Dr. John Licciardone co-authors new JAMA Network article on preventing chronic low back pain impact
John Licciardone, DO, MS, MBA, regents professor in the Texas College of Osteopathic
Medicine at UNT Health Fort Worth, collaborated with investigators at leading pain
research centers nationwide to publish new results from the PACBACK Trial this month
in JAMA Internal Medicine.
The landmark study funded by the National Institutes of Health studied spinal manipulation
and clinician-supported self-management compared with standard guideline-based medical
care for patients with acute or subacute low back pain at increased risk of chronic
disabling pain. It included 1,000 patients at three research clinics from November
2018 to June 2024.
These new results extend beyond those previously reported by the PACBACK Investigators
in JAMA earlier this year. They measured the effectiveness of the various treatments
in preventing disabling chronic low back pain over 12 months primarily using NIH’s
pain impact score, which considers pain intensity, physical function, and how much
pain interferes with activities.
Patients who received clinician-supported self-management reported significantly better
pain impact scores compared with those who received standard medical care based on
clinical practice guidelines, including use of nonsteroidal anti-inflammatory drugs,
skeletal muscle relaxants, and other second-line medications.
The self-management intervention involved a biopsychosocial needs assessment followed
by an individualized treatment plan to support ongoing self-management of pain through
approaches such as pain education, physical exercises, mind-body strategies, and navigating
social roles. Patient-centered communication was a key aspect of the intervention
in persuading patients to adopt and sustain self-management activities throughout
the study.
The outcomes of patients who received spinal manipulation, which was provided by chiropractors
or physical therapists, were not different than those of patients who received standard
medical care. However, patients who received spinal manipulation reported better secondary
outcomes involving lower health care utilization, less medication use, and greater
satisfaction.
“It's interesting to see how well patients may manage their chronic low back pain
when provided with the appropriate counseling during patient-centered communication,”
said Licciardone, who is also executive director of the Osteopathic Research Center
at UNT Health Fort Worth. “These new results reaffirm the effectiveness of biopsychosocial
self-management reported in our previous article.”
In an accompanying commentary to the new article, Steven Atlas, MD, MPH, a physician
in the Division of General Internal Medicine at Massachusetts General Hospital and
a professor at Harvard Medical School said, “To understand the context of this study,
one needs to acknowledge that the long-standing use of medications for low back pain
– typically nonsteroidal anti-inflammatory drugs and muscle relaxants, and for severe
pain, opioids – has changed with recognition of the harms of overprescribing opioids
and the 2017 publication of a clinical practice guideline from the American College
of Physicians.”
The Osteopathic Research Center has conducted several clinical trials with results
that are consistent with these new findings from the PACBACK Trial.
“Our research shows that patients with chronic low back pain treated by osteopathic
physicians generally report better outcomes than patients treated by allopathic physicians,”
said Licciardone. “However, the benefits of osteopathic medical care are not strictly
related to osteopathic manipulative treatment. They are more likely mediated by the
osteopathic approach to health care that closely mirrors the biopsychosocial model
used in the PACBACK Trial, including patient-centered care and physician empathy.
“We continue to face the challenges highlighted when the American College of Physicians
guidelines were first published: how to train a workforce that can deliver guideline-recommended
therapy and actively engage patients in their care, and the need to enact payer coverage
policies to support clinician delivery of care based on a biopsychosocial model,”
said Atlas in his commentary.
Studies such as these, conducted by the PACBACK Investigators and the research being performed at the Osteopathic Research Center through its national Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION), are critical in developing health care policy and the next generation of clinical practice guidelines pertaining to chronic pain.