A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low-back pain. Eur Spine J. 2011;20:40-50. [PMID: 20680369 PMCID: PMC3036024 DOI: 10.1007/s00586-010-1541-4]

Multidisciplinary Digital Therapeutics for Chronic Low Back Pain Versus In-Person Therapeutic Exercise with Education: A Randomized Controlled Pilot Study

Background: Chronic lower back pain (CLBP) is a global health issue leading to significant disability and socioeconomic burden. Traditional treatments, including exercise and cognitive behavioral therapy (CBT), are often limited by physical and temporal constraints. This study aimed to evaluate the efficacy of multidisciplinary digital therapeutics (MORA Cure LBP) compared to conventional treatments. Methods: This multicenter, randomized, controlled pilot study enrolled 46 participants. Participants were randomly assigned in a 1:1 ratio to either a MORA Cure LBP group or control group, which received conventional treatment. Results: At eight weeks, both groups demonstrated improvements compared to baseline. No statistically significant differences were observed between the MORA Cure LBP and control groups in reductions in usual pain intensity (MORA Cure LBP: 3.1 ± 1.9 vs. control: 3.0 ± 1.5, p = 0.809), worst pain intensity (MORA Cure LBP: 5.00 ± 2.18 vs. control: 4.27 ± 1.83, p = 0.247), and functional disability (ODI, MORA Cure LBP: 15.6 ± 9.6 vs. control: 15.6 ± 10.0, p > 0.999). Compliance was significantly higher in the MORA Cure LBP group during the first 4 weeks (MORA Cure LBP: 74.7% ± 27.4 vs. control: 53.1% ± 28.6, p < 0.001). Conclusions: Both multidisciplinary digital therapeutics (MORA Cure LBP) and conventional treatments were effective in reducing pain and functional disability in patients with CLBP, with no significant differences between the two groups. Digital therapeutics, particularly those that integrate CBT and exercise, offer promising alternatives to conventional therapies by improving accessibility and potentially enhancing patient engagement.

A Local Heating Profile to Manage Lower Back Pain in an Automotive Seat: A Pilot Study

Lower back pain (LBP) is one of the most prevalent health losses in adults worldwide. Historically, heat has been successfully used for treating pain and relieving tight muscles. Given the effective contact with the occupant's back and proximity to the heat source, coupled with increasing commute times, automotive seats offer an opportunity to intervene. Fifteen adults (nine female) who experienced acute, subacute, and chronic lower back pain were recruited to examine the effectiveness of heat delivered to the lower back in providing temporary pain relief. Participants sat in a car seat for 38 min on two days, which included a 5-min baseline followed by a 33-min intervention; control, or localized. For the control condition, participants sat for 33 min without any thermal devices on, while the localized condition heated and maintained the seat surface temperature of the lower seat back area to ~45 °C. Over the 33-min control condition, the back skin temperature increased by ~1-2 °C and did not impact the subjective LBP. Heating the lower back for 33 min to ~39 °C reduced the subjective LBP by 10%. We demonstrated that lower back pain can be alleviated from an automotive seat providing heat to the lower back within normal commute times in those with lower back pain.

A critical review of the role of manual therapy in the treatment of individuals with low back pain

The number of low back pain (LBP) cases is projected to increase to more than 800 million by 2050. To address the substantial burden of disease associated with this rise in prevalence, effective treatments are needed. While clinical practice guidelines (CPG) consistently recommend non-pharmacological therapies as first-line treatments, recommendations regarding manual therapy (MT) in treating low back pain vary. The goal of this narrative review was to critically summarize the available evidence for MT behind these recommendations, to scrutinize its mechanisms of action, and propose some actionable steps for clinicians on how this knowledge can be integrated into a person-centered approach. Despite disparate recommendations from CPG, MT is as effective as other available treatments and may be offered to patients with LBP, especially as part of a treatment package with exercise and education. Most of the effects of MT are not specific to the technique. MT and other interventions share several mechanisms of action that mediate treatment success. These mechanisms can encompass patients' expectations, prior experiences, beliefs and convictions, epistemic trust, and nonspecific contextual effects. Although MT is safer than opioids for patients with LBP, this alone is insufficient. Our goal is to encourage clinicians to shift away from outdated and refuted ideas in MT and embrace a person-centered approach rooted in a comprehensive biopsychosocial framework while incorporating patients' beliefs, addressing illness behaviors, and seeking to understand each patient's journey.

Mind-Body Training: A Plausible Strategy against Osteomuscular Chronic Pain-A Systematic Review with Meta-Analysis

(1) Background: Chronic pain, which affects more than one in five adults worldwide, has a negative impact on the quality of life, limiting daily activities and generating absences from work. The aim of the present review is to analyze the efficacy of mind-body therapies as therapeutic strategies for patients with chronic pain. (2) Methods: A systematic review with a meta-analysis was carried out, searching PubMed, Scopus, and Web of Science databases using specific keywords. We selected studies that included mind-body therapies as the primary intervention for older adults with chronic pain. The methodological quality of the articles was assessed using the PEDro scale. (3) Results: Of the 861 studies identified, 11 were included in this review, all of which employed different mind-body therapies as an intervention. The selected studies measured chronic pain as the main variable. (4) Conclusions: This review highlights the value of mind-body exercises in reducing chronic pain in older adults, suggesting their integration as a non-pharmacological therapeutic alternative that improves the quality of life, promoting a holistic approach to pain management.

Multimodal management strategies for chronic pain after spinal surgery: a comprehensive review

"Chronic pain after spinal surgery" (CPSS) is a nonspecific term for cases in which the end result of surgery generally does not meet the preoperative expectations of the patient and surgeon. This term has replaced the previous term i.e., failed back surgery syndrome. CPSS is challenging for both patients and doctors. Despite advancements in surgical techniques and technologies, a subset of patients continue to experience persistent or recurrent pain postoperatively. This review provides an overview of the multimodal management for CPSS, ranging from conservative management to revision surgery. Drawing on recent research and clinical experience, we aimed to offer insights into the diverse strategies available to improve the quality of life of CPSS patients.

The impact of adverse childhood experiences and posttraumatic stress symptoms on chronic pain

Introduction

Chronic pain is a prevalent worldwide health condition. The current study aimed to extend previous research that investigated the dynamics between chronic pain, adverse childhood experiences (ACEs), and post-traumatic stress symptoms (PTSS).

Method

Adult participants worldwide with chronic pain were recruited for this study (N = 199; 89% females). Three hypotheses were proposed: (a) a high ACEs score would result in more severe pain intensity and interference compared to no ACEs; (b) a low ACEs score would result in more severe pain intensity and interference compared to no ACEs; and (c) PTSS would fully mediate the ACEs-pain relationship.

Results

Initially results indicated individuals with high ACEs reported more pain interference than those with no ACEs, although pain intensity did not differ between high and no ACEs. However, after controlling for age, socioeconomic status (SES), and pain duration, low and high ACEs were not significantly associated with pain intensity or interference compared to no ACEs. However, SES status was associated with pain intensity and interference, although not with pain interference after adding low and high ACEs to the model. Because of this the mediation exploration of PTSS was not viable.

Discussion

Implications for practice, limitations and future research outcomes are outlined.

Baduanjin exercise for chronic non-specific low back pain: protocol for a series of N-of-1 trials

INTRODUCTION

Chronic non-specific low back pain (CNLBP) is one of the most common health problems worldwide. According to the clinical guideline released by the American College of Physicians, exercise has been recommended for the treatment of chronic LBP. In recent years, traditional Chinese medicine (TCM) is becoming increasingly popular for the management of chronic LBP. Baduanjin exercise is one of the exercise therapies in TCM. N-of-1 trial is a randomised cross-over self-controlled trial suitable for patients with this chronic disease. A series of similar N-of-1 trials can be pooled to estimate the overall and individual therapeutic effects synchronously by hierarchical Bayesian analysis. And N-of-1 trials are considered as a good tool for evaluating the therapeutic effect of TCM. Therefore, this study aims to conduct a series of N-of-1 trials with hierarchical Bayesian analysis for assessing whether Baduanjin exercise is effective and safe for CNLBP.

METHODS AND ANALYSIS

This study conducts a series of N-of-1 trials on Baduanjin exercise for the management of CNLBP. Fifty participants will receive 1-3 treatment cycles. They will be randomised into a Baduanjin exercise or waiting list group for a week during the two periods of each treatment cycle. The primary outcome is the 10-point Visual Analogue Scale. The secondary outcomes include the Oswestry Disability Index, the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire and the Short Form Health Survey 12. Statistical analysis will be conducted with WinBUGS V.1.4.3 software. Overall and individual therapeutic effects will be estimated synchronously by hierarchical Bayesian analysis.

ETHICS AND DISSEMINATION

This study is approved by the Medical Ethics Committee of Tianjin University of TCM (reference number TJUTCM-EC20220005). Our findings will be published in a peer-reviewed journal or international conference.

TRIAL REGISTRATION NUMBER

ChiCTR2200063307.

Chronic pain after spine surgery: Insights into pathogenesis, new treatment, and preventive therapy

Chronic pain after spine surgery (CPSS) is often characterized by intractable low back pain and/or radiating leg pain, and has been reported in 8-40% of patients that received lumbar spine surgery. We conducted a literature search of PubMed, MEDLINE/OVID with a focus on studies about the etiology and treatments of CPSS and low back pain. Our aim was to provide a narrative review that would help us better understand the pathogenesis and current treatment options for CPSS. This knowledge will aid in the development of optimal strategies for managing postoperative pain symptoms and potentially curing the underlying etiologies. Firstly, we reviewed recent advances in the mechanistic study of CPSS, illustrated both structural (e.g., fibrosis and scaring) and non-structural factors (e.g., inflammation, neuronal sensitization, glial activation, psychological factor) causing CPSS, and highlighted those having not been given sufficient attention as the etiology of CPSS. Secondly, we summarized clinical evidence and therapeutic perspectives of CPSS. We also presented new insights about the treatments and etiology of CPSS, in order to raise awareness of medical staff in the identification and management of this complex painful disease. Finally, we discussed potential new targets for clinical interventions of CPSS and future perspectives of mechanistic and translational research. CPSS patients often have a mixed etiology. By reviewing recent findings, the authors advocate that clinicians shall comprehensively evaluate each case to formulate a patient-specific and multi-modal pain treatment, and importantly, consider an early intraoperative intervention that may decrease the risk or even prevent the onset of CPSS.

Translational potential statement

CPSS remains difficult to treat. This review broadens our understanding of clinical therapies and underlying mechanisms of CPSS, and provides new insights which will aid in the development of novel mechanism-based therapies for not only managing the established pain symptoms but also preventing the development of CPSS.

Selective androgen receptor modulator microparticle formulation reverses muscle hyperalgesia in a mouse model of widespread muscle pain

ABSTRACT

Chronic pain is a significant health problem associated with disability and reduced quality of life. Current management of chronic pain is inadequate with only modest effects of pharmacological interventions. Thus, there is a need for the generation of analgesics for treating chronic pain. Although preclinical and clinical studies demonstrate the analgesic effects of testosterone, clinical use of testosterone is limited by adverse androgenic effects. Selective androgen receptor modulators (SARMs) activate androgen receptors and overcome treatment limitations by minimizing androgenic side effects. Thus, we tested whether daily soluble SARMs or a SARM-loaded microparticle formulation alleviated muscle hyperalgesia in a mouse-model of widespread pain (male and female C57BL/6J mice). We tested whether the analgesic effects of the SARM-loaded microparticle formulation was mediated through androgen receptors by blocking androgen receptors with flutamide pellets. In vitro and in vivo release kinetics were determined for SARM-loaded microparticles. Safety and toxicity of SARM treatment was determined using serum cardiac and liver toxicity panels, heart histology, and conditioned place preference testing. Subcutaneous daily SARM administration, and 2 injections, 1 week apart, of SARM-loaded microparticles alleviated muscle hyperalgesia in both sexes and was prevented with flutamide treatment. Sustained release of SARM, from the microparticle formulation, was observed both in vitro and in vivo for 4 weeks. Selective androgen receptor modulator treatment produced no cardiac or liver toxicity and did not produce rewarding behaviors. These studies demonstrate that SARM-loaded microparticles, which release drug for a sustained period, alleviate muscle pain, are safe, and may serve as a potential therapeutic for chronic muscle pain.

Effects of pharmacotherapy on sleep-related outcomes in adults with chronic low back pain: A systematic review and meta-analysis of randomised controlled trials

Background

Adults with chronic low back pain (CLBP) suffer impaired sleep. Medications for CLBP can impact sleep which in turn may influence treatment outcomes. This systematic review and meta-analysis examined the effects of pharmacotherapy (any type) on sleep in adults with CLBP.

Methods

In this systematic review and meta-analysis, we searched PubMed, CINAHL, SPORTDiscus, PsycINFO, EMBASE, and CENTRAL from inception to 10 July 2022. Randomised controlled trials that investigated the effects of pharmacotherapy on sleep in adults with CLBP were included. Manual citation search of relevant systematic reviews and included studies were also conducted. Mean change from baseline for sleep outcomes (e.g., sleep quality, total sleep time, wake after sleep onset) was the effect of interest. Pairwise inverse-variance random effect meta-analysis was performed to impute pooled estimates (Hedges' g or risk ratios). The Hartung-Knapp-Sidik-Jonkman method was used where there were ≤5 studies. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used for evaluating the certainty of evidence. This study was registered with PROSPERO (CRD42022309419).

Findings

Assessment of 3959 records resulted in nine studies (n = 2927) being included. Pharmacotherapy for CLBP management had a small, yet unlikely clinically significant, effect on improving sleep in adults with CLBP, when compared to placebo (g [95% CI]: -0.23 [-0.37, -0.09], p = .0009; I 2  = 30.1%; n = 1433; studies: n = 8; GRADE: low). Notably, no eligible studies investigated the effect of sleep medications in this population, despite being within the scope of this review.

Interpretation

Pharmacotherapy used to manage CLBP provided improvements in sleep in adults with CLBP. Given that these effects were small and unlikely clinically significant, clinicians could consider alternative treatments (e.g., non-pharmacological interventions) for managing sleep in adults with CLBP. However, low to very low certainty of evidence precluded strong conclusions. To improve certainty of evidence and confidence in the effect estimates, future research needs to use robust method to minimise bias. Additional research evaluating multiple sleep characteristics, using both validated objective and subjective measures, is also warranted to further investigate the influence of distinct sleep parameters.

Funding

The Summer Research Scholarship from the Appleton Institute, Central Queensland University, Australia.

Acupoint catgut embedding for chronic low back pain: A protocol for systematic review and meta-analysis

BACKGROUND

The treatment of acupoint catgut embedding (ACE) effective and safe for patients with chronic low back pain (CLBP) is not yet known. This systematic review will objectively and systematically evaluate the efficacy and safety of ACE in CLBP according to the existing evidence.

METHODS

The protocol of this systematic review and meta-analyses has been registered in PROSPERO with the registration number CRD42019142256. The following electronic databases from inception to November 29, 2022 will be searched: PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Wan Fang Data and Chinese Science Journal Database. Randomised controlled clinical(RCTs) using ACE to treat CLBP will be included. Outcomes will include pain intensity, instrument with assessment function and disability, quality-of-life, and costs. Adverse events will be reported for safety assessment. By screening the titles, abstracts, and full texts, two independent reviewers will select studies, extract data, and assess study quality. Data synthesis, sensitivity analysis, subgroup analysis and risk of bias assessment will be conducted using RevmanV.5.3 software. The Grading of Recommendations Assessment, Development and Evaluation system will be used to assess the quality ofthe evidence.

RESULTS

The efficacy and safety of ACE in the treatment of CLBP has not yet been determined.

CONCLUSION

This systematic review will objectively and systematically evaluate the efficacy and safety of ACE in CLBP according to the existing evidence, which can give high level clinical recommendations to improve patient care and clinical outcomes.

The efficacy of sensory neural entrainment on acute and chronic pain: A systematic review and meta-analysis

Background

Changes to the power of neural oscillations in cortical and sub-cortical structures can change pain perception. Rhythmic sensory stimulation is a non-invasive method that can increase power in specific frequencies of neural oscillations. If the stimulation frequency targets those frequencies related to pain perception, such as alpha or theta frequencies, there can be a reduction in perceived pain intensity. Thus, sensory neural entrainment may provide an alternative to pharmacological intervention for acute and chronic pain. This review aimed to identify and critically appraise the evidence on the effectiveness of sensory entrainment methods for pain perception.

Methods

We undertook a systematic search across Medline, Embase, PsycInfo, Web of Science and Scopus in November 2020 to identify studies investigating the efficacy of sensory entrainment on adults. We assessed studies for their quality using the PRISMA checklist. A random-effects model was used in a meta-analysis to measure the effect of entrainment on pain perception.

Results

Our systematic review yielded nine studies fitting the search criteria. Studies investigated the effect of visual and auditory entrainment on pain intensity rating, electrophysiological markers of pain and amount of analgesia needed during surgery. The meta-analysis suggests that alpha (8–13 Hz) sensory entrainment is effective for acute pain perception, whereas theta (4–7 Hz) entrainment is effective for chronic pain.

Conclusions

Although there is heterogeneity in the current evidence, our review highlights the potential use of sensory entrainment to affect acute and chronic pain. Further research is required regarding the timing, duration and frequency of the stimulation to determine the best application for maximum efficacy.

Biomarkers for Chronic Pain: Significance and Summary of Recent Advances

Chronic pain can be difficult to predict and a challenge to treat. Biomarkers for chronic pain signal an opportunity for advancements in both management and prevention, and through their research and development offer new insights into the complex processes at play. This review considers the latest research in chronic pain biomarker development and considers how close we are to bringing these from bench to bedside. While some headway has been made that offers efficiencies in patient selection, it is unlikely that a single test will encompass the variety of chronic pain phenotypes. We offer some insights for the near future in biomarker development and areas of continued unmet need.

Nonspecific chronic low back pain conditions and therapeutic practices in Burkina Faso

Background

The management of nonspecific chronic low back pain (NCLBP) is complex because of its multifactorial origin.

Objectives

To investigate NCLBP care by evaluating patients’ condition and therapeutic management of health practitioners.

Method

A cross-sectional survey was carried out among 92 patients with NCLBP, 30 medical practitioners (MP) and 20 physiotherapists (PT) from four public health institutions in Burkina Faso. Patients completed the Visual Analogue Scale, Roland Morris Disability Questionnaire and Fear-Avoidance Beliefs Questionnaire. Practitioners were asked about therapy and continuing professional training.

Results

Pain was moderate to intense for 80% of participants with NCLBP. They were functionally affected and showed fear-avoidance beliefs related to physical and work activities. The majority (97%) of medical practitioners prescribed analgesics and 53% prescribed nonsteroidal anti-inflammatory drugs (NSAIDs). Physiotherapy was the most frequently recommended nonpharmacological treatment. Forty-three per cent of medical practitioners referred to physiotherapy; 20% never did. Physiotherapists practised both passive treatments, such as massage (50%), electrotherapy (55%) and thermotherapy (50%), as well as active treatments, such as general exercises (55%), specific exercises (70%), functional revalidation (50%) and back school (40%). Having had recent continuing professional training and assessing risk factors for chronicity were associated with MPs’ and PTs’ therapeutic choices.

Conclusion

Participants with NCLBP showed fear-avoidance beliefs, correlated with their algo-functional status. Prescribing habits of MPs were drug-based. Treatments by PTs were passive and active. Continuing professional training of healthcare practitioners and assessment of risk factors had a positive impact on therapeutic choices.

Clinical implications

Our study is an invitation to the health care system to improve the relationship between a patient’s NCLBP and therapeutic choices.

[Noninvasive Treatments for Acute and Chronic Back Pain]

Noninvasive Treatments for Acute and Chronic Back Pain Abstract. The therapy of back pain - especially the medication with opioids - can be challenging for the treating physician. Specific back pain can often be diagnosed by imaging and successfully treated by surgery or medication. In contrast, nonspecific back pain can be worsened by inappropriate imaging, questionable surgical indications and uncontrolled drug use. For the therapy of nonspecific back pain, maintaining daily activity and exercise therapy is central. Opioids are effective drugs for short-term use. However, long-term use often leads to opioid-induced hyperalgesia and hormonal dysfunction with decreased quality of life and libido. Furthermore, opioids can lead to abuse and addiction. After an ineffective treatment with non-opioids, opioids may be given for a limited time period (if possible shorter than four weeks) according to international guidelines.

Pathogenesis, etiology and treatment of failed back surgery syndrome

Failed back surgery syndrome (FBSS) is associated with persistent lower back pain after and despite one or more surgical interventions. A number of factors underlie and maintain FBSS and successful management of pain chiefly depends on identifying them. Pharmacological, surgical, and non-surgical therapeutic measures are taken to treat the pain. Spinal cord stimulation and nerve stimulation have been widely practiced in this regard and enhanced pain reduction and patient satisfaction. In hernia and recurrent disc degeneration and sagittal imbalance, discectomy and/or fusion are indicated. The present review focuses on FBSS and its underlying components and on available treatment options.

Non-Surgical Interventions for Lumbar Spinal Stenosis Leading To Neurogenic Claudication: A Clinical Practice Guideline

Lumbar spinal stenosis (LSS) causing neurogenic claudication (NC) is increasingly common with an aging population and can be associated with significant symptoms and functional limitations. We developed this guideline to present the evidence and provide clinical recommendations on nonsurgical management of patients with LSS causing NC. Using the GRADE approach, a multidisciplinary guidelines panel based recommendations on evidence from a systematic review of randomized controlled trials and systematic reviews published through June 2019, or expert consensus. The literature monitored up to October 2020. Clinical outcomes evaluated included pain, disability, quality of life, and walking capacity. The target audience for this guideline includes all clinicians, and the target patient population includes adults with LSS (congenital and/or acquired, lateral recess or central canal, with or without low back pain, with or without spondylolisthesis) causing NC. The guidelines panel developed 6 recommendations based on randomized controlled trials and 5 others based on professional consensus, summarized in 3 overarching recommendations: (Grade: statements are all conditional/weak recommendations) Recommendation 1. For patients with LSS causing NC, clinicians and patients may initially select multimodal care nonpharmacological therapies with education, advice and lifestyle changes, behavioral change techniques in conjunction with home exercise, manual therapy, and/or rehabilitation (moderate-quality evidence), traditional acupuncture on a trial basis (very low-quality evidence), and postoperative rehabilitation (supervised program of exercises and/or educational materials encouraging activity) with cognitive-behavioral therapy 12 weeks postsurgery (low-quality evidence). Recommendation 2. In patients LSS causing NC, clinicians and patients may consider a trial of serotonin-norepinephrine reuptake inhibitors or tricyclic antidepressants. (very low-quality evidence). Recommendation 3. For patients LSS causing NC, we recommend against the use of the following pharmacological therapies: nonsteroidal anti-inflammatory drugs, methylcobalamin, calcitonin, paracetamol, opioids, muscle relaxants, pregabalin (consensus-based), gabapentin (very low-quality), and epidural steroidal injections (high-quality evidence). PERSPECTIVE: This guideline, on the basis of a systematic review of the evidence on the nonsurgical management of lumbar spine stenosis, provides recommendations developed by a multidisciplinary expert panel. Safe and effective non-surgical management of lumbar spine stenosis should be on the basis of a plan of care tailored to the individual and the type of treatment involved, and multimodal care is recommended in most situations.

Non-steroidal anti-inflammatory drugs and gabapentinoids for chronic lumbar pain: a Bayesian network meta-analysis of randomized controlled trials

INTRODUCTION

Several pharmacological therapies have been proposed for the management of chronic low back pain (LBP), but no consensus has been reached yet.

SOURCE OF DATA

Recent published literatures identified accessing PubMed, Google scholar, Embase and Scopus.

AREAS OF AGREEMENT

Exploring effective conservative alternatives to the surgical intervention is of especial interest.

AREAS OF CONTROVERSY

The efficacy and safety of non-steroidal anti-inflammatory drugs and gabapentinoids for chronic LBP are debated. Several clinical studies showed controversial results, and the most effective and safe class of drugs has not yet been clarified.

GROWING POINTS

The effects of selective and non-selective NSAIDs and gabapentinoids in chronic LBP are probably over-estimated.

AREAS TIMELY FOR DEVELOPING RESEARCH

The effect of behavioural changes, including exercise, should be explored, alone or in combination with drugs.

Low back pain management - What Australian community pharmacists recommend and how this compares to current clinical guidelines

BACKGROUND

Low back pain (LBP) is a serious and debilitating condition that necessitates proper assessment and management. Community pharmacists are ideally positioned to interact with these patients and provide therapeutic recommendations in line with LBP clinical guidelines, which have changed in recent years. Understanding what therapeutic strategies pharmacists recommend and why, can provide insights into whether these recommendations are in line with current clinical resources.

OBJECTIVES

The objectives of this study were to examine community pharmacists' views, knowledge and practices in LBP management compared to current clinical guidelines; and investigate their views regarding the accessibility and use of clinical LBP resources.

METHODS

A cross-sectional study of Australian community pharmacists was conducted using a structured, self-administered, anonymous online survey. Primary outcomes assessed were pharmacists' views, practices and recommendations in low back pain of different severities, as well as views on the use and accessibility of clinical guidelines.

KEY FINDINGS

A total of 176 pharmacists completed the survey. Most recommended non-pharmacological strategies to manage mild symptoms for both adult and teenage groups, escalating to pharmacological with increasing symptom severity. Approximately 75% reported they would recommend ibuprofen over paracetamol for low back pain. Approximately 40% agreed there is difficulty in finding and accessing clinical resources and more than 40% reported being unaware that there are specific guidelines available for the management of LBP symptoms.

CONCLUSION

Results from this study highlight an important need to further improve the knowledge and awareness of pharmacists in low back pain management, including locating and accessing clinical resources.

Assessment of a taping method combined with manual therapy as a treatment of non-specific chronic low back pain - a randomized controlled trial

Background

Chronic low back pain is the most frequent medical problem and the condition with the most years lived with disability in Western countries. The objective of this study was to assess a new treatment, Medi-Taping, which aims at reducing complaints by treating pelvic obliquity with a combination of manual treatment of trigger points and kinesio taping in a pragmatic RCT with pilot character.

Methods

One hundred ten patients were randomized at two study centers either to Medi-Taping or to a standard treatment consisting of patient education and physiotherapy as control. Treatment duration was 3 weeks. Measures were taken at baseline, end of treatment and at follow-up after 2 months. Main outcome criteria were low back pain measured with VAS, the Chronic Pain Grade Scale (CPGS) and the Oswestry Low Back Pain Disability Questionnaire (ODQ).

Results

Patients of both groups benefited from the treatment by medium to large effect sizes. All effects were pointing towards the intended direction. While Medi-Taping showed slightly better improvement rates, there were no significant differences for the primary endpoints between groups at the end of treatment (VAS: mean difference in change 0.38, 95-CI [− 0.45; 1.21] p = 0.10; ODQ 2.35 [− 0.77; 5.48] p = 0.14; CPGS − 0.19 [− 0.46; 0.08] p = 0.64) and at follow-up. Health-related quality of life was significantly higher (p = .004) in patients receiving Medi-Taping compared to controls.

Conclusions

Medi-Taping, a purported way of correcting pelvic obliquity and chronic tension resulting from it, is a treatment modality similar in effectiveness to complex physiotherapy and patient education.

Trial registration

This trial was registered retrospectively on July 24th, 2019 as Number DRKS00017051 in the German Register of Clinical Trials (Deutsches Register Klinischer Studien).

URL of trial registry record: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017051.

Pain Self-Management Strategies of Chronic Back Pain Sufferers in Thailand: A Qualitative Study (A Doctoral Project)

Background:

Chronic low back pain is among the most common chronic musculoskeletal disorders worldwide. It is prevalent in Thailand, affecting up to 30% of the general population, with much higher rates among manual labourers. Pain self-management, including education, exercise, medication and other components, is an effective strategy for reducing pain intensity and disability rates for chronic low back pain sufferers.

Objective:

To investigate pain self-management strategies among chronic lower back pain sufferers in Thailand.

Methods:

The study design was a qualitative interview-based technique. The study setting was an orthopaedic outpatient department at a university hospital in Northern Thailand. Participants (n = 19) were selected based on recruitment criteria, and data was collected using demographic forms and in-depth interviews. Thematic analysis was used for qualitative analysis, with Wilcoxon signed-rank test used to assess changes in pain levels.

Results:

Participants used a combination of pain self-management modalities, including exercise, modified food consumption, increased rest, herbal treatments, hot and cold compression, Thai massage, and acupressure, along with psychological and spiritual coping tools like meditation and making merit. Ability to use these interventions was dependent on medical support from practitioners as well as social and other support. A small, but significant, mean difference in pain was also observed.

Conclusion:

Findings point to the possibility that there are significant cultural differences in pain self-management modalities and their effectiveness.

A Closer Look into the Association between the Sacroiliac Joint and Low Back Pain

INTRODUCTION

Low back pain is the most common type of global disability and annually costs the United States over two billion dollars. Opioids have been used to reduce low back pain, although current evidence concerning efficacy is lacking. Sacroiliac joint dysfunction (SIJD) is estimated to be a primary pain source of low back pain in between 10 and 25% of affected patients. The primary objective of this study was to evaluate the rate of SIJD identified through osteopathic techniques in a convenience sample of patients seeking low back pain treatment. The secondary objective was to assess prevalence of low back pain and SIJD among different age groups, and genders.

METHODS

Retrospective chart reviews were completed the adult patients who had received osteopathic manipulative treatment for low back pain at Family Health and Wellness Center in Essexville, MI from January 2018 through June 2019. The prevalence of patients with SIJD was identified during reviews of osteopathic procedural documentation for patients seeking low back pain treatment. Data regarding patients' age, sex, and treatment modalities were also extracted. Descriptive statistics consisting of frequencies and percentages were calculated.

RESULTS

A total of 84 patient records were reviewed. A total of 51 (60.7%) patients seeking low back pain treatment were diagnosed with SIJD identified by osteopathic providers. This included patients with both lumbar and sacral diagnoses simultaneously. SIJD alone accounted for 26 (31%) of patients seeking treatment. Female patients were more likely to have SIJD involvement than males. Forty one (48.8%) treated patients were between 45-64 years old. Muscle Energy Technique was documented to be the most used for 68 (81%) patients. In addition, techniques tended to move from direct to indirect for older patients.

DISCUSSION

Our study demonstrated that SIJD appeared to contribute to low back pain in 51 (60.7%) of low back pain cases identified using osteopathic techniques. This is much greater than the previously reported percentages of 10 to 25%. One possible confounding influence included varied resident screening and reporting of sacral dysfunction. Since multiple areas of the body can be treated at one time, our current procedure notes did not allow for distinguishing between which types of modalities were used on each region or capture residents' preferred treatments.

CONCLUSIONS

Although further studies are needed, our results suggest that knowledge of SIJD's impact on low back pain could lead to improved patient outcomes such as decreased medical costs and opioid use.

Analgesic Opioid Misuse and Opioid Use Disorder among Patients with Chronic Non-Cancer Pain and Prescribed Opioids in a Pain Centre in France

(1) Background: Chronic non-cancer pain (CNCP) remains a public health challenge around the world. Opioids (PO) have been increasingly used in the treatment of CNCP in the last 20 years. This study aimed to assess the prevalence of opioid misuse and prescribed-opioid use disorder (p-OUD) among patients with CNCP in a pain centre in France, and to analyse risk factors for moderate or severe p-OUD. (2) Method: A cross-sectional study was conducted, including patients consulting for pain management in the pain centre of Brest University Hospital. A self-questionnaire was administered (sociodemographic data, medical data, PO misuse, and p-OUD according the Diagnostic and Statistical Manual of Mental Disorders 5 (DSM 5) criteria). Descriptive, univariate, and multivariate analyses were conducted, together with a principal component analysis, in order to identify factors associated with p-OUD. (3) Results: In total, 115 patients were included, the majority of whom were women, with a mean age of 52 years old [18–82]; 64.3% (n = 74) had a current prescription for opioid analgesics (weak or strong). In this group, 56.7% (n = 42) had no or only mild p-OUD and 43.3% (n = 32) had current moderate or severe p-OUD. Patients with moderate or severe p-OUD were more likely to have a current antidepressant prescription, to have had psychotherapy, to currently use strong opioids and oxycodone, and to report taking more frequent doses than prescribed and feeling dependent. (4) Conclusions: We showed that the prevalence of current moderate/severe p-OUD concerned 43.3% of the patients with a CNCP seeking treatment in a pain centre. According to these results, several measures are relevant in managing p-OUD among patients with CNCP.

Assessment of the anti-hyperalgesic efficacy of J-2156, relative to clinically available analgesic/adjuvant agents in a rat model of mild to moderate chronic mechanical low back pain (LBP)

Chronic mechanical low back pain (cLBP) is a leading cause of disability and a major socio-economic burden internationally. The lifetime prevalence of non-specific LBP is approximately 84%, with the prevalence of cLBP at about 23%. Clinically available analgesic/adjuvant medications often provide inadequate pain relief in patients experiencing cLBP. Hence, the urgency for discovery of effective and better tolerated medications. Fourteen days after the induction of five shallow annular punctures (5X) in the lumbar intervertebral discs at L4/L5 and L5/L6 in male Sprague-Dawley rats, mechanical hyperalgesia was fully developed in the lumbar axial deep tissues at L4/L5 (primary) and L1 (secondary). Importantly, mechanical allodynia in the hindpaws was absent. From day 28, we assessed the face validity of our mild to moderate LBP-5X rat model using four clinically available analgesic/adjuvant drugs, namely gabapentin, morphine, meloxicam and amitriptyline relative to vehicle. Additionally, the anti-hyperalgesic effects of J-2156, a highly selective small molecule somatostatin type 4 receptor agonist was assessed. Single i.p. bolus doses of gabapentin and meloxicam at the highest doses tested (100 and 30 mg/kg, respectively) alleviated secondary hyperalgesia (L1) but not primary hyperalgesia (L4/5). Morphine at 1 mg/kg alleviated both primary and secondary hyperalgesia in these tissues, whereas amitriptyline at the doses tested, lacked efficacy. These findings attest to the face validity of our model. J-2156 at 10 and 30 mg/kg alleviated secondary hyperalgesia in the lumbar axial deep tissues at L1 with a non-significant trend for relief of primary hyperalgesia in the corresponding tissues at L4/L5 in these animals.

The role of the pharmacist in low back pain management: a narrative review of practice guidelines on paracetamol vs non-steroidal anti-inflammatory drugs

Low back pain (LBP) is a common and costly condition and a leading cause of disabilities across the globe. In Australia and other countries, there has been changes in LBP management guidelines and evidence in recent years, including the use of pharmacotherapy. Inadequately treated LBP is a burden with significant health and economic impacts. Although there is some variability, non-steroidal anti-inflammatory drugs (NSAIDs) have largely replaced paracetamol as the first-choice analgesic for non-specific LBP in many international clinical guidelines, including the current Australian Therapeutic Guidelines. More recent clinical evidence also supports that targeting LBP with the use of NSAIDs can provide superior and more effective relief of LBP symptoms compared with paracetamol. Community pharmacists are one of the most accessible and frequently visited health professionals that offer vital primary healthcare services aimed to provide enhanced clinical outcomes for patients. The position of a community pharmacist is pivotal in LBP assessment and management, from both a pharmacological and non-pharmacological standpoint, including the use of clinical guidelines, yet their roles are often not fully utilized in LBP therapy. Studies investigating the community pharmacist’s views, practices, knowledge, and roles, specifically in LBP management in Australia are variable and limited. This narrative review will briefly cover the impacts of LBP, and to provide a summary on recent evidence, updates and a comparison of the Australian and international low back pain management guidelines on paracetamol vs NSAIDs in LBP, as well as pharmacists’ roles and interventions in a primary healthcare setting in this context.

CT-guided Interventional Therapy of Back Pain - Predictors of Success in Treatment

PURPOSE

 The aim of the presented study was to investigate if distribution of the drug-contrast medium mixture in CT-guided periradicular therapy can predict intervention success.

MATERIALS AND METHODS

 Over a 15-month period, 97 patients admitted to our institution by a pain physician for CT guided periradicular therapy were treated. In 420 CT guided interventions, we measured the relative distribution of the drug mixture in relationship to the neuroforamen. The distribution was correlated to the patient's pain score over time. In addition, dependence of success in treatment with regards to the treating physician was evaluated.

RESULTS

 Ninety percent of the patients experienced a decrease of pain score under therapy, only 10 % showed no change. On average there was an improvement in pain score from 7.4 (2-10) before therapy to 3.7 (0-9) at the end of therapy. We observed a weak correlation of -0.22 (p < 0.028) between distribution of drug mixture to the neuroforamen and reduction of pain score. The therapy outcome displayed a dependency regarding the treating physician (p < 0.0084).

CONCLUSION

 CT guided periradicular therapy offers good pain reduction in most of the patients. Drug distribution near the affected nerve and treating physician are factors for clinical success.

KEY POINTS

  · CT-guided periradicular therapy shows a good or very good improvement in the symptoms in 90 % of the treated patients.. · In addition to technical performance, the treating radiologist is an important parameter determining success.. · The success of CT-guided treatment is only moderately correlated with an absolute distribution of the drug mixture..

CITATION FORMAT

· Stueckle CA, Talarczyk S, Hackert B et al. CT-guided Interventional Therapy of Back Pain - Predictors of Success in Treatment. Fortschr Röntgenstr 2021; 193: 42 - 48.

Reduction of opioid intake after cooled radiofrequency denervation for sacroiliac joint pain: a retrospective evaluation up to 1 year

Background

Opioids can present intolerable adverse side-effects to patients who use these analgesics to mitigate chronic pain. In this retrospective analysis, cooled radiofrequency (CRF) denervation was evaluated to provide pain and disability relief and reduce opioid use in patients with sacroiliac joint (SIJ) derived low back pain (LBP).

Methods

Twenty-seven patients with pain from SIJ refractory to conservative treatments, and taking opioids chronically (> 3 mo), were included. Numeric rating scale (NRS) and Oswestry disability index (ODI) scores were collected at 1, 6, and 12 months post-procedure. Opioid use between baseline and each follow-up visit was compared for the entire group and for those who experienced successful (pain reduction ≥ 50% of baseline value) or unsuccessful CRF denervation.

Results

Severe initial mean pain (NRS score: 7.7 ± 1.0) and disability (ODI score: 50.1 ± 9.0), and median opioid use (morphine equivalent daily dose: 40 ± 37 mg) were significantly reduced up to 12 months post-intervention. CRF denervation was successful in 44.4% of the patients at 12 months. Regardless of procedure success, patients demonstrated similar opioid reductions and changes in opioid use at 12 months. Two patients (7.4%) experienced neuritis following CRF denervation.

Conclusions

CRF denervation of the SIJ can safely elicit pain and disability relief, and reduce opioid use, regardless of intervention success. Future studies may support CRF denervation as a dependable therapy to alleviate opioid use in patients with SIJ-derived LBP and show that opioid use measurements can be a surrogate indicator of pain.

Development of a calculator to establish indications to refer patients with lumbar degenerative disease for spinal surgery consultation

BACKGROUND AND AIM

Low-back pain remains a common pathological entity in the Western population. We have found no data in the literature that assess whether, with correct physical examination and evaluation of simple x-rays of the spine, it is possible to diagnose patients who are highly likely to be candidates for lumbar spine surgery and thus reduce the care burden and resource consumption that this disorder entails. The aim of the study was to develop a user-friendly calculator that allows only patients who are strong candidates for surgical treatment to be referred for spinal surgery consultation.

MATERIAL AND METHOD

An observational and retrospective study that included all adult patients from the healthcare area of Talavera de la Reina (Toledo, Spain) with a clinical and/or radiological diagnosis of degenerative lumbar spine disease referred by other specialists over one calendar year to the spinal surgery unit to assess whether surgery was indicated after unsuccessful conservative treatment. All the patients were assessed under the same protocol with a follow-up of 6years, at the end of which we performed a check of those who had undergone lumber spine surgery.

RESULTS

A total of 201 patients were studied and at the end of the 6-year follow-up, a total of 77 patients had been operated. Concordance of 70% was found between the indication for surgical treatment and the treatment received at the end of the follow-up. Therefore a logistic regression was performed in an attempt to predict the patients that could be referred to the spinal surgery units and from that a calculator was generated, which included the plain x-ray variable as an essential item, and which showed as statistically significant (P<.05): age, Waddell's non-organic signs, Lasegue's sign and plain x-ray assessment. Once this tool had been obtained, the likelihood of undergoing surgery was calculated for all patients who were proposed surgical treatment, obtaining results above 62% as the cut-off point when using the calculator.

CONCLUSIONS

The use of the calculator predicts the possibility of being a candidate for surgical treatment with 70% reliability. Therefore, patients with a result in the calculator of above 62% should be referred for spinal surgery consultation for assessment by a specialist.

Neck Pain and Lower Back Pain

Neck pain is the fourth leading cause of disability. Acute neck pain largely resolves within 2 months. History and physical examination play a key role in ruling out some of the more serious causes for neck pain. The evidence for pharmacologic interventions for acute and chronic musculoskeletal neck pain is limited. Lower back pain is the leading cause of disability and productivity loss. Consultation with a physical medicine and rehabilitation spine specialist within 48 hours for acute pain and within 10 days for all patients with lower back pain may significantly decrease rate of surgical interventions and increase patient satisfaction.

Using Pain Medication Intensity to Stratify Back Pain Among Older Adults

Objective

To examine the prevalence of musculoskeletal back pain among older adults stratified by pain medication intensity to 1) review treatment patterns and 2) consider targeted back pain prevention interventions.

Methods

A random sample of older adults age 64 years and older was utilized to identify new and recurring back pain. Prescription pain medications from drug claims were used to stratify to five unique intensity levels. The characteristics of each level were determined using regression models.

Results

About 10% had musculoskeletal back pain. Of these, 54% (N = 20,645) had new back pain and 46% (N = 17,252) had recurring back pain. Overall, about 35% received physical therapy. Pain medication intensity levels included no prescription pain medications, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, low-dose opioids, and high-dose opioids (new back pain: 39%, 10%, 6%, 23%, and 23%, respectively; recurring back pain 32%, 9%, 4%, 17%, and 38%, respectively). NSAID and muscle relaxant users were younger, healthier, and received physical therapy. Opioid users were younger, in poorer health, used sleep medications, received physical therapy, and had more falls and higher health care utilization and expenditures.

Conclusions

New and recurring back pain patients can be stratified by pain medication intensity to review treatment patterns and target back pain prevention programs. Those with back pain but taking no prescription pain medications may benefit from back pain prevention programs. More research on guidelines for treatment options for those on high levels of pain medications is warranted.

A methodological quality assessment of systematic reviews and meta-analyses of antidepressants effect on low back pain using updated AMSTAR

BACKGROUND

Antidepressants are prescribed widely to manage low back pain. There are a number of systematic reviews and meta-analyses which have investigated the efficacy of the treatments, while the methodological quality of them has not been assessed yet. This study aims to evaluate the methodological quality of the systematic reviews and meta-analyses investigating the effect of antidepressants on low back pain.

METHODS

A systematic search was conducted in PubMed, EMBASE, Medline, and Cochrane Library databases up to November 2018. The 16-item Assessment of Multiple Systematic Reviews (AMSTAR2) scale was used to assess the methodological quality of the studies. Systematic reviews and meta-analyses of the Antidepressants treatment effects on low back pain published in English language were included. There was no limitation on the type of Antidepressants drugs, clinical setting, and study population, while non-systematical reviews and qualitative and narrative reviews were excluded.

RESULTS

A total of 25 systematic reviews and meta-analyses were evaluated; the studies were reported between 1992 and 2017. Obtained results from AMSTAR2 showed that 11 (44%), 9 (36%) and 5 (20%) of the included studies had high, moderate and low qualities, respectively. 13(52%) of studies assessed risk of bias and 2(20%) of meta analyses considered publication bias. Also, 16 (64%) of the included reviews provided a satisfactory explanation for any heterogeneity observed in the results.

CONCLUSIONS

Although the trend of publishing high quality papers in ADs effect on LBP increased recently, performing more high-quality SRs and MAs in this field with precise subgroups of the type of pains, the class of drugs and their dosages may give clear and more reliable evidence to help clinicians and policymakers.

Comparative Effectiveness of Chuna Manipulative Therapy for Non-Acute Lower Back Pain: A Multi-Center, Pragmatic, Randomized Controlled Trial

Current evidence on the effectiveness and safety of Chuna manipulative therapy (CMT) for managing non-acute lower back pain (LBP) is insufficient. We investigated the comparative effectiveness and safety of CMT, a Korean style of manipulation, plus usual care (UC) compared to UC alone for non-acute LBP. We conducted a parallel, two-armed, multi-centered, assessor blinded, pragmatic, randomized controlled trial at four major Korean medical hospitals. Overall, 194 patients were randomly allocated to either CMT plus UC (n = 97) or UC alone (n = 97), for six weeks of treatment and six months follow-up. The primary outcome was measured using the numerical rating scale (NRS) of LBP intensity at 7 weeks. Secondary outcomes included NRS of leg pain, Oswestry Disability Index (ODI) for functional disability, patient global impression of change (PGIC) scale, and safety. A total of 194 patients were included in the intention-to-treat analysis, and 174 patients provided complete data for the primary outcome. At 7 weeks, clinically significant differences between groups were observed in the NRS of LBP (CMT + UC: -3.02 ± 1.72, UC: -1.36 ± 1.75, p < 0.001), ODI scores (CMT + UC: -5.65 ± 4.29, UC: -3.72 ± 4.63, p = 0.003), NRS of leg pain (CMT + UC: -2.00 ± 2.33, UC: -0.44 ± 1.86, p < 0.0001), and PGIC (CMT + UC: -0.28 ± 0.85, UC: 0.01 ± 0.66, p = 0.0119). Mild to moderate safety concerns were reported in 21 subjects. CMT plus UC showed higher effectiveness compared to UC alone in patients with non-acute LBP in reducing LBP and leg pain and in improving function with good safety results using a powered sample size and including mid-term follow-up.

10 kHz SCS therapy for chronic pain, effects on opioid usage: Post hoc analysis of data from two prospective studies

Chronic pain, including chronic low back and leg pain are prominent causes of disability worldwide. While patient management aims to reduce pain and improve daily function, prescription of opioids remains widespread despite significant adverse effects. This study pooled data from two large prospective trials on 10 kHz spinal cord stimulation (10 kHz SCS) in subjects with chronic low back pain and/or leg pain and performed post hoc analysis on changes in opioid dosage 12 months post 10 kHz SCS treatment. Patient-reported back and leg pain using the visual analog scale (VAS) and opioid dose (milligrams morphine equivalent/day, MME/day) were compared at 12 months post-10 kHz SCS therapy to baseline. Results showed that in the combined dataset, 39.3% of subjects were taking >90 MME dose of opioids at baseline compared to 23.0% at 12 months post-10 kHz SCS therapy (p = 0.007). The average dose of opioids in >90 MME group was significantly reduced by 46% following 10 kHz SCS therapy (p < 0.001), which was paralleled by significant pain relief (P < 0.001). In conclusion, current analysis demonstrates the benefits of 10 kHz SCS therapy and offers an evidence-based, non-pharmaceutical alternative to opioid therapy and/or an adjunctive therapy to facilitate opioid dose reduction whilst delivering significant pain relief. Healthcare providers involved in management of chronic non-cancer pain can include reduction or elimination of opioid use as part of treatment plan when contemplating 10 kHz SCS.

Current Concepts in Intradiscal Percutaneous Minimally Invasive Procedures for Chronic Low Back Pain

STUDY DESIGN

A systemic review of thermal annular procedures (TAPs) and percutaneous disk decompression procedures (PDDPs) for the treatment of discogenic chronic low back pain (CLBP) was conducted.

OBJECTIVE

The objective of this review is to evaluate and to compare the effectiveness of TAPs and PDDPs in treating discogenic CLBP and to assess the frequency of complications associated with those procedures.

MATERIALS AND METHODS

English-language journal articles were identified through computerized searches of the PubMed database and bibliographies of identified articles and review papers. Articles were selected for inclusion if percutaneous minimally invasive procedures were the treatment options for patients with CLBP and if follow-up outcome data included evaluations of back pain severity, functional improvement, and/or incidence of complications. For this review, 27 studies were included.

RESULTS

Intradiscal electrothermal therapy (IDET) procedure in properly selected patients may eliminate or delay the need for surgical intervention for an extended period, whereas few adverse effects have been reported. In contrast to IDET, there is far less literature on the effectiveness of radiofrequency annuloplasty and intradiscal biacuplasty procedures. Nucleoplasty is a potentially effective treatment option for patients with contained disc herniation, while the procedure is well tolerated. Increased success rates have been found for percutaneous laser disc decompression and automated percutaneous lumbar discectomy in strictly selected patients.

CONCLUSIONS

These procedures can be effective and may obviate the need for surgery completely. Further prospective randomized sham-controlled trials with higher quality of evidence are necessary to confirm the efficacy of these procedures.

Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP)

Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.

An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.

Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes. 

Immediate effect of pain neuroscience education for recent onset low back pain: an exploratory single arm trial

Study Design: A prospective, single-arm, pre-postintervention study.Objective: To determine the preliminary usefulness of providing pain neuroscience education (PNE) on improving pain and movement in patients presenting with non-chronic mechanical low back pain (LBP).Background: PNE has been shown to be an effective intervention for the treatment of chronic LBP but its usefulness in patients with non-chronic LBP has not been examined.Methods: A single group cohort pilot study was conducted. Eighty consecutive patients with LBP < 3 months completed a demographics questionnaire, leg and LBP rating (Numeric Pain Rating Scale - NPRS), disability (Oswestry Disability Index), fear-avoidance (Fear-Avoidance Beliefs Questionnaire), pain catastrophizing (Pain Catastrophizing Scale), central sensitization (Central Sensitization Inventory), pain knowledge (Revised Neurophysiology of Pain Questionnaire), risk assessment (Keele STarT Back Screening Tool), active trunk flexion and straight leg raise (SLR). Patients received a 15-minute verbal, one-on-one PNE session, followed by repeat measurement of LBP and leg pain (NPRS), trunk flexion and SLR.Results: Immediately after intervention, LBP and leg pain improved significantly (p < 0.001), but the mean change did not exceed minimal clinically important difference (MCID) of 2.0. Active trunk flexion significantly improved (p < 0.001), with the mean improvement (4.7 cm) exceeding minimal detectible change (MDC). SLR improved significantly (p = 0.002), but mean change did not exceed MDC.Conclusions: PNE may be an interesting option in the treatment of patients with non-chronic mechanical LBP. The present pilot study provides the rationale for studying larger groups of patients in controlled studies over longer periods of time.

Power Point Therapy: An Effective and Simple Treatment for Subacute Back Pain - A Randomized Controlled Trial

OBJECTIVE

Subacute low back pain is a frequent problem with the danger of chronification. Conventional treatment options are not always effective. Power Point therapy (PPT) is a novel approach that uses reflexological insights and can be easily applied by practitioners and patients.

METHODS

Randomized, active controlled study comparing 10 units of PPT of 10 min each, with 10 units of standard physiotherapy of 30 min each. Outcomes were functional scores (Roland Morris Disability, Oswestry, McGill Pain Questionnaire, Linton-Halldén - primary outcome) and health-related quality of life (SF-36), as well as blinded assessments by clinicians (secondary outcome).

RESULTS

Eighty patients consented and were randomized, 41 to PPT, 39 to physiotherapy. Measurements were taken at baseline, after the first and after the last treatment (approximately 5 weeks after enrolment). Multivariate linear models of covariance showed significant effects of time and group (p < 0.001) and for the quality of life variables also a significant interaction of time by group (p < 0.001). Clinician-documented variables showed significant differences at follow-up (p = 0.05 to p < 0.0001).

DISCUSSION

Both physiotherapy and PPT improve subacute low back pain significantly. PPT is likely more effective and should be studied further.

Baduanjin exercise for low back pain: A systematic review and meta-analysis

INTRODUCTION

Low back pain (LBP) is one of the most common public health concerns worldwide. Baduanjin is very popular and widely practiced for the management of LBP. This study aims to systematically investigate the efficacy and safety of Baduanjin exercise for patients with LBP.

METHODS

The PubMed, EMBASE, CENTRAL, Web of Science Core Collection, CBM, CNKI, WANFANG and VIP databases were searched from inception to August 2018 to identify potentially eligible studies. Risk of bias was assessed with the Cochrane collaboration's tool. All statistical analyses were conducted with the RevMan 5.3 software.

RESULTS

Nine studies involving 519 patients were included in this systematic review. Our meta-analysis showed that Baduanjin was associated with a small improvement in pain relief compared with general exercise (MD= -0.50, 95% CI: -0.86 to -0.15, P = 0.005). One trial indicated that Baduanjin was superior to routine drug (ibuprofen) in alleviating pain, and the effect was moderate (MD= -1.04, 95% CI: -1.52 to -0.56, P < 0.0001). A descriptive analysis showed that Baduanjin plus other active treatments (such as massage, suspension, or routine drug plus general exercise) had small to moderate effects on low back pain relief compared with active treatments alone. One trial reported that Baduanjin decreased the Oswestry Disability Index (ODI) score compared with routine drug (MD= -4.92, 95% CI= -7.81 to -2.03, P = 0.0009). Another trial found the combination of Baduanjin and electrotherapy offered better improvement than electrotherapy on back-specific function (MD= -6.03, 95% CI= -8.45 to -3.61, P < 0.00001). Three trials suggested that Baduanjin alone or in combination with other treatments achieved greater effects on the Japanese Orthopaedic Association (JOA) score improvement than other treatments. No adverse event was identified in the only study reporting on safety data.

CONCLUSIONS

The present study indicated that Baduanjin is effective for LBP. However, evidence supporting the finding is limited due to the small sample size, potential methodological flaws and significant heterogeneity. More large-scale, well-designed RCTs are warranted.

Acupuncture for chronic uncomplicated musculoskeletal pain associated with the spine: A systematic review protocol

BACKGROUND

Chronic uncomplicated neck pain, back pain, and lower back pain, with incidences of 18%, 17.7% and 36%, respectively. Although these three conditions occur in different parts of the body, we can summarize them as chronic uncomplicated musculoskeletal pain associated with the spine (CMPS) in accordance with the pathogenesis. Acupuncture is often used to treat them. We aim to conduct a systematic review to evaluate the efficacy of acupuncture for patients experiencing CMPS.

METHODS

The following electronic databases will be searched from inception to Mar 2019: Cochrane Central Register of Controlled Trials, Web of Science, ScienceDirect, PubMed, MEDLINE, EMBASE, Springer, WHO International Clinical Trials Registry Platform, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Chinese Science and Technology Periodical Database, and Wanfang Database. All randomized controlled trials published in English or Chinese related to acupuncture for CMPS will be included. The primary outcome will be the visual analog scale. Adverse events will be evaluated as secondary outcomes for safety evaluation. Study selection, data extraction, and assessment of study quality will be performed independently by two reviewers. RevMan V.5.3.5 software will be used for the assessment of risk of bias and data synthesis.

RESULTS

This study will provide a high-quality synthesis of current evidence of acupuncture for CMPS from visual analog scale.

CONCLUSION

The conclusion of our study will provide an evidence to judge whether acupuncture is an effective intervention for patients suffered from CMPS.

ETHICS AND DISSEMINATION

Formal ethical approval is not required, as the data are not individualized. The findings of this systematic review will be disseminated in a peer-reviewed publication and/or presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42018114806.

Efficacy of Low-Dose Amitriptyline for Chronic Low Back Pain: A Randomized Clinical Trial

IMPORTANCE

Antidepressants at low dose are commonly prescribed for the management of chronic low back pain and their use is recommended in international clinical guidelines. However, there is no evidence for their efficacy.

OBJECTIVE

To examine the efficacy of a low-dose antidepressant compared with an active comparator in reducing pain, disability, and work absence and hindrance in individuals with chronic low back pain.

DESIGN, SETTING, AND PARTICIPANTS

A double-blind, randomized clinical trial with a 6-month follow-up of adults with chronic, nonspecific, low back pain who were recruited through hospital/medical clinics and advertising was carried out.

INTERVENTION

Low-dose amitriptyline (25 mg/d) or an active comparator (benztropine mesylate, 1 mg/d) for 6 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was pain intensity measured at 3 and 6 months using the visual analog scale and Descriptor Differential Scale. Secondary outcomes included disability assessed using the Roland Morris Disability Questionnaire and work absence and hindrance assessed using the Short Form Health and Labour Questionnaire.

RESULTS

Of the 146 randomized participants (90 [61.6%] male; mean [SD] age, 54.8 [13.7] years), 118 (81%) completed 6-month follow-up. Treatment with low-dose amitriptyline did not result in greater pain reduction than the comparator at 6 (adjusted difference, -7.81; 95% CI, -15.7 to 0.10) or 3 months (adjusted difference, -1.05; 95% CI, -7.87 to 5.78), independent of baseline pain. There was no statistically significant difference in disability between the groups at 6 months (adjusted difference, -0.98; 95% CI, -2.42 to 0.46); however, there was a statistically significant improvement in disability for the low-dose amitriptyline group at 3 months (adjusted difference, -1.62; 95% CI, -2.88 to -0.36). There were no differences between the groups in work outcomes at 6 months (adjusted difference, absence: 1.51; 95% CI, 0.43-5.38; hindrance: 0.53; 95% CI, 0.19-1.51), or 3 months (adjusted difference, absence: 0.86; 95% CI, 0.32-2.31; hindrance: 0.78; 95% CI, 0.29-2.08), or in the number of participants who withdrew owing to adverse events (9 [12%] in each group; χ2 = 0.004; P = .95).

CONCLUSIONS AND RELEVANCE

This trial suggests that amitriptyline may be an effective treatment for chronic low back pain. There were no significant improvements in outcomes at 6 months, but there was a reduction in disability at 3 months, an improvement in pain intensity that was nonsignificant at 6 months, and minimal adverse events reported with a low-dose, modest sample size and active comparator. Although large-scale clinical trials that include dose escalation are needed, it may be worth considering low-dose amitriptyline if the only alternative is an opioid.

TRIAL REGISTRATION

anzctr.org.au Identifier: ACTRN12612000131853.

Primary care physicians' attitude and reported prescribing behavior for chronic low back pain: An exploratory cross-sectional study

Objective

Recent guidelines for chronic or recurrent low back pain recommend non-pharmacologic treatments as first-line options. The objective of this study was thus to explore the perceived usefulness of several conventional and complementary medicine treatments for chronic or recurrent low back pain by primary care physicians and their reported prescribing behavior.

Design

An exploratory cross-sectional study.

Setting and participants

Primary care physicians of the French-speaking part of Switzerland.

Main outcome measures

Primary care physicians’ perceived usefulness of each conventional and complementary medicine treatment and their reported recommendation behavior were considered dependent variables in multivariate logistic regression models. All correlations were computed between binary variables, and phi coefficients were calculated to estimate correlation strengths.

Results

533 primary care physicians answered the questionnaire (response rate: 25.6%). The top 3 conventional treatments most often considered useful by primary care physicians for chronic or recurrent low back pain were physiotherapy (94.8%), nonsteroidal anti-inflammatory drugs (87.9%), and manual therapy (82.5%), whereas the most prescribed conventional treatments were physiotherapy (99.2%), nonsteroidal anti-inflammatory drugs (97.4%), and acetaminophen (94.4%). Osteopathic treatment (78.4%), yoga (69.3%), and therapeutic massage (63.9%) were the complementary medicine treatments most often considered useful by primary care physicians in managing chronic or recurrent low back pain. Being a female physician, younger than 56 years, trained in complementary medicine, or using complementary medicine were all associated with higher perceived usefulness of complementary medicine treatments in general. The most recommended complementary medicine treatments by primary care physicians were osteopathic treatment (87.3%), acupuncture (69.3%), and therapeutic massage (58.7%). Being a female physician, younger than 56, and using complementary medicine were all associated with more complementary medicine recommendation in general.

Conclusion

Our results highlight the importance of better understanding the prescribing patterns of primary care physicians for chronic or recurrent low back pain. Considering the frequency and burden of chronic or recurrent low back pain, programs focusing on the most (cost-) effective treatments should be implemented.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.