1 Project Summary 2 Low back pain is predicted to affect 80% of the general population at some point in their lifetime. Chronic low 3 back pain (cLBP), the most common non-cancer reason for opioid use, is particularly difficult to diagnose and 4 treat effectively, in part, due to the interconnected biophysical and psychosocial factors which complicate the 5 relationship between impairment, disability, and pain related to cLBP. The biopsychosocial model posits that 6 signals from noxious stimuli are modulated by mental, emotional, and sensory mechanisms that are, in turn, 7 influenced by psychological and social factors. Maladaptive pain cognitions (fear of movement and pain 8 catastrophizing) can lead to compensatory movement patterns that directly affect movement biomechanics and 9 paraspinal muscle (PSM) structure and function, driving further impairment, disrupting the balance between 10 passive and active spine stabilizers, and reinforcing the patient’s perceived disability status. This cyclic 11 relationship between biophysical and psychological factors likely plays a critical role in the manifestation of pain 12 and disability in cLBP. A better understanding of this relationship will inform the identification of 13 interventional phenotypes in cLBP and provide clinicians with better tools for the development of 14 effective and patient-specific diagnosis and treatment plans. This has important implications towards 15 identifying cLBP subgroups that would be better served with physical and/or cognitive therapies, providing an 16 alternative to pharmaceutical interventions. To clarify the relationship between biophysical and psychological 17 factors in cLBP, we will investigate 1) how psychological factors, spinal pathology, and patient perception of pain 18 severity and disability status influence compensatory movement strategies 2) how movement biomechanics, 19 psychological factors, and pain mechanisms relate to PSM quality and 3) how movement biomechanics and 20 PSM quality change over time in relation to psychological factors, pain mechanism, pain severity, and prescribed 21 treatment plan. We hypothesize that 1) maladaptive pain cognitions will have more influence on movement 22 biomechanics and pain-related outcomes over time than biophysical factors and 2) baseline measures of 23 psychological and biophysical factors will be predictive of pain-related outcomes 24 For the training aspect of this study, I will work closely with pain management clinicians, clinical pain 25 researchers, physical therapists, patient advocates, and engineers who will guide my training and provide 26 necessary resources and experiences driving my development toward independence as a clinical pain 27 researcher. I will develop fundamental skills in clinical pain research through coursework in biostatistics and pain 28 assessment and programs on writing grants and publications. Through this structured research experience and 29 training plan, I will learn to communicate effectively and facilitate collaborations that bridge the gap between 30 pain-related measures and biophysical outcomes in patients with cLBP and other chronic pain.

Project Narrative Chronic low back pain (cLBP), the most common non-cancer reason for opioid use, is particularly difficult to diagnose and treat effectively, in part, due to the complicated relationship between variables measuring pain and negative pain attitudes and variables measuring physical impairments. To study the interplay of these factors, this study will assess how these variables influence compensatory movement strategies, muscle health in the lumbar spine, and pain-related patient outcomes in order to identify cLBP patients who would be better served with physical or cognitive therapies rather than opioid prescription. The proposed research plan, which will study how pain-related measures and pain attitudes influence movement strategies and muscle health, has been structured to maximize clinical exposure and facilitate collaborations with pain management and physical medicine clinicians, physical therapists, patient advocates, and engineers who will guide my training and provide the necessary resources and experiences to drive my development toward independence as a clinical pain researcher.