Why We Need Nonpharmacologic Approaches to Manage Chronic Low Back Pain in Older Adults

A Pilot Mixed-Methods Study to Establish the Clinical Usefulness of a Chronic Pain Profile (CPP) for Pain Management

The Chronic Pain Profile (CPP) was developed as a tool for patients to document types and levels of use for all pain management strategies used. This pilot mixed-methods (quantitative and qualitative methods) study aimed to assess the perceived clinical usefulness of the CPP and identify potential areas of difficulty using the CPP among a sample of pharmacists. Data were obtained from an online survey of pharmacists licensed to practice in Arizona. Quantitative analysis included assessing the clinical usefulness of the CPP using 10 numerical items (scores ≥50% = useful), 5 ordinal items (scores ≥ 4 out of 5 = useful), and 11 open-response items. Qualitative analysis was conducted by two independent researchers who coded the comments and identified key themes through consensus. Data were collected for 33 individuals. Mean usefulness scores ranged from 66.6 ± 22.4 to 80.9 ± 23.5, and three of the five ordinal items had a median score ≥ 4. Three key themes (and subthemes) were identified: favorable features of the CPP, which included promoting patient advocacy and saving time when accessing pain information; using the CPP, which included evaluating of the effectiveness and appropriateness of the pain management approach and identifying gaps in patient knowledge; and limitations of the CPP, which included absence of customization, interpretation issues, complexity and wording issues, and concerns of internal consistency and reliability. This pilot study provides initial evidence of the CPP's clinical usefulness that could ultimately be used to help manage pain and improve health outcomes. Further analyses are needed to assess the CPP's validity and explore its use in wider populations of patients with pain.

Acupuncture for chronic low back pain in older adults: Design and protocol for the BackInAction pragmatic clinical trial

BACKGROUND

Back pain prevalence and burden increase with age; approximately one-third of U.S. adults 65 years of age and older experience lower back pain (LBP). For chronic low back pain (cLBP), typically defined as lasting three months or longer, many treatments for younger adults may be inappropriate for older adults given their greater prevalence of comorbidities with attendant polypharmacy. While acupuncture has been demonstrated to be safe and effective for cLBP in adults overall, few studies of acupuncture have either included or focused on adults ≥65 years old.

METHODS

The BackInAction study is a pragmatic, multi-site, three-arm, parallel-groups randomized controlled trial designed to test the effectiveness of acupuncture needling for improving back pain-related disability among 807 older adults ≥65 years old with cLBP. Participants are randomized to standard acupuncture (SA; up to 15 treatment sessions across 12 weeks), enhanced acupuncture (EA; SA during first 12 weeks and up to 6 additional sessions across the following 12 weeks), and usual medical care (UMC) alone. Participants are followed for 12 months with study outcomes assessed monthly with the primary outcome timepoint at 6 months.

DISCUSSION

The BackInAction study offers an opportunity to further understand the effectiveness, dose-dependence, and safety of acupuncture in a Medicare population. Additionally, study results may encourage broader adoption of more effective, safer, and more satisfactory options to the continuing over-reliance on opioid- and invasive medical treatments for cLBP among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04982315. Clinical trial registration date: July 29, 2021.

SolarSPELL health and education: global solutions with local impacts

Background

People in remote regions of developing nations have poor health outcomes with lower life expectancy and quality of life compared to higher-resourced areas. Remote communities typically lack stable access to high-quality health services. International humanitarian and development organizations including the United States Peace Corps have a longstanding history of delivering critical services. However, limited infrastructure including access to reliable electricity or internet restricts development workers’ ability to provide effective health services to rural communities. Technology that enhances health education and service delivery in remote communities may improve health outcomes by impacting health knowledge and behavior.

Methods

We partnered with U.S. Peace Corps to provide portable, solar-powered educational learning libraries (SolarSPELL; www.solarspell.org) to remote communities in Pacific Island nations beginning in 2015 with Peace Corps Vanuatu educational volunteers and expanded in 2017 to include health volunteers (SolarSPELL Health). We conducted ethnographic observation and interviews with Vanuatu Peace Corps volunteers, Ministry of Health officials, and local residents of rural communities. We then conducted a comprehensive evidence review to identify current best practices for assessing and treating the most common conditions. We designed simple 2-page documents with assessment and treatment guidelines, reflecting evidence-based best practices, local culture, and resource availability. Each document was accompanied by a whiteboard video featuring simple drawings and narration designed for Peace Corps volunteers and local community members.

Results

We report on findings from a pilot study focused on education for treating low back pain. Preliminary findings indicate significantly increased knowledge for Peace Corps volunteers (p<.01), along with non-significantly increased self-efficacy scores (p=.169). Interview data indicate high levels of satisfaction with the SolarSPELL technology, and widespread community utilization among Peace Corps volunteers and community residents.

Conclusions

Tailored health content on the SolarSPELL platform increases knowledge about critical health topics among Peace Corps volunteers in under-resourced rural communities. The platform and education may have a positive impact on self-efficacy. However, high baseline levels of self-efficacy noted among Peace Corps volunteers may explain the failure to reach statistically significant increases in self-efficacy scores. This finding merits further study. Future work includes measuring individual and community health outcomes, quality of life, and cost benefit resulting from reductions in lost work and transfers for advanced health services. We plan continued implementation and content expansion of SolarSPELL Health in Vanuatu and additional global sites.

Do Decision Aids Benefit Patients with Chronic Musculoskeletal Pain? A Systematic Review

OBJECTIVE

To review the effect of patient decision aids for adults making treatment decisions regarding the management of chronic musculoskeletal pain.

METHODS

We performed a systematic review of randomized controlled trials of adults using patient decision aids to make treatment decisions for chronic musculoskeletal pain in the outpatient setting.

RESULTS

Of 477 records screened, 17 met the inclusion criteria. Chronic musculoskeletal pain conditions included osteoarthritis of the hip, knee, or trapeziometacarpal joint and back pain. Thirteen studies evaluated the use of a decision aid for deciding between surgical and nonsurgical management. The remaining four studies evaluated decision aids for nonsurgical treatment options. Outcomes included decision quality, pain, function, and surgery utilization. The effects of decision aids on decision-making outcomes were mixed. Comparing decision aids with usual care, all five studies that examined knowledge scores found improvement in patient knowledge. None of the four studies that evaluated satisfaction with the decision-making process found a difference with use of a decision aid. There was limited and inconsistent data on other decision-related outcomes. Of the eight studies that evaluated surgery utilization, seven found no difference in surgery rates with use of a decision aid. Five studies made comparisons between different types of decision aids, and there was no clearly superior format.

CONCLUSIONS

Decision aids may improve patients' knowledge about treatment options for chronic musculoskeletal pain but largely did not impact other outcomes. Future efforts should focus on improving the effectiveness of decision aids and incorporating nonpharmacologic and nonsurgical management options.

Complementary, Integrative, and Nondrug Therapy Use for Pain Among US Military Veterans on Long-term Opioids

BACKGROUND

Long-term opioid therapy for chronic pain arose amid limited availability and awareness of other pain therapies. Although many complementary and integrative health (CIH) and nondrug therapies are effective for chronic pain, little is known about CIH/nondrug therapy use patterns among people prescribed opioid analgesics.

OBJECTIVE

The objective of this study was to estimate patterns and predictors of self-reported CIH/nondrug therapy use for chronic pain within a representative national sample of US military veterans prescribed long-term opioids for chronic pain.

RESEARCH DESIGN

National two-stage stratified random sample survey combined with electronic medical record data. Data were analyzed using logistic regressions and latent class analysis.

SUBJECTS

US military veterans in Veterans Affairs (VA) primary care who received ≥6 months of opioid analgesics.

MEASURES

Self-reported use of each of 10 CIH/nondrug therapies to treat or cope with chronic pain in the past year: meditation/mindfulness, relaxation, psychotherapy, yoga, t'ai chi, aerobic exercise, stretching/strengthening, acupuncture, chiropractic, massage; Brief Pain Inventory-Interference (BPI-I) scale as a measure of pain-related function.

RESULTS

In total, 8891 (65%) of 13,660 invitees completed the questionnaire. Eighty percent of veterans reported past-year use of at least 1 nondrug therapy for pain. Younger age and female sex were associated with the use of most nondrug therapies. Higher pain interference was associated with lower use of exercise/movement therapies. Nondrug therapy use patterns reflected functional categories (psychological/behavioral, exercise/movement, manual).

CONCLUSIONS

Use of CIH/nondrug therapies for pain was common among patients receiving long-term opioids. Future analyses will examine nondrug therapy use in relation to pain and quality of life outcomes over time.

The lived experience of chronic headache: a systematic review and synthesis of the qualitative literature

OBJECTIVE

To systematically review the qualitative literature of the lived experience of people with a chronic headache disorder.

BACKGROUND

Chronic headaches affect 3%-4% of the population. The most common chronic headache disorders are chronic migraine, chronic tension-type headache and medication overuse headache. We present a systematic review and meta-ethnographic synthesis of the lived experience of people with chronic headache.

METHODS

We searched seven electronic databases, hand-searched nine journals and used a modified Critical Appraisal Skills Programme checklist to appraise study quality. Following thematic analysis we synthesised the data using a meta-ethnographic approach.

RESULTS

We identified 3586 unique citations; full texts were examined for 86 studies and 4 were included in the review. Included studies differed in their foci: exploring, patient-centred outcomes, chronic headache as a socially invisible disease, psychological processes mediating impaired quality of life, and the process of medication overuse. Initial thematic analysis and subsequent synthesis gave three overarching themes: 'headache as a driver of behaviour' (directly and indirectly), 'the spectre of headache' and 'strained relationships'.

CONCLUSION

This meta-synthesis of published qualitative evidence demonstrates that chronic headaches have a profound effect on people's lives, showing similarities with other pain conditions. There were insufficient data to explore the similarities and differences between different chronic headache disorders.