The economic burden of back pain in the UK

Evaluating the Usage of Musculoskeletal Spinal Drop-In Services in East Lancashire: A Retrospective Audit of Performance Standards

Lower back pain (LBP) is a prevalent musculoskeletal disorder (MSD) that places a significant burden on patients as well as healthcare and economic systems. Musculoskeletal (MSK) spinal drop-in clinics in the North West of the United Kingdom (UK) have been introduced to provide more targeted therapies for those suffering from LBP. A retrospective audit was conducted from January to February 2017 to evaluate the utilization of the spinal clinic in relation to individual patient Keele STarT Back prognostication scores and to compare these with national guidelines. A total of 50 patients' case notes were reviewed over the four-week period. The focus was placed on how patients were made aware of the clinic, whether they had been seen by a primary care provider, and if first-line therapies had been administered. The results of this study demonstrate that some improvement is required in patient management and seek to provide recommendations for optimizing the service.

The effectiveness of different aerobic exercises to improve pain intensity and disability in chronic low back pain patients: a systematic review

Background: Physical activity, including aerobic exercise, is highly recommended for chronic low back pain (CLBP) patients to improve pain intensity and functional disability. Objectives: To assess the effectiveness of different aerobic exercises to reduce pain intensity and functional disability in patients with CLBP. Methods: A computer-aided search was performed to find Randomised Controlled Trials (RCTs) that evaluated the effectiveness of different aerobic exercises in CLBP. Articles published between January 2007 to December 2020 were included in the review. Quality assessment using the PEDro scale, extraction of relevant information, and evaluation of outcomes were done by two reviewers independently. Results: A total of 17 studies were included that involved 1146 participants. Outcomes suggested that aerobic exercise combined with other interventions was more effective than aerobic exercise alone. Aerobic exercise with higher frequency (≥ 5 days/week) and longer duration (≥ 12 weeks) were effective to gain clinically significant (≥ 30%) improvements. Environment and using pedometer did not seem to influence the outcomes. Conclusions: Pain intensity and functional disability in CLBP patients can be minimized by prescribing aerobic exercise. However, to get better improvements, aerobic exercise should be done in combination with other interventions and at optimum frequency and duration. Further studies should emphasize examining the optimal doses and duration of different aerobic exercises.

Role of non‑coding RNAs in cartilage endplate (Review)

Cartilage endplate (CEP) degeneration is considered one of the major causes of intervertebral disc degeneration (IDD), which causes non-specific neck and lower back pain. In addition, several non-coding RNAs (ncRNAs), including long ncRNAs, microRNAs and circular RNAs have been shown to be involved in the regulation of various diseases. However, the particular role of ncRNAs in CEP remains unclear. Identifying these ncRNAs and their interactions may prove to be is useful for the understanding of CEP health and disease. These RNA molecules regulate signaling pathways and biological processes that are critical for a healthy CEP. When dysregulated, they can contribute to the development disease. Herein, studies related to ncRNAs interactions and regulatory functions in CEP are reviewed. In addition, a summary of the current knowledge regarding the deregulation of ncRNAs in IDD in relation to their actions on CEP cell functions, including cell proliferation, apoptosis and extracellular matrix synthesis/degradation is presented. The present review provides novel insight into the pathogenesis of IDD and may shed light on future therapeutic approaches.

Characteristics of interprofessional rehabilitation programs for patients with chronic low back pain evaluated in the literature: a scoping review protocol

BACKGROUND

Interprofessional rehabilitation programs have demonstrated effectiveness at improving health-related quality of life, function, work abilities, and reducing pain, for patients with chronic low back pain (CLBP). However, the characteristics of interprofessional rehabilitation programs vary widely across studies. Therefore, clarifying and describing key characteristics of interprofessional rehabilitation programs for patients with CLBP will be valuable for future intervention design and implementation. This scoping review aims to identify and describe the key characteristics of interprofessional rehabilitation programs for patients with CLBP.

METHODS

Our scoping review will follow the framework developed by Arksey and O'Malley, further enhanced by Levac et al. and the Joanna Briggs Institute (JBI). Electronic databases, including MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, PubMed, Web of Science, and Cochrane Library, will be searched to identify relevant published studies. Our scoping review will consider all primary source peer-reviewed published articles that evaluated interprofessional rehabilitation programs for adults with CLBP from all countries and any therapeutic settings. The Covidence software will be used to remove duplicates, article screening, record the step-by-step selection process, and data extraction. The analysis will involve a descriptive numerical summary and narrative analysis. Data will be presented in graphical and tabular format based on the nature of the data.

DISCUSSION

This scoping review is expected to provide a source of evidence for developing and implementing interprofessional rehabilitation programs in new settings or contexts. As such, this review will guide future research and provide key information to health professionals, researchers and policymakers interested in designing and implementing evidence and theory-informed interprofessional rehabilitation programs for patients with CLBP.

TRIAL REGISTRATION

https://osf.io/rquxv .

Do Chronic Low Back Pain and Chronic Widespread Pain differ in their association with Depression Symptoms in the 1958 British Cohort?

OBJECTIVE

Depression frequently coexists with chronic pain. Contemporary models suggest that these conditions share pathobiological mechanisms, prompting a need to investigate their temporal association. This investigation aimed to explore two distinctly different chronic pain conditions, and their cross-sectional and prospective associations with depression.

METHODS

Self-reported information was available on chronic widespread pain (CWP), chronic low back pain (CLBP) (45 years), and depression symptoms (45 and 50 years) from up to 9,377 participants in the 1958 British cohort. Depression symptom outcomes were derived by "Clinical Interview Schedule-Revised" (45 years) and "Short Form-36" (50 years). Relationships between both chronic pain conditions and depression symptoms were investigated by fitting four separate logistic regression models, each with varying levels of covariate adjustment, including depression at baseline.

RESULTS

CWP was associated with depression symptoms cross-sectionally (odds ratio [OR] = 2.04, 95% confidence interval [CI] 1.65, 2.52; P < 0.001, n = 7,629), and prospectively when fully adjusted for baseline, sociodemographic, lifestyle, and health covariates (OR = 1.45, 95% CI 1.17, 1.80; P = < 0.001, n = 6,275). CLBP was associated with depression symptoms prospectively (full model: OR = 1.28, 95% CI 1.01, 1.61; P = 0.04, n = 6,288). In fully adjusted models the prospective association of CWP with depression symptoms was more heavily influenced by our covariates than CLBP with depression symptoms.

CONCLUSION

Pain may be a stressor from which depression can arise. Development of depression may be differentially dependant upon the type of pain experienced. Screening for depression symptoms among individuals with both chronic pain conditions is indicated and should be repeated over time.

Grading Systems of Lumbar Facet Joint Inflammatory Changes on Magnetic Resonance Imaging: A Scoping Review

STUDY DESIGN

A scoping review.

OBJECTIVE

We aimed to identify and characterize grading systems of the inflammatory features of the lumbar facet joints (FJs) noted on magnetic resonance imaging and summarize their reliability.

SUMMARY OF BACKGROUND DATA

Chronic low back pain is one of the most common causes of disability worldwide and is frequently accompanied by FJ osteoarthritis. Inflammatory changes in the lumbar FJs are commonly noted in imaging studies of patients with FJ osteoarthritis and low back pain. Several grading systems for these inflammatory changes have been developed. However, these grading system's features and reliability have yet to be reviewed.

MATERIALS AND METHODS

We performed a literature search of studies reporting grading systems for FJ inflammatory changes published in English or Spanish between 1985 and 2022. We collected data on reported interreader reliability measures of each grading system. Finally, we compared the features of inflammation described by each system.

RESULTS

Six studies met the inclusion criteria and were used in our analysis. Features commonly graded in these systems are the hyperintensity signal noted within the FJ, bone marrow edema, and the extent of the soft-tissue edema surrounding the FJs. We found that the interreader reliability measures ranged from 0.56 to 0.96.

CONCLUSIONS

Only 6 studies have reported methods for documenting inflammation in the FJs. Studies varied in the precise tissues and phenomena included in the grading systems. However, the systems were generally reliable. Future studies should document the reliability of these methods when independent investigators are not involved in developing the classification schemes. Further work might combine one or more of these measures to establish a standard and reliable grading system for inflammatory changes in the FJs, including signal intensity within the joint, bone marrow edema, and soft-tissue inflammation.

Predicting patient-reported outcomes following lumbar spine surgery: development and external validation of multivariable prediction models

BACKGROUND

This study aimed to develop and externally validate prediction models of spinal surgery outcomes based on a retrospective review of a prospective clinical database, uniquely comparing multivariate regression and random forest (machine learning) approaches, and identifying the most important predictors.

METHODS

Outcomes were change in back and leg pain intensity and Core Outcome Measures Index (COMI) from baseline to the last available postoperative follow-up (3-24 months), defined as minimal clinically important change (MCID) and continuous change score. Eligible patients underwent lumbar spine surgery for degenerative pathology between 2011 and 2021. Data were split by surgery date into development (N = 2691) and validation (N = 1616) sets for temporal external validation. Multivariate logistic and linear regression, and random forest classification and regression models, were fit to the development data and validated on the external data.

RESULTS

All models demonstrated good calibration in the validation data. Discrimination ability (area under the curve) for MCID ranged from 0.63 (COMI) to 0.72 (back pain) in regression, and from 0.62 (COMI) to 0.68 (back pain) in random forests. The explained variation in continuous change scores spanned 16%-28% in linear, and 15%-25% in random forests regression. The most important predictors included age, baseline scores on the respective outcome measures, type of degenerative pathology, previous spinal surgeries, smoking status, morbidity, and duration of hospital stay.

CONCLUSIONS

The developed models appear robust and generalisable across different outcomes and modelling approaches but produced only borderline acceptable discrimination ability, suggesting the need to assess further prognostic factors. External validation showed no advantage of the random forest approach.

A cross-sectional investigation of back pain beliefs and fear in physiotherapy and sport undergraduate students

BACKGROUND

Although low back pain (LBP) beliefs have been well investigated in mainstream healthcare discipline students, the beliefs within sports-related study students, such as Sport and Exercise Science (SES), Sports Therapy (ST), and Sport Performance and Coaching (SPC) programmes have yet to be explored. This study aims to understand any differences in the beliefs and fear associated with movement in students enrolled in four undergraduate study programmes-physiotherapy (PT), ST, SES, and SPC.

METHOD

136 undergraduate students completed an online survey. All participants completed the Tampa Scale of Kinesiophobia (TSK) and Back Beliefs Questionnaire (BBQ). Two sets of two-way between-subjects Analysis of Variance (ANOVA) were conducted for each outcome of TSK and BBQ, with the independent variables of the study programme, study year (1st, 2nd, 3rd), and their interaction.

RESULTS

There was a significant interaction between study programme and year for TSK (F(6, 124) = 4.90, P < 0.001) and BBQ (F(6, 124) = 8.18, P < 0.001). Post-hoc analysis revealed that both PT and ST students had lower TSK and higher BBQ scores than SES and SPC students particularly in the 3rd year.

CONCLUSIONS

The beliefs of clinicians and trainers managing LBP are known to transfer to patients, and more negative beliefs have been associated with greater disability. This is the first study to understand the beliefs about back pain in various sports study programmes, which is timely, given that the management of injured athletes typically involves a multidisciplinary team.

Understanding the burden of chronic back pain: a spatial microsimulation of chronic back pain at small area level across England

PURPOSE

Chronic back pain (CBP) carries a significant burden. Understanding how and why CBP prevalence varies spatially, as well as the potential impact of policies to decrease CBP would prove valuable for public health planning. This study aims to simulate and map the prevalence of CBP at ward-level across England, identify associations which may explain spatial variation, and explore 'what-if' scenarios for the impact of policies to increase physical activity (PA) on CBP.

METHODS

A two-stage static spatial microsimulation approach was used to simulate CBP prevalence in England, combining national-level CBP and PA data from the Health Survey for England with spatially disaggregated demographic data from the 2011 Census. The output was validated, mapped, and spatially analysed using geographically weighted regression. 'What-if' analysis assumed changes to individuals' moderate-to-vigorous physical activity (MVPA) levels.

RESULTS

Large significant clusters of high CBP prevalence were found predominantly in coastal areas and low prevalence in cities. Univariate analysis found a strong positive correlation between physical inactivity and CBP prevalence at ward-level (R² = 0.735; Coefficient = 0.857). The local model showed the relationship to be stronger in/around cities (R² = 0.815; Coefficient: Mean = 0.833, SD = 0.234, Range = 0.073-2.623). Multivariate modelling showed this relationship was largely explained by confounders (R² = 0.924; Coefficient: Mean = 0.070, SD = 0.001, Range = 0.069-0.072). 'What-if' analysis showed a detectable reduction in CBP prevalence for increases in MVPA of 30 and 60 min (- 2.71%; 1, 164, 056 cases).

CONCLUSION

CBP prevalence varies at ward-level across England. At ward-level, physical inactivity is strongly positively correlated with CBP. This relationship is largely explained by geographic variation in confounders (the proportion of residents that are: over 60, in low-skilled jobs, female, pregnant, obese, smokers, white or black, disabled). Policies to increase PA by 30 min weekly MVPA will likely result in a significant reduction in CBP prevalence. To maximise their impact, policies could be tailored to areas of high prevalence, which are identified by this study.

Evaluation of the impact of a smartphone application on adherence to home exercise program for people with chronic low back pain: research protocol for a pilot randomised controlled trial

INTRODUCTION

Multidisciplinary rehabilitation programmes are highly recommended for individuals with the most disabling low back pain (LBP). However, the long-term adherence to regular home exercise is often poor. We aim to perform a prospective, controlled, pilot, randomised study that will evaluate the impact of a smartphone application on adherence to exercise programme for people with chronic LBP (CLBP).

METHODS AND ANALYSIS

120 participants with non-specific CLBP aged 18-65 years will be recruited and randomised in two groups: an experimental group benefitting from education in the application's use in addition to a conventional multidisciplinary rehabilitation programme (exercises and self-management education) and a control group who will only participate in the multidisciplinary rehabilitation programme. Both groups will undergo the programme 5 days a week for 3 weeks. The primary outcome will be a change in patient's adherence to physical exercise (Exercise Adherence Rating Scale) at 6 months. Secondary outcomes will be function (Oswestry Disability Index), beliefs concerning physical activity (Evaluation of Physical Activity Perception), pain (Numeric Rating Scale), and physical capacity and qualitative adherence (video).Statistical analyses will be performed according to intention to treat. A linear mixed model will be used to compare the primary endpoint between groups at 6 months post-randomisation.The study could demonstrate the impact of using a smartphone application on adherence to exercise programme in people with CLBP. We hypothesise that the application's use will improve outcomes through improved exercise adherence.

ETHICS AND DISSEMINATION

The study was approved by the medical ethics committee of Ile de France 3. The results of this study will be disseminated in peer-reviewed publications and presentations at international scientific meetings and will also be disseminated to the participants.

TRIAL REGISTRATION NUMBER

NCT04264949.

Biomechanical and clinical relationships between lower back pain and knee osteoarthritis: a systematic review

BACKGROUND

Osteoarthritis (OA) and lower back pain (LBP) are most common health problems which lead to pain and disability. This study aimed to systematically review the evidence to find any relationship between knee osteoarthritis (KOA) and LBP or any potential causation.

METHODS

The databases of Scopus, MEDLINE, and Embase were searched from inception to 01 October 2022. Any study published in English assessing live humans over 18 years with KOA and LBP was eligible to be included. Studies were independently screened by two researchers. Data of the included studies were extracted based on the participants, outcomes related to knee and lumbar spine, reported association or causation between LBP and KOA, and study design. Data were narratively analyzed and presented as graphs and table. Methodology quality was assessed.

RESULTS

Of 9953 titles and abstracts, duplicates were removed, and 7552 were screened. Altogether, 88 full texts were screened, and 13 were eligible for the final inclusion. There were some biomechanical and clinical causations were observed for the concurrent presence of LBP and KOA. Biomechanically, high pelvic incidence is a risk factor for development of spondylolisthesis and KOA. Clinically, knee pain intensity was higher in KOA when presents with LBP. Less than 20% of studies have justified their sample size during the quality assessment.

DISCUSSION

Development and progression of KOA in patients with degenerative spondylolisthesis may be induced by significantly greater mismatches of lumbo-pelvic sagittal alignment. Elderly patients with degenerative lumbar spondylolisthesis and severe KOA reported a different pelvic morphology, increased sagittal malalignment with a lack of lumbar lordosis due to double-level listhesis, and greater knee flexion contracture than in patients with no to mild and moderate KOA. People with concurrent LBP and KOA have reported poor function with more disability. Both LBP and lumbar kyphosis indicate functional disability and knee symptoms in patients with KOA.

CONCLUSIONS

Different biomechanical and clinical causations were revealed for the concurrent existence of KOA and LBP. Therefore, careful assessment of both back and knee joints should be considered when treating KOA and vice versa.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022238571.

Intervertebral disc degeneration and how it leads to low back pain

The purpose of this review was to evaluate data generated by animal models of intervertebral disc (IVD) degeneration published in the last decade and show how this has made invaluable contributions to the identification of molecular events occurring in and contributing to pain generation. IVD degeneration and associated spinal pain is a complex multifactorial process, its complexity poses difficulties in the selection of the most appropriate therapeutic target to focus on of many potential candidates in the formulation of strategies to alleviate pain perception and to effect disc repair and regeneration and the prevention of associated neuropathic and nociceptive pain. Nerve ingrowth and increased numbers of nociceptors and mechanoreceptors in the degenerate IVD are mechanically stimulated in the biomechanically incompetent abnormally loaded degenerate IVD leading to increased generation of low back pain. Maintenance of a healthy IVD is, thus, an important preventative measure that warrants further investigation to preclude the generation of low back pain. Recent studies with growth and differentiation factor 6 in IVD puncture and multi-level IVD degeneration models and a rat xenograft radiculopathy pain model have shown it has considerable potential in the prevention of further deterioration in degenerate IVDs, has regenerative properties that promote recovery of normal IVD architectural functional organization and inhibits the generation of inflammatory mediators that lead to disc degeneration and the generation of low back pain. Human clinical trials are warranted and eagerly anticipated with this compound to assess its efficacy in the treatment of IVD degeneration and the prevention of the generation of low back pain.

Duration of Education and Back Pain: Lessons From English Schooling Reforms

This study aimed to examine the associations of increases in the duration of education with back pain using the exogenous variation generated by the English schooling reforms of 1947 and 1972. We analyzed cross-sectional data derived from 9 waves (waves 1-9; 2002-2019) of the English Longitudinal Study of Ageing. An instrumental variables regression using 2-stage least squares with the 2-way cluster-robust standard error was used. The mean severity of back pain, measured using the Numerical Rating Scale, was used as the outcome. A total of 22,868 observations from 5,070 participants were included (the 1947 reform = 16,565 observations from 3,231 participants, mean age = 74.5 years; the 1972 reform = 6,303 observations from 1,839 participants, mean age = 59.3 years). The schooling reforms significantly extended years of school attendance by a mean of 0.57 years for the 1942 reform cohort and 0.66 years for 1972 reform cohort. For participants born within 5 years of the pivotal cohorts, an additional year of education decreased the severity of back pain by 0.78 points (95% confidence interval: 0.65, 0.92) for the 1972 reform cohort. Our finding underscores the importance of the length of education in the reduction of back pain in middle-aged individuals.

The reliability of video fluoroscopy, ultrasound imaging, magnetic resonance imaging and radiography for measurements of lumbar spine segmental range of motion in-vivo: A review

BACKGROUND

Lower back pain (LBP) is a principal cause of disability worldwide and is associated with a variety of spinal conditions. Individuals presenting with LBP may display changes in spinal motion. Despite this, the ability to measure lumbar segmental range of motion (ROM) non-invasively remains a challenge.

OBJECTIVE

To review the reliability of four non-invasive modalities: Video Fluoroscopy (VF), Ultrasound imaging (US), Magnetic Resonance Imaging (MRI) and Radiography used for measuring segmental ROM in the lumbar spine in-vivo.

METHODS

The methodological quality of seventeen eligible studies, identified through a systematic literature search, were appraised.

RESULTS

The intra-rater reliability for VF is excellent in recumbent and upright positions but errors are larger for intra-rater repeated movements and inter-rater reliability shows larger variation. Excellent results for intra- and inter-rater reliability are seen in US studies and there is good reliability within- and between-day. There is a large degree of heterogeneity in MRI and radiography methodologies but reliable results are seen.

CONCLUSIONS

Excellent reliability is seen across all modalities. However, VF and radiography are limited by radiation exposure and MRI is expensive. US offers a non-invasive, risk free method but further research must determine whether it yields truly consistent measurements.

Data-driven network analysis identified subgroup-specific low back pain pathways: a cross-sectional GLA:D Back study

OBJECTIVES

To understand the physical, activity, pain, and psychological pathways contributing to low back pain (LBP) -related disability, and if these differ between subgroups.

METHODS

Data came from the baseline observations (n = 3849) of the "GLA:D Back" intervention program for long-lasting nonspecific LBP. 15 variables comprising demographic, pain, psychological, physical, activity, and disability characteristics were measured. Clustering was used for subgrouping, Bayesian networks (BN) were used for structural learning, and structural equation model (SEM) was used for statistical inference.

RESULTS

Two clinical subgroups were identified with those in subgroup 1 having worse symptoms than those in subgroup 2. Psychological factors were directly associated with disability in both subgroups. For subgroup 1, psychological factors were most strongly associated with disability (β = 0.363). Physical factors were directly associated with disability (β = -0.077), and indirectly via psychological factors. For subgroup 2, pain was most strongly associated with disability (β = 0.408). Psychological factors were common predictors of physical factors (β = 0.078), pain (β = 0.518), activity (β = -0.101), and disability (β = 0.382).

CONCLUSIONS

The importance of psychological factors in both subgroups suggests their importance for treatment. Differences in the interaction between physical, pain, and psychological factors and their contribution to disability in different subgroups may open the doors toward more optimal LBP treatments.

The Swedish version of the Lumbar Spine Instability Questionnaire: A clinimetric study of validity and reliability

INTRODUCTION

The Lumbar Spine Instability Questionnaire (LSIQ) is a patient-reported outcome measure (PROM) suggested to measure clinical instability of the spine.

OBJECTIVE

The aim was to translate and cross-culturally adapt the LSIQ into Swedish and to test its measurement properties.

METHODS

We included people with low back pain (LBP) seeking primary care (n = 101). The LSIQ was translated using international recommendations. Construct validity was investigated via the Roland Morris Disability Questionnaire (RM) and the Numeric Pain Rating Scale (NPRS). Reliability was tested via test-retest (Intra Class Correlation, ICC_2.1) (n = 50) and by analyzing internal consistency (Cronbach Alpha). A suggested cutoff score was used to study discriminative ability.

RESULTS

The LSIQ was successfully translated into Swedish. For construct validity, a moderate correlation was shown with the RM (rho 0.58) and the NPRS (rho 0.47). Test-retest demonstrated high reliability for the total score (ICC_2.1 0.94, 95% CI 0.86-0.96). Internal consistency reached a Cronbach Alpha of 0.64. Participants scoring higher on the LSIQ (≥9) showed significantly higher pain and lower disability levels, were of higher age and less physically active.

CONCLUSION

The Swedish LSIQ shows acceptable measurement properties regarding test-retest reliability and validity. To further study the usefulness of the LSIQ and the suggested cutoff score, the dimensionality needs to be investigated.

Feasibility and acceptability to use a smartphone-based manikin for daily longitudinal self-reporting of chronic pain

Background

As management of chronic pain continues to be suboptimal, there is a need for tools that support frequent, longitudinal pain self-reporting to improve our understanding of pain. This study aimed to assess the feasibility and acceptability of daily pain self-reporting using a smartphone-based pain manikin.

Methods

For this prospective feasibility study, we recruited adults with lived experience of painful musculoskeletal condition. They were asked to complete daily pain self-reports via an app for 30 days. We assessed feasibility by calculating pain report completion levels, and investigated differences in completion levels between subgroups. We assessed acceptability via an end-of-study questionnaire, which we analysed descriptively.

Results

Of the 104 participants, the majority were female (n = 87; 84%), aged 45-64 (n = 59; 57%), and of white ethnic background (n = 89; 86%). The mean completion levels was 21 (± 7.7) pain self-reports. People who were not working (odds ratio (OR) = 1.84; 95% confidence interval (CI), 1.52-2.23) were more likely, and people living in less deprived areas (OR = 0.77; 95% CI, 0.62-0.97) and of non-white ethnicity (OR = 0.45; 95% CI, 0.36-0.57) were less likely to complete pain self-reports than their employed, more deprived and white counterparts, respectively. Of the 96 participants completing the end-of-study questionnaire, almost all participants agreed that it was easy to complete a pain drawing (n = 89; 93%).

Conclusion

It is feasible and acceptable to self-report pain using a smartphone-based manikin over a month. For its wider adoption for pain self-reporting, the feasibility and acceptability should be further explored among people with diverse socio-economic and ethnic backgrounds.

Cross-Country Differences in Pain Medication Before and After Spinal Cord Stimulation: A Pooled Analysis of Individual Patient Data From Two Prospective Studies in the United Kingdom and Belgium

OBJECTIVES

Spinal cord stimulation (SCS) can reduce the need for opioids; however, the influence on the full spectrum of pain medication is less known. The aims of this study were to explore general prescription practices for patients scheduled for SCS, potential differences in prescriptions between Belgium and United Kingdom, and the influence of SCS on pain medication.

MATERIALS AND METHODS

Individual patient data from the TRIAL-STIM study in the United Kingdom and DISCOVER in Belgium were pooled. Medication use was collected before SCS and three months after SCS from 180 chronic pain patients. The Medication Quantification Scale III (MQS) was used to calculate a total score for medication use, as well as subscores for several classes. Differences in prescription practices between United Kingdom and Belgium were evaluated with two-sided Wilcoxon tests. To evaluate differences in medication use after three months of SCS between United Kingdom and Belgium, Tweedie-generalized linear models were calculated.

RESULTS

There was a statistically significant difference (-6.40 [95% CI from -3.40 to -9.10]) between the median total MQS score in United Kingdom and Belgium before SCS. Additionally, a significant difference was found for nonsteroidal anti-inflammatory drugs (NSAIDs) (-3.40 [95% CI -3.40 to -6.80]), neuropathic agents (-2.30 [95% CI -0.40 to -3.80]), and benzodiazepines (1.83e-05 [95% CI 2.64-05 to 7.45-05]) between United Kingdom and Belgium, before SCS. Tweedie-generalized models revealed a statistically significant interaction between country and time for MQS, neuropathic agents, and opioids.

CONCLUSIONS

Our combined analysis revealed differences in prescription practice in patients scheduled for SCS implantation between Belgium and United Kingdom. NSAIDs and neuropathic mood agents are more frequently used in the United Kingdom, presumably due to easier access to repeat prescriptions and over the counter medications. After three months of SCS, a decrease in medication use is observed in both countries, with higher reductions in Belgium, presumably due to strict regulations concerning reimbursement criteria.

Caregiving for older people living with chronic pain: analysis of the English longitudinal study of ageing and health survey for England

Background

Chronic pain is a disabling condition. Many people with chronic pain seek informal support for everyday activities of daily living (ADL). However, there remains uncertainty on the type of people with chronic pain who access this support, what types of support they need and who provides such support. The purpose of this analysis was to answer these uncertainties.

Methods

Data from the Health Survey for England (HSE) and English Longitudinal Study of Ageing (ELSA) were accessed. People who reported chronic pain (moderate or above for minimum of 12 months) were identified. From these cohorts, we determined if individuals self-reported receiving informal care. Data on caregiver profiles and caregiving activities were reported through descriptive statistics. Logistic regression analyses were performed to compare health status outcomes between people with pain who received and who did not receive informal care.

Results

2178 people with chronic pain from the ELSA cohort and 571 from the HSE cohort were analysed. People who received care were frequently female, older aged with several medical morbidities including musculoskeletal diseases such as arthritis. People with chronic pain received informal care for several diverse tasks. Most frequently these related to instrumental activities of daily living (IADL) such as shopping and housework. They were most frequently provided by partners or their children. Although they reported greater disability and symptoms ( p < 0.001), people who received care did not report differences in health status, loneliness or wellbeing ( p = 0.27; p = 0.46).

Conclusions

Whilst it may be possible to characterise people living in chronic pain who receive informal care, there is some uncertainty on the impact of informal caregiving on their health and wellbeing. Consideration should now be made on how best to support both care recipients and informal caregivers, to ensure their health and quality of life is promoted whilst living with chronic pain.

Feasibility of a theory-based intervention to reduce sedentary behaviour among contact centre staff: the SUH stepped-wedge cluster RCT

Background

Sedentary behaviour is linked to increased risk of type 2 diabetes, cardiovascular disease, musculoskeletal issues and poor mental well-being. Contact (call) centres are associated with higher levels of sedentary behaviour than other office-based workplaces. Stand Up for Health is an adaptive intervention designed to reduce sedentary behaviour in contact centres.

Objectives

The objectives were to test the acceptability and feasibility of implementing the intervention; to assess the feasibility of the study design and methods; to scope the feasibility of a future health economic evaluation; and to consider the impact of COVID-19 on the intervention. All sites received no intervention for between 3 and 12 months after the start of the study, as a waiting list control.

Design

This was a cluster-randomised stepped-wedge feasibility design.

Setting

The trial was set in 11 contact centres across the UK.

Participants

Eleven contact centres and staff.

Intervention

Stand Up for Health involved two workshops with staff in which staff developed activities for their context and culture. Activities ranged from using standing desks to individual goal-setting, group walks and changes to workplace policies and procedures.

Main outcome measures

The primary outcome was accelerometer-measured sedentary time. The secondary outcomes were subjectively measured sedentary time, overall sedentary behaviour, physical activity, productivity, mental well-being and musculoskeletal health.

Results

Stand Up for Health was implemented in 7 out of 11 centres and was acceptable, feasible and sustainable (objective 1). The COVID-19 pandemic affected the delivery of the intervention, involvement of contact centres, data collection and analysis. Organisational factors were deemed most important to the success of Stand Up for Health but also the most challenging to change. There were also difficulties with the stepped-wedge design, specifically maintaining contact centre interest (objective 2). Feasible methods for estimating cost-efficiency from an NHS and a Personal Social Services perspective were identified, assuming that alternative feasible effectiveness methodology can be applied. Detailed activity-based costing of direct intervention costs was achieved and, therefore, deemed feasible (objective 3). There was significantly more sedentary time spent in the workplace by the centres that received the intervention than those that did not (mean difference 84.06 minutes, 95% confidence interval 4.07 to 164.1 minutes). The other objective outcomes also tended to favour the control group.

Limitations

There were significant issues with the stepped-wedge design, including difficulties in maintaining centre interest and scheduling data collection. Collection of accelerometer data was not feasible during the pandemic.

Conclusions

Stand Up for Health is an adaptive, feasible and sustainable intervention. However, the stepped-wedge study design was not feasible. The effectiveness of Stand Up for Health was not demonstrated and clinically important reductions in sedentary behaviour may not be seen in a larger study. However, it may still be worthwhile conducting an effectiveness study of Stand Up for Health incorporating activities more relevant to hybrid workplaces.

Future work

Future work could include developing hybrid (office and/or home working) activities for Stand Up for Health; undertaking a larger effectiveness study and follow-up economic analysis (subject to its success); and exploring organisational features of contact centres that affect the implementation of interventions such as Stand Up for Health.

Trial registration

This trial is registered as ISRCTN11580369.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 13. See the NIHR Journals Library website for further project information.

Iliopsoas hematoma secondary to small needle scalpel for the treatment of nonspecific low back pain: A case report

INTRODUCTION

Nonspecific low back pain (NSLBP) is one of the most common symptoms which can happen all ages and it accounts for the majority of low back pain (LBP). Current clinical studies have shown that rest, physical therapy, acupuncture (including small needle scalpel) and non-steroidal antiinflammatory drugs are effective treatments for NSLBP. However, the safety of small needle scalpel for treatment of NSLBP was reported rarely.

PATIENT CONCERNS

A 63-year-old female patient was referred to the emergency department for right lower back pain, right lower quadrant ache, weakness of flexion right hip joints and worsening pain with walking after the treatment of small needle scalpel, which was performed by a rural doctor; the symptoms had been lasting for 9 hours.

DIAGNOSIS

She was diagnosed with traumatic iliopsoas hematoma because she experienced increased back pain after accepting small needle scalpel. Clopidogrel was stopped and the patient did not received a blood transfusion and just monitored Blood routine examination, liver and function, coagulation function after admission.

INTERVENTIONS

She had rest in bed absolutely for 3 days after admission. On the fourth day, she restarted taking Clopidogrel 75 mg every day and has gradually increased time for ambulation. She was discharged home and was ambulating with the help of a walking frame on day 7 and her follow-up abdominal CT scan on day 11 revealed reduced slightly hematoma. She was treated with rest, and showed an gradual recovery in approximately 3 weeks.

OUTCOMES

At day 85, the patient's LBP symptoms had completely disappeared and the result of liver function, renal function, coagulation function, blood routine was normal.

CONCLUSION

Small needle scalpel is a form of acupuncture. In China, small needle scalpel therapy has been used to treat various kinds of chronic pain. Anticoagulation therapy is a risk for bleeding, and patients who used Clopidogrel prepare to adopting small needle scalpel needs to be very cautious.

Chondroitin sulfate-based composites: a tour d'horizon of their biomedical applications

Chondroitin sulfate (CS), a natural anionic mucopolysaccharide, belonging to the glycosaminoglycan family, acts as the primary element of the extracellular matrix (ECM) of diverse organisms. It comprises repeating units of disaccharides possessing β-1,3-linked N-acetyl galactosamine (GalNAc), and β-1,4-linked D-glucuronic acid (GlcA), and exhibits antitumor, anti-inflammatory, anti-coagulant, anti-oxidant, and anti-thrombogenic activities. It is a naturally acquired bio-macromolecule with beneficial properties, such as biocompatibility, biodegradability, and immensely low toxicity, making it the center of attention in developing biomaterials for various biomedical applications. The authors have discussed the structure, unique properties, and extraction source of CS in the initial section of this review. Further, the current investigations on applications of CS-based composites in various biomedical fields, focusing on delivering active pharmaceutical compounds, tissue engineering, and wound healing, are discussed critically. In addition, the manuscript throws light on preclinical and clinical studies associated with CS composites. A short section on Chondroitinase ABC has also been canvassed. Finally, this review emphasizes the current challenges and prospects of CS in various biomedical fields.

Differences in pain, disability, and psychological function in low back pain patients with and without anxiety

Objectives: Non-specific low back pain affects people of all ages and is a leading contributor to disease burden worldwide. Chronic low back pain (LBP) reduces working hours, increases comorbidities, and increases rehabilitation needs. The aim of this study was to evaluate whether there were differences in pain, dysfunction, and psychological factors between two groups. The supplementary demonstrated the relationship between these influencing factors and anxiety.

Methods: A cross-sectional study was designed to analyze the differences in pain, disability, and psychological function in non-specific LBP patients with and without anxiety. In total, 60 subjects were divided into two groups based on self-rated anxiety scores: 30 patients with SAS score ≥50 were in the low back pain with anxiety group, and 30 for the LBP without anxiety group with SAS score &lt;50. The pain intensity was assessed using the Visual Analog Scale; psychological function, using the Pain Anxiety Symptoms Scale, the Tampa Scale for Kinesiophobia, and the Fear Avoidance Beliefs Questionnaire; functional disability, using the Oswestry Disability Index and the Roland–Morris Disability Questionnaire; quality of life using 36-Item Short-Form Health Survey questionnaire; and the quality of sleep using Pittsburgh Sleep Quality Index, and the relationships between variables and anxiety scores were estimated using Spearman correlation analysis.

Results: A total of 60 participants were enrolled after self-rated anxiety was assessed and the full investigation was finished. The analyses showed significant differences of pain intensity (p = 0.034, disability (ODI, p = 0.007; RMDQ, p = 0.012) and psychological function (TSK, p = 0.000; PASS, p = 0.009; FABQ, p = 0.000; SF-36, p = 0.000; and PSQI, p = 0.000) between the two groups. Spearman correlation analysis showed that the anxiety score had significant positive correlations with functional disability (ODI, p = 0.004 and 95% CI = 0.112–0.573; RMDQ, p = 0.003, 95% CI = 0.135–0.586) and psychological function (TSK, p = 0.001, 95% CI = 0.174–0.612), excellent positive correlation with quality of sleep (PASS, p = 0.025, 95% CI = 0.031–0.512), and strongly negative correlations with the quality of life (SF-36, p = 0.000, 95% CI = 0.761–0.433).

Conclusion: We recognized that anxiety in low back pain patients was mainly due to interaction with the intensity of pain, disability level, and a mass of psychological function. The future research direction could be to alleviate the anxiety on the comprehensive efficacy of patients with low back pain.

Low back pain and its determinants among wait staff in Gondar town, North West Ethiopia: A cross-sectional study

Background

Low back pain is a common public health issue in the working population and one of the leading causes of disability. It is the leading cause of work-related conditions and the most common reason for filing a workers' compensation claim in low- and middle-income countries. Ethiopia is a developing country; there is a shortage of working materials, skilled labor, and a lack of awareness of ergonomics posture, which lead to lifting heavy objects, long periods of standing, repetitive twisting, and same sustained posture for long periods of time without a shift. As a result, the purpose of this study was to assess the prevalence and associated factors of work-related low back pain among restaurant wait staff in Gondar, Ethiopia, in the year 2019.

Methods

Institution-based cross-sectional study, including 420 restaurant wait personnel, was undertaken from 1 March to 30 April 2019. A simple random sampling procedure was used to choose the restaurants and wait staff. A standardized Nordic questionnaire was used to collect data. Data were entered into Epi Info 7 and analyzed in SPSS version 20. The univariate and multivariate logistic regression analyses were calculated. The significance of associations was reported by a P-value of < 0.05 and an adjusted odds ratio (AOR). The model fitness checked by the Hosmer–Lemeshow goodness of fit test was used.

Result

In this study, a total of 420 participants (99.53% response rate) ranging in age from 17 to 53 years old participated, with 184 (43.8%) participants reporting low back pain at some point in the past 12 months. Female participants had a higher prevalence of 130 (70.6%). Sex (AOR = 2.98; 95% CI: 1.07–8.30), frequent exercise (AOR 0.47; 95% CI: 0.24, 0.93), extended standing (AOR 8.82; 95% CI: 3.30, 20.32], and repetitive tasks (AOR 7.49; 95% CI: 4.29, 13.19) were all found to be significant predictors in low back pain.

Conclusion

More than two-fifth of waitresses and waiters reported low back discomfort at some point in the past 12 months. Predisposing factors for low back discomfort among restaurant wait staff included being female, standing for long periods of time while serving, and performing repetitive tasks. Regular exercise was found to be a protective factor against low back pain in wait staff. Delivering ongoing safety training is among the most potent essential measures required in preventing low back pain.

Different Phases in Manual Materials Handling Have Different Performance Criteria: Evidence From Multi-Objective Optimization

A manual material handling task involves the phases of reaching, lifting, unloading, and standing up (RLUS). Understanding the mechanisms of manual material handling is important for occupational health and the development of assist devices. Predictive models are becoming popular in exploring which performance criterion is appropriate in the lifting phase. However, limited attempts have been performed on the other phases. The associated performance criterion for predicting other phases is unknown. In this study, an optimization model for predicting RLUS has been developed with the multi-objective optimization method. Two performance criteria (minimum dynamic effort and maximum balance) were studied to explore their importance in each phase. The result shows that maximum balance leads to joint angle errors 27.6% and 40.9% smaller than minimum dynamic effort in reaching and unloading phases, but 40.4% and 65.9% larger in lifting and standing up phases. When the two performance criteria are combined, the maximum balance could help improve the predicting accuracy in the reaching, lifting, and unloading phases. These findings suggest that people prefer different performance criteria in different phases. This study helps understand the differences in motion strategies in manual materials handling (MMH), which would be used to develop a more accurate predictive model.

Biopsychosocial Factors for Chronicity in Individuals with Non-Specific Low Back Pain: An Umbrella Review

Low back pain (LBP) is a global and disabling problem. A considerable number of systematic reviews published over the past decade have reported a range of factors that increase the risk of chronicity due to LBP. This study summarizes up-to-date and high-level research evidence on the biopsychosocial prognostic factors of outcomes in adults with non-specific low back pain at follow-up. An umbrella review was carried out. PubMed, the Cochrane Database of Systematic Reviews, Web of Science, PsycINFO, CINAHL Plus and PEDro were searched for studies published between 1 January 2008 and 20 March 2020. Two reviewers independently screened abstracts and full texts, extracted data and assessed review quality. Fifteen systematic reviews met the eligibility criteria; all were deemed reliable according to our criteria. There were five prognostic factors with consistent evidence of association with poor acute-subacute LBP outcomes in the long term (high levels of pain intensity and disability, high emotional distress, negative recovery expectations and high physical demands at work), as well as one factor with consistent evidence of no association (low education levels). For mixed-duration LBP, there was one predictor consistently associated with poor outcomes in the long term (high pain catastrophism). We observed insufficient evidence to synthesize social factors as well as to fully assess predictors in the chronic phase of LBP. This study provides consistent evidence of the predictive value of biological and psychological factors for LBP outcomes in the long term. The identified prognostic factors should be considered for inclusion into low back pain explanatory models.

Best Exercise Options for Reducing Pain and Disability in Adults With Chronic Low Back Pain: Pilates, Strength, Core-Based, and Mind-Body. A Network Meta-analysis

OBJECTIVE

To determine which type of exercise is best for reducing pain and disability in adults with chronic low back pain (LBP).

DESIGN

Systematic review with a network meta-analysis (NMA) of randomized controlled trials (RCTs).

LITERATURE SEARCH

Six electronic databases were systematically searched from inception to July 2021.

STUDY SELECTION CRITERIA

RCTs testing the effects of exercise on reducing self-perceived pain or disability in adults (aged 18-65 years) with chronic LBP.

DATA SYNTHESIS

We followed the PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses, incorporating NMAs of health care interventions) statement when reporting our NMA. A frequentist NMA was conducted. The probability of each intervention being the most effective was conducted according to surface under the cumulative ranking curve (SUCRA) values.

RESULTS

We included 118 trials (9710 participants). There were 28 head-to-head comparisons, 7 indirect comparisons for pain, and 8 indirect comparisons for disability. Compared with control, all types of physical exercises were effective for improving pain and disability, except for stretching exercises (for reducing pain) and the McKenzie method (for reducing disability). The most effective interventions for reducing pain were Pilates, mind-body, and core-based exercises. The most effective interventions for reducing disability were Pilates, strength, and core-based exercises. On SUCRA analysis, Pilates had the highest likelihood for reducing pain (93%) and disability (98%).

CONCLUSION

Although most exercise interventions had benefits for managing pain and disability in chronic LBP, the most beneficial programs were those that included (1) at least 1 to 2 sessions per week of Pilates or strength exercises; (2) sessions of less than 60 minutes of core-based, strength, or mind-body exercises; and (3) training programs from 3 to 9 weeks of Pilates and core-based exercises. J Orthop Sports Phys Ther 2022;52(8):505-521. Epub: 19 June 2022. doi:10.2519/jospt.2022.10671.

Back pain treatment: a new perspective

This article aims to provide new perspectives for the treatment of low back pain (LBP). A narrative literature review highlights the treatment strategies currently anchored in the guidelines as well as the extensive attempts to identify subgroups within the non-specific low back pain (NSLBP) classification. A variety of multimodal approaches exist for both diagnostic assessments and therapy approaches. Nonetheless, there are often gaps in the classification systems as well as in published treatment concepts with regard to the implementation of musculoskeletal functional disorders. Indeed, a growing body of evidence shows that more holistic and flexible approaches are needed to individually diagnose and target the complexity of LBP. As an example, both a diagnostic and a (independently developed) therapeutic LBP concept will be presented and discussed. Ultimately, guidelines and subgroup classification systems can only reflect the complexity of LBP, if they capture its entire multidimensional and biopsychosocial character in both the diagnostic and therapeutic processes. Furthermore, the expansion of the pain definition to include the nociplastic pain mechanism, as an important driver of LBP, has the potential to provide important impulses for further necessary research. In conclusion, the implementation of a functional musculoskeletal approach along with the emerging nociceptive pain concept in individually targeted holistic approaches seems to be the successful way to deal with the complexity of LBP.

Clinical Characteristics and Mechanisms of Musculoskeletal Pain in Long COVID

Objective

Musculoskeletal (MSK) pain is being increasingly reported by patients as one of the most common persistent symptoms in post-COVID-19 syndrome or Long COVID. However, there is a lack of understanding of its prevalence, characteristics, and underlying pathophysiological mechanisms. The objective of this review is to identify and describe the features and characteristics of MSK pain in Long COVID patients.

Methods

The narrative review involved a literature search of the following online databases: MEDLINE (OVID), EMBASE (OVID), CINAHL, PsyclNFO, and Web of Science (December 2019 to February 2022). We included observational studies that investigated the prevalence, characteristics, risk factors and mechanisms of MSK pain in Long COVID. After screening and reviewing the initial literature search results, a total of 35 studies were included in this review.

Results

The overall reported prevalence of MSK pain in Long COVID ranged widely from 0.3% to 65.2%. The pain has been reported to be localized to a particular region or generalized and widespread. No consistent pattern of progression of MSK pain symptoms over time was identified. Female gender and higher BMI could be potential risk factors for Long COVID MSK pain, but no clear association has been found with age and ethnicity. Different pathophysiological mechanisms have been hypothesized to contribute to MSK pain in Long COVID including increased production of proinflammatory cytokines, immune cell hyperactivation, direct viral entry of neurological and MSK system cells, and psychological factors.

Conclusion

MSK pain is one of the most common symptoms in Long COVID. Most of the current literature on Long COVID focuses on reporting the prevalence of persistent MSK pain. Studies describing the pain characteristics are scarce. The precise mechanism of MSK pain in Long COVID is yet to be investigated. Future research must explore the characteristics, risk factors, natural progression, and underlying mechanisms of MSK pain in Long COVID.

Practicable performance-based outcome measures of trunk muscle strength and their measurement properties: A systematic review and narrative synthesis

Introduction

The evaluation of muscle strength is frequently used as part of the physical examination process, with decreased trunk muscle strength reported in individuals with spinal disorders (e.g., low back pain). Access to practicable performance-based outcome measures (PBOM) to monitor patients’ progress in spinal rehabilitation is essential. Knowledge of the psychometric properties of the available practicable PBOM for trunk strength evaluation is therefore needed to inform practitioners and further research.

Objective

To synthesise evidence on the measurement properties of practicable measures of trunk muscle strength in adults with and without musculoskeletal pain.

Methods

Following a published and registered protocol [PROSPERO CRD42020167464], databases were searched from the database inception date up to 30th of June 2021. Citations and grey literature were also searched. Eligibility criteria comprised: 1) studies which examined the psychometric properties of the trunk strength outcome measures, 2) included adults ≥ 18 years, either asymptomatic or with spinal musculoskeletal pain. Non-English language studies were excluded. Two independent reviewers evaluated the quality and synthesized the data from included studies according to the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist. The overall quality of evidence was evaluated using a modified Grading of Recommendations Assessment Development and Evaluation (GRADE).

Results

From 34 included studies, 15 different PBOMs were identified that have been investigated for reliability and validity, none evaluated responsiveness. In asymptomatic individuals, high quality evidence supports intra-rater reliability of digital-loading cells and moderate quality evidence supports the criterion validity of the hand-held dynamometer. Very low quality evidence exists for the reliability and validity estimates of testing tools among individuals with spinal pain.

Conclusions

Findings underpin a cautious recommendation for the use of practicable PROMs to evaluate muscle strength in individuals with spinal pain in clinical practice due to the level of evidence and the heterogeneity of the protocols used. Further high quality research to explore the psychometric properties of the practicable PBOMs with detailed methodology is now needed.

Deletion of ApoE Leads to Intervertebral Disc Degeneration via Aberrant Activation of Adipokines

STUDY DESIGN

Animal experiment: a mouse model of intervertebral disc (IVD) degeneration induced by deletion of apolipoprotein E (apoE).

OBJECTIVE

The aim of this study was to investigate the role and mechanism of apoE on the process of IVD degeneration.

SUMMARY OF BACKGROUND DATA

Abnormal lipid metabolism has been demonstrated to be closely related to IVD degeneration, a common chronic degenerative joint disease. ApoE, a component of apolipoproteins, plays a crucial role in lipid transportation and metabolic balance. But the relationship between apoE and IVD degeneration remains largely unknown.

METHODS

ApoE knockout (KO) mouse was employed to investigate the progressive disc degeneration. The changes of vertebral bone and intervertebral disc space were measured by micro-computed tomography (micro-CT). The histo-morphological changes of cartilage endplate (CEP) and underlying signals were tested using immunohistochemistry and immunofluorescence staining.

RESULTS

The deletion of apoE gene accelerated the lumbar spine degeneration. Compared with WT mice, apoE KO mice showed reduced IVD space and increased vertebral bone mass. The progressive CEP degeneration was further found with cartilage degradation and endplate sclerosis in apoE KO mice. The deletion of apoE stimulated abnormal CEP bone remodeling and activation of adipokines signals.

CONCLUSION

The deletion of apoE gene induced abnormal activation of adipokines signals, thus contribute to the CEP degeneration.

LEVEL OF EVIDENCE

N/A.

Association between cardiovascular risk factors and degenerative disc disease of the thoracolumbar spine in the general population: results from the KORA MRI Study

BACKGROUND

Little is known about the associations between cardiovascular risk factors (CRF) and disc degeneration (DD).

PURPOSE

To evaluate the potential association between CRFs and intervertebral DD in a population-based sample.

METHODS

A total of 400 participants from the community-based KORA-study were assessed in terms of CRFs, specifically obesity, hypertension, diabetes, elevated LDL-c, low HDL-c, elevated triglycerides, smoking status, and alcohol consumption. The patients additionally underwent whole-body magnetic resonance imaging (MRI) using T2-weighted single-shot fast-spin-echo and T1 dual-echo gradient-echo Dixon pulse sequences. Thoracic and lumbar DD were assessed using the Pfirrmann score and for the presence of disc bulging/protrusion. Cross-sectional associations between CRFs and MR-based Pfirrmann score were then analyzed.

RESULTS

A total of 385 individuals (58.2% men; mean age 56.3 ± 9.2 years) were included. Prevalence of DD was 76.4%. Older age (β = 0.18; 95% CI 0.12-0.25; P < 0.001) and higher body mass index (BMI) (β = 0.19; 95% CI 0.06-0.30; P = 0.003) were significantly associated with DD of the thoracolumbar spine. Diabetes was significantly associated with DD at T7/8 (P = 0.029) and L3/4 (P = 0.017). Hypertension correlated significantly with DD in univariate analysis, but the association did not persist using multivariate analysis (β = 0.53; 95% CI -0.74 to 1.81; P = 0.41). None of the other CRFs (P ≥ 0.11) were associated with advanced DD. Disc bulging was independently associated with hypertension (β = 0.47; 95% CI 0.27-0.81; P = 0.01).

CONCLUSION

A significant independent association exists between age, BMI, and intervertebral DD. In contrast, there is no significant association between cardiovascular risk factors and DD. Providing strong evidence that the pathologic process undergirding DD is mechanical, rather than microvascular, in nature.

Group and individual telehealth for chronic musculoskeletal pain: A scoping review

BACKGROUND CONTEXT

Musculoskeletal (MSK) pain presents a global challenge. Individual and group pain management programmes (PMPs) are recommended approaches for patients with chronic MSK disorders. With advances in remote healthcare capability, telehealth, and the recent COVID-19 pandemic, the importance of telehealth PMPs has become even more evident. Nevertheless, it is not known how patients perceive PMPs for their MSK complaint when delivered via telehealth.

OBJECTIVE

To synthesise the evidence of patients' experiences of group and individual telehealth PMPs for chronic MSK pain.

DESIGN

A scoping review informed by the PRISMA extension for scoping reviews.

DATA SOURCES

Based on a planned search strategy, modified following initial searches, an electronic search was conducted of key databases: Cochrane Library, Medline, CINAHL, EMBASE, AMED, SportDiscus and APA PsychInfo from 2010 until 11 May 2021.

STUDY SELECTION

Any qualitative or mixed methods study reporting patient experiences of telehealth PMPs for patients with MSK disorders.

DATA EXTRACTION AND DATA SYNTHESIS

Data were extracted and synthesised using thematic analysis.

RESULTS

From 446 identified studies, 10 were included. Just two studies investigated group telehealth PMPs for patients with MSK disorders, with eight delivered individually. Four main themes emerged: (1) Usability of the technology, (2) Tailored care, (3) Therapeutic alliance and (4) Managing behaviour. The findings highlight patient acceptability of telehealth to support self-management for chronic MSK disorders, with appropriate clinical and technical support. Group telehealth has the potential to empower patients with peer support. Remote delivery of PMPs also impacts on how patients and providers interact, communicate and develop a therapeutic relationship.

CONCLUSIONS AND IMPLICATIONS

Barriers and enablers to engagement in telehealth PMPs for patients with chronic MSK disorders have been identified. Peer support and group cohesiveness can be achieved remotely to enhance the patient experience. There is a critical need for further research in this area.

Is it possible to discriminate workers with a higher prevalence of low back pain considering daily exposure time in a work-related lumbar posture? A diagnostic accuracy study

The study aimed to develop and validate a cut-off for daily postures to discriminate workers with low back pain. The self-reported episode of low back pain in the last year and during the previous week and the total spent time in occupational postures of 529 workers were used to screen workers who more likely would report low back pain. The receiver operating characteristics curve verified the ability of daily time in each posture in discriminating workers with low back pain in a training sample. Then, the chi-squared test and measurements of the diagnostic accuracy were performed in the testing sample. The daily time spent in a given posture was not able to accurately discriminate against workers with low back pain. Total time spent walking was the only daily posture that discriminated workers with low back pain in the last year in the testing sample, albeit with low accuracy. Practitioner Summary: The daily time spent in a given posture was not able to accurately distinguish workers with low back pain. Total spent time in walking presented modest diagnostic accuracy and should be interpreted cautiously. The spent time in a particular posture did not detect workers with LBP in the last week.

Physical therapy of patients undergoing first-time lumbar discectomy: a survey of current UK practice

BACKGROUND

The type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers.

METHOD

Physical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing (preop, postop), and rehabilitation content for patients undergoing lumbar discectomy.

RESULTS

Seventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription.

CONCLUSIONS

Whilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery.

Delivering Mindfulness-Based Interventions for Insomnia, Pain, and Dysfunctional Eating Through a Text Messaging App: Three Randomized Controlled Trials Investigating the Effectiveness and Mediating Mechanisms

Background

Although text messaging has the potential to be the core intervention modality, it is often used as an adjunct only. To improve health and alleviate the distress related to insomnia, pain, and dysregulated eating of people living in urban areas, text messaging–based mindfulness-based interventions were designed and evaluated in 3 randomized controlled trials.

Objective

This study investigated the effectiveness and mediating mechanisms of text messaging–based mindfulness-based interventions for people with distress related to insomnia, pain, or dysregulated eating.

Methods

In these trials, 333, 235, and 351 participants were recruited online and randomized to intervention and wait-list control conditions for insomnia, pain, and dysregulated eating, respectively. Participants experienced 21 days of intervention through WhatsApp Messenger. Participants completed pre-, post-, 1-month follow-up, and 3-month follow-up self-report questionnaires online. The retention rates at postmeasurements were 83.2% (139/167), 77.1% (91/118), and 72.9% (129/177) for intervention groups of insomnia, pain, and dysregulated eating, respectively. Participants’ queries were answered by a study technician. Primary outcomes included insomnia severity, presleep arousal, pain intensity, pain acceptance, and eating behaviors. Secondary outcomes included mindfulness, depression, anxiety, mental well-being, and functional impairments. Mindfulness, dysfunctional beliefs and attitudes about sleep, pain catastrophizing, and reactivity to food cues were hypothesized to mediate the relationship between the intervention and outcomes.

Results

For all 3 studies, the intervention groups showed significant improvement on most outcomes at 1-month follow-up compared to their respective wait-list control groups; some primary outcomes (eg, insomnia, pain, dysregulated eating indicators) and secondary outcomes (eg, depression, anxiety symptoms) were sustained at 3-month follow-up. Medium-to-large effect sizes were found at postassessments in most outcomes in all studies. In the intervention for insomnia, mediation analyses showed that dysfunctional beliefs and attitudes about sleep mediated the effect of the intervention on all primary outcomes and most secondary outcomes at both 1-month and 3-month follow-ups, whereas mindfulness mediated the intervention effect on presleep arousal at 1-month and 3-month follow-ups. In the intervention for pain, pain catastrophizing mediated the effect of intervention on pain intensity and functioning at both 1-month and 3-month follow-ups, whereas mindfulness only mediated the effect of intervention on anxiety and depressive symptoms. In the intervention for dysregulated eating, power of food mediated the effect of intervention on both uncontrolled and emotional eating at both 1-month and 3-month follow-ups and mindfulness was found to mediate the effect on depressive symptoms at both 1-month and 3-month follow-ups.

Conclusions

These 3 studies converged and provided empirical evidence that mindfulness-based interventions delivered through text messaging are effective in improving distress related to sleep, pain, and dysregulated eating. Text messaging has the potential to be a core intervention modality to improve various common health outcomes for people living a fast-paced lifestyle.

Trial Registration

Clinical Research and Biostatistics Clinical Trials Registry CUHK_CCRB00559; https://tinyurl.com/24rkwarz

The role of the social determinants of health in outcomes of surgery for low back pain: a systematic review and narrative synthesis

BACKGROUND CONTEXT

Low back pain is a major cause of morbidity and disability worldwide and is responsible for vast societal impact. Rates of surgical intervention for lumbar spine disorders continue to rise but poor outcomes remain common. Understanding how the social determinants of health (SDH) influence spinal surgical outcomes stands to inform appropriately tailored care practices and lead to better patient outcomes.

PURPOSE

To determine the relationships between the SDH and pain, opioid use, disability and work absenteeism following lumbar spine surgery.

STUDY DESIGN

Systematic review and narrative synthesis.

METHODS

We searched Embase, the Cochrane Library, Medline, and Web of Science from inception to April 21, 2020. Studies eligible for inclusion involved participants receiving lumbar spine surgery and investigated the relationship between at least one SDH and post-surgical pain, opioid use, disability or work absenteeism. We evaluated the risk of bias of included studies and used the PROGRESS-Plus framework to organize a narrative synthesis of findings.

RESULTS

Relevant data was extracted from twenty-three studies involving 30,987 adults from 12 countries. A total of 107 relationships between the SDH and post-surgical outcomes were evaluated, 67 in multivariate analyses. Education was investigated in 23 analyses (14 studies): 70% revealed significant independent relationships between lower education and poorer outcomes. Socioeconomic status was investigated in nine analyses (four studies): 67% revealed independent relationships between lower socioeconomic status and poorer outcomes. Gender was investigated in 40 analyses (22 studies): indications that male versus female sex was associated with poorer outcomes were equivocal. Place of residence, race/ethnicity, and social capital were infrequently investigated.

CONCLUSIONS

Low educational attainment and low-income status are clear independent contributors to poorer outcomes following lumbar spine surgery. Occupational factors and work context are likely to be influential. Further research is critical to guide best-practice spinal surgery through a health equity lens.

STUDY REGISTRATION

PROSPERO registration number CRD42015015778.

Low-dose mesenchymal stem cell therapy for discogenic pain: safety and efficacy results from a 1-year feasibility study

Aim: To evaluate safety and efficacy of low dose autologous adipose-derived mesenchymal stem cells (ADMSCs) for treatment of disc degeneration resulting in low back pain (LBP). Methods: Nine participants with chronic LBP originating from single-level lumbar disc disease underwent intradiscal injection of 10 million ADMSCs with optional repetition after 6 months. Results: No unexpected or serious adverse events were recorded. Seven (78%) of participants reported reductions in pain 12 months after treatment. Five (56%) reported increased work capacity. Three (33%) reduced analgesic medication. Improvements in EQ-5D and Oswestry disability index results were observed. MRI demonstrated no further disc degeneration and improvements to annular fissures and disc protrusions. Conclusion: This study provides initial evidence of safety and efficacy of ADMSCs for discogenic LBP.

Self-Assembling Peptide Hydrogels as Functional Tools to Tackle Intervertebral Disc Degeneration

Low back pain (LBP), caused by intervertebral disc (IVD) degeneration, is a major contributor to global disability. In its healthy state, the IVD is a tough and well-hydrated tissue, able to act as a shock absorber along the spine. During degeneration, the IVD is hit by a cell-driven cascade of events, which progressively lead to extracellular matrix (ECM) degradation, chronic inflammation, and pain. Current treatments are divided into palliative care (early stage degeneration) and surgical interventions (late-stage degeneration), which are invasive and poorly efficient in the long term. To overcome these limitations, alternative tissue engineering and regenerative medicine strategies, in which soft biomaterials are used as injectable carriers of cells and/or biomolecules to be delivered to the injury site and restore tissue function, are currently being explored. Self-assembling peptide hydrogels (SAPHs) represent a promising class of de novo synthetic biomaterials able to merge the strengths of both natural and synthetic hydrogels for biomedical applications. Inherent features, such as shear-thinning behaviour, high biocompatibility, ECM biomimicry, and tuneable physiochemical properties make these hydrogels appropriate and functional tools to tackle IVD degeneration. This review will describe the pathogenesis of IVD degeneration, list biomaterials requirements to attempt IVD repair, and focus on current peptide hydrogel materials exploited for this purpose.

Quantifying the Employer Burden of Persistent Musculoskeletal Pain at a Large Employer in the United Kingdom: A Non-interventional, Retrospective Study of Rolls-Royce Employee Data

OBJECTIVE

To quantify the burden of work-relevant persistent musculoskeletal (MSK) pain to a large UK employer.

METHODS

A retrospective, longitudinal, analytical cohort study using linked Rolls-Royce data systems. Cases were employees with a MSK-related referral to occupational health; controls were age-, sex-, and job role-matched employees without such a referral. Outcomes were compared during 12 months' follow-up.

RESULTS

Overall, 2382 matched case-control pairs were identified (mean age: 46 y; 82% male). Cases took 39,200 MSK-related sickness absence days in total (equating to £50 million in sickness absence costs). Cases took significantly more all-cause sickness absence days than controls (82,341 [£106 million] versus 19,628 [£26 million]; P < 0.0001).

CONCLUSIONS

Despite access to extensive occupational health services, the burden of work-relevant persistent MSK pain remains high in Rolls-Royce. There is a clear need to better understand how to effectively reduce this burden.

Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review

Chronic low back pain remains highly prevalent, costly, and the leading cause of disability worldwide. Symptoms are complex and treatment involves an interdisciplinary approach. Due to diverse anatomical etiologies, treatment outcomes with interventional options are highly variable. A novel approach to treating chronic axial low back pain entails the use of peripheral nerve stimulation to the lumbar medial branch nerve, and this review examines the clinical data of the two different, commercially available, non-spinal neuromodulation systems. This review provides the clinician a succinct narrative that presents up-to-date data objectively. Our review found ten clinical studies, including one report of two cases, six prospective studies, and three randomized clinical trials published to date. Currently, there are different proposed mechanisms of action to address chronic axial low back pain with different implantation techniques. Evidence suggests that peripheral nerve stimulation of the lumbar medial branch nerve may be effective in improving pain and function in patients with chronic axial low back pain symptoms at short and long term follow up, with good safety profiles. Further long-term data is needed to consider this intervention earlier in the pain treatment algorithm, but initial data are promising.

Generalization of fear of movement-related pain and avoidance behavior as predictors of work resumption after back surgery: a study protocol for a prospective study (WABS)

Background

Previous studies indicated that about 20% of the individuals undergoing back surgery are unable to return to work 3 months to 1 year after surgery. The specific factors that predict individual trajectories in postoperative pain, recovery, and work resumption are largely unknown. The aim of this study is to identify modifiable predictors of work resumption after back surgery.

Methods

In this multisite, prospective, longitudinal study, 300 individuals with radicular pain undergoing a lumbar decompression will be followed until 1-year post-surgery. Prior to surgery, participants will perform a computer task to assess fear of movement-related pain, avoidance behavior, and their generalization to novel situations. Before and immediately after surgery, participants will additionally complete questionnaires to assess fear of movement-related pain, avoidance behavior, optimism, expectancies towards recovery and work resumption, and the duration and severity of the pain. Six weeks, 3 months, 6 months, and 12 months after surgery, they will again complete questionnaires to assess sustainable work resumption, pain severity, disability, and quality of life. The primary hypothesis is that (generalization of) fear of movement-related pain and avoidance behavior will negatively affect sustainable work resumption after back surgery. Second, we hypothesize that (generalization of) fear of movement-related pain and avoidance behavior, negative expectancies towards recovery and work resumption, longer pain duration, and more severe pain before the surgery will negatively affect work resumption, pain severity, disability, and quality of life after back surgery. In contrast, optimism and positive expectancies towards recovery and work resumption are expected to predict more favorable work resumption, better quality of life, and lower levels of pain severity and disability after back surgery.

Discussion

With the results of this research, we hope to contribute to the development of strategies for early identification of risk factors and appropriate guidance and interventions before and after back surgery.

Trial registration The study was preregistered on ClinicalTrials.gov: NCT04747860 on February 9, 2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00736-5.

Effects of booster sessions on self-management interventions for chronic musculoskeletal pain: a systematic review and meta-analysis of randomised controlled trials

ABSTRACT

Our objective was to investigate the effectiveness of booster sessions after self-management interventions as a means of maintaining self-management behaviours in the treatment of chronic musculoskeletal pain. We searched MEDLINE, EMBASE, Science Citation Index, Cochrane Central Register of Controlled Trials, and PsychINFO. Two authors independently identified eligible trials and collected data. We calculated the odds ratio for the analyses of dichotomous data and standardised mean differences (SMDs) with 95% confidence interval (CI) for continuous variables. Our search identified 14 studies with a total of 1695 patients. All studies were at high risk of bias and provided very low quality evidence. For the primary outcomes, booster sessions had no evidence of an effect on improving patient-reported outcomes on physical function (SMD -0.13, 95% CI -0.32 to -0.06; P = 0.18), pain-related disability (SMD -0.16, 95% CI -0.36 to 0.03; P = 0.11), and pain self-efficacy (SMD 0.15, 95% CI -0.07 to 0.36; P = 0.18). For the secondary outcomes, booster sessions caused a significant reduction in patient-reported pain catastrophising (SMD -0.42, 95% CI -0.64 to -0.19; P = 0.0004) and no evidence of an effect on patient-reported pain intensity, depression, coping, or treatment adherence. There is currently little evidence that booster sessions are an effective way to prolong positive treatment effects or improve symptoms of long-term musculoskeletal conditions after self-management interventions. However, the studies were few with high heterogeneity, high risk of bias, and overall low quality of evidence. Our review argues against including booster sessions routinely to self-management interventions for the purpose of behaviour maintenance.

Bardoxolone Methyl Ameliorates Compression-Induced Oxidative Stress Damage of Nucleus Pulposus Cells and Intervertebral Disc Degeneration Ex Vivo

Intervertebral disc degeneration (IDD) is the main cause of low back pain, and little is known about its molecular and pathological mechanisms. According to reports, excessive compression is a high-risk factor for IDD; compressive stress can induce oxidative stress in nucleus pulposus (NP) cells during IDD progression that, in turn, promotes cell apoptosis and extracellular matrix (ECM) degradation. Currently, NP tissue engineering is considered a potential method for IDD treatment. However, after transplantation, NP cells may experience oxidative stress and induce apoptosis and ECM degradation due to compressive stress. Therefore, the development of strategies to protect NP cells under excessive compressive stress, including pretreatment of NP cells with antioxidants, has important clinical significance. Among the various antioxidants, bardoxolone methyl (BARD) is used to protect NP cells from damage caused by compressive stress. Our results showed that BARD can protect the viability of NP cells under compression. BARD inhibits compression-induced oxidative stress in NP cells by reducing compression-induced overproduction of reactive oxygen species (ROS) and malondialdehyde. Thus, BARD has a protective effect on the compression-induced apoptosis of NP cells. This is also supported by changes in the expression levels of proteins related to the mitochondrial apoptosis pathway. In addition, BARD can inhibit ECM catabolism and promote ECM anabolism in NP cells. Finally, the experimental results of the mechanism show that the activation of the Nrf2 signaling pathway participates in the protection induced by BARD in compressed NP cells. Therefore, to improve the viability and biological functions of NP cells under compression, BARD should be used during transplantation.

Examining the association between group context effects and individual outcomes in an interdisciplinary group-based treatment for chronic pain based on Acceptance and Commitment Therapy

Background: Although cognitive-behavioural treatments for chronic pain are delivered in groups, there is little research investigating group effects in these treatments. Purpose: The aim of this study was to investigate associations between group composition variables at the start of treatment and individual outcomes following intensive interdisciplinary treatment for pain based on Acceptance and Commitment Therapy. Methods: This was a secondary analysis of routinely collected observational data. Five-hundred and sixteen patients completed a standard set of demographic, pain-related, and psychosocial measures at pre- and post-treatment. Intracluster correlations (ICCs) were computed to examine the clustering of outcomes within groups and multilevel models explored the association between group composition variables and individual level outcomes. Results: The ICCs for pain intensity (0.11) and interference (0.09) suggested that multilevel models were warranted for these outcomes, while a multilevel model for post-treatment depression (ICC=0.04) was not warranted. Group percentage of participants receiving disability 8 benefits and group mean pain intensity at pre-treatment were significantly positively associated with individual level pain intensity at post-treatment, controlling for pre-treatment individual level pain intensity. Group mean pain intensity at pre-treatment was the only group variable that significantly predicted post-treatment pain interference at the individual level. Psychosocial group composition variables were not significantly associated with individual level outcomes. Conclusions: Given the limited predictive utility of group composition variables in the current study, future research should undertake direct assessment of group level therapeutic and counter-therapeutic processes to advance understanding of who benefits from group treatments for pain and how. As the variance in outcomes accounted for by group clustering was relatively small and significant within groups variance remained, research is also needed to further understand individual level factors that influence cognitive-behavioural treatment outcomes for pain.

Ketamine therapy for chronic pain in The Netherlands: a nationwide survey

OBJECTIVES

Ketamine is used to treat chronic refractory pain. However, there are no scientific guidelines for ketamine use in the Netherlands. The aim of this survey was to provide an overview of the use of ketamine for chronic pain in the Netherlands.

METHODS

All pain clinics in the Netherlands were contacted. A digital survey, available from June 2019 to January 2020, was sent to 68 pain clinics. The survey was completed by one pain physician as a representative of the entire pain department. The survey included questions about ketamine treatment indications, administration, dose, duration, treatment repetition and the inpatient or outpatient setting.

RESULTS

The survey was completed by 51 pain clinics (75.0%). Thirty-one clinics used ketamine for chronic pain treatment. The most common indication was Complex Regional Pain Syndrome (83.9%). Pain clinics administered ketamine via intravenous infusions (96.8%), iontophoresis (61.3%), subcutaneous (3.2%) or oral administration (3.2%). Intravenous ketamine treatment was offered in an inpatient setting in 14 pain clinics, in both an inpatient and outpatient setting in 11 pain clinics and in six pain clinics in an outpatient setting. In the outpatient setting, the median starting dose was 5 mg/h (IQR=17.5-5). The median maximum dose was 27.5 mg/h (IQR=100-11.9). The median infusion duration was 6 h (IQR=8-4). In the inpatient setting, the median starting dose was 5 mg/h (IQR=5-1.5) and the median maximum dose was 25 mg/h (IQR=25-14). Patients were admitted to hospital for a median of 4 days (IQR=5-1).

CONCLUSIONS

The results of this Dutch nationwide survey study show that there are heterogeneous treatment protocols with different indications, treatment setting and dosing regimen for the treatment of chronic pain with ketamine. This study encourages the formulation of a broader consensus and the development of evidence based guidelines for ketamine treatment.

Joint effects of back pain and mental health conditions on health care utilization and costs in Ontario, Canada: A population-based cohort study

ABSTRACT

We assessed the joint effects of back pain and mental health conditions on healthcare utilization and costs in a population-based sample of Ontario adults. We included Ontario adult respondents of Canadian Community Health Survey between 2003-2012, followed to 2018 by linking survey data to administrative databases. Joint exposures were self-reported back pain and mental health conditions (fair/poor mental health, mood, anxiety disorder). We built negative binomial, modified Poisson, and linear (log-transformed) models to assess joint effects (effects of two exposures in combination) of comorbid back pain and mental health condition on healthcare utilization, opioid prescription, and costs, adjusting for sociodemographic, health-related and behavioural factors. We evaluated positive additive and multiplicative interaction (synergism) between back pain and mental health conditions with relative-excess risk due-to-interaction (RERI) and ratio of rate-ratios (RR). The cohort (n=147,486) had a mean age of 46 years (SD=17), and 51% were female. We found positive additive and multiplicative interaction between back pain and fair/poor mental health (RERI=0.40;RR=1.12) and mood disorder (RERI=0.41;RR=1.04), but not anxiety for back pain-specific utilization. For opioid prescription, we found positive additive and multiplicative interaction between back pain and fair/poor mental health (RERI=2.71;RR=3.20) and anxiety (RERI=1.60;RR=1.80), and positive additive interaction with mood disorder (RERI=0.74). There was no evidence of synergism for all-cause utilization or costs. Combined effects of back pain and mental health conditions on back pain-specific utilization or opioid prescription were greater than expected, with evidence of synergism. Health services targeting back pain and mental health conditions together may provide greater improvements in outcomes.