Supporting Research in Pain Management for Veterans and Military Service Members
Supporting Research in Pain Management for Veterans and Military Service Members

Sequenced Care Pathway vs Pain Navigator Pathway for Veterans with Low Back Pain

The AIM-Back Cluster Randomized Clinical Trial

Steven Z. George, PhD; Cynthia J. Coffman, PhD; Rebecca North, PhD; Trevor A. Lentz, PhD; Courtni France, MA; Ashley Choate, MPH; Corey B. Simon, PhD;
Chad E. Cook, PhD; Francis J. Keefe, PhD; Kelli D. Allen, PhD; Adam P. Goode, PhD; Heather King, PhD; Jennifer Naylor, PhD; Lindsay A. Ballengee, PhD;
Tyler L. Cope, DPT; Joseph Leo Brothers, MPH; Ivonne Guzman, BS; Travis Linton, DPT; Catherine Stanwyck, BS; Christa Tumminello, MPH; Susan N. Hastings,MD

JAMA Network Open – April 2026

doi:10.1001/jamanetworkopen.2026.4421

Background

The rate of reported low back pain (LBP) is increasing, particularly so in the veteran population, where severe low back pain is more likely, as is the use, reliance on, and abuse of opioids.  Nonpharmacological therapies can minimize utilization of higher-risk treatments, such as opioids and surgery and optimize long-term outcomes for reduced pain, but there are critical unanswered questions surrounding best practices for addressing chronic back pain.

Primary Study

The AIM-Back trial compared two different non-pharmacological care pathways–Sequenced Care Pathway (SCP) or Pain Navigator Pathway (PNP)–for increasing and improving veteran access to nonpharmacological approaches.  Both pathways were evaluated for their effectiveness in limiting pain interference and improving physical function. Additionally, this study looked at the impact each pathway had on lessening sleep disturbances from pain.

More About the AIM-Back Trial
Participants:
  • Veterans, aged 18 years seeking outpatient care for LBP in participating primary care clinics
  • Attended initial AIM-Back baseline visit
  • Participants were agreeable to and able to be contacted by phone to complete additional surveys, outside of those on electronic health records (EHR) collection.
Clinics:
  • 19 primary care clinics within the Veterans Health Administration
  • Existing clinic personnel delivering either care pathway (SCP or PNP)
  • Saw between 800 and 5000 unique patients with a LBP diagnosis in the previous year
  • No shared clinicians

Findings

Low back pain (LBP) is a leading cause of disability, and there is limited evidence from clinical practice to support the effectiveness of alternative care models. The AIM-Back trial findings suggests no advantage of a sequenced care pathway vs a care pathway that navigates individuals with low back pain to commonly used nondrug treatments (eg, physical therapy, yoga, tai chi, chiropractic, or acupuncture).
 
Sequenced Care Pathway vs Pain Navigator Pathway for Veterans With Low Back Pain

Care Pathway Core Components

  • Pain modulation
  • Physical activity instruction
  • Risk stratification
  • Psychologically-informed physical therapy (if indicated)
  • A combination of local and remote care delivery
  • Shared decision-making
  • Care coordination
  • Facilitated referrals to nondrug services
  • Pain navigators could be physical therapists, nurses, chiropractors, occupational therapists, whole health coaches and pain medicine specialists
  • Mostly remote care delivery
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Advantages & Disadvantages

  • The SCP has the advantage of limiting variability in care
  • SCP's primary disadvantage is that it disrupts existing clinical workflows
  • The PNP's primary advantage is it's flexibility in care options offering a patient-centered approach through its flexibility in care options
  • The PNP offers a patient-centered approach
  • The main disadvantage of the PNP is that it requires a number of referrals for nonpharmacological therapies

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