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7 Articles in this Series
Introduction
Addressing Arthralgia in Children
An ACR/ARHP Preview
Axial Spondylitis: Mimics, Progression, the Need for MRI, and New Management Recommendations
How Rheumatic Diseases Can Hurt Sexual Health
Tanezumab for Hip and Knee OA; Cosentyx for Ankylosing Spondylitis; and Upadacitinib for RA
Treating Chronic Musculoskeletal Pain in Older Adults
Uncovered Inflammatory Pathways of Osteoarthritis Call for New Targets

Treating Chronic Musculoskeletal Pain in Older Adults

To achieve sustainable patient outcomes, strategies should involve biopsychosocial approaches.
An ACR/ARHP 2018 Meeting Highlight with Una E. Makris, MD, and Kelli Allen, PhD.

 

As the pain management community well knows, adults over age 65 who experience pain in later life are also at increased risk for developing a number of disorders impacting sleep, mobility, and more, shared Una E. Makris, MD, an associate professor of Internal Medicine in the Division of Rheumatic Diseases at UT Southwestern Medical Center. After reviewing the epidemiology of chronic musculoskeletal (MSK) pain, Dr. Makris, who is also a physician and investigator at the Dallas VA Medical Center, used this ACR/ARHP 2018 talk to call for a new approach to managing MSK pain in older adults.

She used chronic low back pain (cLBP) as her example, noting that cLBP is the most common chronic pain condition and the second most common reason for an office visit. While diagnostic and therapeutics in back pain have skyrocketed, she noted, patient outcomes have not improved.

The Problem with Current Approaches to Management

Back pain, in particular, not only affects functional activities but it also affects sleep, relationships, emotional health, fatigue, and isolation in older adults. In fact, Dr. Makris said, this multifactorial condition often includes biopsychosocial factors that may explain some of the discrepancies between imaging findings, clinical presentation, and response to treatments.  

For this reason, she uses a biopsychosocial model in her geriatric pain population and with the veterans she treats. Dr. Makris emphasized that current approaches involving medications alone and/or surgery are largely ineffective and unappealing.

For example, monotherapy with NSAIDs and opioids are not the ideal treatment, especially in older patients with multimorbidity and polypharmacy. Guidelines propose non-pharmacologic interventions as first-line for chronic pain conditions. Unfortunately, based on her clinical and academic setting experience, “nonpharmacological solutions are rarely used first-line.”

And of the multiple implementation-ready therapies that can be used, few focus exclusively on older adults or those with comorbid conditions (see also the section on current models below). Thus, Dr. Makris said, there is an urgent need to develop new, effective behavioral interventions for older adults—and these interventions need to be sustainable and simultaneous, meaning that they also treat common comorbid conditions like depression.

MOTIVATE: A Novel Telecare Intervention

One such intervention that Dr. Makris and colleagues have been working on is called MOTIVATE: Moving to Improve cLBP and Depression in Older Adults. This is a telehealth program that focuses on improving cLBP and depression in older adults. “In many of my patients, I tell them that I cannot fully treat your pain if the depression or PTSD is not managed,” she said. The telecare program, therefore, targets both comorbidities. The MOTIVATE five-year study was built on prior VA study called HOPE: Healthy Outcomes Through Patient Empowerment. The core components of the MOTIVATE program include:

  • behavioral activation (not cognitive restructuring)
  • goals (eg, a physical activity like walking) that are consistent with the patients’ values (see Knittle et al, Health Psy Rev, 2018 for evidence on motivation and physical activity)
  • a focus on how older adults are uniquely motivated to make and sustain behavioral change.

Understanding the time horizons of this demographic group and how healthcare teams can influence and positively frame messaging for them specifically is key, she explained, and differentiates this intervention from others. By tapping into older adults’ values, goals can be used to motivate and activate a behavioral change, Dr. Makris explained. “Telling patients in a clinical setting to do a specific exercise may not appeal to their day to day life or interests, and thus, may not be sustainable,” explained Dr. Makris. “The health coaching via phone personalizes the values and goals to each patient.”

In a pretest, 7 veterans age 65 or older with cLBP and comorbid depression participated in 8 telecare sessions over a period of 10 to 12 weeks. Led by a health coach, sessions start by establishing repertoire, work through goal setting and planning (again, goals must be linked to the patient’s values and to a physical activity such as walking), and end with boosting (ie, motivating) the patients through any barriers that may arise. Upon completion of the MOTIVATE intervention, Veterans were interviewed and found the health coach to be particularly helpful in encouraging behavioral change. They found it helpful to identify values and link their goals to what matters most to them. The Veterans who have completed the program so far stated that the physical activity behaviors they learned, especially linking to specific goals, is something they plan to continue now that the intervention is complete.

The messaging and content of the intervention were informed and developed by stakeholders including experts, patients, and clinical leaders. The goal is to develop an intervention that is relevant, effective and yields sustained results over time. Dr. Makris said they will be rolling out a pilot randomized controlled trial in January 2019.

Don’t Fear Potential Barriers

“One of the goals is to create effective and sustainable intervention without burdening the healthcare provider, “ said Dr. Makris. Looking ahead, for instance, perhaps the health coach would deliver the intervention via video technology that is accessed by the patient.

Some pain practitioners may find it difficult to ask questions beyond pain intensity – but we need to be asking questions related to function and to start a treatment plan by working with an interdisciplinary team, advised Dr. Makris, who noted that she regularly works with a PharmD on her cases. Unfortunately, the current pain mindset involves quick fixes and passive strategies, she noted, but by applying more behavioral, approaches, patient outcomes will be more sustainable.

Dr. Makris addressed possible audience pushback head on—noting that the literature shows telehealth is “accessible, effective, flexible, and efficient.” She also pointed to data showing older adults do use technology—smartphone adoption has nearly quadrupled in the past five years among seniors and they are also using more wearable, like fit bits. “Technology will not be a barrier for them, she said.

Know the Current Models

In the second portion of the ACR/AHRP session on MSK pain older adults, Kelli Allen, PhD, of the Thurston Arthritis Research Center at the University of North Carolina at Chapel Hill and Durham VA Medical Center, focused on various existing models of care and how to deliver them to older patients.

Dr. Allen used osteoarthritis (OA) and cLBP as examples of chronic MSK pain in older adults, both of which are not one-specialty conditions in terms of optional management, she said, pointing to guidelines that call for pharmacological and nonpharmacological interventions. For instance, she referred to Meneses et al, Osteoarth Cart, 2016, for an algorithm of guideline-based care in knee OA.

Despite existing guidelines for MSK conditions, Dr. Allen said gaps remain. “Ninety percent of older adults with LBP do not meet physical activity recommendations and  80% of adults with OA are overweight or obese. Only 3 to 7% of those with chronic pain use cognitive behavioral strategies,” she cited. Healthcare systems across the globe are starting to figure out how to use these interdisciplinary interventions.

Common approaches for MSK care include:

  • Stepped models, which start with low intensity. These most widely studied approaches form the basis for the VA’s national pain management strategy and have evidence for LBP, depression, and MSK pain, she noted. Dr. Allen pointed to the Edmond et al, Pain Medicine, 2018 paper and the Project STEP / SCOPE Telecare study by Kroenke et al, JAMA, 2014, as examples of stepped care pain management models.
  • Collaborative care models, which Dr. Allen does not just mean “co-located” care but really should involve two or more practitioners of different specialties working together on the patient’s treatment plan. Collaborative care examples include: Goode et al, Phs Ther, 2018, and the ongoing VOICE study at the Patient-Centered Outcomes Research Institute of 1,400 veterans who are on moderate to high opioid doses. It compares an integrated pain team and a traditional collaborative management.
  • Stratified care models, which use risk stratification based on assessment to inform the care approach. Examples from Dr. Allen include: the Hill et al, STarTBack study from 2011, and Foster et al, Ann Fam Med, 2015, the IMPaCT Back study.

Choose Behavioral Approaches First, Interventions Later

Overall, both clinicians made the point that, even though the MSK care guidelines start with low-intensity solutions (eg, education, nutrition, and other biopsychosocial approaches) as frontline approaches that then lead up to more invasive interventions and opioids, many practitioners do not follow this model; they go to Step 4, for example, at the start.

“Clearly,” said Dr. Allen, “the complexity of care for older adults with MSK conditions requires a multidisciplinary approach. While existing models have good evidence more work is needed to research older adult targets, specifically including those with high disease complexity and comparative effectiveness models.”

Added Dr. Makris, “as patient populations age, we are going to see more chronic inflammatory conditions of the muscles and of the spine…Knowing how to approach the care of these patients for sustainable outcomes will be key to avoiding more medication management challenges.”

Drs. Makris and Allen disclosed that their views do not represent those of the VA or the federal government. 

 

Next summary: Uncovered Inflammatory Pathways of Osteoarthritis Call for New Targets
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