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.

Creation of an Interprofessional Teledementia Clinic for Rural Veterans: Preliminary Data

The teledementia clinic is a new model of care that expands the reach of specialized geriatric and dementia care using clinical video telehealth (CVT) to rural veterans, who frequently lack access to specialty care. The clinic is a Veterans Affairs (VA) Geriatric Research, Education, and Clinical Center clinical demonstration project. It is located in the Pittsburgh VA Healthcare System tertiary referral hospital and serves veterans in affiliated rural community-based outpatient clinics (CBOCs). Rural CBOC primary care providers refer clinic patients, or referral is according to previous cognitive impairment diagnosis in a VAPHS geriatric clinic. Patients undergo interprofessional dementia assessment by a geriatrician, geropsychologist, geriatric psychiatrist or neurologist, and social worker using CVT technology. Metrics for clinic evaluation included rural patients served and savings in travel time, distance, and costs. Assessments collected depended upon individual presentation and included cognitive tests, geriatric depression scales, functional assessment, and the Zarit Burden Interview. A patient satisfaction survey was created and administered. In the first year, 95 individuals were served in 156 clinic visits and 251 interprofessional provider encounters. Of patients served, 61 lived in rural ZIP codes, 72 were diagnosed with dementia, 19 were diagnosed with mild cognitive impairment, and four were found to have primarily psychiatric diagnoses rather than cognitive impairment. The average Functional Assessment Staging of Alzheimer's Disease Scale score was 4.3 ± 1.3. This clinic model demonstrates that CVT technology is a feasible means of providing interprofessional dementia evaluations and follow-up to rural presidents.

Metabolic reprogramming during neuronal differentiation

Newly generated neurons pass through a series of well-defined developmental stages, which allow them to integrate into existing neuronal circuits. After exit from the cell cycle, postmitotic neurons undergo neuronal migration, axonal elongation, axon pruning, dendrite morphogenesis and synaptic maturation and plasticity. Lack of a global metabolic analysis during early cortical neuronal development led us to explore the role of cellular metabolism and mitochondrial biology during ex vivo differentiation of primary cortical neurons. Unexpectedly, we observed a huge increase in mitochondrial biogenesis. Changes in mitochondrial mass, morphology and function were correlated with the upregulation of the master regulators of mitochondrial biogenesis, TFAM and PGC-1α. Concomitant with mitochondrial biogenesis, we observed an increase in glucose metabolism during neuronal differentiation, which was linked to an increase in glucose uptake and enhanced GLUT3 mRNA expression and platelet isoform of phosphofructokinase 1 (PFKp) protein expression. In addition, glutamate-glutamine metabolism was also increased during the differentiation of cortical neurons. We identified PI3K-Akt-mTOR signalling as a critical regulator role of energy metabolism in neurons. Selective pharmacological inhibition of these metabolic pathways indicate existence of metabolic checkpoint that need to be satisfied in order to allow neuronal differentiation.

Addressing both depression and pain in late life: the methodology of the ADAPT study

OBJECTIVE

To describe the methodology of the first NIH-funded clinical trial for seniors with comorbid depression and chronic low back pain.

METHODS

Randomized controlled effectiveness trial using stepped care methodology. Participants are ≥60 years old. Phase 1 (6 weeks) is open treatment with venlafaxine xr 150 mg/day and supportive management (SM). Response is 2 weeks of PHQ-9 ≤5 and at least 30% improvement in the average numeric rating scale for pain. Nonresponders progress to phase 2 (14 weeks) in which they are randomized to high-dose venlafaxine xr (up to 300 mg/day) with problem solving therapy for depression and pain (PST-DP) or high-dose venlafaxine xr and continued SM. Primary outcomes are the univariate pain and depression response and both observed and self-reported disability. Survival analytic techniques will be used, and the clinical effect size will be estimated with the number needed to treat. We hypothesize that self-efficacy for pain management will mediate response for subjects randomized to venlafaxine xr and PST-DP.

RESULTS

Not applicable.

CONCLUSIONS

The results of this trial will inform the care of these complex patients and further understanding of comorbid pain and depression in late life.

Efficacy of periosteal stimulation therapy for the treatment of osteoarthritis-associated chronic knee pain: an initial controlled clinical trial

OBJECTIVES

To examine the efficacy of periosteal stimulation therapy (PST, osteopuncture) for the treatment of chronic pain associated with advanced knee osteoarthritis.

DESIGN

Randomized, controlled clinical trial.

SETTING

Outpatient pain clinic.

PARTICIPANTS

Eighty-eight community-dwelling older adults with moderate knee pain or greater for 3 months or longer and Kellgren-Lawrence (K-L) grade 2 through 4 radiographic severity (80% had K-L 4).

INTERVENTION

Participants were randomized to receive PST or control PST once a week for 6 weeks.

MEASUREMENTS

Pain severity and self-reported function (Western Ontario and McMasters University Osteoarthritis Index (WOMAC)) and physical performance (Short Physical Performance Battery (SPPB)) were assessed at baseline, after the last PST session (post), and 3 months later (follow-up). Pain severity was also assessed monthly using the multidimensional pain inventory short form.

RESULTS

Pain was reduced significantly more in the PST group than in the control PST group at post (P=.003; mean WOMAC pain subscale baseline 9.4 vs 6.4) and 1 month later (P<.001), but by 2 months, pain levels had regressed to pre-intervention levels. The group-by-time interaction for the WOMAC function scale was significant at post (P=.04) but not at follow-up (P=.63). No significant group differences were found for the SPPB. Neither analgesic use nor global improvement differed between groups. There were four treatment dropouts.

CONCLUSION

PST affords short-term modest pain reduction for older adults with advanced knee OA. Future research should test the effectiveness of booster treatments in sustaining analgesic benefits and of combining PST with therapeutic exercise in ameliorating disability risk.

Reduced cell anchorage may cause sarcolemma-specific collagen VI deficiency in Ullrich disease

BACKGROUND

COL6 gene mutations are associated with Ullrich congenital muscular dystrophy (UCMD), which is clinically characterized by muscle weakness from early infancy, hyperlaxity of distal joints, and multiple proximal joint contractures. We previously reported that the majority of patients with UCMD have sarcolemma-specific collagen VI deficiency (SSCD). More recently, we found heterozygous COL6A1 glycine substitutions in patients with UCMD with SSCD.

OBJECTIVE

To elucidate how COL6A1 glycine mutation leads to SSCD.

METHODS

We evaluated the synthesis, formation, and binding of collagen VI to the extracellular matrix in fibroblasts with p.G284R mutation in COL6A1.

RESULTS

Collagen VI was normally secreted into the cultured medium in fibroblasts harboring p.G284R mutation. When the medium with normal collagen VI was added to collagen VI-deficient fibroblast culture, collagen VI bound surrounding the cells, while collagen VI with p.G284R mutation did not. Cell adhesion of fibroblasts with p.G284R mutation was markedly reduced similarly to that of collagen VI-deficient cells. Interestingly, this reduction in adhesion of the cells with p.G284R mutation was recovered by the addition of the medium with normal collagen VI, which would suggest a therapeutic strategy for a replacement therapy.

CONCLUSION

Heterozygous glycine substitution in COL6A1 may cause decreased binding of collagen VI microfibrils to the extracellular matrix resulting in sarcolemma-specific collagen VI deficiency.