A major pragmatic clinical trial published this month in JAMA Network Open offers new insight into how the U.S. health system can support Veterans living with chronic low back pain—one of the most common and disabling conditions affecting former service members.
The clinical trial, known as AIM-Back, tested two non-drug care pathways for low back pain in 19 Veterans Affairs (VA) primary care clinics nationwide. Neither approach proved superior to the other, but these findings highlighted how novel care pathways are developed and delivered in real-world settings. AIM-Back trial results provide foundational data that potentially will make it easier for health systems to offer non-drug treatments in the future and also provide important avenues for future research.
“Chronic back pain is commonly experienced by veterans,” said Steven Z. George, PT, PhD, FAPTA, a Duke Orthopaedics and Duke Clinical Research Institute (DCRI) researcher who, along with S. Nicole Hastings, MD, MHS, from Duke General Internal Medicine and the Durham VA, led the study. “This trial shows how non-drug care pathways for low back pain can be implemented in routine clinical settings and hopefully provide Veterans access to a wider range of treatment options.”
Why This Matters for Veterans
Low back pain is one of the leading reasons veterans seek medical care, and there is inconsistent access to treatments like physical therapy, acupuncture, chiropractic care, yoga, massage, tai-chi, and movement-based therapies. This is a significant issue for healthcare systems now that these treatments are recommended by clinical practice guidelines as “front-line” options, meaning they should be offered before other options such as drugs, injections, or surgery.
The AIM-Back trial was designed to test practical solutions that work in real health care settings—specifically, VA primary care clinics, where many veterans first seek treatment for back pain.
One AIM-Back care pathway used a structured, step-by-step treatment approach that included pain education, pain modulation, physical activity coaching, risk stratification, and psychologically informed physical therapy (if indicated). The other care pathway focused on shared decision-making, with trained “pain navigators” helping veterans choose and access non-drug treatments that matched their needs and preferences and were aligned with recent clinical practice guidelines.
What the Study Found
More than 1,800 veterans participated in the trial, making it one of the largest trials of its kind. After three months, veterans in both groups showed similar outcomes for pain and physical function.
“The structured care pathway was what we thought would be the better option, but that was not the case,” said George, who emphasized that there are still lessons to be learned from this trial. “These findings suggest flexibility in the choice of care pathway VA clinics implement based on their specific resources and veterans’ needs and preferences.”
A Smart Investment in Veteran Health
The study was funded by the National Institutes of Health (National Center for Complimentary and Integrative Health), with support from the Department of Defense and the Department of Veterans Affairs through the NIH–DoD–VA Pain Management Collaboratory, a national effort to improve non‑drug pain care for service members and veterans.
The Pain Management Collaboratory was established recognizing that chronic pain affects both active-duty service members and veterans, and that better care depends on coordination among military, veteran, and civilian health systems. By merging NIH scientific leadership with DoD and VA health system expertise, the initiative supports large, real-world studies—like AIM-Back—that can shape care across the country.
The study reflects a broad, cross-institutional collaboration that brings together expertise from across Duke and beyond. The research team included faculty from Duke Orthopaedics—George, Chad E. Cook, Adam P. Goode, Trevor A. Lentz, and Corey B. Simon—along with colleagues from across Duke University, including Cynthia Coffman, Francis Keefe, Heather King, and Rebecca North. The effort also drew on support from the Duke Clinical Research Institute, with contributions from Lindsay Ballengee, Joseph Leo Brothers, and Tyler Cope. Additional collaborators included Kelli Allen of the University of North Carolina at Chapel Hill, Travis Linton of Duke Health, and a dedicated team from the Durham VA Health Care System: Ashley Choate, Courtni France, Ivonne Guzman, Jennifer Naylor, Catherine Stanwyck, and Christa Tumminello.
Their combined expertise was invaluable in ensuring the AIM-Back trial reflected the realities of everyday care for veterans.
“This work gives us direction for future work in this area,” George said. “The next steps are to match the right care to the right veteran, at the right time, so that better clinical outcomes result.”