Impact of COVID-19 on utilization of nonpharmacological and pharmacological treatments for chronic low back pain and clinical outcomes

Abstract

Context: The novel coronavirus 2019 (COVID-19) pandemic has impacted the delivery of health care services throughout the United States, including those for patients with chronic pain.

Objectives: To measure changes in patients' utilization of nonpharmacological and pharmacological treatments for chronic low back pain and related outcomes during the COVID-19 pandemic.

Methods: A pre-post study was conducted within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry) using data in the 3 months before and 3-6 months after the declaration of a national emergency related to COVID-19. Participants 21-79 years old with chronic low back pain were included in the study and provided self reported data at relevant quarterly encounters. Use of exercise therapy, yoga, massage therapy, spinal manipulation, acupuncture, cognitive behavioral therapy, nonsteroidal antiinflammatory drugs, and opioids for low back pain was measured. The primary outcomes were low back pain intensity and back related functioning measured with a numerical rating scale and the Roland Morris Disability Questionnaire, respectively. Secondary outcomes included health related quality of life scales measured with the Patient Reported Outcomes Measurement Information System, including scales for physical function, anxiety, depression, low energy/fatigue, sleep disturbance, participation in social roles and activities, and pain interference with activities.

Results: A total of 476 participants were included in this study. The mean age of participants at baseline was 54.0 years (standard deviation, ±13.2 years; range, 22-81 years). There were 349 (73.3%) female participants and 127 (26.7%) male participants in the study. Utilization of exercise therapy (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.23-0.57), massage therapy (OR, 0.46; 95% CI, 0.25-0.83), and spinal manipulation (OR, 0.53; 95% CI, 0.29-0.93) decreased during the pandemic. A reduction in NSAID use was also observed (OR, 0.67; 95% CI, 0.45-0.99). Participants reported a significant, but not clinically relevant, improvement in low back pain intensity during the pandemic (mean improvement, 0.19; 95% CI, 0.03-0.34; Cohen's d, 0.11). However, White participants reported a significant improvement in low back pain intensity (mean improvement, 0.28; 95% CI, 0.10-0.46), whereas Black participants did not (mean improvement, -0.13; 95% CI, -0.46 to 0.19; p for interaction=0.03). Overall, there was a significant and clinically relevant improvement in pain interference with activities (mean improvement, 1.11; 95% CI, 0.20-2.02; Cohen's d, 0.20). The use of NSAIDs during the pandemic was associated with marginal increases in low back pain intensity.

Conclusions: Overall, decreased utilization of treatments for chronic low back pain did not adversely impact pain and functioning outcomes during the first 6 months of the pandemic. However, Black participants experienced significantly worse pain outcomes than their White counterparts.

Keywords: COVID-19; chronic low back pain; nonpharmacological therapy; opioids; pain management.