Do analgesics improve functioning in patients with chronic low back pain? An explorative triple-blinded RCT

Paracetamol Combination Therapy for Back Pain and Osteoarthritis: A Systematic Review and Meta-Analyses

BACKGROUND AND OBJECTIVE

Although paracetamol (acetaminophen) combined with other analgesics can reduce pain intensity in some pain conditions, its effectiveness in managing low back pain and osteoarthritis is unclear. This systematic review investigated whether paracetamol combination therapy is more effective and safer than monotherapy or placebo in low back pain and osteoarthritis.

METHODS

Online database searches were conducted for randomised trials that evaluated paracetamol combined with another analgesic compared to a placebo or the non-paracetamol ingredient in the combination (monotherapy) in low back pain and osteoarthritis. The primary outcome was a change in pain. Secondary outcomes were (serious) adverse events, changes in disability and quality of life. Follow-up was immediate (≤ 2 weeks), short (> 2 weeks but ≤ 3 months), intermediate (> 3 months but < 12 months) or long term (≥ 12 months). A random-effects meta-analysis was conducted. Risk of bias was assessed using the original Cochrane tool, and quality of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Twenty-two studies were included. Pain was reduced with oral paracetamol plus a non-steroidal anti-inflammatory drug (NSAID) at immediate term in low back pain (paracetamol plus ibuprofen vs ibuprofen [mean difference (MD) - 6.2, 95% confidence interval (CI) -10.4 to -2.0, moderate evidence]) and in osteoarthritis (paracetamol plus aceclofenac vs aceclofenac [MD - 4.7, 95% CI - 8.3 to - 1.2, moderate certainty evidence] and paracetamol plus etodolac vs etodolac [MD - 15.1, 95% CI - 18.5 to - 11.8; moderate certainty evidence]). Paracetamol plus oral tramadol reduced pain compared with placebo at intermediate term for low back pain (MD - 11.7, 95% CI - 19.2 to - 4.3; very low certainty evidence) and osteoarthritis (MD - 6.8, 95% CI - 12.7 to -0.9; moderate certainty evidence). Disability scores improved in half the comparisons. Quality of life was infrequently measured. All paracetamol plus NSAID combinations did not increase the risk of adverse events compared to NSAID monotherapy.

CONCLUSIONS

Low-to-moderate quality evidence supports the oral use of some paracetamol plus NSAID combinations for short-term pain relief with no increased risk of harm for low back pain and osteoarthritis compared to its non-paracetamol monotherapy comparator.

Impact of Prescription Medicines on Work-Related Outcomes in Workers with Musculoskeletal Disorders or Injuries: A Systematic Scoping Review

PURPOSE

Medicines are often prescribed to workers with musculoskeletal disorders (MSDs) and injuries to relieve pain and facilitate their recovery and return to work. However, there is a growing concern that prescription medicines may have adverse effects on work function. This scoping review aimed to summarize the existing empirical evidence on prescription medicine use by workers with MSD or injury and its relationship with work-related outcomes.

METHODS

We identified studies through structured searching of MEDLINE, EMBASE, PsycINFO, CINAHL Plus, Scopus, Web of Science and Cochrane library databases, and via searching of dissertations, theses, and grey literature databases. Studies that examined the association between prescription medicine and work-related outcomes in working age people with injury or MSDs, and were published in English after the year 2000 were eligible.

RESULTS

From the 4884 records identified, 65 studies were included for review. Back disorders and opioids were the most commonly studied musculoskeletal conditions and prescription medicines, respectively. Most studies showed a negative relationship between prescription medicines and work outcomes. Opioids, psychotropics and their combination were the most common medicines associated with adverse work outcomes. Opioid prescriptions with early initiation, long-term use, strong and/or high dose and extended pre- and post-operative use in workers' compensation setting were consistently associated with adverse work function. We found emerging but inconsistent evidence that skeletal muscle relaxants and non-steroidal anti-inflammatory drugs were associated with unfavorable work outcomes.

CONCLUSION

Opioids and other prescription medicines might be associated with adverse work outcomes. However, the evidence is conflicting and there were relatively fewer studies on non-opioid medicines. Further studies with more robust design are required to enable more definitive exploration of causal relationships and settle inconsistent evidence.

Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review

BACKGROUND

Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point.

METHODS

In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used.

RESULTS

Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001).

CONCLUSION

Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ.

LEVEL OF EVIDENCE

I systematic review of RCTs.

Opioid Prescription Clusters Associated With Early or Unplanned Military Separation

INTRODUCTION

Early/unplanned military separation in Active Component U.S. service members can result in reduced readiness during periods of high-tempo combat and increased demand for health care services within the Military Health System and Veterans Administration. Although current assessment tools leverage prescription data to determine deployment-limiting medication receipt and the need for interventions or waivers, there is a lack of understanding regarding opioid prescription patterns and subsequent early/unplanned military separation after return from deployment. As such, understanding these relationships could support future tool development and strategic resourcing. Therefore, the goal of the present study was to identify unique 12-month opioid prescription patterns and evaluate their relationship with early/unplanned military separation in Active Component service members who returned from deployment.

MATERIALS AND METHODS

This retrospective, IRB-approved cohort study included data from 137,654 Active Component Army service members who returned from deployment between 2007 and 2013, received a post-deployment (index) opioid prescription, and had at least 1 year of Active Component service post-opioid initiation. A k-means clustering analysis identified clusters using opioid prescription frequency, median dose, median days supply, and prescription breaks (≥30 days) over the 12-month post-initiation (monitoring) period. A generalized additive model examined whether cluster membership and additional covariates were associated with early/unplanned separation.

RESULTS

In addition to the single opioid prescription (38%), the cluster analysis identified five clusters: brief/moderate dose (25%), recurrent breaks (16%), brief/high dose (11%), long/few prescriptions (8%), and high prescription frequency (2%). In the generalized additive model, the probability of early/unplanned military separation was higher for the high prescription frequency cluster (74%), followed by recurrent breaks (45%), long/few prescriptions (37%), brief/moderate dose (30%), and brief/high dose (29%) clusters, relative to the single prescription (21%) cluster. The probability of early/unplanned separation was significantly higher for service members with documented substance use disorders, mental health conditions, or traumatic brain injuries during the monitoring periods. Service members assigned male were more likely to have an early/unplanned separation relative to service members assigned female. Latinx service members and service members whose race was listed as Other were less likely to experience early/unplanned separation relative to white service members. Relative to Junior Officers, Junior Enlisted and Senior Enlisted service members were more likely to experience early/unplanned separation, but Senior Officers were less likely.

CONCLUSIONS

Further evaluation to support the integration of longitudinal opioid prescription patterns into existing tools (e.g., a screening tool for deployment-limiting prescriptions) may enable more timely intervention and support service delivery to mitigate the probability and impact of early/unplanned separation.

Fibromyalgia pain management effectiveness from the patient perspective: a qualitative evidence synthesis

PURPOSE

This qualitative evidence synthesis aimed to identify and integrate findings where adults with fibromyalgia discussed how they managed their pain, and their perceptions of prescribed treatments from healthcare professionals.

MATERIALS AND METHODS

A comprehensive search strategy was implemented in PubMed, Scopus, ISI Web of Science, and Cinahl Plus databases. The GRADE-CERQual framework was used to evaluate the findings confidence. The findings were analyzed using an inductive thematic analysis approach.

RESULTS

A total of 35 studies (N = 728) were included. The confidence in the findings ranged from high to low confidence. Patients with fibromyalgia often do not benefit from seeking medical attention due to provider stigma, and have varying views on medication effectiveness commonly reporting feeling like "walking chemists." They find mixed effects from exercise, and consider psychological support essential, although the benefits of cognitive-behavioral therapy were controversial. Combining cognitive-behavioral therapy with physical exercise appears more effective, while natural and complementary therapies have short-term benefits and high costs.

CONCLUSIONS

Pain management is a source for frustration and an unmet need for patients with fibromyalgia. The current findings provide crucial insight for providers and researchers; and support the need for fibromyalgia phenotyping and precision medicine approaches to pain management.Implications for RehabilitationChronic widespread pain is the defining feature of fibromyalgia, yet pain reduction is often an unmet need for these individuals.The lack of effective treatments resulting in long-term relief proves frustrating for patients and healthcare providers.Rehabilitation professional should consider the unique insight into this complex, heterogeneous condition that this qualitative synthesis provides to better understand their patient's perspective on pain management.Given the differing perspectives on pain treatment approaches individuals with fibromyalgia report, providers should discuss with each patient their current strategies and take a patient-centered, individualized approach to form an effective treatment plan.

An Updated Overview of Low Back Pain Management

We aimed to determine the recommendation level for the treatment of acute and chronic low back pain (LBP). A systematic review (SR) of the literature was performed and all English-language articles that discuss acute and chronic LBP, including MEDLINE and the Cochrane Database of Systematic Reviews, were searched. Of the 873 searched literature reports, 259 articles, including 131 clinical trials, 115 SRs, nine meta-analyses, and four clinical guidelines were analyzed. In these articles, high-quality randomized controlled trials, SRs, and used well-written clinical guidelines were reviewed. The results indicated multiple acute and chronic LBP treatment methods in the literature, and these reports when reviewed included general behavior, pharmacological therapy, psychological therapy, specific exercise, active rehabilitation and educational interventions, manual therapy, physical modalities, and invasive procedures. The Trial conclusions and SRs were classified into four categories of A, B, C, and D. If there were not enough high-quality articles, it was designated as "I" (insufficient). This review and summary of guidelines may be beneficial for physicians to better understand and make recommendations in primary care.

Pharmacotherapy for Spine-Related Pain in Older Adults

As the population ages, spine-related pain is increasingly common in older adults. While medications play an important role in pain management, their use has limitations in geriatric patients due to reduced liver and renal function, comorbid medical problems, and polypharmacy. This review will assess the evidence basis for medications used for spine-related pain in older adults, with a focus on drug metabolism and adverse drug reactions. A PubMed/OVID search crossing common spine, neck, and back pain terms with key words for older adults and geriatrics was combined with common drug classes and common drug names and limited to clinical trials and age over 65 years. The results were then reviewed with identification of commonly used drugs and drug categories: nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, corticosteroids, gabapentin and pregabalin, antispastic and antispasmodic muscle relaxants, tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tramadol, and opioids. Collectively, 138 double-blind, placebo-controlled trials were the focus of the review. The review found a variable contribution of high-quality studies examining the efficacy of medications for spine pain primarily in the geriatric population. There was strong evidence for NSAID use with adjustments for gastrointestinal and renal risk factors. Gabapentin and pregabalin had mixed evidence for neuropathic pain. SNRIs had good evidence for neuropathic pain and a more favorable safety profile than TCAs. Tramadol had some evidence in older patients, but more so in persons aged < 65 years. Rational therapeutic choices based on geriatric spine pain diagnosis are helpful, such as NSAIDs and acetaminophen for arthritic and myofascial-based pain, gabapentinoids or duloxetine for neuropathic and radicular pain, antispastic agents for myofascial-based pain, and combination therapy for mixed etiologies. Tramadol can be well tolerated in older patients, but has risks of cognitive and classic opioid side effects. Otherwise, opioids are typically avoided in the treatment of spine-related pain in older adults due to their morbidity and mortality risk and are reserved for refractory severe pain. Whenever possible, beneficial geriatric spine pain pharmacotherapy should employ the lowest therapeutic doses with consideration of polypharmacy, potentially decreased renal and hepatic metabolism, and co-morbid medical disorders.

Does preoperative opioid therapy in patients with a single lumbar disc herniation positively influence the postoperative outcome detected by quantitative sensory testing?

The importance of the type of pain medication in spinal disease is an ongoing matter of debate. Recent guidelines recommend acetaminophen and NSAIDs as first-line medication for lumbar disc herniation. However, opioid pain medication is commonly used in patients with chronic pain, and therefore also in patients with sciatica. The aim of this study is to evaluate if opioids have an impact on the outcome in patients suffering from lumbar disc herniation. To assess this objectively quantitative sensory testing (QST) was applied. In total, 52 patients with a single lumbar disc herniation confirmed on magnetic resonance imaging (MRI) and treated by lumbar sequesterectomy were included in the trial. Patients were analysed according to their preoperative opioid intake: 35 patients who did not receive opioids (group NO) and 17 patients, who received opioids preoperatively (group O). Further evaluation included detailed medical history, physical examination, various questionnaires, and QST. No pre- and postoperative differences were detected in thermal or mechanical thresholds (p > 0.05). Wind-up ratio (WUR) differed significantly between groups 1 week postoperatively (p = 0.025). The NRS for low back pain was rated significantly higher in the non-opioid group (NO) after 1-week follow-up (p = 0.026). Radicular pain tended to be higher in the NO group after 12 months of follow-up (p = 0.023). Opioids seem to be a positive predictor for the postoperative pain outcome in early follow-up in patients undergoing lumbar sequesterectomy. Furthermore, patients presented with less radicular pain 1 year after surgery.

Impact of Work-Related Chronic Low Back Pain on Functional Performance and Physical Capabilities in Women and Men: A Sex-Wise Comparative Study

Purpose

This study is aimed at determining the impact of work-related low back pain (LBP) on functional performance and physical capabilities.

Methods

This cross-sectional study included women (n = 25, mean age, 38.12 ± 4.59) and men (n = 25, mean age, 37.20 ± 5.38) with a history of work-related mechanical chronic LBP who visited our university hospital's outpatient department. All participants were assessed for primary outcomes, including the severity of LBP on rest and on activity, functional performance, and physical capabilities using a numeric pain rating scale (NPRS), Roland-Morris disability questionnaire (RDQ), five-time sit-to-stand test (FTSST), and fifty-foot walk test (FFWT), respectively. Independent t-tests compared the scores of the outcomes between groups while Pearson's correlation coefficient identified the correlation between the outcomes' measures at a significance level of 0.05.

Results

With a response rate of 63.29%, a total of fifty participant's data were obtained for the analysis. A comparison between women and men groups highlighted a significant difference in the scores of the FTSST and FFWT; however, there were insignificant differences in the scores of the NPRS at rest, NPRS on activity, and RDQ. The bivariate correlation revealed a highly significant, positive, and moderate correlation between the scores of NPRS at rest and FTSST, NPRS on activity and FTSST, NPRS at rest and FFWT, NPRS on activity and FFWT, FTSST and RDQ, and FFWT and RDQ in the women group. Similarly, there was a significant, positive, and low correlation between the scores of FTSST and RDQ and FFWT and RDQ in the men group.

Conclusion

Work-related chronic LBP affected the physical capabilities of women more than those of men. However, it equally affected the functional performance of all participants in the study. Furthermore, work-related chronic LBP affected the physical capabilities (FTSST and FFWT) and functional performance (RDQ) of women more than those of men.

Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition

BACKGROUND

The latest clinical guidelines are mandatory for physicians to follow when practicing evidence-based medicine in the treatment of low back pain. Those guidelines should target not only Japanese board-certified orthopaedic surgeons, but also primary physicians, and they should be prepared based entirely on evidence-based medicine. The Japanese Orthopaedic Association Low Back Pain guideline committee decided to update the guideline and launched the formulation committee. The purpose of this study was to describe the formulation we implemented for the revision of the guideline with the latest data of evidence-based medicine.

METHODS

The Japanese Orthopaedic Association Low Back Pain guideline formulation committee revised the previous guideline based on a method for preparing clinical guidelines in Japan proposed by Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014. Two key phrases, "body of evidence" and "benefit and harm balance" were focused on in the revised version. Background and clinical questions were determined, followed by literature search related to each question. Appropriate articles were selected from all the searched literature. Structured abstracts were prepared, and then meta-analyses were performed. The strength of both the body of evidence and the recommendation was decided by the committee members.

RESULTS

Nine background and nine clinical qvuestions were determined. For each clinical question, outcomes from the literature were collected and meta-analysis was performed. Answers and explanations were described for each clinical question, and the strength of the recommendation was decided. For background questions, the recommendations were described based on previous literature.

CONCLUSIONS

The 2019 clinical practice guideline for the management of low back pain was completed according to the latest evidence-based medicine. We strongly hope that this guideline serves as a benchmark for all physicians, as well as patients, in the management of low back pain.

Pain catastrophizing and mental health phenotypes in adults with refractory chronic pain: A latent class analysis

Chronic pain, pain catastrophizing, and mental health disorders such as anxiety or depression frequently occur together and are challenging to treat. To help understand the relationship between these conditions, we sought to identify distinct phenotypes associated with worse pain and function. In a cohort of people with chronic pain on opioids seeking medical cannabis in New York, we conducted latent class analysis to identify clusters of participants based on pain catastrophizing and mental health symptoms of depression, anxiety, post-traumatic stress disorder (PTSD) and attention deficit/hyperactivity disorder (ADHD). We then compared clusters with respect to sociodemographic and clinical characteristics using descriptive statistics. Among 185 participants, we identified four discrete groups: low pain catastrophizing and low mental health symptoms (49% of participants), low pain catastrophizing and ADHD-predominant mental health symptoms (11%), high pain catastrophizing and anxiety-predominant mental health symptoms (11%), and high pain catastrophizing and high mental health symptoms (30%). The group with high pain catastrophizing and high mental health symptoms had the worst pain intensity and interference, disability, insomnia, and quality of life, compared to the two groups with lower pain catastrophizing, though not all differences were statistically significant. Our findings highlight the importance of identifying and addressing pain catastrophizing in patients with comorbid chronic pain and mental health symptoms.

Comparative safety review of current treatment options for chronic low back pain and unmet needs: a narrative review

Introduction: The healthcare expenditures in the United States are substantial for the management of refractory, chronic low back pain (CLBP). The objective of this review is to summarize and evaluate the safety profiles of different pharmacological treatment options used in the management of CLBP.Areas covered: The authors conducted a search of randomized controlled trials (RCTs) assessing the safety profiles of different pharmacological agents used in the management of CLBP. This narrative review covered corticosteroids, opioids, antidepressants, gabapentinoids, nonsteroidal anti-inflammatory drugs, muscle relaxants, anti-nerve growth factor antibodies and topical agents, as monotherapy or in combination.Expert opinion: The risk-benefit ratio of a particular treatment is a subject driving the ongoing development of pharmaceuticals. The most commonly reported AEs across all drug classes are of gastrointestinal nature, followed by neurological and skin-related. These AEs include nausea, dizziness, constipation, arthralgia, headache, dry mouth, pruritus, etc. The majority of the AEs reported are not life-threatening, although they may lower patients' quality of life, thus, affecting their compliance. One of the biggest limitations of our review stems from the paucity of safety assessments in published RCTs. Advances in our understanding of the neurobiology of pain will promote development of new therapeutic strategies.

Patient phenotyping in clinical trials of chronic pain treatments: IMMPACT recommendations

There is tremendous interpatient variability in the response to analgesic therapy (even for efficacious treatments), which can be the source of great frustration in clinical practice. This has led to calls for “precision medicine” or personalized pain therapeutics (ie, empirically based algorithms that determine the optimal treatments, or treatment combinations, for individual patients) that would presumably improve both the clinical care of patients with pain and the success rates for putative analgesic drugs in phase 2 and 3 clinical trials. However, before implementing this approach, the characteristics of individual patients or subgroups of patients that increase or decrease the response to a specific treatment need to be identified. The challenge is to identify the measurable phenotypic characteristics of patients that are most predictive of individual variation in analgesic treatment outcomes, and the measurement tools that are best suited to evaluate these characteristics. In this article, we present evidence on the most promising of these phenotypic characteristics for use in future research, including psychosocial factors, symptom characteristics, sleep patterns, responses to noxious stimulation, endogenous pain-modulatory processes, and response to pharmacologic challenge. We provide evidence-based recommendations for core phenotyping domains and recommend measures of each domain.

The pharmacological management of chronic lower back pain

INTRODUCTION

Treating chronic low back pain (LBP) can be challenging, and the most effective pharmacological therapy is controversial. The present systematic review investigated the efficacy of various pharmacological compounds to achieve pain relief and improve disability in chronic LBP patients. The present study focused on acetaminophen, amoxicillin, flupirtine, baclofen, tryciclic antidepressants (TCAs), duloxetine, topiramate, gabapentinoids, non-steroid anti-inflammatory drugs (NSAIDs) and opioids.

AREAS COVERED

All randomized clinical trials comparing two or more drug treatments for chronic low back pain were accessed. Studies reporting outcomes concerning patients with neurologic or mechanic, specific or aspecific low back pain with or without radiculopathy were included. LBP was considered chronic if pain had lasted more than 6 weeks. Data from 47 articles (9007 patients: mean age: 52.62 ± 7.0 years; mean BMI: 28.26 ± 2.8; mean follow-up: 3.23 ± 3.2 months) were obtained.

EXPERT OPINION

According to published level I evidence, only baclofen, duloxetine, NSAIDs, and opiates showed to improve pain and disability levels in patients with LBP. However, the patients' demographics are heterogeneous, and the results must be interpreted with caution and in the light of possible adverse events connected to the use of these drugs.

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of low back pain

BACKGROUND CONTEXT

The North American Spine Society's (NASS) Evidence Based Clinical Guideline for the Diagnosis and Treatment of Low Back Pain features evidence-based recommendations for diagnosing and treating adult patients with nonspecific low back pain. The guideline is intended to reflect contemporary treatment concepts for nonspecific low back pain as reflected in the highest quality clinical literature available on this subject as of February 2016.

PURPOSE

The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with nonspecific low back pain. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition.

STUDY DESIGN

This is a guideline summary review.

METHODS

This guideline is the product of the Low Back Pain Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guideline was submitted to an internal and external peer review process and ultimately approved by the NASS Board of Directors.

RESULTS

Eighty-two clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature.

CONCLUSIONS

The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with nonspecific low back pain. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx.

The Concerns About Pain (CAP) Scale: A Patient-Reported Outcome Measure of Pain Catastrophizing

Pain catastrophizing has been recognized as an important and consistent psychosocial predictor of nearly every key pain-related outcome. The purpose of this study was to develop a new measure of pain catastrophizing using modern psychometric methodology. People with chronic pain (N = 795) responded to thirty items. Data were analyzed using item response theory, including assessment of differential item functioning and reliability. Sensitivity to change and validity were examined using data collected from patients undergoing spinal fusion surgery (n = 184) and participating in an ongoing longitudinal aging with a disability survey study (n = 1,388). The final 24-item bank had no items with significant local dependence, misfit, or differential item functioning. Results provided strong evidence of reliability and validity. Six- and 2-item short forms were developed for use when computer adaptive testing is not feasible or desirable. The item bank was named the University of Washington Concerns About Pain scale because the term "catastrophizing" was considered stigmatizing by people with chronic pain. Guidance for score interpretation was developed with extensive feedback from individuals with chronic pain. The Concerns About Pain item bank, short forms, and user manuals are free and publicly available to all users and can be accessed online at https://uwcorr.washington.edu/measures/. PERSPECTIVE: This article presents the development of the University of Washington Concerns About Pain scale, the first item response theory-based item bank of pain catastrophizing. The measure is intended for clinicians interested in improving outcomes of patients with chronic pain and for researchers who study impact of and treatment interventions aimed at reducing pain catastrophizing.

[Consensus statement on the use of acetaminophen/tramadol in patients with moderate-severe pain]

OBJECTIVES

To present recommendations on the use of the paracetamol/tramadol (P/T) combination in patients with moderate-intense pain based on best evidence and experience.

METHODS

The method of nominal groups and Delphi was followed, and supported by a systematic literature review (SLR). A multidisciplinary panel of 12 experts in pain management was selected. In the first nominal group meeting, the aim, scope, users, and sections of the consensus document, were defined, along with the preliminary general recommendations. For the SLR, the inclusion and exclusion criteria, as well as the search strategies, were defined. Two reviewers selected and analysed the articles. This evidence was discussed in a second nominal group meeting, and definitive recommendations were developed. For each recommendation, the evidence levels and grade of recommendation grades were classified according to the Oxford model, and the grade according to the Delphi technique. It was defined as an agreement if at least 70% of the participants scored ≥7 for each recommendation (1=total disagreement to 10=total agreement).

RESULTS

A total of 20 recommendations were produced, which covered general aspects, such as the assessment of pain, and those specific to P/T management. These latter included the indications of the P/T combination (patient profile, dosing, prescription, formulations), risk management (contraindications, precautions, interactions, concomitant use with other medications, follow-up, special situations), and patient education.

CONCLUSIONS

These recommendations attempt to resolve any of the routine clinical questions, and help in the making of decisions on the use of the P/T combination in patients with moderate-intense pain.

Measuring Pain Catastrophizing and Pain-Related Self-Efficacy: Expert Panels, Focus Groups, and Cognitive Interviews

PURPOSE

Pain-related self-efficacy and pain catastrophizing are important psychosocial determinants of pain and can be therapeutic targets for chronic pain management. Advances in psychometric science have made shorter or dynamically administered instruments possible. The aim of this study was to generate and test candidate items for two new patient-reported outcome measures of pain-related self-efficacy and pain catastrophizing.

METHODS

An expert panel of pain clinicians and researchers was convened to establish construct definitions of pain-related self-efficacy and pain catastrophizing and guide item development. Two patient advisors provided guidance throughout the project. Nineteen people with chronic pain participated in focus groups about their perspectives and experiences related to pain-related self-efficacy and pain catastrophizing. Twenty-two people with chronic pain participated in cognitive interviews to test proposed candidate items.

RESULTS

Saturation was reached after three focus groups with no new subdomains identified by participants in the third focus group. Following cognitive interviews, five of the 48 initial pain-related self-efficacy candidate items were dropped and seven required substantial revision resulting in 43 pain-related self-efficacy candidate items. After two rounds of cognitive interviews, ten items were eliminated and ten substantially revised, resulting in a set of 30 from the initial 43 pain catastrophizing candidate items.

CONCLUSION

This article summarizes results of the qualitative phase of the development of new measures of pain-related self-efficacy and pain catastrophizing. Candidate items will be field tested with a large sample of people with chronic pain and the data will be used to calibrate items to an item response theory model. Resulting item banks and short forms will be made publicly available to researchers and clinicians.

Combination Drug Therapy for the Management of Low Back Pain and Sciatica: Systematic Review and Meta-Analysis

Combining medicines may give greater pain relief and/or improved tolerability. We conducted a systematic review to investigate the effects of combination drug therapy in patients with low back pain and/or sciatica on pain, disability, and adverse events. Databases and trial registers were searched from inception to July 27, 2017, for randomized trials of (sub)acute or chronic back pain or sciatica participants that were administered combination drug therapy compared with monotherapy or placebo. Of the 27 studies included, most combinations (21 of 23) consisted of single trials. Most combinations had no or small effect on pain and disability. A clinically important difference was found in one combination, buprenorphine plus pregabalin versus buprenorphine for chronic back pain at immediate (mean difference = -23.30; 95% confidence interval = -27.68 to -18.92) and short (mean difference = -27.60; 95% confidence interval = -31.70 to -23.50) terms; however, the quality of evidence was low. There was no statistically significant increased risk of serious adverse events. When the risk of adverse events was statistically significant, it favored monotherapy or placebo. There is no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence. Perspective: Combining medicines may give greater pain relief and/or improved tolerability compared with single-ingredient medicines. However, the lack of studies and overall low quality of evidence limit the recommendation of combination drug therapy for the management of low back pain and sciatica.

Alternatives to Opioids in the Pharmacologic Management of Chronic Pain Syndromes: A Narrative Review of Randomized, Controlled, and Blinded Clinical Trials

Chronic pain exerts a tremendous burden on individuals and societies. If one views chronic pain as a single disease entity, then it is the most common and costly medical condition. At present, medical professionals who treat patients in chronic pain are recommended to provide comprehensive and multidisciplinary treatments, which may include pharmacotherapy. Many providers use nonopioid medications to treat chronic pain; however, for some patients, opioid analgesics are the exclusive treatment of chronic pain. However, there is currently an epidemic of opioid use in the United States, and recent guidelines from the Centers for Disease Control (CDC) have recommended that the use of opioids for nonmalignant chronic pain be used only in certain circumstances. The goal of this review was to report the current body of evidence-based medicine gained from prospective, randomized-controlled, blinded studies on the use of nonopioid analgesics for the most common noncancer chronic pain conditions. A total of 9566 studies were obtained during literature searches, and 271 of these met inclusion for this review. Overall, while many nonopioid analgesics have been found to be effective in reducing pain for many chronic pain conditions, it is evident that the number of high-quality studies is lacking, and the effect sizes noted in many studies are not considered to be clinically significant despite statistical significance. More research is needed to determine effective and mechanism-based treatments for the chronic pain syndromes discussed in this review. Utilization of rigorous and homogeneous research methodology would likely allow for better consistency and reproducibility, which is of utmost importance in guiding evidence-based care.

Impact of patient information leaflets on pain medication intake behavior: a pilot study

Negative wording in package information leaflets of pain medication is associated with a tendency to evoke negative emotions and lower willing to take medication.

Introduction:

Patient information leaflets on pain medication primarily list side effects while positive effects and action mechanisms remain underrepresented. Nocebo research has shown that negative instructions can lower analgesic effects.

Objectives:

Research on information leaflets and their influence on mood, memory of side effects, and intake behavior of healthy participants is needed.

Methods:

To determine the ratio of positive to negative phrases, 18 information leaflets of common, over-the-market analgesics were examined of which 1 was selected. In a randomized, controlled study design, 18 healthy participants read this leaflet while 18 control group participants read a matched, neutral leaflet of an electrical device. Collected data concerned the recall of positive and negative contents, mood, anxiety, and the willingness to buy and take the drug.

Results:

All examined leaflets listed significantly more side effects than positive effects (t₁₇ = 5.82, P < 0.01). After reading the analgesic leaflet, participants showed a trend towards more negative mood (F_1,34 = 3.78, P = 0.06, η_p² = 0.1), a lower intention to buy [χ² (1, n = 36) = 12.5, P < 0.01], a higher unwillingness to take the medication [χ² (1, n = 36) = 7.2, P < 0.01], and even a greater recall for side effects than positive effects (t₁₇ = 7.47, P < 0.01).

Conclusion:

Reading the patient information leaflets can increase fear and lower the intention to buy and the willingness to take a pain medication.

An Updated Overview of Low Back Pain Management in Primary Care

Currently, guidelines for lower back pain (LBP) treatment are needed. We reviewed the current guidelines and high-quality articles to confirm the LBP guidelines for the Korean Society of Spine Surgery. We searched available databases for high-quality articles in English on LBP published from 2000 to the present year. Literature searches using these guidelines included studies from MEDLINE, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, and Embase. We analyzed a total of 132 randomized clinical trials, 116 systematic reviews, 9 meta-analyses, and 4 clinical guideline reviews. We adopted the SIGN checklist for the assessment of article quality. Data were subsequently abstracted by a reviewer and verified. Many treatment options exist for LBP, with a variety of recommendation grades. We assessed the recommendation grade for general behavior, pharmacological therapy, psychological therapy, and specific exercises. This information should be helpful to physicians in the treatment of LBP patients.

Patient phenotyping in clinical trials of chronic pain treatments: IMMPACT recommendations

There is tremendous interpatient variability in the response to analgesic therapy (even for efficacious treatments), which can be the source of great frustration in clinical practice. This has led to calls for "precision medicine" or personalized pain therapeutics (ie, empirically based algorithms that determine the optimal treatments, or treatment combinations, for individual patients) that would presumably improve both the clinical care of patients with pain and the success rates for putative analgesic drugs in phase 2 and 3 clinical trials. However, before implementing this approach, the characteristics of individual patients or subgroups of patients that increase or decrease the response to a specific treatment need to be identified. The challenge is to identify the measurable phenotypic characteristics of patients that are most predictive of individual variation in analgesic treatment outcomes, and the measurement tools that are best suited to evaluate these characteristics. In this article, we present evidence on the most promising of these phenotypic characteristics for use in future research, including psychosocial factors, symptom characteristics, sleep patterns, responses to noxious stimulation, endogenous pain-modulatory processes, and response to pharmacologic challenge. We provide evidence-based recommendations for core phenotyping domains and recommend measures of each domain.

The Role of Psychosocial Processes in the Development and Maintenance of Chronic Pain

The recently proposed Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) provides an evidence-based, multidimensional, chronic pain classification system. Psychosocial factors play a crucial role within several dimensions of the taxonomy. In this article, we discuss the evaluation of psychosocial factors that influence the diagnosis and trajectory of chronic pain disorders. We review studies in individuals with a variety of persistent pain conditions, and describe evidence that psychosocial variables play key roles in conferring risk for the development of pain, in shaping long-term pain-related adjustment, and in modulating pain treatment outcomes. We consider "general" psychosocial variables such as negative affect, childhood trauma, and social support, as well as "pain-specific" psychosocial variables that include pain-related catastrophizing, self-efficacy for managing pain, and pain-related coping. Collectively, the complexity and profound variability in chronic pain highlights the need to better understand the multidimensional array of interacting forces that determine the trajectory of chronic pain conditions.

PERSPECTIVE

The AAPT is an evidence-based chronic pain classification system in which psychosocial concepts and processes are essential in understanding the development of chronic pain and its effects. In this article we review psychosocial processes that influence the onset, exacerbation, and maintenance of chronic pain disorders.

Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis

IMPORTANCE

Opioid analgesics are commonly used for low back pain, however, to our knowledge there has been no systematic evaluation of the effect of opioid dose and use of enrichment study design on estimates of treatment effect.

OBJECTIVE

To evaluate efficacy and tolerability of opioids in the management of back pain; and investigate the effect of opioid dose and use of an enrichment study design on treatment effect.

DATA SOURCES

Medline, EMBASE, CENTRAL, CINAHL, and PsycINFO (inception to September 2015) with citation tracking from eligible randomized clinical trials (RCTs).

STUDY SELECTION

Placebo-controlled RCTs in any language.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted data and assessed risk of bias. Data were pooled using a random effects model with strength of evidence assessed using the grading of recommendations assessment, development, and evaluation (GRADE).

MAIN OUTCOMES AND MEASURES

The primary outcome measure was pain. Pain and disability outcomes were converted to a common 0 to 100 scale, with effects greater than 20 points considered clinically important.

RESULTS

Of 20 included RCTs of opioid analgesics (with a total of 7925 participants), 13 trials (3419 participants) evaluated short-term effects on chronic low back pain, and no placebo-controlled trials enrolled patients with acute low back pain. In half of these 13 trials, at least 50% of participants withdrew owing to adverse events or lack of efficacy. There was moderate-quality evidence that opioid analgesics reduce pain in the short term; mean difference (MD), -10.1 (95% CI, -12.8 to -7.4). Meta-regression revealed a 12.0 point greater pain relief for every 1 log unit increase in morphine equivalent dose (P = .046). Clinically important pain relief was not observed within the dose range evaluated (40.0-240.0-mg morphine equivalents per day). There was no significant effect of enrichment study design.

CONCLUSIONS AND RELEVANCE

For people with chronic low back pain who tolerate the medicine, opioid analgesics provide modest short-term pain relief but the effect is not likely to be clinically important within guideline recommended doses. Evidence on long-term efficacy is lacking. The efficacy of opioid analgesics in acute low back pain is unknown.

Paracetamol for low back pain

BACKGROUND

Analgesic medication is the most frequently prescribed treatment for low back pain (LBP), of which paracetamol (acetaminophen) is recommended as the first choice medication. However, there is uncertainty about the efficacy of paracetamol for LBP.

OBJECTIVES

To investigate the efficacy and safety of paracetamol for non-specific LBP.

SEARCH METHODS

We conducted searches on the Cochrane Central Register of Controlled Trials (CENTRAL, which includes the Back and Neck Review Group trials register), MEDLINE, EMBASE, CINAHL, AMED, Web of Science, LILACS, and IPA from their inception to 7 August 2015. We also searched the reference lists of eligible papers and trial registry websites (WHO ICTRP and ClinicalTrials.gov).

SELECTION CRITERIA

We only considered randomised trials comparing the efficacy of paracetamol with placebo for non-specific LBP. The primary outcomes were pain and disability. We also investigated quality of life, function, adverse effects, global impression of recovery, sleep quality, patient adherence, and use of rescue medication as secondary outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed the data extraction and assessed risk of bias in the included studies. We also evaluated the quality of evidence using the GRADE approach. We converted scales for pain intensity to a common 0 to 100 scale. We quantified treatment effects using mean difference for continuous outcomes and risk ratios for dichotomous outcomes. We used effect sizes and 95% confidence intervals as a measure of treatment effect for the primary outcomes. When the treatment effects were smaller than 9 points on a 0 to 100 scale, we considered the effect as small and not clinically important.

MAIN RESULTS

Our searches retrieved 4449 records, of which three trials were included in the review (n = 1825 participants), and two trials were included in the meta-analysis. For acute LBP, there is high-quality evidence for no difference between paracetamol (4 g per day) and placebo at 1 week (immediate term), 2 weeks, 4 weeks, and 12 weeks (short term) for the primary outcomes. There is high-quality evidence that paracetamol has no effect on quality of life, function, global impression of recovery, and sleep quality for all included time periods. There were also no significant differences between paracetamol and placebo for adverse events, patient adherence, or use of rescue medication. For chronic LBP, there is very low-quality evidence (based on a trial that has been retracted) for no effect of paracetamol (1 g single intravenous dose) on immediate pain reduction. Finally, no trials were identified evaluating patients with subacute LBP.

AUTHORS' CONCLUSIONS

We found that paracetamol does not produce better outcomes than placebo for people with acute LBP, and it is uncertain if it has any effect on chronic LBP.

Functional Capacity Evaluation Research: Report from the Second International Functional Capacity Evaluation Research Meeting

INTRODUCTION

Functional capacity evaluations are an important component of many occupational rehabilitation programs and can play a role in facilitating reintegration to work thus improving health and disability outcomes. The field of functional capacity evaluation (FCE) research has continued to develop over recent years, with growing evidence on the reliability, validity and clinical utility of FCE within different patient and healthy worker groups. The second International FCE Research Conference was held in Toronto, Canada on October 2nd 2014 adjacent to the 2014 Work Disability Prevention Integration conference. This paper describes the outcomes of the conference.

REPORT

Fifty-four participants from nine countries attended the conference where eleven research projects and three workshops were presented. The conference provided an opportunity to discuss FCE practice, present new research and provide a forum for discourse around the issues pertinent to FCE use. Conference presentations covered aspects of FCE use including the ICF-FCE interface, aspects of reliability and validity, consideration of specific injury populations, comparisons of FCE components and a lively debate on the merits of 'Man versus Machine' in FCE's.

FUTURE DIRECTIONS

Researchers, clinicians, and other professionals in the FCE area have a common desire to improve the content and quality of FCE research and to collaborate to further develop research across systems, cultures and countries.

Pharmacological management of chronic low back pain in older patients: a randomized controlled trial of the effect of pregabalin and opioid administration

PURPOSE

Pregabalin and opioids are used to treat chronic low back pain (LBP). No previous investigations have compared the efficacy of pregabalin and that of opioids for chronic LBP.

METHODS

We performed a randomized controlled trial of pregabalin and opioids in 65 consecutive patients aged 65 years or older who had chronic LBP. Each agent was administered randomly in different phases. Pain and activities of daily living (ADL) were evaluated after 4 weeks of treatment using the visual analog scale, Japanese Orthopaedic Association score, Roland Morris Disability Questionnaire, short-form McGill Pain Questionnaire, EuroQol quality-of-life scale, and geriatric depression scale. Neuropathic pain was evaluated using a neuropathic pain screening questionnaire.

RESULTS

The effectiveness rate was 73.3% for pregabalin and 83.3% for opioid, showing no significant difference. The mean durations until the onset of effect were 10.2 and 6.1 days, respectively, albeit without significant difference. Pregabalin was effective for LBP with neuropathic pain, whereas opioids were effective for non-neuropathic pain. The improvement of ADL was greater with opioids than with pregabalin. Pregabalin was effective for LBP in patients with lower limb symptoms, whereas opioids were effective for those without lower limb symptoms.

CONCLUSIONS

Aside from screening tests, consideration of neuropathic pain and lower extremity symptoms may be an integral component in the selection of the appropriate medication for chronic LBP. Moreover, the therapeutic objectives, including pain relief and/or improvement of ADL, should be specified.