Grand Rounds July 31, 2026: Sequenced Care Pathway Versus Pain Navigator Pathway for Veterans With Low Back Pain: Results and Reflections From the AIM-Back Cluster Randomized Clinical Trial (Steven Z. George, PT, PhD; S. Nicole Hastings, MD, MHS)

Posted on by Sophia Ramirez

Speakers

Steven Z. George, PT, PhD
Distinguished Professor
Departments of Orthopaedic Surgery and Population Health Sciences
Duke Clinical Research Institute
Duke University

S. Nicole Hastings, MD, MHS
Distinguished Professor and Chief
Division of General Internal Medicine and Population Health Sciences
Duke University School of Medicine
Center of Innovation to Accelerate Discovery and Practice Transformation
Durham Veterans Affairs Health Care System Health Services Research

Keywords

Low Back Pain; Veterans; Non-Pharmacological Pain Treatment; Treatment Delivery; Care Pathways

Key Points

  • Low back pain (LBP) is a leading cause of disability, work loss, and reduced quality of life globally. Veterans with LBP have higher pain severity and higher rates of high impact chronic pain. Clinical practice guidelines advocate for non-drug treatment options, but evidence supporting the effectiveness of different delivery methods in real-world settings is lacking. The AIM-Back trial sought to increase access to non-pharmacological treatments for LBP among veterans by way of a 2-arm, multisite, cluster randomized pragmatic trial.
  • Participants in Arm 1 followed a Sequenced Care Pathway (SCP) consisting of on-site physical therapy, physical activity training, and psychologically informed practice. Participants in Arm 2 followed a Pain Navigator Pathway (PNP), in which a pain navigator provided practical support with decision-making and scheduling around local treatment options. The research team hypothesized that the SCP would result in lower pain interference and/or greater improvement in physical function when compared to the coordinated PNP at 3 months.
  • The SCP and the PNP resulted in similar, clinically meaningful improvements in physical function and pain interference outcomes. Opioid use did not impact outcomes. This is the first trial the research team is aware of that compared 2 different care pathways for LBP. Their lack of a usual care comparator was intentional – they suspected it would be a barrier to site recruitment – but limited their ability to interpret whether what they observed was a regression to the mean.
  • The subgroup analyses suggest that there are opportunities for tailoring treatments. The presenters argued that trialists should work towards answering “for whom does this intervention work differently or better” and “how does it work” in addition to “does it work”.

Discussion Themes

Navigators assigned treatments pragmatically, based on patient preference, prior successful treatments, clinical guidelines, and local service availability, rather than random assignment.

The researchers realized early that EHR follow-up rates were lower than hoped; consequently, a survey – originally intended for secondary data – served to capture primary outcome information.

To maintain site participation, the team focused on fitting the trial into existing workflows, obtaining leadership buy-in, and using a dedicated implementation team to provide constant feedback and encouragement to clinic staff.