S4 The Journal of Pain
increased pain and hypoesthesia which may predispose them to
lower quarter joint trauma.
(109) Aging Back Clinics − A Geriatric Syndrome Approach to
Treating Low Back Pain in Older Adults: Results of a
Preliminary Randomized Controlled Trial
D. Weiner, A. Gentili, M. Rossi, K. Coffey-Vega, K. Rodriguez, K. Hruska,
L. Hausmann, and S. Perera; VA Pittsburgh Healthcare System, Pittsburgh,
PA
Treating chronic low back pain (CLBP) with spine-focused interven-
tions is common, potentially dangerous, and often ineffective. We
posit that CLBP in older adults is a geriatric syndrome − a final com-
mon pathway for the expression of multiple contributors. We have
published evidence and expert consensus-based algorithms to
guide evaluation and treatment of key biopsychosocial CLBP con-
tributors in older adults − hip osteoarthritis, myofascial pain, fibro-
myalgia, sacroiliac joint syndrome, lumbar spinal stenosis, leg
length inequality, lateral hip/thigh pain, anxiety, depression,
insomnia, and maladaptive coping. This preliminary trial tests the
feasibility and efficacy of care based on these algorithms in Aging
Back Clinics (ABC). Fifty-five English-speaking Veterans age 60-89
with CLBP and no red flags, prior back surgery, dementia, impaired
communication, or uncontrolled psychiatric illness were random-
ized to ABC care or usual care (UC) over 6 months. ABC care was
implemented by geriatricians trained in CLBP assessment who: 1)
performed a structured history and physical examination to iden-
tify pain contributors, 2) provided structured education to partici-
pants about their contributors, and 3) recommended additional
care using collaborative decision making. Primary outcomes were
low back pain severity (0 to 10 current, and 7-day average and
worst pain) and pain-related disability (Roland Morris [RM] ques-
tionnaire). Follow up data were collected monthly by telephone.
ABC participants experienced significantly greater reduction in 7-
day average (-1.22 points; p=0.023) and worst pain (-1.70 points;
p=0.003) at 6 months. Neither present pain nor RM score at 6-
months was statistically significant but favored ABC in magnitude.
Descriptively, participants randomized to UC were more likely to
experience pain-related emergency room visits (45.8 vs 30.8%;
p=0.5136) and be exposed to Beers’ list medications, specifically
non-COX2 nonsteroidal anti-inflammatory drugs (73.1% vs. 54.2)
and muscle relaxants (42.3% vs. 16.7). These preliminary data sug-
gest that ABC care reduces pain and exposure to other potential
morbidity.
(110) Impact of Pain Severity among Patients with
Osteoarthritis on Healthcare Use in the United States
R. Robinson, J. Bobula, J. Cappelleri, A. Bushmakin, L. Tive, L. Viktrup,
J. Mellor, N. Williams, P. Hubanova, and J. Jackson; Eli Lilly and Company,
Indianapolis, IN
Osteoarthritis (OA) is the leading cause of disability in older adults.
Total healthcare costs tend to rise as pain severity associated with
OA increases. To understand treatment and healthcare resource
utilization (HCRU) by OA pain severity, data were collected from
Feb-May 2017 using US Adelphi Disease Specific Programme, a
cross-sectional survey of primary care physicians, rheumatologists,
orthopedists and their patients. Descriptive statistics were used and
all data were analysed using SPSS v6 and Stata v14.1. A total of 841
patients seeking care for OA were included. Patient-reported pain
severity (Numeric Rating Scale; 0-10) over the last week was catego-
rized as none/mild (45.4%; 0-3), moderate (35.9%, 4-6) and severe
(18.7%; 7-10) pain. The majority of patients were female (61%) and
white (78%) and the average age was 64.6 years. Increased pain
severity was associated with a higher Body Mass Index and
increased reliance on walking aids (21%, 38%, 47%), modifications
to home (9%, 19%, 31%), and need for caregivers (5%, 14%, 31%)
(all p<0.0001). Hospitalizations (5%, 8%, 12%; p=0.0281) over the
last 12 months also increased with pain severity. Anxiety (12%,
18%, 24%), depression(11%, 17%, 24%), and chronic low back
pain (5%, 22%, 17%) were the top three physician-reported condi-
tions that were twice as likely either with moderate or severe pain
versus no/mild pain. Physician-reported HCRU tended to include
multiple modalities and varied by pain level in terms of specialties
seen and procedures used. Over-the-counter and prescription medi-
cation use were frequently used across all pain levels. Physician-
patient discussions increased by pain severity for opioid sparing
approaches (22%, 25%, 38%; p=0.0007) and non-medical interven-
tions (68%, 67%, 80%; p=0.0098). Comprehensive care beyond diet
and exercise was infrequent. Results are exploratory and no
Abstracts
adjustments for multiple comparisons were included. Further
research to better understand the relationship between pain sever-
ity and treatment is needed.
(111) Trends in Diagnostic Coding for Musculoskeletal
Conditions: An Evaluation of ICD-10 Use in the Veterans Health
Administration
B. Coleman, J. Goulet, D. Higgins, T. Kawecki, H. Bathulapalli, and
A. Heapy; VA Connecticut Healthcare System, West Haven, CT
Musculoskeletal disorders (MSD) are the most common diagnoses
among Veterans presenting with pain in the Veterans Health Adminis-
tration (VHA). The implementation of the International Statistical Clas-
sification of Diseases and Related Health Problems, Tenth Revision
(ICD-10) sought to increase specification of diagnoses, but studies have
yet to evaluate this effect. In this study, we examined the most fre-
quently utilized MSD-related ICD-10 diagnostic codes and describe
their association with Veteran characteristics. A cross-sectional analysis
of all Veterans assigned an ICD-10 diagnostic “M-code” representing
“Diseases of the Musculoskeletal System and Connective Tissue” in
2016 and 2017 was performed. Data were obtained from the VHA
Musculoskeletal Disorders (MSD) Cohort, which includes over 5 million
Veterans. We examined coding frequency among patient visits
(n=31,619,884). A total of 36 of the possible 6,487 ICD-10 M-codes
demonstrated a frequency of greater than 0.50% of all visits, account-
ing for 63.74% of all MSD coded visits. “Low Back Pain” (M54.5) was
the most commonly used code (18.32%). The next most common codes
were “Cervicalgia” (M54.2, 3.55%), “Pain in Right Knee” (M25.561,
3.09%), “Pain in Left Knee” (M25.562, 2.93%), and “Pain in Right
Shoulder” (M25.511, 2.79%). Other codes of interest included “Gout,
Unspecified” (M10.9, 1.99%), “Unspecified Osteoarthritis, Unspecified
Site” (M19.90, 1.35%), “Rheumatoid Arthritis, Unspecified Site”
(M06.9, 0.77%), and “Fibromyalgia” (M79.7, 0.61%). Of the 36 most
used codes, 28 (77.78%) were nonspecific diagnoses that do not spec-
ify a site of involvement or that describe pain in a general anatomic
region. Patient age, gender, race, and pain intensity scores were exam-
ined to compare demographic differences in diagnostic coding pat-
terns. Our findings suggest that providers in VHA are selecting
musculoskeletal diagnoses from a limited subset of ICD-10 codes.
Despite over 6,000 possible M-codes, a small number of codes account
for most MSD-related visits, possibly due to homogeneity in Veteran
MSD conditions.
(112) Childhood Adversity Linked to Heightened Pain
Sensitivity in Adults
R. Sheinberg, C. Campbell, A. Kearson, E. Burton, and J. Letzen; Johns
Hopkins Hospital, Baltimore, MD
Childhood experiences of adverse social conditions have demon-
strated lifelong downstream health-related consequences. Since more
exposure to adverse childhood events (ACEs) are associated with
poorer outcomes, their exposure can be considered a social determi-
nant of health and wellness. The mechanism of ACEs contributing to
adverse health consequences may lie in chronic activation of the stress
pathway, leading to dysregulation of the neuroendocrine, immune,
and autonomic systems. Chronic stress, experienced in childhood,
appears to change the physiologic response to subsequent stress, per-
haps though HPA and immune axes. A link appears to exist between
retrospective reports of ACEs and adult pain-related medical condi-
tions like arthritis, neck and back pain and headaches. The
“sensitization” hypothesis posits that prior exposure to distress sensi-
tizes individuals to respond more robustly to subsequent stressors.
Those with more ACEs generally experience more chronic inflamma-
tion and heightened pro-inflammatory mediators may be a common
pathway of increased risk for facilitating pain. The current study
sought to evaluate pain facilitation, hyper-responsiveness of nocicep-
tive pathways. Pain facilitation can be measured in healthy partici-
pants using quantitative sensory testing (QST). We conducted
secondary data analyses of QST data from 130 healthy participants to
examine the effect of childhood adversity on psychosocial factors and
pain facilitation. Participants completed several questionnaires and
underwent a QST battery with multiple pain facilitatory indices,
including thermal and mechanical temporal summation, and assess-
ment of aftersensations (Z-scored and combined into one composite
score). Correlations revealed significant associations between ACEs
and psychosocial factors, including the traumatic life events, cata-
strophizing, fear of pain, depression, insomnia and sleep quality,
aches and pains (r’s=0.2-0.5; p’s<0.05), as well as pain facilitation
(r=0.2, p<0.05). These data suggest that further investigation to