Cyberseminar transcript
Spotlight on Pain Management
An Internet-mediated Exercise Intervention for Veterans with Chronic Low Back Pain
Sarah L. Krein, PhD, RN
June 5, 2012
Bob Kerns: Good morning, everybody, and welcome to this month’s spotlight on pain management. I'm Bob Kerns. I'm National Program Director for Pain Management in VA Central Office. And it’s my pleasure to welcome you to today’s spotlight on pain management. I want to take a moment to thank the Center for Information Dissemination and Education Resources, CIDER, an HSR&D funded resource center; and Heidi Schlueter, in particular, for their support of this monthly conference.
Today it’s my pleasure to introduce Sarah Krein. Sarah is a PhD nurse and research health science specialist at the Ann Arbor VA Center for Clinical Management Research. And a research associate professor of Internal Medicine at the University of Michigan. Dr. Krein’s research interest includes chronic illness care and complex chronic disease with a specific interest in chronic pain management. The work she is presenting today was funded for a grant from the VA’s Health Services Research and Development Service.
It is my pleasure to welcome Dr. Krein, who is going to present an Internet mediated exercise intervention for Veterans with chronic low back pain. Thank you, Sarah.
Sarah Krein: Ok, thanks a lot, Bob and I really appreciate the opportunity to share today some of the results of our recently completed study. Well, this is kind of hot off the press material. What I want to cover in the next 40 or 45 minutes is just to start out with a brief background to help you understand what motivated our research in this area.
Then talk about the conceptual framework for the project, which I think provides a really nice overview of the intervention, the type of activity we were trying to promote. Then the outcomes that we're hoping to achieve. I will talk specifically about the intervention component. We study design and then present our six month study findings and wrap it up with a few implications.
To start out, probably no big surprise to most of the folks on the line today; low back pain is a very prevalent health condition with about a quarter of adults in the U.S. reporting low back pain in the past three months; about half of us, reporting back pain during the given year. It is also an extremely costly condition and has significant negative consequences regardless of age.
I always find this somewhat – of some interest given that a lot of the work that I have done in chronic conditions seemed to be more selected towards older adults. But chronic back pain does not seem to be quite so selective; so, can impact younger people in terms of employment and income opportunities. It also impacts older folks in terms of mobility and social function.
Now, in our VA primary care patients, we know that about 50 to 70 percent report chronic pain. We also have data to suggest the prevalence may be higher among female Veterans. Pain is, of course, a costly disorder in the VA as well as outside.
We also know that the number of Veterans with chronic low back pain appears to be growing steadily. I think most of us are well aware of the returning Iraqi and Afghanistan Veterans and the issues that they are facing with chronic pain, which includes chronic back pain. Given that pain is such a prevalent condition, it is good to know that we also have a number of strategies for managing chronic back pain. There is varying levels of evidence for all of these different management strategies. Of course, one is pharmacotherapy. There has been a lot of interest as of late in the use opioids, which will not be the topic today since that was covered a couple of weeks ago very nicely.
There are also the more interventional strategies like surgery and perhaps injections or other types of intervention. Then, of course, there are strategies like exercise therapy; multidisciplinary pain programs, and psychological intervention. Given all of these strategies, my colleagues and I were interested in finding out a little bit more about what our patients use to manage their chronic low back pain.
So, a couple of years ago we conducted a study. This was a survey of primary care patients in VA. Just to orient people a little bit to this slide, we actually had three groups of patients. One that was just a general primary care patient population. We had one group that had heart failure and another group that had diabetes. Now again, there was some overlap amongst these groups. I am sure that most of you know how a lot of our patients have multiple chronic conditions.
And of these groups, we then asked if they had chronic pain? Among our patients about 60 percent, maybe a little over 60 percent in some of these different subgroups reported chronic pain, which was defined as pain that persisted for more than six months. Of those patients, we then asked what type of strategies they used to manage their pain. Now, about 80 percent reported using pain medications. Then above that as you see on this slide, there were a number of different types of nonpharmacologic strategies that patients reported using.
You can see there is a pretty good distribution. Things such as physical therapy, relaxation therapy, injections, exercise. They are pretty evenly distributed across the different subgroups as well. A few differences with our heart failure patients. But to me the most startling part of this slide is the big bars right in the middle. The most prominent strategy that patients report using for chronic back pain or for chronic, which is what we were asking about in most of these patients who had chronic back pain was rest; which is perhaps not a recommended strategy for most patients with a chronic pain condition.
What is a recommended management strategy? Well, if you look at the VA/DoD Low Back Pain Clinical Practice Guideline. I am focusing specifically here on recommendation seven. What we learned is that for patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits. Specifically for patients with chronic or sub-acute back pain. This includes intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, and massage, spinal manipulation, and yoga, cognitive behavioral therapy, or progressive relaxation.
Exercise therapy is one of those recommended nonpharmacologic therapies. What is the evidence that goes into this recommendation? Over the past couple of years, there have been several systematic review and meta-analysis looking specifically at exercise and exercise therapies. What we have learned from all of those studies is that exercise therapy appears to be at least as effective as other conservative therapies. Maybe slightly to moderately superior to no treatment or usual care. There does appear to be some benefits with exercise therapies. But it is also a little disconcerting to know that the evidence is many cases is graded as low quality. A lot of the studies are viewed as low quality for a variety of reasons; some having to do with the way the studies are conducted.
It is not really always that they are a bad study, but that there are some problems with how they have been conducted. How the findings have been determined. There is also some difficulty though in these studies and especially when you want to pool the evidence as you would in a meta-analysis. In that the outcomes that are looked at vary also across the different studies. In some studies, it is – the focus is really on pain and pain levels as the primary outcome. While in other studies it is really more focusing on function and functional measures.
Then the other issue that comes into play is just the simple heterogeneity. This comes in two forms. One is heterogeneity in the study populations. The subgroups of patients that are studied vary from more occupational health types of patients to patients who are being seen in pain clinics. To perhaps just a more general population of patients in the community. Then the other thing is just the types of exercise intervention and what constitutes exercise therapy.
On this slide, I wanted to share with you a definition of exercise therapy. This came from one of the more recent systematic reviews in which defined exercise therapy as a series of specific movements with the aim of training or developing the body by routine practice or physical training to promote good physical health. I think you are beginning to see that it is a pretty broad definition. There are a lot of different things that can fall into being considered as exercise therapy if you use this definition.
Again, if you look at the studies and the types of things that have been evaluated, you do see quite a broad variety. There are supervised exercise programs. There are home based programs. Programs that are aimed more at general physical fitness or aerobic exercise. Then those that are more back specific. Things that focus on muscle strengthening, flexibility, or even stretching exercises.
If you think about all of these different approaches, it probably begins to become more clear as to why there is sort of a mixed result in some of the evidence that we currently have about the benefits of exercise therapy. But another thing that came out of some of these reviews. And especially from work done by Hayden and colleagues. This was published back in 2005, which I found quite useful. Especially as we were starting to plan the intervention that we wanted to use for our projects – was that they also identified characteristics of the types of exercise therapy that they felt would be of most benefit. Again, this was based on the evidence that they were reviewing at that point and time.
Those characteristics included programs that seemed to be of most benefit were those that were individually designed. Had some level of supervision, whether it was at home, or in some kind of facility based program. Adherence, perhaps no big surprise, the fact that people need to actually participate in the activity. And achieve some level or some dosage is important. Then they also identified stretching as being perhaps of more benefit for pain and decreasing pain. Whereas strengthening exercises appeared to be more useful for improving function.
These are perhaps the ideal characteristics of an exercise program or an exercise therapy. But to my knowledge, no one has really evaluated the specific combination. With respect to exercise therapy, that again has kind of left us thinking more about what is it about the type of exercise therapy for a low back pain? And is there a specific type of therapy that we can provide to our patient that will be of benefit?
Just to summarize and recap very quickly as I've just described. Chronic pain is – or back pain in particular is very prevalent. The patients use a lot of different strategies to manage their chronic pain, including some such as rest that may not be recommended. We know that exercise is a key component in the management of people with chronic back pain. And also for people with other chronic conditions. It is really I think important again for our Veteran population who have multiple conditions. That this could be a very useful type of strategy for all of their condition. Not to mention that another VA study found that a little regular exercise extends men’s lives. Perhaps another benefit as well.
But of course, the most effective exercise regimen and perhaps even more importantly, how to effectively and efficiently assist people with using exercise therapy is still to be determined. My colleagues and I thought long and hard about what we thought we could do to help remedy this situation. We thought specifically about what people can do. What people will do and what we can help them do. I suppose that the strategy depicted in this slide, which is behind the remote strategy might have been one solution. But, we kind of decided that was not very feasible. We did not want to go into people’s homes on a regular basis.
So, from there we moved on to Veterans walk to beat back pain. So, Veterans walk to beat back pain. This slide is now showing you the conceptual framework for this study. It has a couple of different components. On the left-hand side of this slide, you can see the intervention components. I am going to go through these individually again just to give you a bit more information about what we were asking people to do. How we tried to assist them in engaging in exercise. In this case, our exercise of choice was walking.
Walking is great there in the middle of the slide as well. Then on the right-hand side, you can see our primary outcome in this particular study was to try to improve pain-related function, or decreased disability. So, the intervention components included an enhanced pedometer, a website, and an E-community. It tried to promote walking to improve function.
The other thing on the slide I just want to mention is we have this direct pathway that we felt might lead to improvement. But we also had a couple of things that we tried to target specifically as perhaps mediating or moderating factors that we know also are important in trying to improve or to get people to exercise and to walk. Also, perhaps reduce their functional disability.
A couple of things that we tried to focus on during the course of this study. Some of the materials that we provided also were to improve self-efficacy so people’s confidence and their ability to engage in this particular walking program. We focused a little bit on pain-related fears since that is also something that comes up frequently for patients who have chronic pain conditions. The fear that they are going to injure themselves worse. Then that we also tried to focus a bit on knowledge and knowledge gaps. You can also see in the right-hand side in addition to pain-related disabilities, our primary outcome. We also had some secondary outcomes that we wanted to look at, including quality of life. Pain, so actually pain, it tends to be; and then depression.