Deconstructing Chronic Low Back Pain in the Older Adult-Step by Step Evidence and Expert-Based Recommendations for Evaluation and Treatment. Part VIII: Lateral Hip and Thigh Pain

Meralgia Paresthetica

PURPOSE OF REVIEW

This review article summaries the epidemiology, etiology, clinical presentations, and latest treatment modalities of meralgia paresthetica, including the latest data about peripheral and spinal cord stimulation therapy. Meralgia paresthetica (MP) causes burning, stinging, or numbness in the anterolateral part of the thigh, usually due to compression of the lateral femoral cutaneous nerve (LFCN).

RECENT FINDINGS

There are emerging data regarding the benefit of interventional pain procedures, including steroid injection and radiofrequency ablation, and other interventions including spinal cord and peripheral nerve stimulation reserved for refractory cases. The strength of evidence for treatment choices in meralgia paraesthetica is weak. Some observational studies are comparing local injection of corticosteroid versus surgical interventions. However, more extensive studies are needed regarding the long-term benefit of peripheral and spinal cord stimulation therapy.

Caring for older veterans with chronic low back pain using a geriatric syndrome approach: Rationale and methods for the aging back clinics (ABC) trial

The purpose of the ongoing trial is to improve care of older Veterans with chronic low back pain (CLBP, i.e., low back pain for ≥6 months on ≥ half the days). Current CLBP care is limited by being either overly spine-focused or non-specifically prescribed and both approaches frequently lead to suboptimal reduction in pain and improvement in function. Through prior studies we have laid the foundation for a patient-centered approach to care for older Veterans with CLBP in which the spine is a source of vulnerability but not the sole treatment target. The approach considers CLBP a geriatric syndrome, a final common pathway for the expression of multiple contributors rather than a disease of the spine. We describe here the rationale and design of a randomized controlled trial to test the efficacy of an older Veteran-centered approach to CLBP care in "Aging Back Clinics (ABCs)" compared with Usual Care (UC). Three hundred thirty Veterans age 65-89 with CLBP will be randomized to ABCs or UC and followed for 12 months after randomization. We will assess the impact of ABCs on our primary outcome of pain-associated disability with the Oswestry Disability Index at 6 and 12 months, and secondary outcomes of pain intensity, health-related quality of life, balance confidence, mobility and healthcare utilization. If shown efficacious, the approach tested in ABCs has the potential to transform the care of older adults with CLBP by improving the quality of life for millions, reducing morbidity and saving substantial healthcare costs.

Aging Back Clinics-a Geriatric Syndrome Approach to Treating Chronic Low Back Pain in Older Adults: Results of a Preliminary Randomized Controlled Trial

OBJECTIVE

Treating chronic low back pain (CLBP) with spine-focused interventions is common, potentially dangerous, and often ineffective. This preliminary trial tests the feasibility and efficacy of caring for CLBP in older adults as a geriatric syndrome in Aging Back Clinics (ABC).

DESIGN

Randomized controlled trial.

SETTING

Outpatient clinics of two VA Medical Centers.

SUBJECTS

Fifty-five English-speaking veterans aged 60-89 with CLBP and no red flags for serious underlying illness, prior back surgery, dementia, impaired communication, or uncontrolled psychiatric illness.

METHODS

Participants were randomized to ABC care or usual care (UC) and followed for six months. ABC care included 1) a structured history and physical examination to identify pain contributors, 2) structured participant education, 3) collaborative decision-making, and 4) care guided by condition-specific algorithms. Primary outcomes were low back pain severity (0-10 current and seven-day average/worst pain) and pain-related disability (Roland Morris). Secondary outcomes included the SF-12 and health care utilization.

RESULTS

ABC participants experienced significantly greater reduction in seven-day average (-1.22 points, P = 0.023) and worst pain (-1.70 points, P = 0.003) and SF-12 interference with social activities (50.0 vs 11.5%, P = 0.0030) at six months. ABC participants were less likely to take muscle relaxants (16.7 vs 42.3%, P = 0.0481). Descriptively, UC participants were more likely to experience pain-related emergency room visits (45.8% vs 30.8%) and to be exposed to non-COX2 nonsteroidal anti-inflammatory drugs (73.1% vs 54.2%).

CONCLUSIONS

These preliminary data suggest that ABC care for older veterans with CLBP is feasible and may reduce pain and exposure to other potential morbidity.

Development of an Evaluative, Educational, and Communication-Facilitating App for Older Adults with Chronic Low Back Pain: Patient Perceptions of Usability and Utility

OBJECTIVE

The purpose of this study is to examine the usability and utility of an office-based iPad app that we developed for older adults with chronic low back pain (CLBP). The app screens for conditions that contribute to back pain and pain interference and provides personalized education based on patient responses. It also facilitates patient-provider communication regarding treatment targets and expectations.

METHODS

Forty-six older adults (age ≥60 years) with CLBP were recruited from the Veterans Affairs and from the Pittsburgh community. Testing was split into two phases. Alpha testing (N = 15) was used to drive design changes to the app. Beta testing (N = 30, after one participant withdrew) used a structured questionnaire to evaluate the app's usability and utility.

RESULTS

The application was rated highly for usability and utility (9.6 and 8.9 out of 10, respectively). The majority of participants (82.1%) agreed that the app would help them communicate with their doctor and that it gave them useful information about potentially harmful or unnecessary interventions such as opioids and imaging (79.2% and 75.0%). Participants (age ≥60 years, mean age = 75.5 years) were able to successfully use the application without assistance and would be willing to do so in their primary care office.

CONCLUSIONS

We present the development of a CLBP app that screens for pain contributors and provides personalized education based on patient responses. Such an app could be employed in a variety of clinical settings to help educate patients about their CLBP and to curtail unnecessary interventions. Patient outcomes are being tested in an ongoing clinical trial.

Epidural Fat and Its Association with Pain, Physical Function, and Disability Among Older Adults with Low Back Pain and Controls

Objective

To examine epidural fat and its relationship to pain, physical function, and disability among older adults with chronic low back pain, chronic low back pain plus leg pain, and controls.

Design

Cross-sectional, comparative study.

Setting

Standardized examinations were conducted in a research laboratory, and magnetic resonance images were obtained.

Subjects

A total of 93 adults age 60 to 85 years (24 with chronic back pain, 25 with chronic back pain plus leg pain, and 44 controls).

Methods

Reliability for assessment of epidural fat diameter, averaged across spinal levels, was established (intraclass correlation coefficient = 0.95). Linear regression was used to explore how epidural fat diameter related to self-reported (Short Form-36 Health Survey: physical component summary score) and performance-based (stair climb performance) measures of physical function among adults with chronic back pain with and without leg pain, as compared with controls, while controlling for age, sex, and body mass index. Associations between epidural fat and pain intensity and low back pain-related disability were also explored (P ≤ 0.050).

Results

Epidural fat helped explain self-reported function (P < 0.001); adults with axial low back pain (LBP) may have a relationship between epidural fat and self-report function that is different from controls (P = 0.015). Relationships between epidural fat and stair performance were significantly different from controls for those with LBP (P = 0.000) but not for those with LBP plus leg pain (P = 0.366). Relationships between epidural fat and pain intensity and/or disability were not found.

Conclusions

Increased epidural fat may help explain better function among older adults with chronic axial back pain, but not among those who also report leg pain.

An E-learning Module on Chronic Low Back Pain in Older Adults: Effect on Medical Resident Attitudes, Confidence, Knowledge, and Clinical Skills

Objective

To determine 1) the feasibility of implementing an e-learning module on chronic low back pain (CLBP) in an older adult into an existing internal medicine residency curriculum and 2) the impact of this module on resident attitudes, confidence, knowledge, and clinical skills relating to CLBP.

Methods

Participants were assigned to complete either the online module (N = 73) or the Yale Office-based curriculum on CLBP (N = 70). Attitudes, confidence, and knowledge were evaluated pre- and postintervention via survey. A retrospective blinded chart review of resident clinic encounters was conducted, wherein diagnosis codes and physical exam documentation were rated as basic or advanced.

Results

There was no improvement in overall knowledge scores in either group (60% average on both metrics). There were tendencies for greater improvements in the intervention group compared with controls for confidence in managing fibromyalgia (2.4 to 2.9 vs 2.5 to 2.5, P = 0.06) and leg length discrepancy (1.8 to 2.5 vs 1.5 to 1.9, P = 0.05). Those exposed to the online module also showed an increase in the percentage of physical exam documentation rated as advanced following the intervention (13% to 32%, P = 0.006), whereas the control group showed no change (14% to 12%, P = 0.68).

Conclusions

An online module on CLBP in the older adult was a feasible addition to an existing curriculum for internal medicine residents. The module positively and substantively impacted resident clinical behaviors, as evidenced by enhanced sophistication in physical exam documentation; it also was associated with improved confidence in certain aspects of chronic pain management.

Which Seems to Be Worst? Pain Severity and Quality of Life between Patients with Lateral Hip Pain and Low Back Pain

Purpose

The aim of this study was to compare the pain severity, health-related quality of life (HRQoL), and risk of continue having pain with prognostic risk scores (PRS), between patients referring greater trochanteric pain syndrome (GTPS) and chronic low back pain (CLBP).

Methods

A descriptive, cross-sectional design using nonprobability convenience sampling was performed. A total sample of 102 patients were recruited from two primary health-care centers and divided into GTPS (n = 51) and CLBP (n = 51) groups. The primary outcome was pain severity which was assessed with the Spanish version of the Graded Chronic Pain Scale (GCPS). The secondary outcome was the HRQoL which was measured using the Spanish version of EuroQoL Five Dimensions and Five Levels (EQ-5D-5L) as well as the PRS.

Results

Significant differences (P<0.05) were found within both groups in the pain severity global score with a medium effect size showing greater values for the CLBP group with regards to the GTPS group. The PRS in both groups did not show statistical differences (P>0.05). Nevertheless, subjects referring CLBP showed greater levels in the PRS than patients with GTPS. Comparing both groups, the HRQoL showed statistical differences (P<0.05) in the “pain/discomfort” domain in the CLBP group with respect to the GTPS group, but not in the other domains.

Conclusions

Patients who suffered from CLBP showed greater pain severity and HRQoL discomfort with regard to patients with GTPS. Despite greater scores for CLBP, the PRS did not seem to be different between both conditions.

Biopsychosocial Profiles and Functional Correlates in Older Adults with Chronic Low Back Pain: A Preliminary Study

Objective

To describe key peripheral and central nervous system (CNS) conditions in a group of older adults with chronic low back pain (CLBP) and their association with pain severity and self-reported and performance-based physical function.

Design

Cross-sectional.

Setting

Outpatient VA clinics.

Subjects

Forty-seven community-dwelling veterans with CLBP (age 68.0 ± 6.5 years, range = 60–88 years, 12.8% female, 66% white) participated.

Methods

Data were collected on peripheral pain generators—body mass index, American College of Rheumatology hip osteoarthritis criteria, neurogenic claudication (i.e., spinal stenosis), sacroiliac joint (SIJ) pain, myofascial pain, leg length discrepancy (LLD), and iliotibial band pain; and CNS pain generators—anxiety (GAD-7), depression (PHQ-9), insomnia (Insomnia Severity Index), maladaptive coping (Fear Avoidance Beliefs Questionnaire, Cognitive Strategies Questionnaire), and fibromyalgia (fibromyalgia survey). Outcomes were pain severity (0 to 10 scale, seven-day average and worst), self-reported pain interference (Roland Morris [RM] questionnaire), and gait speed.

Results

Approximately 96% had at least one peripheral CLBP contributor, 83% had at least one CNS contributor, and 80.9% had both peripheral and CNS contributors. Of the peripheral conditions, only SIJ pain and LLD were associated with outcomes. All of the CNS conditions and SIJ pain were related to RM score. Only depression/anxiety and LLD were associated with gait speed.

Conclusions

In this sample of older veterans, CLBP was a multifaceted condition. Both CNS and peripheral conditions were associated with self-reported and performance-based function. Additional investigation is required to determine the impact of treating these conditions on patient outcomes and health care utilization.