in the administrative data and then in the chart.That's our plan.  Those are our results.  Do we have any more questions?

*Moderator:*  For questions, if the audience can use the Q and A screen in Adobe Connect at the lower right hand corner of your screen, just type your questions in there and we will take those on the call.

*Patsi Sinnott:*  I wonder if anyone was surprised by the prevalence data, recurrent prevalence, and had any other thoughts about that.

*Moderator:*  We'll see if we get questions in on that.  We did receive one question.  We have received one question in here.  Has any attention been given to suicidal ideation or attempts?

*Patsi Sinnott:*  I’m not familiar with anything but maybe Bob has a comment.  Bob Kerns?

*Moderator:*  Bob, if you are speaking, we are not able to hear you right now.  I'm not sure if you are muted or if they screwed up when they were unmuting your line from the operator.

*Patsi Sinnott:*  To my knowledge, there have been no initiatives to diagnose spine pain more frequently or *[cross talk 39:07]*

*Robert Kerns:*Hi, I'm back.

*Patsi Sinnott:*  Hi Bob.

*Robert Kerns:*Can you hear me now?

*Patsi Sinnott:*  Yeah.

*Robert Kerns:*Yeah, what was the question?

*Patsi Sinnott:*  Has any attention been given to suicidal ideation or attempts in patients with back or neck pain?

*Robert Kerns:*I think a couple points.  There are a few groups in VA that are specifically studying pain and suicidal ideation and attempts.  I point to a group in Ann Arbor kind of led by Mark Ilgen, a group here at VA Connecticut led by Joe Goulet, and folks at VA Portland, Oregon, Steve Dobbs and Ben Marasco.  I think a paper by, I think it's Ilgen, specifically looked at sights or diagnoses of pain and found some specific linkages.  This was widely disseminated in VA what I'm now not remembering. I think low back pain actually was one of those conditions, along with migraine and a couple of others that seemed to have some specific predictive value.  I'd have to go back to the original paper to raise my confidence about that.I think that you're also speaking to an important distinction between suicidal ideation and actual attempts.  On the attempts level, there's a similar complexity that you've kind of been talking about, kind of what we can get out of VA data, in this case, distinguishing suicidal attempts from accidental overdose with opioids or other contributing factors is potentially problematic.  The broader point is knowing that there may be different predictors of suicidal ideation after controlling for other known predictors, thus notably depression for example, versus the relationship between pain, particularly low back or back pain, neck pain, and actual suicide attempts.

*Patsi Sinnott:*  Thanks.

*Robert Kerns:*I actually was typing a long question.  Can I take my privilege and ask it now?

*Patsi Sinnott:*  Sure.  Then we'll go back to the questions.

*Robert Kerns:**[Chuckle]* Yeah, so you reflected on the concept of chronification.  Earlier in your talk you noted some data on mental health comorbidities as potentially—I think you were kind of implying or inferring some role of mental health or emotional functioning as possible or putative predictors of chronification.  I wonder if you could reflect on that some more, and also speculate on other possible predictors of a transition of acute to chronic low back pain or neck pain, including other important individual difference variables, or even variables that might be related to military service, such as what branch of the service, combat-related experience and trauma, et cetera.  Like I said, it's a big picture question but I'm wondering if you can comment on that a little bit.

*Patsi Sinnott:*  Yeah, it's a big picture question.  We haven't done any predictive work at all.  This is really just descriptive to provide background.  I can kind of reinforce the issues about recurrence, that back pain and neck pain are highly recurrent, that there are social and emotional constructs surrounding the chronification, but nothing, to my knowledge, has been done in VA.  We don't have any other predictors like period of service, kind of service, whether people were hurt during service or otherwise.  This is all very early descriptive data, just to provide a background.  I'm sorry I can't speak more about that.  I can tell you that in the non-VA world, that there's been a lot of evaluation of emotional and mental health disorders with implications from those papers that they are predictive.  They're not particularly well-done studies and they don't control for the potential reverse effects.  I know from my own work that, in a workers comp world, the longer a case languishes, even controlling for access to health care, the longer a case languishes in that sort of Neverland of claim acceptance, the higher probability there is for the patient will become chronically disabled.  We don't know why. We only know that the more delays there are in the administrative function around back pain in workers comp, the more likely the patient is to become chronically disabled, controlling for access to medical care.No, I don't have—and I'm not implying that these mental health conditions are predictive of chronicity.  I only want to describe them at this point.

*Robert Kerns:*Thank you.

*Patsi Sinnott:*  Did you—okay.  Then Ann, your question about any initiatives to diagnose spine pain, as far as I know, there have not been.  I know that the 1999 guidelines for back pain have been updated.  There's a directive that goes out by them, but I also know that there was a pilot project to look at compliance with the VAVOD guidelines for primary care.  The EPRP program only did a pilot.  They were not able to proceed because they were unable to identify patients who were truly acute.  The guidelines really are about acute injuries rather than chronic problems.The next question is how can we convert these rising rates into other—I'm sorry, Michael—into additional support for PACT—Heidi, maybe you can read the question?

*Moderator:*Sure.  The question is how can we convert these rising rates into additional support for PACT to provide great care for these Veterans?

*Patsi Sinnott:*  Yes.  There is a policy question for you, but at this point we don't—I mean I believe there are physical therapists assigned to and participating in PACT across the country.  I know from my own experience that the differentiation between acute and chronic is muddled and that it's my opinion that clinicians need to be very clear what they're treating, whether they're treating somebody with an acute injury versus a chronic injury because the treatment is different and, as you know, one VA is one VA, that my observation is that the way these patients are handled across the country varies significantly.   For example, in some cases patients can't get the physical therapy until they go to PM&R.  In some cases they can't get to PM&R until they go to PT.  There's just a lot of variation out there that has to be understood better and then managed.  Then again, I just want to emphasize this is a preliminary, kind of stage setting work.The next question, how does the prevalence rate in the VA compare to the overall prevalence?  Well, remember—let's see.  The 60 to 80 percent of the population all have back pain that interferes with their daily activities during their lifetime and 60 to 80 percent of those with back pain will—I’m sorry—60 to 80 percent of the population will have back pain and 20 to 70 percent will have neck pain.  In North Carolina, the prevalence by survey has increased from 4 percent to almost 11 percent between 1992 and 2004.  Then the second question, I don’t know of any comparative data from Veterans in other countries or cultures so I can't address that question, but it's a great question.  Again, it's not an area that's heavily researched.The next question on the clinical practices is an IPR program.  I'm sorry.  I don't know what is an IPR program.  Why is it that that's...?  I'm sorry, Heidi, would you read the rest of the question?

*Moderator:*Sure.  I am the clinical director of an IPR program.  Why is it that vets are almost always not referred to this clinic until all other options have failed?  I do believe it is important that self-management is introduced earlier rather than after years of pain have been endured.

*Patsi Sinnott:*  Right.  Well, I agree with you as well.  Is an IPR, is that a pain center?  I don't know.

*Moderator:*Yeah, that I'm unsure about.

*Patsi Sinnott:*  Then the Rita Harvey question, I'm not sure that—are involved in chronic low back pain.  I don't see the rest of that question.  I think we talked to Bob.  How much do you think ligaments and tendon injuries are involved in chronic low back pain?  I think everything is painful and you need very careful discrimination to find out what is actually generating the pain at hand and what is—these are tools for chiropractors and physical therapists to try to discriminate.  That's where their technical expertise is.  Bob has another question.  From your experience, how valuable is it going to be to try—Heidi, could you read the rest of that?

*Moderator:*Yep.  From your experience, how valuable is it going to be to try to distinguish no susceptive or muscular-skeletal from neuropathic pain in future work to characterize these conditions among Veterans?

*Patsi Sinnott:*  I think it's really important because we are just starting to understand the neuropathic—I think we're just starting to understand all of those things, the origins of the pain, the cyclic function of the pain, and how to interfere with those self-regenerating loops, as well as the emotional ability to manage your own response to pain.  All of this is going to be more and more important as we learn more about these things.Rita Harvey, you have another question?  Heidi, would you read that?

*Moderator:*I wonder if our simple treatments and continued inflammation resulting in laxity of such structures progress to the chronic progress that we are unable to stop with our current treatment.

*Patsi Sinnott:*  I think you have a very interesting concept, and I think it's something certainly that those people who do manipulative therapies are concerned about, that there's just so much elasticity in collagen tissue and you have to be careful not to overdo all of that—to do it at all without balancing it with muscle strengthening and by mechanics.  I think you have something—all of these things go into the treatment of back pain.  Michael's saying—is the next question.

*Moderator:*What we have here, it is regarding chronification.  Please see Franklin's paper about placing sealing dosage on opioids and decreased rates of death and of disability applications in Washington state re: worker's comp.

*Patsi Sinnott:*  Right.

*Moderator:*He sent in that.  I'm going to try to put this up on the screen here so that it—

*Patsi Sinnott:*  The American Journal of Industrial Medicine.

*Moderator:*Yeah, I have that up on the screen for anyone that wants to see that right now.

*Patsi Sinnott:*  Then it is a question about hypnotherapy?

*Moderator:*Is any consideration being given for using hypnotherapy as an alternative method for pain management?

*Patsi Sinnott:*  Bob might answer that, or Alicia, that as far as I know, yes, hypnotherapy is one of the treatments being used.  Again, we should differentiate between acute and chronic problems.  The next question about overlap between fiscal years?

*Moderator:*How much overlap is there across the *[cross talk 56:40]*?

*Robert Kerns:*Actually, this is Bob.  Can you hear me?

*Speaker:*We can hear you Bob.

*Patsi Sinnott:*  Sure.

*Speaker:*Can I make a comment really about these alternative approaches?  In fact, one may be interested in a review that I was involved in, actually published in 2007 on psychological interventions for back pain specifically.  If you're interested, you can back channel me in.  I can give you the citation or even a PDF of the paper.  In that paper we kind of clustered different kinds of psychological interventions.  One cluster was what we called self-regulatory treatments that included biofeedback, hypnotherapy, and relaxation training.  In fact, in terms of pain reduction, that cluster had relatively large—it had large effects on pain intensity ratings.  We didn't break it out by hypnotherapy versus the other kinds of interventions, but those kinds of interventions have a long history of use and may be particularly appropriate evidence-based strategies for back pain.The broader context though is that, when thinking about a broader array of what we might call complementary or integrative treatments, I think the leadership in VA about these interventions have been very good about making clear and referring to the evidence for different kinds of alternative approaches, of which there are a growing number for which there is good evidence of their efficacy for specific pain conditions like low back pain, which is often the most commonly studied.  There is also growing evidence about the lack of efficacy or effectiveness of other interventions, now a growing body of research that really has done nice trials of certain interventions and really not found benefit, relative to control conditions.  It's important to make those distinctions.Then the other distinction, the last comment I make is implied by what I just said, is that evidence of support for a specific intervention like hypnotherapy and low back pain doesn't necessarily mean that that benefit may be generalized.  Other chronic pain conditions, people often, I think, make a mistake, an understandable mistake, and kind of overgeneralizing from the empirical evidence.  We really want to avoid doing that.  Veterans, from a policy perspective, are entitled to interventions that have specifically have a body of evidence that supports their efficacy, if not effectiveness as first or second-line interventions.  We can go to other innovative treatments when Veterans have had the benefit of accessing these evidence-based therapies, but we don’t want to jump over providing those therapies to offer other interventions that are less likely or there really isn't a good evidence base to suggest that they will be of benefit.Sorry for that long editorializing, but that seems to be kind of connected to that line of questioning.  I hope it's helpful.

*Patsi Sinnott:*  Great.  Then there's one more question that's about the fiscal years.  I just want to say this is counts of people seeking care.  We don’t know, because we have not followed individual patients over time.  We don't know what proportion of the population in fiscal year '11 is the same as the population in fiscal year '04.  We have not added to the population.  We've only counted those who presented for care in each year.

*Host:*Thank you Patsi.  This is Robin.  I just wanted to jump in because we're reaching the end of our time. 

*Patsi Sinnott:*  Yeah.

*Host:*I would encourage anybody, if they have other questions, to go ahead and email us.  We very much appreciate your presentation Patsi.  Our audience has some great questions for you.  I just want to remind everybody to hold on for another minute or two for the feedback form.  Our next Cyber Seminar will be on January 7th by Dr. Karen Seal.  We'll be sending out registration information to everyone around the 15th of the month.  I want to thank everyone for joining us at this HSR&D Cyber Seminar and we hope to see you at a future session.

*[End of Audio]*

Page 1 of 13