CHICAGO—Rheumatology healthcare providers should embrace collaborative approaches to manage chronic musculoskeletal pain in older adult patients, including models of care that involve multiple providers, patients and their caregivers. That was the message delivered by two speakers in the Interdisciplinary Management of Chronic Musculoskeletal Pain in Older Adults session at the 2018 ACR/ARHP Annual Meeting.
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“As musculoskeletal specialists, it is particularly appropriate [we] focus on the aging population. The National Institute on Aging predicts a very large increase in disability will be caused by increases in age-related disease, and arthritis and back pain are at the top of that list.1 This has enormous implications for social support systems, resources and our economy,” said Una E. Makris, MD, MSc, associate professor of medicine at UT Southwestern Medical Center, Dallas.
Although chronic pain prevalence statistics vary, as many as 80% of people in nursing homes will experience chronic pain.2 “We know that aging is a risk factor for chronic musculoskeletal pain. We also know that pain in later life increases the risk for multiple adverse effects,” including falls and fracture, depression and/or anxiety, and frailty and mobility problems, she said.3-5
Chronic Pain: Disabling & Costly
Chronic back pain in older adults is a particular concern: It is the most common chronic pain condition reported by adults and the second most common reason for a medical office visit, and for disability.6,7 Its management and impact are costly: Direct and indirect costs related to low back pain exceeded $100 billion in 2005 dollars.8 Although the number of diagnostic tests and therapies has increased, patient-reported—and general—outcomes have not improved, she said.
Based on focus group research among older adults with chronic back pain living in New York, Dr. Makris and her colleagues identified important domains related to patients’ experience, including sleep, fatigue, social isolation, physical activity, emotional health and relationships with family and friends, that are potential targets for treatment intervention.9
“Chronic back pain is complex and multifactorial. The majority of older adults will have degenerative changes of lumbar spine imaging, but not everyone has chronic back pain. Of those individuals who do, not everyone experiences disability. We know that some of the discrepancies that may account for differences between imaging, clinical presentations and response to therapy are indeed these psychosocial factors which are known to influence the course of disease,” and contribute to the phenotype and multiple clinical presentations of back pain that rheumatologists see in their older patients, she said.10
Physical pain and mental health are often connected. Patients with back pain may also have depression, anxiety and post-traumatic stress disorder (PTSD), said Dr. Makris.
“This overlap population is more time and resource intensive. As a clinician, this population is the most challenging. I tell my patients, ‘I cannot treat your pain if your depression and/or PTSD is not managed,” she said. “Our interventions must be informed by the biopsychosocial model of pain,” in which social, physiological and psychological factors all contribute to chronic pain.11 “Our current approach often falls short. There’s an urgent need for effective therapies. [For] older adults, medications and surgery are less appealing … because [they] have more multimorbidity, polypharmacy, frailty and fragmented social support systems.
Although the number of diagnostic tests & therapies [for chronic back pain] has increased, patient-reported outcomes & outcomes in general have not improved.
Opioids are associated with adverse events (e.g., altered mental status and falls) in older adults and may not be more effective at treating musculoskeletal pain than NSAIDs or acetaminophen.12 The CDC and ACP recommend clinicians avoid opioids when treating chronic pain, and use non-pharmacological, behavioral therapy first, said Dr. Makris, who added that many older patients and want alternatives to pills or surgery.13,14
Multiple implementation-ready modalities exist “that we could be offering,” said Dr. Makris, including manual, behavioral and movement therapies (i.e., cognitive-behavioral therapy, mindfulness training, tai chi, yoga or physical activity programs).
“Despite this, very few interventions focus exclusively on older adults, or those with comorbid physical and mental health conditions,” said Dr. Makris. “There is still an urgent need to develop effective behavioral interventions. But questions remain: How are older adults motivated to make and sustain behavioral change? How can we simultaneously target low back pain and depression? And how can we use technology to augment delivery and assess these interventions?”15
Motivation to Exercise
With a grant from the U.S. Veterans Administration (VA) Health Services Research and Development, Dr. Makris developed and is currently studying the efficacy of a telephone-delivered patient intervention called MOTIVATE: Moving to Improve cLBP and Depression in Older Adults. The phone sessions tap into patients’ personal values and goals to motivate them to make healthy changes, such as joining a walking program. The multiphase program includes a health coach contacting older veterans by phone to discuss behavioral changes, setting goals for activity and action planning. The coach also talks to patients about getting their caregivers, family and friends involved in the process.
“We are focusing on how older adults are uniquely motivated to make and sustain behavioral change,” she said. “We have spent a lot of time talking about how to frame messages in a positive … manner.”
Dr. Makris and her colleagues worked with panels of veterans, geriatricians, physical therapists and others to develop the right messaging and wording for the call and program content. “I wanted to develop this intervention with an eye for implementation and dissemination, so it’s not just sitting on my bookshelf when the next grant ends,” she said. They plan to launch a randomized controlled trial of MOTIVATE in 2019, enrolling 30 veterans aged 65 or older with chronic low back pain and depression, as well as 30 controls.
“My overarching goal is to develop high-quality, effective interventions that can be feasibly integrated into care for older adults without placing an additional burden on healthcare providers,” she said.
In the future, Dr. Makris and her colleagues hope to expand the physical activity intervention to other patient populations; evaluate health utilization outcomes, including opioid use and reduction; incorporate innovative technology to boost sustainability; and capture dynamic variables. “There are wearable devices that could be used, and we are looking into the health coach delivering video messaging right into the patient’s home. And then, how can we use the patient’s social environment—the spouse, caregivers or grandchildren—to help sustain behavior? What happens in the home is the most important over time,” she said.
Challenges ahead, she said, include access to behavioral interventions, reimbursement gaps and a needed culture change.
“We are moving from a biomedical model to a biopsychosocial model. It’s often difficult to convince our colleagues to start working in interdisciplinary teams, or to be asking questions that are not just pain intensity related, but related to function,” she said. For some patients, “behavioral treatment is often viewed as an afterthought, less effective as a pain treatment, a last resort or can even be stigmatized. Some of that may be how we communicate about this to our patients.” More people may be able to utilize behavioral interventions as technology, such as wearable devices to track physical activity or videoconferencing, advances, she added. “Telehealth and technology will be used more and more to deliver and assess interventions, and this will enhance access.”
Evidence-based care models for older adults with chronic musculoskeletal pain focus on both medical management and behavioral interventions, and these approaches involve collaboration between care teams and their patients to set and achieve pain management goals, said Kelli D. Allen, PhD, an exercise physiologist at the University of North Carolina Thurston Arthritis Research Center, Chapel Hill. Care needs to be multifactorial and multidisciplinary to be effective.16
“Not only does it require multiple professionals to deliver care to older adults, but the care is complex in terms of how it is operationalized,” she said. “If you’re doing optimal management of osteoarthritis or back pain, you need to operationalize treatment recommendations. What therapy is done by whom? How do you move patients between therapies?”17
Obesity, pain and other factors often lead adults with musculoskeletal conditions to be physically inactive, so rheumatology care providers are interested in behavioral interventions that include exercise, said Dr. Allen.18,19 Models include stepped care, collaborative care and stratified care.
“Stepped care models begin with a low-intensity or low-resource treatment, and then step up if the patients do not make clinically relevant improvements. They mirror what you’d do in a clinical setting. You can also step down,” she said. “The idea is to deliver the right care at the right time to the right person. Hopefully, that optimizes outcomes, and also reduces costs and saves resources.”
Collaborative care models involve providers from different disciplines who work together to treat patients and monitor their progress, said Dr. Allen. “These programs involve varying degrees of integration. Ideally, it’s more than co-located care. The idea is really working together on a patient’s treatment plan.
“Stratified care models include initial risk stratification based on some type of standardized assessment, and then care is provided based on that risk.”
Stepped care models for pain management have been the most widely implemented and tested of the three approaches, and are the basis for the VA’s pain management strategy.20 Step 1 of the VA’s approach is self-care based on the biopsychosocial model, and using various behavioral tools to help people manage their pain.
“These include weight management, exercise and conditioning, and mindfulness. There may be referrals elsewhere, but it is implemented and managed in the primary care space,” said Dr. Allen. “If their pain is treatment refractory, then in step 2, they’d go on to see other specialty referrals. If there is continued pain or other comorbidities that are preventing progress, then step 3 is referral to interdisciplinary pain centers or other specialty care, but this is reserved for patients who failed to achieve benefits from the therapies in earlier steps.”
Stepped care models require measurement via telephone-based or electronic medical record-based tools to assess how well a patient’s therapy is working, she said.
Collaborative care models embrace the interdisciplinary team approach to care. In one trial of 401 patients with musculoskeletal pain who were randomized to receive either collaborative pain care or usual care at five VA primary care clinics, a care manager worked in conjunction with a pain specialist to manage patients in the collaborative care arm, assess their needs and then refer them to physical, occupational or recreational therapy, following up with the pain specialist on the decisions made.21
Stratified care models are newer and have less evidence behind them. In one non-randomized, implementation trial published in 2014, 922 patients with low back pain who received care at a family practice clinic were compared with a subsequent group of patients who received a new, stratified back pain intervention called the STarT Back Tool.22 This tool uses questionnaires to help providers identify levels of pain risk and disability so they can target patients for particular interventions. The study showed small, but significant, benefits for patients who used the STarT Back Tool over those receiving typical care, she said.
Susan Bernstein is a freelance journalist based in Atlanta.
- National Institute on Aging, National Institutes of Health, U.S. Department of Health and Human Services, U.S. Department of State. Why Population Aging Matters: A Global Perspective (Publication No. 07-6134). 2007 Mar.
- AGS Panel on Persistent Pain in Older Persons. The management of persistent pain in older persons. J Am Geriatr Soc. 2002 Jun;50(6 Suppl):S205–S224.
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- Reid MC, Williams CS, Gill TM. The relationship between psychological factors and disabling musculoskeletal pain in community-dwelling older persons. J Am Geriatr Soc. 2003 Aug;51(8):1092–1098.
- Leveille SG, Ling S, Hochberg MC, et al. Widespread musculoskeletal pain and progression of disability in older disabled women. Ann Intern Med. 2001 Dec;135(12):1038–1046.
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- Makris UE, Higashi RT, Marks EG, et al. Physical, emotional and social impacts of restricting pain in older adults: A qualitative study. Pain Med. 2017 Jul 1;18(7):1225–1235.
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- Krebs EE, Gravely A, Nugent S, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872–882.
- Qaseem A, Wilt TJ, McLean RM, et al. Noninvasive treatments for acute, subacute and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514–530.
- Makris UE, Higashi RT, Marks EG, et al. Ageism, negative attitudes and competing comorbidities: Why older adults may not seek care for restricting back pain: A qualitative study. BMC Geriatr. 2015 Apr 8;15:39.
- Reid MC, Ong AD, Henderson CR Jr. Why we need nonpharmacologic approaches to manage chronic low back pain in older adults. JAMA Intern Med. 2016 Mar;176(3):338–339.
- Raveendran R, Nelson AE. Lower extremity osteoarthritis: Management and challenges. N C Med J. 2017 Sep–Oct.78(5):332–336.
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- Moore BA, Anderson D, Dorflinger L, et al. Stepped care model of pain management and quality of pain care in long-term opioid therapy. J Rehabil Res Dev. 2016;53(1):137–146.
- Dobscha SK, Corson K, Perrin NA, et al. Collaborative care for chronic pain in primary care: A cluster randomized trial. JAMA. 2009 Mar 25;301(12):1242–1252.
- Bamford A, Nation A, Durrell S, et al. Implementing the Keele stratified care model for patients with low back pain: An observational impact study. BMC Musculoskelet Disord. 2017 Feb 3;18(1):66.