Making Better Lives: Patient-Focused Care for Low Back Pain (LBP)
Condition: Chronic Low Back Pain; Hip Ostearthritis; Myofascial Pain Syndrome; Fibromyalgia; Depression; Maladaptive Coping; Lumbar Spinal Stenosis; Insomnia; Sacroiliac Joint Pain; Lateral Hip and Thigh Pain; Anxiety; Dementia; Recent Leg Length Discrepancy
MeSH terms: Fibromyalgia; Myofascial Pain Syndromes; Spinal Stenosis; Arthralgia; Leg Length Inequality; Dementia; Back Pain; Low Back Pain; Constriction, Pathologic; Depression
Study type: Interventional

Summary: 
      Back pain is a huge problem for millions of Americans, including nearly 11 million Veterans.
      Our older Veterans suffer the most. Citizens spend billions of dollars, yet consistently get
      poor results. Primary Care Providers are often tasked with diagnosing and treating Chronic
      Low Back Pain, even though they are often undereducated in the field. These PCPs often use
      advanced imaging, usually MRIs to guide care. These images often show degenerative disc
      disease and other common pathologies in older adults, even those who are pain free, which can
      lead to misdiagnosis and treatment. The investigators believe that Chronic Low Back Pain is a
      syndrome, a final common pathway for the expression of multiple contributors that often lie
      outside the spine itself. For example, hip osteoarthritis, knee pain, and even anxiety could
      all lessen back pain if addressed and treated probably.

      Investigators will measure participants' low back pain-associated disability with the
      well-validated RMDQ. Data will be collected at baseline and monthly via telephone. The
      investigators hypothesize that veterans who receive PCCET will experience significantly
      greater reduction in low back pain-associated disability than those who receive IAUC at six
      months.

      Investigators will also measure participants' low back pain with the 0-10 Numeric Rating
      Scale for Pain. Data will be collected at baseline and monthly via telephone. The
      investigators hypothesize that veterans who receive PCCET will experience significantly
      greater reduction in low back pain than those who receive IAUC at six months.

      The goal of this study is to compare patients treated with usual care, which usually starts
      with imaging, versus patients who are treated by trained geriatricians who know how to
      recognize and address 11 key conditions that commonly drive pain and disability in older
      adults. The investigators believe that older patients who receive care tailored to their
      needs by educated PCPs will ultimately have less back pain and, more importantly, better
      quality of life.
    

Detailed description: 
      Nearly half of our 22 million US military Veterans are age 65 and older and, within this
      population, low back pain is common, costly and often disabling. The prevalence of low back
      pain in those 85+, the most vulnerable and fastest growing segment of society, is estimated
      at 44%. Chronic low back pain (CLBP, i.e., present for 6 months or more) is associated with
      the overwhelming majority of healthcare resource utilization and personal suffering. Treating
      back problems cost Americans more than $30 billion in 2007- up from $16 billion in 1997 (in
      2007 dollars). Despite these staggering data, there is no evidence that the care of patients
      with CLBP has improved, and the use of invasive, potentially morbid, and often ineffective
      interventions (e.g., epidural corticosteroid injections and spine surgery) continues to
      skyrocket. Primary care providers (PCP) who are tasked with treating CLBP without adequate
      education often use advanced imaging (most commonly magnetic resonance imaging [MRI]) to
      guide care. Imaging-identified pathology (e.g., degenerative disc and facet disease, bulging
      discs) is ubiquitous in older adults, even in those that are pain-free. It is not surprising,
      therefore, that imaging-guided treatments often lead to suboptimal outcomes and potential
      morbidity. In contrast to how CLBP is often conceptualized and treated, the investigators
      conceptualize CLBP as a syndrome, that is, a final common pathway for the expression of
      multiple contributors that often lie outside the spine itself, for example, hip
      osteoarthritis, fibromyalgia syndrome, and anxiety. Treating CLBP and ameliorating disability
      in older adults necessitates addressing multiple conditions and risk factors; however, the
      expertise to evaluate and treat all of the disorders that can contribute to CLBP typically
      resides in multiple specialty silos, making a comprehensive approach to treating CLBP
      difficult to implement.

      Through the support of a 2-year Rehab R&D Merit Review pilot award, the investigators have
      laid the essential foundation for delivering more comprehensive and patient-centric care to
      older Veterans with CLBP. The investigators have:

        -  1) synthesized, through a modified Delphi process, evidence on evaluating and treating
           11 key conditions that commonly drive pain and disability in older adults with CLBP

        -  2) created algorithms to be used in the clinical setting to treat these 11 conditions

        -  3) successfully trained geriatrician providers in a practical structured assessment of
           the 11 conditions, and

        -  4) validated the prevalence of these conditions specifically in older Veterans

      In the current application, the investigators are proposing a 2-site pilot study to explore
      the impact of delivering patient-centered comprehensive evaluation and treatment (PCCET) as
      compared with imaging-associated usual care (IAUC) to older Veterans with CLBP. In addition
      to examining whether PCCET is more effective than IAUC for reducing pain and functional
      limitations when delivered by geriatricians in 2 VA medical centers, the investigators will
      evaluate PCCET's impact on health-related quality of life and health care utilization. The
      investigators also will collect data to identify barriers and facilitators to implementing
      PCCET from the perspective of patients and providers.
    

Intervention name(s): Patient-Centered Care; Imaging-Directed Care
Intervention type(s): Other; Other
Intervention description(s): Patient-centered care will be directed by geriatricians who have been trained to assess and treat 11 conditions that commonly affect chronic low back pain. Treatments may involve behavioral components, physical therapy, or medical treatments such as cortisone shots, depending on the patient's needs.; Imaging-Directed Care will allow patients to follow-up their initial imaging with whatever course they (and/or their doctor) chose, should they chose to follow any course at all.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Treatment
Keywords: Chronic Low Back Pain; Aged; Elderly; Primary Care; Assessment; Lumbar; Spinal Stenosis; Hip Osteoarthritis; Myofascial Pain Syndrome; Fibromyalgia; Depression; Maladaptive Coping; Lumbar Spinal Stenosis; Insomnia; Sacroiliac Joint Pain; Lateral Hip and Thigh Pain; Anxiety; Dementia; Recent Leg Length Discrepancy