Study Protocol: The Back Pain Outcomes Using Longitudinal Data (BOLD) Registry

Jeffrey G Jarvik; Bryan A Comstock; Brian W Bresnahan; Srdjan S Nedeljkovic; David R Nerenz; Zoya Bauer; Andrew L Avins; Kathryn James; Judith A Turner; Patrick Heagerty; Larry Kessler; Janna L Friedly; Sean D Sullivan; Richard A Deyo


BMC Musculoskelet Disord. 2012;13(64) 

In This Article


Back pain is a particularly important problem for older adults. The prevalence of severe, disabling back pain increases in older adults.[1,2] Moreover, with an aging population, the importance of back pain in the U.S. will only increase in coming decades. Despite this, there is a paucity of research on back pain in older age, and most studies to date have been small.[1]

The Back pain Outcomes using Longitudinal Data (BOLD) project establishes a large, community-based registry of patients aged 65 years and older presenting with new episodes of healthcare visits for back pain. BOLD's primary aim is to establish an infrastructure that allows the conduct of prospective, controlled studies comparing the effectiveness of diagnostic and treatment strategies for back pain in the elderly. The importance of BOLD stems from the high prevalence, clinical impact and cost of back pain, combined with a relative lack of comparative effectiveness data, especially for older adults. Back pain, an Institute of Medicine priority condition,[3] is one of the most important causes of functional limitations and disability among adults in the United States. Back pain is also one of the most common reasons for physician visits.[4] The economic impact of back pain is substantial. Martin et al., estimated that in 2005, the marginal direct cost of care for people with back pain compared to those without was over $86 billion.[5]

Although there are numerous guidelines regarding the diagnosis and treatment of back pain in general, these evidence-based guidelines do not focus on the elderly. Age-related differences in the causes of back pain highlight the need for specific guidelines for diagnosing and treating back pain in older adults. For example, back pain due to metastatic cancer has a higher prevalence in older adults. In a study of primary care patients with back pain, age older than 50 years was associated with a higher likelihood of having cancer (positive likelihood ratio = 2.7), although the absolute probability of having cancer remained small at 1.2%.[6] This increased risk of cancer, as well the greater prevalence in older adults of other conditions such as spinal stenosis, vertebral compression fractures and aortic aneurysms, has led most guidelines to call for early diagnostic imaging in the elderly. However, it remains unclear how early imaging in the elderly affects clinical outcomes and costs associated with the treatment of back pain. A primary goal of the BOLD project is to enrich the existing knowledge base regarding back pain in the elderly to help clinicians and patients make informed, evidence-based decisions regarding their care.