Biopsychosocial Model
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.”
