The epidemiology, economic burden, and pharmacological treatment of chronic low back pain in France, Germany, Italy, Spain and the UK: a literature-based review

The effects of shoes and insoles for low back pain: a systematic review and meta-analysis of randomized controlled trials

The aim of this review was to examine the effects of shoes and insoles on low back pain (LBP). Seven electronic databases were searched from their inception to May 2020. The methodological quality of the 14 included studies was assessed by PEDro scale. Quality of evidence was assessed using GRADE. Moderate evidence on the disability questionnaire score (SMD, 0.52; 95% CI, 0.28 to 0.77; P < 0.001) and pain score (SMD, 0.61; 95% CI, 0.36 to 0.85; P < 0.001) of the custom-made orthotics for chronic LBP compared with no orthotics/insoles intervention was found. Meta-analysis results also showed moderate evidence on the disability questionnaire score (SMD, 0.44; 95% CI, 0.05 to 0.82; P =0.03) in patients who wore unstable shoes compared with regular shoes. Pain and life quality scores showed low-quality evidence of unstable shoes for chronic LBP. Custom-made orthotics and unstable shoes can be recommended to patients as a management option of chronic LBP.

MicroRNA‑25‑3p regulates human nucleus pulposus cell proliferation and apoptosis in intervertebral disc degeneration by targeting Bim

Intervertebral disc degeneration (IDD) is a degenerative disease of the spine originating from the intervertebral disc. MicroRNAs (miRNAs or miRs) are a group of endogenous small non‑coding RNAs that act on target genes and play a critical role in numerous biological processes. However, the underlying mechanism of miR‑25‑3p in IDD remains unclear. Therefore, the present study aimed to explore the role of miR‑25‑3p in the pathogenesis of IDD. The results demonstrated that miR‑25‑3p was downregulated in rat degenerative nucleus pulposus (NP) cells and that Bcl‑2 interacting mediator of cell death (Bim) was a direct target of miR‑25‑3p. Next, to investigate the effect of miR‑25‑3p on normal NP cell proliferation and apoptosis, NP cells were transfected with an miR‑25‑3p inhibitor, a negative control of miR‑25‑3p inhibitor, miR‑25‑3p inhibitor + control‑small interference RNA (siRNA) or miR‑25‑3p inhibitor + Bim‑siRNA for 48 h and cell proliferation and apoptosis were then analyzed. The results demonstrated that the miR‑25‑3p inhibitor could decrease NP cell proliferation and induce cell apoptosis, and these effects were reversed by Bim‑siRNA. In addition, an in vitro cell model of IDD was established by subjecting NP cells to 10 ng/ml interleukin (IL)‑1β for 24 h. Further experiments suggested that IL‑1β treatment induced a reduction in NP cell proliferation and an increase in cell apoptosis, which were prevented by the miR‑25‑3p mimic. All the effects of miR‑25‑3p mimic on IL‑1β‑treated NP cells were significantly reversed by Bim upregulation. These findings suggested that miR‑25‑3p may be a novel therapeutic target for IDD prevention.

The Economic and Social Burden of Low Back Pain in Spain: A National Assessment of the Economic and Social Impact of Low Back Pain in Spain

STUDY DESIGN

Economic evaluation of the costs of low back pain (LBP) in Spain from a societal perspective, including direct and indirect costs, based on a national representative sample of the general population, the National Health Survey of 2017 (NHS 2017).

OBJECTIVE

To estimate the costs attributable to LBP in Spain.

SUMMARY OF BACKGROUND DATA

LBP has a high prevalence and is associated with lower quality of life, functional status, and increased use of health services. Studies that assess the socio-economic burden of LBP from a general population perspective have not been published yet in Spain.

METHODS

Data from NHS 2017 were used. Direct costs (consultations-general practitioner, specialist and emergency departments-, diagnostic tests, hospitalizations, physiotherapy, psychologist, and medication consumption) and indirect costs (absenteeism and presenteeism) were assessed. Multivariate models were obtained to determine the independent attributable effect of LBP in each variable. Costs were determined through existing regional healthcare services public data.

RESULTS

Prevalence of LBP was 17.1% for men and 24.5% for women, and increased with age, low educational status, higher body mass index, and was associated with less physical activity, and lower self-perceived health. Multivariate analysis demonstrated that LBP was independently associated with a significant increase both in the utilization of all health services and on work day losses. Attributable costs of LBP were 8945.6 million euros, of which 74.5% implied indirect costs, representing overall 0.68% of Spanish Gross Domestic Product.

CONCLUSION

Spain is paying a heavy price for LBP, mostly associated with its significant impact on absenteeism and presenteeism, as well as a noteworthy effect on excess health services utilization. These findings underscore the need to address this considerable public health and social problem through interventions that address widely LBP and that have demonstrated to be cost-effective.

LEVEL OF EVIDENCE

3.

The prevalence of low back pain among female hospital staff at childbearing age

Background

Low back pain (LBP) is considered the most common work-related musculoskeletal disorder among female healthcare workers. The aim of this study is to compare the prevalence of LBP and non-ergonomic risk factors between female nurses, office workers, and patient transporters, and the effect of pain on job performance.

Methods

Based on semi-structured interviews, we conducted a cross-sectional study on Jordanian female hospital workers between January and July, 2017.

Results

We included 209 participants with a mean age of 35.57 ± 8 years from four Jordanian medical centers. Nurses have significantly higher frequency of LBP (82.5%; p = 0.05) compared to both office workers (67.5%) and patient transporters (68.6%). The mean difference in pain score using Visual Analogue Scale (VAS) after treatment varied significantly (p = 0.003), since it was 28.2 (±35.4) for office workers, compared to 22.8 (±26.5) for nurses and 6.5 (±33.7) for patient transporters. A higher frequency of nurses reported that LBP affected their job performance (64.9%; p = 0.013), and 43.3% of them reported having previous sick leaves due to LBP (p = 0.008).

Conclusions

LBP is common among female hospital workers, with significantly higher prevalence among female nurses when compared to other female hospital staff.

Beyond pain and disability: an explanatory mixed methods study exploring outcomes after physiotherapy intervention in patients with chronic low back pain

Purpose: The primary aim of this study was to explore relevant outcome domains for patients with chronic low back pain (CLBP) undergoing physiotherapy. A secondary aim was to examine potential discrepancies between meaningful changes in pain and disability and the global perception of improvement.Methods: An explanatory mixed methods design was employed. Twenty-two patients with CLBP completed self-reported measures before and after a physiotherapy programme. After the intervention, three focus groups were conducted with patients who perceived an overall improvement. Discussions were recorded, transcribed and analysed using thematic analysis.Results: Quantitative analysis showed an inconsistent relationship between changes in pain and disability measures and global improvements as perceived by patients. Two main themes emerged from the thematic analysis: "pain relief" (subthemes: reducing pain intensity and other symptoms; reducing medication intake; improving sleep quality) and "gaining control over the LBP condition" (subthemes: ability to self-manage; return to function; and sense of well-being and normality).Conclusion: Patients with CLBP perceived multiple outcomes from physiotherapy treatment that cover the domains of global, physical, mental and social health. These study findings suggest that the targets of measurement for physiotherapy need to be expanded in order to reflect outcome domains valued by patients.Implications for rehabilitationMinimum important changes in pain intensity and disability were not valid indicators of global improvements as perceived by patients.Patients with chronic low back pain undergoing physiotherapy perceived gains in multiple health domains that ranged beyond pain and disability domains.Physiotherapy outcome assessment needs to integrate other patient-relevant outcomes such as medication intake, sleep quality, ability to self-manage and sense of well-being.

Pain rates in general population for the period 1991-2015 and 10-years prediction: results from a multi-continent age-period-cohort analysis

Background

Pain is a common symptom, often associated with neurological and musculoskeletal conditions, and experienced especially by females and by older people. The aims of this study are to evaluate the temporal variations of pain rates among general populations for the period 1991–2015 and to project 10-year pain rates.

Methods

We used the harmonized dataset of ATHLOS project, which included 660,028 valid observations in the period 1990–2015 and we applied Bayesian age–period–cohort modeling to perform projections up to 2025. The harmonized Pain variable covers the content “self-reported pain experienced at the time of the interview”, with a dichotomous (yes or no) modality.

Results

Pain rates were higher among females, older subjects, in recent periods, and among observations referred to cohorts of subjects born between the 20s and the 60s. The 10-year projections indicate a noteworthy increase in pain rates in both genders and particularly among subjects aged 66 or over, for whom a 10–20% increase in pain rate is foreseen; among females only, a 10–15% increase in pain rates is foreseen for those aged 36–50.

Conclusions

Projected increase in pain rates will require specific interventions by health and welfare systems, as pain is responsible for limited quality of subjective well-being, reduced employment rates and hampered work performance. Worksite and lifestyle interventions will therefore be needed to limit the impact of projected higher pain rates.

Endoscopic facet joint denervation for treatment of chronic lower back pain

OBJECTIVES

Percutaneous radiofrequency is an established method for treatment of chronic low back pain of intervertebral facet etiology. Endoscopic techniques have the advantage of visualization of the facet joint and the dorsal medial ramus and thus allow for more accurate denervation. It was thus hypothesized that pain reduction is vaster and longer enduring.

PATIENTS AND METHODS

A total of 98 consecutive patients that underwent endoscopic facet joint denervation (EFJD) were included in this study. Prior to intervention and for follow-up, patients were asked to complete VAS_pain, ODI, COMI and EQ5D questionnaires.

RESULTS

VAS_pain was reduced significantly (EFJD: p < 0.001) at last follow-up. Values for ODI, COMI and EQ5D showed significant improvements towards subjective well-being at last follow-up.

CONCLUSION

EFJD is a promising technique for the treatment of facet joint syndrome caused CLBP as it contributes to sustaining significant pain reduction and improvement of subjective quality of life parameters.

Multicolumn spinal cord stimulation for predominant back pain in failed back surgery syndrome patients: a multicenter randomized controlled trial

Despite optimal medical management (OMM), low back pain (LBP) can be disabling, particularly after spinal surgery. Spinal cord stimulation (SCS) is effective in reducing neuropathic leg pain; however, evidence is limited for LBP. This prospective, open-label, parallel-group trial randomized (1:1) failed back surgery syndrome (FBSS) patients with predominant LBP to SCS plus OMM (SCS group) or OMM alone (OMM group) at 28 sites in Europe and the Americas. If trial stimulation was successful, a multicolumn SCS system was implanted. Outcomes were assessed at baseline (before randomization) and at 1, 3, 6, and 12 months after randomization. Patients could change treatment groups at 6 months. The primary outcome was the proportion of patients with ≥50% reduction in LBP (responder) at 6 months. Secondary outcomes included change in pain intensity, functional disability, and health-related quality of life (HRQoL). The results are posted at ClinicalTrials.gov under registration number NCT01697358. In the intent-to-treat analysis, there were more responders in the SCS group than in the OMM group (13.6%, 15/110 vs 4.6%, 5/108, difference 9% with 95% confidence interval 0.6%-17.5%, P = 0.036) at 6 months. The SCS group improved in all secondary outcomes compared with the OMM group. The OMM group only improved in HRQoL. In the SCS group, 17.6% (18/102) experienced SCS-related adverse events through 6 months, with 11.8% (12/102) requiring surgical reintervention. Adding multicolumn SCS to OMM improved pain relief, HRQoL, and function in a traditionally difficult-to-treat population of failed back surgery syndrome patients with predominant LBP. Improvements were sustained at 12 and 24 months.

Informal caring for back pain: overlooked costs of back pain and projections to 2030

This study models the economic costs of informal caring for people with back pain, using a microsimulation model, Care&WorkMOD, from 2015 to 2030. Care&WorkMOD was based on 3 national Australian Surveys of Disability, Ageing and Carers (2003, 2009, 2012) data sets for individuals aged 15 to 64 years. Estimated national income loss due to caring for people with back pain was AU$258 million in 2015, increasing to $398 million in 2030 (54% increase). Lost income tax revenue to the Australian government due to informal care of people with back pain was estimated to be AU$78 million in 2015, increasing to AU$118 million in 2030 (50% increase), and additional welfare payments were estimated to rise from $132 million in 2015 to AU$180 in 2030 (36% increase). Larger growth in lost income, compared with the increase in welfare payments, means that there would be an increasing income gap between those out of the labour force providing informal care and noncarers who are in the labour force, leading to increased inequality. Informal carers are defined as providers of informal, unpaid assistance to someone with a health condition, for at least 6 months. Informal carers of people with back pain who are out of the labour force incur substantial economic costs. Furthermore, back pain is a large economic burden on national governments. Policies addressing back pain prevention and treatment, and supporting carers, may offset government welfare expenditure, while improving the socioeconomic well-being of carers and patients.

A step-by-step protocol for isolation of murine nucleus pulposus cells

The intervertebral disc (IVD) is composed of three separate tissues with distinct origins and properties. Elucidating changes occurring in these tissues in response to injury or age is paramount to identify new therapies to better manage disc and spine degenerative conditions, including low back pain. Despite their small size and different mechanical load pattern compared to higher species, the use of mouse models represents a cost-effective and powerful approach to better understand the formation, maintenance, and degeneration of the IVD. However, the isolation of the different compartments of the IVD is complicated by their diminutive size. Here, we describe a simple, step-by-step protocol for the isolation of the nucleus pulposus (NP) tissues that can then be processed for further analyses. Analysis from mouse NP tissues shows sufficient quantities of RNAs, purity of the NP fraction, and overall RNA quality for gene expression studies, and reveals no increase in expression of disc degeneration markers, including TNFa, IL1b, and Mmp1 up to 15 months of age in C57BL6 wildtype mice.

High-Frequency Spinal Cord Stimulation for the Treatment of Chronic Low Back and Leg Pain: Implantation Technique of Percutaneous Leads and Implantable Pulse Generator

Spinal cord stimulation (SCS) is an evidence-based, reversible but invasive procedure for the treatment of chronic pain syndromes: for example, in patients with failed-back-surgery syndrome or complex regional pain syndrome. A more recent, similar technique uses high-frequency stimulation for SCS and follows a different mechanism of action that does not result in paresthesia. This Technical Note and video present surgical instructions of a "2-way cut-down" technique for a high-frequency SCS trial period and permanent implantation of an implantable pulse generator.

Downregulation of microRNA-129-5p increases the risk of intervertebral disc degeneration by promoting the apoptosis of nucleus pulposus cells via targeting BMP2

miR-129-5p is implicated in many diseases, such as laryngeal cancer and breast cancer. In this study, we studied the mechanism underlying the role of BMP2 in intervertebral disc degeneration (IDD). We used a luciferase assay system to determine the relationship between BMP2 and miR-129-5 expression. In addition, Western blot and real-time PCR were used to confirm the regulatory relationship between miR-129-5p and its targets, while flow cytometry was used to evaluate the effect of miR-129-5p on the apoptosis of neural progenitor cells (NPCs). BMP2 was confirmed as a direct target of miR-129-5p. Furthermore, the expression of miR-129 was downregulated along with upregulated BMP2 expression in IDD patients. Meanwhile, BMP2 was validated as the target of miR-129-5p in cells transfected with miR-129-5p and BMP2 siRNA. Also, compared with NPCs transfected with blank/scramble controls or miR-129-5p inhibitors, the NPCs treated with miR-129-5p mimics or BMP2 siRNA exhibited evidently elevated viability and inhibited apoptosis. The data demonstrated that miR-129-5p was poorly expressed in IDD patients, and the dysregulation of miR-129-5p might contribute to the development of IDD by targeting BMP2 expression.

Criteria for inclusion in programs of functional restoration for chronic low back pain: Pragmatic Study

BACKGROUND

Individuals with chronic low back pain (cLBP) may benefit from multimodal functional restoration programs (FRPs).

OBJECTIVE

The aim of this study was to analyze characteristics of individuals with cLBP who were referred or not to an FRP. Because cLBP is a bio-psycho-social disorder, medical and social parameters were analysed.

METHODS

This was an observational cross-sectional study performed in 2017 in 6 tertiary centres in France. Consecutive individuals with cLBP visiting a rheumatologist or physical medicine and rehabilitation physician were included. Individuals referred or not to an FRP were compared by demographic characteristics, duration of sick leave over the past year, self-reported physical activity>1h/week, pain (numeric rating scale 0-10), anxiety/depression (Hospital Anxiety and Depression Scale), disability (Oswestry Disability Index) and kinesiophobia (Tampa Kinesiophobia Scale). Univariate and multivariate logistic regression analyses were performed, estimating odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We included 147 individuals with cLBP. The mean (SD) age was 49 (12) years and 88 (60%) were women; 58 (38%) were referred to an FRP. On multivariate analysis, referral to an FRP was associated with reduced pain level (OR: 0.95, 95% CI: 0.91-0.99, for each 1-point increase in pain score), self-reported lack of physical activity (OR: 0.84, 95% CI: 0.72-0.98) and longer sick leave (OR: 1.03, 95% CI: 1.01-1.05, for 30 more days of sick leave).

CONCLUSION

In this multicentric observational study, referral to an FRP was linked to pain, self-reported physical activity and sick leave but not medical characteristics assessed. These findings confirm the bio-psycho-social approach of FRPs for cLBP.

The Chinese Association for the Study of Pain (CASP): Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain

Chronic nonspecific low back pain (CNLBP) is defined as pain or discomfort originating from the waist, which lasts for at least 12 weeks, but no radiculopathy or specific spinal diseases. CNLBP is a complicated medical problem and places a huge burden on healthcare systems. Clinical manifestation of CNLBP includes discogenic LBP, zygapophyseal joint pain, sacroiliac joint pain, and lumbar muscle strain. Further evaluation should be completed to confirm the diagnosis including auxiliary examination, functional assessment, and clinical assessment. The principle of the management is to relieve pain, restore function, and avoid recurrence. Treatment includes conservative treatment, minimally invasive treatment, and rehabilitation. Pharmacologic therapy is the first-line treatment of nonspecific LBP, and it is most widely used in clinical practice. Interventional therapy should be considered only after failure of medication and physical therapy. Multidisciplinary rehabilitation can improve physical function and alleviate short-term and long-term pain. The emphasis should be put on the prevention of NLBP and reducing relevant risk factors.

Prevalence and predictors of low back pain in a Southern Nigerian hospital

Background

Low back pain (LBP) is the most common musculoskeletal disease in adults. The data on LBP from Sub-Saharan Africa are inadequate. The aim of this study was to assess the prevalence and analyze the predictors of LBP among hospital staff in a Nigerian tertiary hospital.

Materials and Methods

The study participants were recruited using an opt-in approach, with the aim of including representative numbers from each professional cadre. Each participant gave formal consent. Ethical clearance was obtained.

Results

Five hundred and sixty-three participants with the mean age of 36.0 ± 8.3 years and 62% female were interviewed. The point prevalence of LBP was 234 (42% [95% confidence interval [CI]: 37%-45%]). Profession was a significant predictor of LBP (P = 0.001) - nurses (53% [95% CI 43%-63%]), administrative officers (49% [95% CI 40%-59%]), engineers (50% [95% CI 24%-76%]), and health information staff (50% [95% CI 26%-75%]) had the highest prevalence. In univariate regression, female gender, increasing age, body mass index ≥25 kg/m2, and frequently adopting a bending posture, were significantly associated with LBP, while in multivariate regression, only the female gender was a significant predictor.

Conclusion

The pattern of both the professions at risk, due to the well-known mechanisms of poor ergonomics, and the marked risk for the female gender, in the hospital setting, suggest underresourced work and societal environments as the underlying factors-more research is needed.

Chronic Low Back Pain: Current Pharmacotherapeutic Therapies and a New Biological Approach

Chronic low back pain (CLBP) syndrome represents one of the leading causes of long-term disability worldwide. The prevalence of CLBP has been rising significantly in relation to increasing average life expectancy. CLBP results from chronification of acute low back pain. There are many factors contributing to the CLBP crisis; common etiopathogenetic factors include e.g., functional blockage of intervertebral joints. The treatment of CLBP is complex. An important part of treatment consists of pain pharmacotherapy, for which several groups of drugs are used. The problem lies in the side effects of many of these traditionally used medications. Therefore, new and safer treatment methods are being sought. Innovative options for CLBP pharmacology include injections containing collagen, which can be combined with other traditionally used drugs, which helps reduce dosages and increase the overall safety of CLBP therapy.

Microparticles for controlled growth differentiation factor 6 delivery to direct adipose stem cell-based nucleus pulposus regeneration

Currently, there is no effective long‐term treatment for intervertebral disc (IVD) degeneration, making it an attractive candidate for regenerative therapies. Hydrogel delivery of adipose stem cells (ASCs) in combination with controlled release of bioactive molecules is a promising approach to halt IVD degeneration and promote regeneration. Growth differentiation factor 6 (GDF6) can induce ASC differentiation into anabolic nucleus pulposus (NP) cells and hence holds promise for IVD regeneration. Here, we optimised design of novel poly(DL‐lactic acid‐co‐glycolic acid) (PLGA)–polyethylene glycol–PLGA microparticles to control GDF6 delivery and investigated effect of released GDF6 on human ASCs differentiation to NP cells. Recombinant human (rh)GDF6 was loaded into microparticles and total protein and rhGDF6 release assessed. The effect of microparticle loading density on distribution and gel formation was investigated through scanning electron microscopy. ASC differentiation to NP cells was examined after 14 days in hydrogel culture by quantitative polymerase chain reaction, histological, and immunohistochemical staining in normoxic and IVD‐like hypoxic conditions. RhGDF6 microparticles were distributed throughout gels without disrupting gelation and controlled rhGDF6 release over 14 days. Released GDF6 significantly induced NP differentiation of ASCs, with expression comparable with or exceeding media supplemented rhGDF6. Microparticle‐delivered rhGDF6 also up‐regulated sulphated glycosaminoglycan and aggrecan secretion in comparison with controls. In hypoxia, microparticle‐delivered rhGDF6 continued to effectively induce NP gene expression and aggrecan production. This study demonstrates the effective encapsulation and controlled delivery of rhGDF6, which maintained its activity and induced ASC differentiation to NP cells and synthesis of an NP‐like matrix suggesting suitability of microparticles for controlled growth factor release in regenerative strategies for treatment of IVD degeneration.

Comparison between the STarT Back Screening Tool and the Örebro Musculoskeletal Pain Screening Questionnaire: Which tool for what purpose? A semi-systematic review

BACKGROUND

Prevention of chronicization of low back pain requires accurate detection of at-risk patients. Questionnaires have been validated, including the STarT Back Screening Tool (SBST) and the Örebro Musculoskeletal Pain Screening Questionnaire (OMPSQ). This review aims to compare these questionnaires in terms of predictive value and in terms of aims, to guide the choice in clinical practice.

METHODS

This study is a semi-systematic literature review. Studies evaluating at least one of the questionnaires and written between 1997 and October 10th 2017 were selected from Pubmed database. Inclusion criteria were pain duration<3months, outcomes including pain, function and/or global recovery. For work outcomes, inclusion criteria were extended to chronic patients. Studies had to provide information on sensitivity, specificity and area under the ROC Curve (AUC).

RESULTS

Twenty-eight studies met our inclusion criteria (7 SBST, 21 original OMPSQ, 3 short OMPSQ). The OMPSQ best predicted a Pain NRS≥3 at 3 months (AUC=0.64 (0.50-0.78)) and at 6 months (AUC between 0.70 (no confidence interval provided) and 0.84 (0.71-0.97)). The SBST and the OMPSQ are comparable to predict an Oswestry Disability Index≥30% at 6 months. A single study showed no difference between the SBST and the OMPSQ to predict absenteeism≥30 days at 6 months. The two questionnaires cannot be compared for "global recovery" outcomes.

CONCLUSION

The OMPSQ seems better than the SBST for predicting "pain" and "work" outcomes, the SBST may be better for "function" outcomes. These results should be taken with caution because of the high heterogeneity between studies. It should be noted that the OMPSQ was elaborated with the aim of creating a prognostic tool while the SBST was devised as a treatment-allocating tool and is easier to use in clinical practice. This should guide the choice of using one questionnaire rather than the other.

A guided and unguided internet- and mobile-based intervention for chronic pain: health economic evaluation alongside a randomised controlled trial

OBJECTIVE

This study aims at evaluating the cost-effectiveness and cost-utility of a guided and unguided internet-based intervention for chronic pain patients (ACTonPain_guided and ACTonPain_unguided) compared with a waitlist control group (CG) as well as the comparative cost-effectiveness of the guided and the unguided version.

DESIGN

This is a health economic evaluation alongside a three-arm randomised controlled trial from a societal perspective. Assessments were conducted at baseline, 9 weeks and 6 months after randomisation.

SETTING

Participants were recruited through online and offline strategies and in collaboration with a health insurance company.

PARTICIPANTS

302 adults (≥18 years, pain for at least 6 months) were randomly allocated to one of the three groups (ACTonPain_guided, ACTonPain_unguided, CG).

INTERVENTIONS

ACTonPain consists of seven modules and is based on Acceptance and Commitment Therapy. ACTonPain_guided and ACTonPain_unguided only differ in provision of human support.

PRIMARY AND SECONDARY OUTCOME MEASURES

Main outcomes of the cost-effectiveness and the cost-utility analyses were meaningful change in pain interference (treatment response) and quality-adjusted life years (QALYs), respectively. Economic evaluation estimates were the incremental cost-effectiveness and cost-utility ratio (ICER/ICUR).

RESULTS

At 6-month follow-up, treatment response and QALYs were highest in ACTonPain_guided (44% and 0.280; mean costs = €6,945), followed by ACTonPain_unguided (28% and 0.266; mean costs = €6,560) and the CG (16% and 0.244; mean costs = €6,908). ACTonPain_guided vs CG revealed an ICER of €45 and an ICUR of €604.ACTonPain_unguided dominated CG. At a willingness-to-pay of €0 the probability of being cost-effective was 50% for ACTonPain_guided (vs CG, for both treatment response and QALY gained) and 67% for ACTonPain_unguided (vs CG, for both treatment response and QALY gained). These probabilities rose to 95% when society's willingness-to-pay is €91,000 (ACTonPain_guided) and €127,000 (ACTonPain_unguided) per QALY gained. ACTonPain_guided vs ACTonPain_unguided revealed an ICER of €2,374 and an ICUR of €45,993.

CONCLUSIONS

Depending on society's willingness-to-pay, ACTonPain is a potentially cost-effective adjunct to established pain treatment. ACTonPain_unguided (vs CG) revealed lower costs at better health outcomes. However, uncertainty has to be considered. Direct comparison of the two interventions does not indicate a preference for ACTonPain_guided.

TRIAL REGISTRATION NUMBER

DRKS00006183.

Therapeutic potential of growth differentiation factors in the treatment of degenerative disc diseases

Intervertebral disc (IVD) degeneration is a major contributing factor to chronic low back pain and disability, leading to imbalance between anabolic and catabolic processes, altered extracellular matrix composition, loss of tissue hydration, inflammation, and impaired mechanical functionality. Current treatments aim to manage symptoms rather than treat underlying pathology. Therefore, IVD degeneration is a target for regenerative medicine strategies. Research has focused on understanding the molecular process of degeneration and the identification of various factors that may have the ability to halt and even reverse the degenerative process. One such family of growth factors, the growth differentiation factor (GDF) family, have shown particular promise for disc regeneration in in vitro and in vivo models of IVD degeneration. This review outlines our current understanding of IVD degeneration, and in this context, aims to discuss recent advancements in the use of GDF family members as anabolic factors for disc regeneration. An increasing body of evidence indicates that GDF family members are central to IVD homeostatic processes and are able to upregulate healthy nucleus pulposus cell marker genes in degenerative cells, induce mesenchymal stem cells to differentiate into nucleus pulposus cells and even act as chemotactic signals mobilizing resident cell populations during disc injury repair. The understanding of GDF signaling and its interplay with inflammatory and catabolic processes may be critical for the future development of effective IVD regeneration therapies.

The Effectiveness and Safety of Utilizing Mobile Phone-Based Programs for Rehabilitation After Lumbar Spinal Surgery: Multicenter, Prospective Randomized Controlled Trial

Background

Rehabilitation is crucial for postoperative patients with low back pain (LBP). However, the implementation of traditional clinic-based programs is limited in developing countries, such as China, because of the maldistribution of medical resources. Mobile phone–based programs may be a potential substitute for those who have no access to traditional rehabilitation.

Objective

The aim of this study was to examine the efficacy of mobile phone–based rehabilitation systems in patients who underwent lumbar spinal surgery.

Methods

Patients who accepted spinal surgeries were recruited and randomized into 2 groups of rehabilitation treatments: (1) a mobile phone–based eHealth (electronic health) program (EH) or (2) usual care treatment (UC). The primary outcomes were (1) function and pain status assessed by the Oswestry Disability Index (ODI) and (2) the visual analog scale (VAS). Secondary outcomes were (1) general mental health and (2) quality of life (Likert scales, EuroQol-5 Dimension health questionnaire, and 36-item Short-Form Health Survey). All the patients were assessed preoperatively and then at 3, 6, 12, and 24 months postoperatively.

Results

A total of 168 of the 863 eligible patients were included and randomized in this study. Our analysis showed that the improvement of primary outcomes in the EH group was superior to the UC group at 24 months postoperatively (ODI mean 7.02, SD 3.10, P<.05; VAS mean 7.59, SD 3.42, P<.05). No significant difference of primary outcomes was found at other time points.

A subgroup analysis showed that the improvements of the primary outcomes were more significant in those who completed 6 or more training sessions each week throughout the trial (the highest compliance group) compared with the UC group at 6 months (ODI mean 17.94, SD 5.24, P<.05; VAS mean 19.56, SD 5.27, P<.05), 12 months (ODI mean 13.39, SD 5.32, P<.05; VAS mean 14.35, SD 5.23, P<.05), and 24 months (ODI mean 18.80, SD 5.22, P<.05; VAS mean 21.56, SD 5.28, P<.05).

Conclusions

This research demonstrated that a mobile phone–based telerehabilitation system is effective in self-managed rehabilitation for postoperative patients with LBP. The effectiveness of eHealth was more evident in participants with higher compliance. Future research should focus on improving patients’ compliance.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-TRC-13003314; http://www.chictr.org.cn/showproj.aspx?proj=6245 (Archived by WebCite at http://www.webcitation.org/766RAIDNc)

The retroneural approach: an alternative technique for lumbar transforaminal epidural steroid injections

BACKGROUND

Compared with other available injection techniques for lumbar transforaminal epidural steroid injections (LTFESIs), the traditionally performed subpedicular approach is associated with a higher risk of spinal cord infarction, a rare but catastrophic complication.

PURPOSE

To assess the short-term efficacy of the retroneural approach for computed tomography (CT)-guided LTFESIs with respect to different needle-tip positions.

MATERIAL AND METHODS

This retrospective analysis included 238 patients receiving 286 CT-guided LTFESIs from January 2013 to January 2016. Short-term outcomes in terms of pain relief were assessed using the visual analogue scale (VAS) at baseline and 30 min after. The needle-tip location was categorized as extraforaminal, junctional, or foraminal relative to the neural foramen. Additionally, the distance from the needle tip to the nerve root was measured.

RESULTS

A mean pain reduction of 3.22 points (±2.17 points) on the VAS was achieved. The needle-tip location was extraforaminal in 48% (136/286), junctional in 42% (120/286), and foraminal in 10% (28/286) of the cases. The mean distance from the needle tip to the nerve root was 3.83 mm (±3.37 mm). There was no significant correlation between pain relief and needle-tip position in relation to the neural foramen. Therapy success was not dependent on the distance between the needle tip and the nerve root. No major complications were observed.

CONCLUSION

In our population treated with LTFESIs, the retroneural approach was shown to be an effective technique, with no significant differences in pain relief following different needle-tip positions.

Endoscopic Sacrolumbar Facet Joint Denervation in Osteoarthritic and Degenerated Zygapophyseal Joints

Chronic low-back pain (CLBP) has an increasing incidence and yields a tremendous health economic burden. There are different anatomic structures that may be responsible for CLBP, such as lumbar intervertebral discs, sacroiliac joints, nerve root dura, fascia, ligaments, and muscles. However, to a large extent, CLBP is associated with structural changes in and around the facet (zygapophyseal) joint. If conservative treatment strategies fail, symptoms and pain can effectively be reduced by denervation or rhizotomy of the medial branch of the dorsal ramus of the spinal nerve through radiofrequency ablation. In this technical description with video, we present an endoscopic technique for radiofrequency rhizotomy. This technique has the advantage of directly visualizing the facet joint as well as its surrounding structures including the medial branches.

Therapeutic Potential of Naringin for Intervertebral Disc Degeneration: Involvement of Autophagy Against Oxidative Stress-Induced Apoptosis in Nucleus Pulposus Cells

Intervertebral disc degeneration (IDD) is a major cause of lower back pain, but few efficacious medicines have been developed for IDD. Increased nucleus pulposus cells apoptosis is a dominant pathogenesis of IDD and is considered a therapeutic target. Previously, our group proved that autophagy may protect nucleus pulposus cells against apoptosis. As one of the major bioflavonoids of citrus, naringin activates autophagy. Therefore, we hypothesize that naringin may have therapeutic potential for IDD by activating autophagy in nucleus pulposus cells. In this study, we evaluated the effects of naringin on TBHP-induced oxidative stress in nucleus pulposus cells in vitro as well as in puncture-induced rat IDD model in vivo. Our results showed that naringin could reduce the incidence of oxidative stress-induced apoptosis in nucleus pulposus cells and promoted the expression of autophagy markers LC3-II/I and beclin-1. Meanwhile, inhibition of autophagy by 3-MA may partially reverse the anti-apoptotic effect of naringin, indicating that autophagy was involved in the protective effect of naringin in nucleus pulposus cells. Further study showed that autophagy regulation of naringin may be related to AMPK signaling. Also, we found that naringin treatment can regulate the expression of collagen II, aggrecan and Mmp13 to sustain the extracellular matrix. Furthermore, our in vivo study showed that naringin can ameliorate IDD in puncture-induced rat model. In conclusion, our study suggests that naringin can protect nucleus pulposus cells against apoptosis and ameliorate IDD in vivo, the mechanism may relate to its autophagy regulation.

Quantitative MRI correlates with histological grade in a percutaneous needle injury mouse model of disc degeneration

Low back pain due to disc degeneration is a major cause of morbidity and health care expenditures worldwide. While stem cell-based therapies hold promise for disc regeneration, there is an urgent need to develop improved in vivo animal models to further develop and validate these potential treatments. The objectives of this study were to characterize a percutaneous needle injury model of intervertebral disc degeneration in the mouse caudal spine, and compare two non-invasive quantitative imaging techniques, microcomputed tomography and magnetic resonance imaging (MRI), as effective measures of disc degeneration in this model. Percutaneous needle injury of mouse caudal discs was undertaken using different needle sizes and injury types (unilateral or bilateral annulus fibrosus (AF) puncture). Mice were euthanized 4 weeks post-injury, and MRI and microcomputed tomography were used to determine T2 relaxation time of the NP and disc height index, respectively. Disc condition was then further assessed using semi-quantitative histological grading. Bilateral AF puncture with either 27 or 29G needles resulted in significantly lower T2 relaxation times compared to uninjured controls, while disc height index was not significantly affected by any injury type. There was a strong, inverse linear relationship between histological grade and NP T2 relaxation time. In this study, we demonstrated that quantitative MRI can detect disc degeneration in the mouse caudal spine 4 weeks following percutaneous needle injury, and may therefore serve as a surrogate for histology in longitudinal studies of both disc degeneration and cell-based therapies for disc regeneration using this model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2771-2779, 2018.

DEEP Study: Indirect and Out-of-pocket Costs of Persistent Orofacial Pain

Persistent orofacial pain (POFP) is common and caused by a group of conditions affecting the face, head, or mouth. Recent research highlighted a problematic care pathway with high costs to the health care provider, but the financial impact on patients and employers is not understood. This study aimed to describe patient (out-of-pocket) and employer (indirect) costs of POFP and to identify whether the dichotomized Graded Chronic Pain Scale (GCPS) was predictive of costs. A cohort of 198 patients was recruited from primary and secondary care settings in North East England and followed over a 24-mo period. Patients completed the GCPS and Use of Services and Productivity Questionnaire every 6 mo and a Time and Travel Questionnaire at 14 mo. Questionnaires examined the implications of health care utilization on patients’ everyday lives and personal finances. Time and travel costs were calculated and applied to use-of-services data to estimate out-of-pocket costs, while the human capital method and QQ method (quantity and quality of work completed) were used to estimate absenteeism and presenteeism costs, respectively. Per person per 6-mo period (in 2017 pounds sterling), mean out-of-pocket costs were £333 (95% CI, £289 to £377), and indirect costs were £1,242 (95% CI, £1,014 to £1,470). Regression analyses indicated that over 6 mo, the GCPS was predictive of the following: out-of-pocket costs—a difference of £311 between low and high GCPS per person per 6-mo period (95% CI, £280 to £342; P < 0.01, n = 705 observations over 24 mo); indirect costs—a difference of £2,312 between low and high GCPS per person per 6-mo period (95% CI, £1,886 to £2,737; P < 0.01; n = 352 observations over 24 mo). This analysis highlights “hidden” costs of POFP and supports the use of the dichotomized GCPS to identify patients at risk of higher impact and associated costs and thereby stratify care pathways and occupational health support appropriately.

Clinical Manifestation of Acute, Subacute, and Chronic Low Back Pain in Different Age Groups: Low Back Pain in 35,446 Patients

BACKGROUND

Low back pain (LBP) is a major healthcare problem causing tremendous economic costs.

METHODS

Clinical manifestation of LBP was characterized in 35,446 patients. We focused on the comparison of the acute, subacute, and chronic LBP stage with regard to patients' ages, based on epidemiologic and clinical questionnaires (eg, painDETECT Questionnaire, Pain Disability Index), pain intensity, pain descriptors, and functional impairment.

RESULTS

We found that neuropathic components were most frequent in chronic LBP patients at the ages of 51 to 60 years. Elderly LBP patients showed a decrease in neuropathic and an increase in nociceptive pain. The most frequently reported pain descriptors were "pressure pain" and "pain attacks" through all stages of LBP, whereas "burning" and "prickling" were most frequent in the chronic stage. Patients after back surgery presented neuropathic pain symptoms most frequently and had the highest amount of pain medication intake.

CONCLUSIONS

Burning and prickling were revealed as possible indicators for LBP chronicity. Combined with pain attacks and pressure pain, these 4 pain descriptors might be a promising adjunct to pain intensity in terms of outcome parameters for future LBP studies. The decrease of neuropathic pain syndromes in the elderly might be explained by degenerative processes. The presented work provides important insights on LBP management in the acute, subacute, and chronic stages.

Understanding the Etiology of Chronic Pain From a Psychological Perspective

The etiology of chronic pain-related disability is not fully understood, particularly from a clinical perspective. Investigations to date have identified risk factors and elucidated some important processes driving the development of persistent pain problems. Yet this knowledge and its application are not always accessible to practicing physical therapists or other clinicians. This article aims to summarize the main psychological processes involved in the development of chronic pain disability and to derive some guidelines for treatment and future research. To this end, the focus is on the paradox of why coping strategies that are helpful in the short term continue to be used even when-ironically-they maintain the problem in the long term. To aid in summarizing current knowledge, 4 tenets that elucidate the etiology of chronic pain are described. These tenets emphasize that chronic pain disability is a developmental process over time, contextual factors set the stage for this development, underlying transdiagnostic psychological factors fuel this development, and the principles of learning steer the development of pain behaviors. With these tenets, an explanation of how a chronic problem develops for one person but not another is provided. Finally, hypotheses that can be empirically tested to guide clinical application as well as basic research are generated. In conclusion, understanding the psychological processes underlying the etiology of chronic pain provides testable ideas and a path forward for improving treatment interventions.

Low Magnitude of Compression Enhances Biosynthesis of Mesenchymal Stem Cells towards Nucleus Pulposus Cells via the TRPV4-Dependent Pathway

Mesenchymal stem cell- (MSC-) based therapy is regarded as a promising tissue engineering strategy to achieve nucleus pulposus (NP) regeneration for the treatment of intervertebral disc degeneration (IDD). However, it is still a challenge to promote the biosynthesis of MSC to meet the requirement of NP regeneration. The purpose of this study was to optimize the compressive magnitude to enhance the extracellular matrix (ECM) deposition towards discogenesis of MSCs. Thus, we constructed a 3D culture model for MSCs to bear different magnitudes of compression for 7 days (5%, 10%, and 20% at the frequency of 1.0 Hz for 8 hours/day) using an intelligent and mechanically active bioreactor. Then, the underlying mechanotransduction mechanism of transient receptor potential vanilloid 4 (TRPV4) was further explored. The MSC-encapsulated hybrids were evaluated by Live/Dead staining, biochemical content assay, real-time PCR, Western blot, histological, and immunohistochemical analysis. The results showed that low-magnitude compression promoted anabolic response where high-magnitude compression induced the catabolic response for the 3D-cultured MSCs. The anabolic effect of low-magnitude compression could be inhibited by inhibiting TRPV4. Meanwhile, the activation of TRPV4 enhanced the biosynthesis analogous to low-magnitude compression. These findings demonstrate that low-magnitude compression promoted the anabolic response of ECM deposition towards discogenesis for the 3D-cultured MSCs and the TRPV4 channel plays a key role on mechanical signal transduction for low-magnitude compressive loading. Further understanding of this mechanism may provide insights into the development of new therapies for MSC-based NP regeneration.

Total Disc Replacement Versus Anterior-Posterior Interbody Fusion in the Lumbar Spine and Lumbosacral Junction: A Cost Analysis

STUDY DESIGN

Prospective observational cohort study.

OBJECTIVES

To analyze clinical and economic results in patients with degenerative disc disease in the lumbar area for patients who received combined anterior and posterior fusion or total disc replacement (TDR).

METHODS

The study included 75 patients, 38 in the fusion group and 37 in the TDR group, who received either anterior/posterior fusion or TDR for lumbar disc disease from January 2005 to December 2008 with a minimum follow-up of 24 months. We collected data with regard to clinical parameters, demographics, visual analogue scale scores, Oswestry Disability Index scores, SF-36 and SF-6D data, surgery time, amount of blood loss, transfusion of blood products, number of levels, duration of hospital stay, and complications. For cost analysis, general infrastructure, theatre costs, as well as implant costs were examined, leading to primary hospital costs. Furthermore, average revision costs were examined, based on the actual data. Statistical analysis was performed using t tests for normal contribution and Mann-Whitney test for skew distributed values. The significance level was set to .05.

RESULTS

There was a higher surgery time, more blood loss, and longer hospital stay for the fusion group, compared with the TDR group. In addition, the hospital costs for the primary procedure and revision were 35% higher in the fusion group. The clinical data in terms of SF-36 and SF-6D showed no difference between these 2 groups.

CONCLUSIONS

TDR is a good alternative to anterior and posterior lumbar fusion in terms of short follow-up analysis for clinical data and cost analysis. General advice cannot be given due to missing data for long-term costs in terms of surgical treatment of adjacent level or further fusion techniques.

Comparison of Chiropractic Treatment Outcomes Depending on the Language Region in Switzerland: A Prospective Outcomes Study

OBJECTIVES

Switzerland has optimal conditions for research of language-based cultural influences on low back pain (LBP). The aim of this study was to compare LBP treatment outcomes after chiropractic care between patients from the German- and French-speaking regions of Switzerland.

METHODS

Baseline Numeric Rating Scale for pain (NRS), demographic, and Oswestry Disability Index (ODI) data were collected from patients presenting to 51 Swiss-German and 12 Swiss-French chiropractors. Prospective outcome data included the proportion reporting clinically relevant improvement on the Patient Global Impression of Change scale and the NRS change scores collected at 1 week; 1, 3, and 6 months; and 1 year. ODI change scores were collected until 3 months. The proportion improved between the 2 groups was compared using the χ² test. NRS and ODI change scores were compared using the unpaired t test.

RESULTS

At baseline, only patient age comparing 853 Swiss-German and 215 Swiss-French patients revealed a significant difference. The Patient Global Impression of Change, NRS, and ODI had no significant differences between both patient groups up to 6 months. Between 6 months and 1 year the proportion reporting improvement continued to increase to 83.5% for German-speaking Swiss but reduced to 73.1% for French-speaking Swiss (P = .01). The NRS change scores were also higher for German speaking Swiss at 1 year compared with Swiss-French citizens (P = .01).

CONCLUSION

Treatment outcome data for LBP are comparable in the German and French parts of Switzerland until the 1-year time point, when people located in the French-speaking regions are more likely to have an increase in pain levels.

Development of a device to reduce the risk of injury in handling unstable loads

BACKGROUND

Manual material handling (MMH) task is the most common cause of work-related musculoskeletal disorders (MSDs). Operators carrying unstable loads were recently shown to be at greater risk of back injury compared to workers carrying stable loads.

OBJECTIVE

This study focused on developing a device to minimize trunk muscle activity and cardiovascular demand while handling a 19-liter bottle.

METHOD

After evaluating several designs, one was selected to be developed, manufactured and tested through an experimental study. Healthy participants (n = 42) manually carried a 19-liter bottle. The carrying technique (i.e., carrying a lateral load while holding the load using the dominant hand, pulling the load using the developed device, carrying the load on the back using the developing device) was the independent variable. The muscular activities (e.g., neck extensor, upper trapezius, pectoralis major, deltoid medial, rectus abdominis, and erector spinae muscles of the dominant side), cardiac costs, plantar pressures, walking speeds, and subjective measures were the dependent variables.

RESULTS

Results show that carrying the developed device like a backpack significantly reduced trunk muscle activity, cardiovascular demand, and plantar pressure compared to the usual practice. The present results suggest that carrying a 19-liter water bottle using the developed device is likely to contribute to lower MSDs.

CONCLUSION

Implementation of the develop device recommended to lessen the risk of injury when handling unstable loads such as liquids.

Static Compression Induces ECM Remodeling and Integrin α2β1 Expression and Signaling in a Rat Tail Caudal Intervertebral Disc Degeneration Model

STUDY DESIGN

A three-level rat tail caudal intervertebral disc (IVD) degeneration (IVDD) model was established to study effects of static compression on extracellular matrix (ECM) remodeling and integrin signaling in IVDs during IVDD.

OBJECTIVE

The aim of this study was to investigate the effect of compression force on ECM remodeling and integrin signaling in IVDs during IVDD.

SUMMARY OF BACKGROUND DATA

Integrins sense mechanical environment alteration via binding to ECM ligands and trigger intracellular signaling for pathological ECM remodeling during IVDD. However, the role of compression force in ECM remodeling and integrin signaling during IVDD remains elusive.

METHODS

Compared with the classical one-level rat tail IVDD model that exerts axial stress on the 8th to 9th caudal vertebral bodies, a three-level model was established by using an Ilizarov-type apparatus to exert stress on the 7th to 10th caudal vertebral bodies in rat tails for four weeks. To exclude side effects from surgical stab injury on manipulated discs, intact coccygeal (Co) disc Co8-9 was analyzed.

RESULTS

In three-level IVDD model, significant degeneration of the Co8-9 disc was observed. Quantitative real-time polymerase chain reaction (qRT-PCR) showed elevated mRNA expression of collagen types I, III, and V; matrix metalloproteinases (MMPs) 2, 3, 9, 13, 14; and decreased mRNA expression of collagen type II in Co8-9 disc. Compression loading altered the expression of integrin α2β1 (upregulated) and α10β1 (downregulated) in NP cells, and activated integrin downstream signaling. By contrast, one-level model showed more severe disc degeneration and ECM remodeling. Integrin α1, α2, α11, and β1 were upregulated, whereas α10 was downregulated. Similar activation of integrin signaling was observed.

CONCLUSION

Static compression altered collagen and MMP expression, and promoted β1 integrin expression and signaling in IVD. Compared with one-level rat tail IVDD model, three-level model showed milder effects on disc degeneration, ECM remodeling, and integrin expression, suggesting one-level model might involve other causes that induce IVDD via mechanisms independent of compression force.

LEVEL OF EVIDENCE

N/A.

Possible involvement of the oxLDL/LOX-1 system in the pathogenesis and progression of human intervertebral disc degeneration or herniation

Epidemiological studies have concluded that hyperlipidemia and atherosclerosis were related to intervertebral disc degeneration (IVDD). The presence of oxidized low density lipoprotein (ox-LDL) and the expression of lectin-like oxidized low density lipoprotein receptor 1 (LOX-1) have not been explored in this tissue. In this study, we investigated the presence of ox-LDL and the expression of its receptor LOX-1 in non-degenerated, degenerated or herniated human intervertebral discs (IVDs). The expression of LOX-1 and matrix metalloproteinase 3 (MMP3) were studied after incubating nucleus pulposus cells (NPCs) with ox-LDL. The presence of ox-LDL and LOX-1 was positively related with the extent of IVDD in nucleus pulposus (NP), end-plate cartilage and outer annulus fibrous, but not with the extent of degeneration of inter annulus fibrous. Ox-LDL significantly reduced the viability of human NPCs in a dose and time-dependent manner, and increased the expression of MMP3 induced by LOX-1. Pretreatment with anti-human LOX-1 monoclonal antibody reversed these effects. Ox-LDL, principally mediated by LOX-1, enhanced MMP3 production in NPCs through the NF-κB signaling pathway. In conclusion, increased accumulation of ox-LDL and LOX-1 in IVDs indicates a specific role of the receptor-ligand interaction in degeneration or herniation of IVDs.

Application of advanced biomechanical methods in studying low back pain - recent development in estimation of lower back loads and large-array surface electromyography and findings

Low back pain (LBP) is a major public health problem and the leading disabling musculoskeletal disorder globally. A number of biomechanical methods using kinematic, kinetic and/or neuromuscular approaches have been used to study LBP. In this narrative review, we report recent developments in two biomechanical methods: estimation of lower back loads and large-array surface electromyography (LA-SEMG) and the findings associated with LBP. The ability to estimate lower back loads is very important for the prevention and the management of work-related low back injuries based on the mechanical loading model as one category of LBP classification. The methods used for estimation of lower back loads vary from simple rigid link-segment models to sophisticated, optimization-based finite element models. In general, reviewed reports of differences in mechanical loads experienced in lower back tissues between patients with LBP and asymptomatic individuals are not consistent. Such lack of consistency is primarily due to differences in activities under which lower back mechanical loads were investigated as well as heterogeneity of patient populations. The ability to examine trunk neuromuscular behavior is particularly relevant to the motor control model, another category of LBP classification. LA-SEMG not only is noninvasive but also provides spatial resolution within and across muscle groups. Studies using LA-SEMG showed that healthy individuals exhibit highly organized, symmetric back muscle activity patterns, suggesting an orderly recruitment of muscle fibers. In contrast, back muscle activity patterns in LBP patients are asymmetric or multifocal, suggesting lack of orderly muscle recruitment. LA-SEMG was also shown capable of capturing unique back muscle response to manual therapy. In conclusion, estimation of low back load and LA-SEMG techniques demonstrated promising potentials for understanding LBP and treatment effects. Future studies are warranted to fully establish clinical validity of these two biomechanical methods.

Burst or High-Frequency (10 kHz) Spinal Cord Stimulation in Failed Back Surgery Syndrome Patients With Predominant Back Pain: One Year Comparative Data

OBJECTIVES

Burst and 10 kHz spinal cord stimulation (SCS) demonstrated improvement for failed back surgery syndrome (FBSS) with predominant, refractory back pain. Here, we report the long-term follow-up of a previously published study comparing the safety and efficacy of burst vs. 10 kHz SCS for predominant back pain (70% of global pain) of FBSS patients.

METHODS

This comparative, observational study extended the follow-up period up to 20 months evaluating both SCS modalities. Pain intensity (visual analog scale [VAS_B , VAS_L ]), functional capacity (Pittsburgh Sleep Quality Index [PSQI]; depression (Beck Depression Inventory [BDI]), stimulation parameters and hardware and/or stimulation associated adverse events were recorded and analyzed over time.

RESULTS

Overall VAS_B (t_1,12  = 66.76, p < 0.001) and VAS_L (t_1,12  = 4.763, p < 0.049; p < 0.001) declined over time. Burst significantly decreased VAS_B by 87.5% (±17.7) (mean 8 ± 0.76 to 1 ± 1.41; t₁ =12.3, p < 0.001), and 10 kHz significant decreased VAS_B by 54.9% (±44) (mean 8 ± 0.63 to 3.5 ± 3.27; t₁ =3.09, p = 0.027). No significant differences for between SCS types were revealed (t₁ =1.75, p = 0.13). VAS_L was significantly suppressed for burst (burst: 3.6 ± 1.59 to 1.5 ± 1.06; t₁  = 3.32, p = 0.013). A significant effect of time was found for functional outcome with no significant differences between SCS types (PSQI: t_1,12  = 8.8, p = 0.012; and BDI: t₁  = 53.3, p < 0.001). No stimulation/hardware-related complications occurred.

DISCUSSION

Long-term data of this comparative study suggests that burst responsiveness was superior to 10 kHz in our small-scale cohort, thus a larger, randomized-controlled comparative study design is highly recommended.

Low back pain in healthy postmenopausal women and the effect of physical activity: A secondary analysis in a randomized trial

Epidemiological studies on the prevalence of musculoskeletal pain have consistently shown that this is a relevant health problem, with non-specific low back pain (LBP) being the most commonly reported in adult females. Conflicting data on the association between LBP symptoms and physical activity (PA) have been reported. Here, we investigated the prevalence of LBP and the effect of a 24-month non-specific PA intervention on changes in LBP prevalence in a series of Italian healthy postmenopausal women. We performed a secondary analysis in the frame of the DAMA trial, a factorial randomized intervention trial aimed to evaluate the ability of a 24-month intervention, based on moderate-intensity PA, and/or dietary modification, in reducing mammographic breast density in healthy postmenopausal women. The PA intervention included at least 1 hour/day of moderate PA and a more strenuous weekly activity, collective walks and theoretical group sessions. A self-administered pain questionnaire was administered at baseline and at the end of the intervention. The questionnaire was specifically structured to investigate the occurrence of musculoskeletal pain, the body localization, intensity and duration of the pain. Two hundred and ten women (102 randomized to PA intervention, 108 not receiving the PA intervention) filled out the questionnaires. At baseline LBP was present in 32.9% of the participants. Among women randomized to the PA intervention, LBP prevalence at follow up (21.6%) was lower than at baseline (33.3%) (p = 0.02), while in women who did not receive the PA intervention the LBP prevalence at baseline and follow up were 32.4% and 25.9%, respectively (p = 0.30). Overall, there was no significant between-group effect of PA intervention on LBP. Further studies are needed to understand the role of non-specific PA intervention, aimed to improve overall fitness, on LBP prevalence.

An interpenetrating network-strengthened and toughened hydrogel that supports cell-based nucleus pulposus regeneration

Hydrogel is a suitable scaffold for the nucleus pulposus (NP) regeneration. However, its unmatched mechanical properties lead to implant failure in late-stage disc degeneration because of structural failure and implant extrusion after long-term compression. In this study, we evaluated an interpenetrating network (IPN)-strengthened and toughened hydrogel for NP regeneration, using dextran and gelatin as the primary network while poly (ethylene glycol) as the secondary network. The aim of this study was to realize the NP regeneration using the hydrogel. To achieve this, we optimized its properties by adjusting the mass ratios of the secondary/primary networks and determining the best preparation conditions for NP regeneration in a series of biomechanical, cytocompatibility, tissue engineering, and in vivo study. We found the optimal formulation of the IPN hydrogel, at a secondary/primary network ratio of 1:4, exhibited high toughness (the compressive strain reached 86%). The encapsulated NP cells showed increasing proliferation, cell clustering and matrix deposition. Furthermore, the hydrogel could support long-term cell retention and survival in the rat IVDs. It facilitated rehydration and regeneration of porcine degenerative NPs. In conclusion, this study demonstrates the tough IPN hydrogel could be a promising candidate for functional disc regeneration in future.

Trends in diagnosis of painful neck and back conditions, 2002 to 2011

Neck and back pain are pervasive problems. Some have suggested that rising incidence may be associated with the evidence of rising prevalence.To describe the trends in diagnosis of painful neck and back conditions in a large national healthcare system.A retrospective observational cohort study to describe the incidence and prevalence of diagnosis of neck and back pain in a national cohort.Patients were identified by International Classification of Diseases, 9 Revision (ICD-9) codes in Department of Veterans Affairs (VA) national utilization datasets in calendar years 2002 to 2011.Descriptive statistics were used to analyze the data. Prevalent cases were compared with all veterans who sought health care in each year. Incident cases were identified following a 2 years clean period in which the patient was enrolled and received care, but not services for any back or neck pain conditions.From 2004 to 2011, 3% to 4% of the population was diagnosed with incident back pain problems, the rate increasing on average, 1.75% per year. During the same period, 12.3% to 16.2% of the population was diagnosed with a prevalent back pain problem, the rate increasing on average 4.09% per year.In a national population, the prevalence rate for diagnosis of neck and back pain grew 1.8 to 2.3 times faster than the incidence rate. This suggests that the average duration of episodes of care is increasing. Additional research is needed to understand the influences on the differential rate of change and to develop efficient and effective care systems.

Icariin Prevents H2O2-Induced Apoptosis via the PI3K/Akt Pathway in Rat Nucleus Pulposus Intervertebral Disc Cells

Icariin is a prenylated flavonol glycoside derived from the Chinese herb Epimedium sagittatum. This study investigated the mechanism by which icariin prevents H₂O₂-induced apoptosis in rat nucleus pulposus (NP) cells. NP cells were isolated from the rat intervertebral disc and they were divided into five groups after 3 passages: (A) blank control; (B) 200 μM H₂O₂; (C) 200 μM H₂O₂ + 20 μM icariin; (D) 20 μM icariin + 200 μM H₂O₂ + 25 μM LY294002; (E) 200 μM H₂O₂ + 25 μM LY294002. LY294002 is a selective inhibitor of the phosphoinositide 3-kinase (PI3K)/Akt signaling pathway. NP cell viability, apoptosis rate, intracellular reactive oxygen species levels, and the expression of AKT, p-AKT, p53, Bcl-2, Bax, caspase-3 were estimated. The results show that, compared with the control group, H₂O₂ significantly increased NP cell apoptosis and the level of intracellular ROS. Icariin pretreatment significantly decreased H₂O₂-induced apoptosis and intracellular ROS and upregulated p-Akt and BCL-2 and downregulated caspase-3 and Bax. LY294002 abolished the protective effects of icariin. Our results show that icariin can attenuate H2O2-induced apoptosis in rat nucleus pulposus cells and PI3K/AKT pathway is at least partly included in this protection effect.

The effectiveness of transforaminal epidural steroid injection in patients with radicular low back pain: Combination of pain provocation with effectiveness results

Objectives

This study aims to investigate the efficacy of transforaminal epidural steroid injection (TFESI) on low back pain relief and functional impairments and whether pain provocation during injection has an effect on pain relief in mid-term.

Patients and methods

The study, which was conducted between September 2012 and September 2013, included 62 patients with low back pain (38 males, 24 females; median age 45 years; min 22 - max 88 years). All injections were applied under C-arm fluoroscopy guidance, using a mix of betamethasone and lidocaine. A 100 mm Visual Analog Scale (VAS) for pain, Oswestry Disability Index (ODI), and Short Form-36 were administered before the injection, and at post-injection second and 12th weeks. Presence of any pain provocation was questioned during injection.

Results

The most frequent level of intervention was L5 level. Median initial VAS score was 80.0 (50.0;100.0) mm, which was measured as 45.0 (0.0;90.0) mm and 30.0 (0.0;100.0) mm at the post-injection second and 12th weeks, respectively. Median initial ODI score was 25.0 (9.0;43.0) points, which was measured as 17.0 (3.0;38.0) and 12.5 (1.0;38.0) points at the post-injection second and 12th weeks, respectively. All subgroup scores of SF-36 improved significantly during the follow-up period. We detected statistically significant improvements in the outcome measurements at the post-injection second and 12th weeks (p<0.05). There were significant differences between patients with positive and moderate pain provocation in terms of VAS (p=0.004) and ODI (p=0.006) scores.

Conclusion

In this follow-up study, transforaminal epidural steroid injection was found to be effective in both the early period and in the mid-term. Pain provocation was not clinically predictive for better outcome according to the results.

Isolation and identification of stem cells from degenerated human intervertebral discs and their migration characteristics

Mesenchymal stem cells (MSCs) have been isolated and identified separately from the three components of intervertebral disc, i.e. annulus fibrosus (AF), nucleus pulposus (NP), and cartilage endplate (CEP). However, few studies have been carried out to compare the properties of these three kinds of stem cells, especially their migration ability which is essential for their potential clinical application. In this study, MSCs were isolated from AF, NP, and CEP, respectively, of human degenerated discs and identified by surface markers and multilineage differentiation assay at passage 3. These three types of stem cells were named as AF-MSCs, NP-MSCs, and CEP-MSCs. Then, their biological characteristics were compared in terms of proliferation, passage, colony formation, migration, and invasion capacity. Results showed that all the three types of cells were identified as MSCs and had similar characteristics in proliferation, passage, and colony formation capacity. CEP-MSCs showed the highest migration and invasion potency, while NP-MSCs showed the lowest migration ability and almost no invasion potency, suggesting that CEP-MSCs had the most powerful properties of migration and invasion when compared with AF-MSCs and NP-MSCs. It was also found that the expression of CXCR4 was higher in CEP-MSCs than in the other two, suggesting that SDF-1/CXCR4 axis may play significant roles in the migration of these cells.

Meloxicam in Russia: 20 years together

Meloxicam is one of the most commonly used representatives of the group of nonsteroidal anti-inflammatory drugs prescribed in our country. It has been used in Russian clinical practice for 20 years and established itself as an effective and rather safe analgesic and anti-inflammatory medications. During this period almost 48 million packages of brand-name meloxicam have been sold; millions of people in our country have been successfully treated with this drug. During this period, there have been at least 29 Russian clinical trials of brand-name meloxicam, which covered 3,736 patients. In all the trials, meloxicam has demonstrated a good therapeutic potential (a substantial improvement in more than 75% of patients) and a low incidence of side effects, which averaged 6.4% (30.5% in the control groups). The good tolerability of brand-name meloxicam (Movalis) is confirmed by a total of 120 spontaneous reports of the adverse events due to this drug, which were sent to the Federal Service for Health Supervision in December 2008 to July 2015 (over the last 7 years). This number seems negligible (nearly 30 million packages) if the amount of meloxicam sold over the period is taken into account. Extensive experience in clinical practice with this drug and a wide series of national clinical trials support the good reputation of brand-name meloxicam among Russian physicians and patients. This review briefly gives the data of Russian and main foreign clinical trials of the therapeutic effect and safety of meloxicam.

Transient physical and psychosocial activities increase the risk of nonpersistent and persistent low back pain: a case-crossover study with 12 months follow-up

BACKGROUND CONTEXT

A previous study has shown that transient physical and psychosocial activities increased the risk of developing low back pain. However, the link between these factors in triggering nonpersistent or persistent episodes remains unclear.

PURPOSE

We aimed to investigate the association of transient exposures to physical and psychosocial activities with the development of nonpersistent or persistent low back pain.

STUDY DESIGN

This was a case-crossover study with 12 months follow-up.

PATIENT SAMPLE

We included 999 consecutive participants seeking care for a sudden onset of low back pain.

OUTCOME MEASURES

Development of low back pain was the outcome measure.

MATERIALS AND METHODS

At baseline, participants reported transient exposures to 12 predefined activities over the 4 days preceding pain onset. After 12 months, participants were asked whether they had recovered and the date of recovery. Exposures in the 2-hour period preceding pain onset (case window) were compared with the 2-hour period, 24 hours before pain onset (control window) in a case-crossover design for all participants. Conditional logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CI), and interaction analyses were used to compare estimates of nonpersistent (i.e., <6 weeks duration) and persistent cases. This study received funding from Australia's National Health and Medical Research Council (APP1003608).

RESULTS

There were 832 participants (83%) who completed the 12 months follow-up successfully. Of these, 430 participants had nonpersistent low back pain (<6 weeks duration), whereas 352 reported persistent symptoms (≥6 weeks duration). Exposure to several transient activities, such as manual tasks involving heavy loads, awkward postures, live people or animals, moderate or vigorous physical activity, and being fatigued or tired during a task or activity, significantly increased the risk of both nonpersistent and persistent low back pain, with ORs ranging from 2.9 to 11.7. Overall, the risk of developing a persistent or a nonpersistent episode of low back pain associated with the included physical factors did not differ significantly.

CONCLUSIONS

Our results revealed that previously identified triggers contribute equally to the development of both nonpersistent and persistent low back pain. Future prevention strategies should focus on controlling exposure to these triggers as they have the potential to decrease the burden associated with both acute and chronic low back pain.

The indirect costs of back problems (dorsopathies) in Australians aged 45 to 64 years from 2015 to 2030: results from a microsimulation model, Health&WealthMOD2030

This study projected the indirect costs of back problems through lost productive life years (PLYs) from the individual's perspective (lost disposable income), the governmental perspective (reduced taxation revenue, greater welfare spending), and the societal perspective (lost gross domestic product, GDP) from 2015 to 2030, using Health&WealthMOD2030-Australia's first microsimulation model on the long-term impacts of ill-health. Quantile regression analysis was used to examine differences in median weekly income, welfare payments, and taxes of people unable to work due to back problems with working full-time without back problems as comparator. National costs and lost GDP resulting from missing workers due to back problems were also projected. We projected that 90,000 people have lost PLYs due to back problems in 2015, increasing to 104,600 in 2030 (16.2% increase). People with lost PLYs due to back problems are projected to receive AU$340.91 less in total income and AU$339.77 more in welfare payments per week than full-time workers without back problems in 2030 and pay no income tax on average. National costs consisted of a loss of AU$2931 million in annual income in 2015, increasing to AU$4660 million in 2030 (60% increase). For government, extra annual welfare payments are projected to increase from AU$1462 million in 2015 to AU$1709 million in 2030 (16.9% increase), and lost annual taxation revenue to increase from AU$671 million in 2015 to $961 million in 2030 (43.2% increase). We projected losses in GDP of AU$10,543 million in 2015, increasing to AU$14,522 million in 2030 due to back problems.

Gabapentinoids for chronic low back pain: a protocol for systematic review and meta-analysis of randomised controlled trials

INTRODUCTION

Chronic low back pain (CLBP) is a common condition and causes significant pain, distress and disability across the world. It is multifactorial in aetiology and is challenging to manage. Although the underlying mechanism of pain is predominantly non-specific, many argue that there is a substantial neuropathic pain element. Neuropathic pain is more severe, with significant disability. Gabapentinoids, including gabapentin and pregabalin, have proven efficacy in some neuropathic pain conditions. Despite no clear evidence, a substantial population of patients with CLBP are treated with gabapentinoids.

OBJECTIVES

We aim to assess whether the use of gabapentinoids is effective and safe in the treatment of predominant CLBP, by conducting a systematic review and meta-analysis of randomised control trials (RCTs).

METHODOLOGY

We will search the databases of MEDLINE, EMBASE and Cochrane for RCTs published in English language and have used gabapentinoids for the treatment of CLBP. Study selection and data extraction will be performed independently by paired reviewers using structured electronic forms, piloted between pairs of reviewers. The review outcomes will be guided by Initiative on Methods, Measurement and Pain Assessment in Clinical Trials guidelines, with pain relief as the primary outcome. We propose to carry out meta-analysis if there are three or more studies in a particular outcome domain, using a random effects model. Pooled outcomes will be reported as weighted mean differences or standardised mean differences and risk ratios with their corresponding 95% CIs, for continuous outcomes and dichotomous outcomes, respectively. Rating of quality of evidence will be reported using GRADE summary of findings table.

DISCUSSION

The proposed systematic review will be able to provide valuable evidence to help decision-making in the use of gabapentinoids for the treatment of CLBP. This will help advance patient care and potentially highlight limitations in existing evidence to direct future research.

ETHICS AND DISSEMINATION

Being a systematic review, this study would not necessitate ethical review and approval. We plan to report and publish our study findings in a high impact medical journal, with online access.

TRIAL REGISTRATION NUMBER

CRD42016034040.

Rating Scales for Pain in Parkinson's Disease: Critique and Recommendations

BACKGROUND

We aimed at critically appraising the clinimetric properties of existing pain scales or questionnaires and to give recommendations for their use in Parkinson's disease (PD).

METHODS

Clinimetric properties of pain scales used in PD were systematically evaluated. A scale was classified as 'recommended' if was used in PD, showed adequate clinimetric properties, and had been used by investigators other than the original developers; as 'suggested' if it was used in PD and fulfilled only one other criterion; and as 'listed' if it was used in PD but did not meet the other criteria. Only scales rating pain intensity or for syndromic classification were assessed.

RESULTS

Eleven of the 34 scales initially considered fulfilled inclusion criteria. Among the scales rating pain intensity, the "Brief Pain Inventory short form," "McGill Pain Questionnaire short and long forms," "Neuropathic Pain Symptoms Inventory," "11-point Numeric Rating Scale," "10-cm Visual Analog Scale," and "Pain-O-Meter" were "recommended with caution" because of lack of clinimetric data in PD, whereas the "King's PD Pain Scale" was "recommended." Among scales for pain syndromic classification, the "DN4" was "recommended with caution" because of lack of clinimetric data in PD; the "Leeds Assessment of Neuropathic Symptoms and Signs," "Pain-DETECT," and the "King's PD Pain Scale" were "suggested."

CONCLUSIONS

King's PD pain scale can be recommended for the assessment of pain intensity in PD. Syndromic classification of pain in PD may be achieved by the DN4, but clinimetric data in PD are needed for this scale.

CD146 defines commitment of cultured annulus fibrosus cells to express a contractile phenotype

Characterization of cells is important for facilitating cell-based therapies for degenerative diseases of intervertebral discs. For this purpose, we analyzed mouse annulus fibrosus cells by flowcytometory to detect phenotypic change in their primary cultures. After examination of sixteen cell surface proteins, we focused on CD146 that solely increased during culture expansion. CD146 is known to be a marker for mesenchymal stem cells and for their vascular smooth muscle commitment with expression of contractile phenotype enhanced by SM22α. We sorted CD146+ cells to elucidate their characteristics and the key factors that play a role in this change. Whole cell cultures showed the ability for tripotent differentiation toward mesenchymal lineages, whereas sorted CD146+ cells did not. Expression of CD146 was elevated by addition of transforming growth factor β1, and sorted CD146+ cells expressed higher levels of mRNA for SM22α and Elastin than did CD146- cells. Morphologically, CD146+ cells more broadly deposited extracellular type I collagen than CD146- cells and showed filamentous actin bundles traversing their cytoplasm and cell-cell junctions. Moreover, CD146+ cells demonstrated significantly higher gel contraction properties than CD146- cells when they were embedded in collagen gels. Human annulus fibrosus CD146+ cells also showed higher contractility. Immunohistochemistry determined CD146+ cells localized to the outermost annulus layers of mouse intervertebral disc tissue with co-expression of SM22α. These results suggest that increment of CD146 expression indicates gradual change of cultured annulus fibrosus cells to express a contractile phenotype and that transforming growth factor β1 enhances this cellular commitment. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1361-1372, 2016.