What causes low back pain to flare: Has a major opportunity to understand back pain been missed?

PROJECT SUMMARY/ABSTRACT Low back pain (LBP) is traditionally viewed as either a transient condition with acute episodes or a chronic persisting condition. However, it is increasingly recognized that for most (>80% of cases), LBP has a variable and ongoing trajectory characterized by fluctuating symptoms – with periods of worse symptoms referred to as “flares”. Current work regarding risk factors for LBP only considers those associated with a new episode or the transition to chronic LBP. Findings from that work has failed to deliver effective strategies to prevent new episodes or chronicity, nor reduce the excessive burden of LBP. The underlying premise of this proposal is that fluctuation or flaring of LBP is mediated by transient/fluctuating exposure to a range of factors across multiple domains, that differ between individuals, and identification of these factors could provide a basis for a completely new model to personalize care. This project will take a fresh look at LBP by directly addressing this question using innovative methods that are enabled by recent advances in technology. The work is based on our extensive collaboration with people with LBP that has provided critical insight into how flares are defined (which surprisingly is not based on pain alone) and their perspective of the potential causes for LBP flares. Our multidisciplinary research team propose an innovative case-crossover study that will address two aims. AIM 1 will examine, at multiple timepoints over a period of 3 months, an array of candidate biological/behavioral, psychological, social, and environmental risk factors for LBP flare that have been selected based on consumer perspective, literature review and our extensive preliminary studies. Measures will be made in the “real word” using advanced wearable and online technologies. AIM 2 will involve an embedded study of individuals from the main participant cohort who flare frequently. For 7 days, eligible individuals will undergo more intensive “real- world” physiological and biomechanical measures using an innovative combination of wearable sensors and home-based sample/data collection to investigate potential mechanisms underlying two surprising preliminary observations: (1) that poor sleep is a potent risk factor for a subsequent flare (as opposed to the traditional view that pain interferes with and causes poor sleep), and (2) that low rather than high physical activity is a risk factor for LBP flare. We aims to identify not only if, but how, daily variations in sleep quality and physical activity – two of the most important, yet modifiable health behaviors – drive flare of LBP. Together these data will fill a major gap by providing new understanding of mechanisms that drive the fluctuating experience of LBP. Such factors will provide the foundation to develop and test more targeted and personalized interventions to reduce the enormous – and worsening – burden of this condition on sufferers and society.