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

Current Physiotherapy Assessment and Treatment Practices for Low Back Pain in Nigeria: A National Survey

INTRODUCTION

Despite advances in physiotherapy care for Low Back Pain (LBP) worldwide, studies suggest that physiotherapists in Nigeria do not adhere to international guidelines, and it is not known whether recent treatment approaches developed for LBP are recognized or applied by physiotherapists in Nigeria.

OBJECTIVES

To evaluate the current assessment and treatment practices used by physiotherapists in Nigeria for people with recent onset, recurrent and chronic LBP.

DESIGN

A descriptive cross-sectional electronic national survey.

PARTICIPANTS

Two hundred and sixty-seven registered physiotherapists who treat LBP across all 36 states of Nigeria completed the survey anonymously via REDCap.

RESULTS

Two hundred and sixty-seven physiotherapists (mean age = 37.6 years, SD = 9.1; 53.6% female) completed the survey in full. Although most physiotherapists (> 95%) regularly applied traditional assessment methods (e.g., history of presenting complaint, observation for spinal deformity, palpation), only approximately 30% screened for red flag pathology. Very few physiotherapists assessed patients with LBP for psychological distress (< 8%) or risk stratification/prognostic factors (< 4%). For treatment, electrophysical agents and muscle techniques (e.g., massage) predominated (> 95%), while few physiotherapists used cognitive-behavioural strategies (< 2%), individualised multimodal treatment programs (e.g., cognitive functional therapy, StarT Back or STOPS, < 1.5%), validated outcome measures (< 15%), clinical practice guidelines (< 10%) or a clinical reasoning strategy/framework (< 20%). Most Nigerian physiotherapists (> 99%) expressed interest in learning evidence-based LBP assessment and treatment methods from international experts.

CONCLUSION

There is very limited application of contemporary assessment and treatment practices for LBP by Nigerian physiotherapists; however, they are very interested in learning these methods from international experts.

The effect of core stability training combined with fascial release on patients with nonspecific low back pain

BACKGROUND

Non-specific lower back pain (NLBP) is treated with a variety of therapies, including health education, exercise therapy, soft tissue release, psychological interventions, and shockwave therapy. However, some studies have shown that core stability training or fascial release therapy alone is not effective in the treatment of low back pain.

BJECTIVE

The aim of this study was to investigate the effects of core stability training on patients' inflammatory cytokine levels and lumbar muscle temperature when combined with fascial release for the treatment of non-specific low back pain.

METHODS

In this study, a total of 60 patients with non-specific low back pain who were treated in Mindong Hospital of Ningde City between December 2021 and January 2023 were selected and randomly and equally divided into a control group (30 cases) and an experimental group (30 cases). The control group received core stability training, while the experimental group added fascial release surgery to this. We compared and assessed the pain visual analog score (VAS), Oswestry dysfunction index (ODI), lumbar spine mobility (including anterior flexion, posterior extension, left flexion, and right flexion), as well as levels of inflammatory factors IL-6, TNF-a, and muscle tissue temperature in the two groups.

RESULTS

This study has been successfully implemented and covered 60 patients throughout the trials. Upon comparison, the two groups did not show statistically significant differences in baseline data such as age, gender and duration of disease (p> 0.05). After four weeks of treatment, the test group showed statistically significant (p< 0.05) differences in VAS scores, ODI scores, and IL-6 and TNF-a levels that were significantly lower than those of the control group. It is worth mentioning that the muscle tissue temperature of the patients in the test group, as well as their performance in lumbar anterior flexion, posterior extension, left flexion, and right flexion mobility, were significantly better than those of the control group, and these differences also showed statistical significance (p< 0.05).

CONCLUSION

The combination of core stability training and fascial release demonstrates significant clinical results in the treatment of nonspecific lower back pain. Through medical thermography and serum inflammatory factor testing, we were able to assess the treatment effect more objectively, providing a strong basis for future clinical practice.

Nonpharmacological Spine Pain Management in Clinical Practice Guidelines: A Systematic Review Using AGREE II and AGREE-REX Tools

OBJECTIVE: To summarize the content and critically appraise the quality and applicability of recent clinical practice guidelines (CPGs) for nonpharmacological, nonsurgical management of spine pain. DESIGN: Systematic review of CPGs. LITERATURE SEARCH: Six databases and seven guideline clearinghouses. STUDY SELECTION CRITERIA: Included de novo CPGs for nonpharmacological, nonsurgical management of spine pain designed for any primary health care providers, published in English, Arabic, French, or traditional Chinese within the past 12 years. DATA SYNTHESIS: Five reviewers independently appraised the guidelines using AGREE II and AGREE-REX. Interrater agreements were calculated for each domain and the total score of these tools using the intraclass correlation coefficient (2, 1) with absolute agreement. RESULTS: We included 30 CPGs, primarily (90%) developed in Western countries, which contained 404 recommendations. High-quality CPGs consistently recommended exercise therapy and multimodal care, encompassing a combination of exercises, mobilization/manipulation, education, alternative medicine, and cognitive-behavioral treatments. Generally, CPGs did not recommend assistive (eg, corsets and orthosis) devices or electro/thermotherapies (eg, therapeutic ultrasound and transcutaneous electrical nerve stimulation). Approximately half of the CPGs demonstrated good methodological quality according to AGREE II, whereas the rest were of poor quality. On the AGREE-REX assessment, one third of the recommendations were of excellent quality. CONCLUSION: Although recent guidelines frequently recommended exercise therapy and multimodal care for the management of spine pain, their recommendations often overlooked demographics and comorbidities. Despite methodological improvements, most CPGs lacked simple clinical applicability and considerations of knowledge users' values. J Orthop Sports Phys Ther 2025;55(1):1-14. Epub 4 November 2024. doi:10.2519/jospt.2024.12729.

Imaging observation of intervertebral disc degeneration in patients with old thoracolumbar fracture-related kyphotic deformity

Old thoracolumbar fracture with kyphosis (OTLFK) often results in low back pain, with intervertebral disc degeneration being a significant contributor. We hypothesized that patients with OTLFK exhibit distinct patterns of disc degeneration compared to those with chronic low back pain without kyphotic deformity. This study aimed to investigate the characteristics of disc degeneration in OTLFK patients and explore its association with sagittal spinal parameters and endplate injury. A retrospective analysis was conducted on 52 patients with OTLFK (observation group, OG) and 104 age-, gender-, and BMI-matched patients with chronic low back pain (control group, CG) treated at our hospital between February 2017 and March 2023. Intervertebral disc degeneration from T11/12 to L5/S1 was assessed using MRI T2-weighted images and the Pfirrmann grading system. Sagittal spinal parameters-including lumbar lordosis (LL), thoracic kyphosis (TK), local kyphosis Cobb angle (LKCA), thoracolumbar kyphosis (TLK), pelvic tilt(PT), sacral slope(SS), and sagittal vertical axis (SVA)-and endplate injury grades were measured in the OG. Differences in disc degeneration between the two groups were compared, and correlations between disc degeneration, sagittal parameters, and endplate injury were analyzed. The OG exhibited significantly higher overall disc degeneration grades compared to the CG (p < 0.05), particularly at levels T11/12, T12/L1, L1/2, and L2/3. In the OG, grade IV and V degenerations were predominantly found from T11/12 to L2/3, whereas in the CG, they were mainly at L4/5 and L5/S1. Disc degeneration in the OG was significantly correlated with sagittal parameters and endplate injury grades (p < 0.05). Patients with OTLFK have higher grades of disc degeneration in the thoracolumbar region compared to those with chronic low back pain without kyphosis. Disc degeneration in OTLFK is associated with abnormal sagittal alignment and endplate injury, suggesting that kyphotic deformity and altered spinal biomechanics contribute to accelerated disc degeneration.

Effects of the active break intervention on nonspecific low back pain among young people: a randomized controlled trial

INTRODUCTION

Every end-range position maintained for a prolonged time causes a static load on the spine and may lead to musculoskeletal discomfort. Prolonged flexed sitting is a strong predictor of low back pain (LBP). The study aimed to evaluate the effectiveness of the Active Break program, implemented among young people, in reducing perceived low back pain and discomfort, as well as associated disability level resulting from prolonged sitting.

METHODS

A randomized controlled trial was conducted among young people with non-specific LBP. Participants were randomized into groups: an experimental group participating in the tested Active Break intervention (AB-group, n = 25), and a control group (C-group, n = 25) with self-administered care recommendations. The program took 12 weeks. The outcomes were average pain intensity (Visual Analogue Scale, VAS), disability (Oswestry Disability Index, ODI), perceived low back discomfort (LBD) during prolonged sitting (Borg scale), and global perceived improvement (Global Perceived Effect, GPE).

RESULTS

VAS, ODI, and LBD scores after the 12-week intervention were significantly lower than those at baseline in the AB-group. In the C-group, differences were not statistically significant. Post-intervention inter-group VAS, LBD, and GPE differences were significant.

CONCLUSIONS

The 12-week study of the Active Break intervention for young people with non-specific low back pain demonstrated significant improvement. Our research offers valuable evidence-based practices for managing and preventing low back pain, benefiting individuals, educators, healthcare professionals, personal trainers, and family physicians.

TRIAL REGISTRATION

The study was registered at ClinicalTrials.gov [NCT05810519], registration date: 31/03/2023.

Characteristics and mechanical mechanisms of intervertebral disc degeneration in old thoracolumbar fractures with kyphosis: clinical observations and finite element analyses

BACKGROUND

Low back pain is a common complication in patients with old thoracolumbar fractures with kyphosis (OTLFK), and intervertebral disc degeneration (IDD) is a major contributor. Mechanical abnormalities are believed to play a key role in the development to IDD. This study aimed to investigate the characteristics of lumbar disc degeneration and underlying mechanical mechanisms in patients with OTLFK.

METHODS

A total of 52 patients with OTLFK were included from February 2017 to March 2023 as the observation group (OG). A control group (CG) of individuals with chronic low back pain were matched for age, body mass index, and gender. The disc degeneration grades and distribution in both groups were observed. Intact, 20°, 30°, and 40° kyphotic finite element (FE) models were established. Intervertebral disc pressures (IDPs) were calculated under standing, flexion, extension, lateral bending, and axial rotation conditions.

RESULTS

The overall IDD in the OG was higher than that in the CG. The grades from T11 to L3 were higher in the OG (p < 0.05), while there was no significant difference from L4 to S1. Degeneration levels IV and V were concentrated in the T11-L3 segment in the OG; whereas, in the CG, this was in L4/5 and L5/S1 (p < 0.05). The FE analysis results showed that, in the kyphotic model, the IDP was higher than the intact model in the standing position, flexion, lateral bending, and rotation, but lower in extension.

CONCLUSIONS

Patients with OTLFK exhibit higher-grade disc degeneration concentrated in the thoracolumbar segment. Abnormal mechanical stress may contribute to this degeneration, highlighting the importance of managing stress in kyphotic deformities.

Structural changes of the multifidus in animal models of intervertebral disk degeneration: a systematic review

Study design

Low back pain (LBP) is a widespread clinical symptom affecting nearly all age groups and is a leading cause of disability worldwide. Degenerative changes in the spine and paraspinal tissues primarily contribute to the etiology of LBP.

Objectives

We conducted this systematic review of animal models of paraspinal muscle (PSM) degeneration secondary to degenerative intervertebral disc (IVD), providing a comprehensive evaluation of PSM structural changes observed in these models at both macroscopic and microscopic levels.

Methods

PubMed, EMBASE, Web of Science, Cochrane Library, and MEDLINE Ovid databases were searched through November 2023. Literature was sequentially screened based on titles, abstracts, inclusion of animal models and full texts. A manual search of reference lists from all eligible studies was also performed to identify any eligible article. Two independent reviewers screened the articles according to inclusion and exclusion criteria. The risk of bias was assessed using the Systematic Review Centre for Laboratory Animal Experimentation's Risk of Bias tool.

Results

A total of nine studies were included in the final analysis after a comprehensive screening process. The included studies were assessed for various aspects of the multifidus muscle. Given the limited number of studies and the substantial heterogeneity among them, a quantitative meta-analysis was deemed inappropriate.

Conclusions

This systematic review shows a comprehensive analysis of structural changes in the multifidus muscle in animal models of IVD degeneration and offers crucial insights for developing improved rodent models of IVD degeneration and assessing a battery of approaches for multifidus degeneration.

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.

Temporal Trends in the Epidemiology of Lower Back Pain in the United States

STUDY DESIGN

This was an observational study.

OBJECTIVE

This study aims to explore sociodemographic and regional geographic variations in lower back pain (LBP) incidence, prevalence, and burden in the United States (US from 2000 to 2019).

SUMMARY OF BACKGROUND DATA

LBP is a major contributor to lost wages and disability in the United States. As LBP is associated with increasing age and sedentary lifestyle, the incidence of LBP is expected to rise. Due to LBP's multifactorial causes, US epidemiological trends lack sufficient data.

MATERIALS AND METHODS

Descriptive epidemiological data including disability-adjusted life years (DALYs), incidence, and prevalence per 100,000 population from 2000 to 2019 were collected from the Global Burden of Disease database. State-level data regarding poverty, insurance and employment status were obtained from the US Government Census Bureau and US Department of Labor. Statistical significance was indicated by P <0.05.

RESULTS

From 2000 to 2019, the US demonstrated reductions in LBP incidence, prevalence, and DALYs. Regional analysis demonstrated the Midwest to have the greatest mean incidence, prevalence, and DALYs; with Midwestern females significantly more affected than females in other regions. Those aged 25 to 49 in the Midwest were impacted significantly more across all measures compared with age-matched populations in other regions. Nationally, there were no significant associations between unemployment and LBP. Poverty was inversely correlated with LBP incidence. Uninsured status was positively correlated with prevalence and DALYs.

CONCLUSION

Although there has been progress in reducing the impact of LBP in the United States, the Midwest region has greater rates for all measures compared with other US regions. Further, females and those aged 25 to 49 in the Midwest were more likely to be affected by LBP compared with counterparts in other regions. Future studies should identify specific factors contributing to elevated LBP rates in the Midwest in order to guide targeted interventions to reduce the incidence and burden of LBP there.

An Update on Emerging Regenerative Medicine Applications: The Use of Extracellular Vesicles and Exosomes for the Management of Chronic Pain

PURPOSE OF REVIEW

Chronic pain affects nearly two billion people worldwide, surpassing heart disease, diabetes, and cancer in terms of economic costs. Lower back pain alone is the leading cause of years lived with disability worldwide. Despite limited treatment options, regenerative medicine, particularly extracellular vesicles (EVs) and exosomes, holds early promise for patients who have exhausted other treatment options. EVs, including exosomes, are nano-sized structures released by cells, facilitating cellular communication through bioactive molecule transfer, and offering potential regenerative properties to damaged tissues. Here, we review the potential of EVs and exosomes for the management of chronic pain.

RECENT FINDINGS

In osteoarthritis, various exosomes, such as those derived from synovial mesenchymal stem cells, human placental cells, dental pulp stem cells, and bone marrow-derived mesenchymal stem cells (MSCs), demonstrate the ability to reduce inflammation, promote tissue repair, and alleviate pain in animal models. In intervertebral disc disease, Wharton's jelly MSC-derived EVs enhance cell viability and reduce inflammation. In addition, various forms of exosomes have been shown to reduce signs of inflammation in neurons and alleviate pain in neuropathic conditions in animal models. Although clinical applications of EVs and exosomes are still in the early clinical stages, they offer immense potential in the future management of chronic pain conditions. Clinical trials are ongoing to explore their therapeutic potential further, and with more research the potential applicability of EVs and exosomes will be fully understood.

Guideline concordant care for acute low back pain: A mixed-methods analysis of determinants of implementation

INTRODUCTION

We conducted an explanatory, sequential mixed-methods study to measure variation in the use of imaging and physical therapy (PT) for acute low back pain (LBP) and to identify implementation determinants that might explain variation in use across 22 EDs and 27 urgent cares in urban and rural locations within a community-based health system.

METHODS

We described the patient population and measured concordance with LBP guideline recommendations on imaging and PT referral from January-June 2023. We conducted key informant interviews with physicians and advanced practice providers (APPs), n = 30, from these 49 sites between July - September 2023 and performed content analysis to identify implementation determinants to guideline concordance.

RESULTS

From January-June 30, 2023, 1047 Intermountain Health employed or affiliated physicians and APPs at the 22 adult EDs and 27 adult UCs cared for 8047 patient encounters involving acute LBP with no red flags. 29% of acute LBP patient encounters included an imaging order (ED: 43%; UC: 18%) and 5% included a PT order (ED: 7%; UC: 4%). 17 ED and 13 UC physicians and APPs participated in semi-structured interviews. Their patient encounters represent 6% of the overall study population (ED: 5%; UC: 7%) with order rates and patient population characteristics similar to the full study population. ED and UC clinicians were generally familiar with LBP guideline recommendations but varied significantly in their knowledge and beliefs of the appropriate application of guidelines in evaluation and treatment plans.

DISCUSSION

Guideline concordance for use of imaging and PT varied substantially across physicians and advance practice providers providing care at EDs and UC centers within a community-based health system. Implementation strategies that address barriers identified by this study, including varied understanding of the PT discipline, complex workflows for placing PT referrals, the medico-legal assurance that imaging provides, and the lack of feedback loops in ED and UC centers should be tested in future hybrid implementation-effectiveness trials to increase concordance to LBP guidelines and minimize harm related to overuse of imaging and underuse of conservative first-line treatment approaches.

Acupuncture combined with Chinese herbal medicine for discogenic low back pain: protocol for a multicentre, randomised controlled trial

INTRODUCTION

Discogenic low back pain is a common form of chronic low back pain. In traditional Chinese medicine, combinations of acupuncture and herbal medicine are frequently used to manage this condition. However, evidence for the efficacy of a combined approach remains scarce. To address this gap, we designed a multicentre, randomised controlled trial to compare the effects of the combined use of acupuncture and Chinese herbal medicine, and their separate applications along with non-steroidal anti-inflammatory drugs, in treating discogenic low back pain.

METHODS AND ANALYSIS

This is a multicentre, prospective, randomised, four-arm, parallel-controlled trial involving patients with discogenic low back pain. Patients will be randomly divided into four groups (acupuncture combined with herbal medicine, acupuncture, herbal medicine and positive drug control) at a 1:1:1:1 ratio. All patients will undergo a 4-week treatment regimen consisting of acupuncture (active or sham acupuncture) and oral medication (herbal medicine or placebo granules and celecoxib or placebo capsules), as well as a 3-month follow-up assessment. The primary outcome measure will be pain intensity, measured using the Visual Analogue Scale after a 4-week treatment period. Secondary outcome measures will include the lumbar pressure pain threshold, pain-related disability measured using the Oswestry Disability Index, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, 36-Item Short-Form Health Survey and incidence of adverse events. Assuming an SD of 1.8, minimal clinically important difference of 1.5 and a 10% dropout rate, at least 97 participants per group are needed, totalling 388 participants.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Dongzhimen Hospital Affiliated with Beijing University of Chinese Medicine (approval number: 2024DZMEC-083-03) and the other seven participating subcentres. All participants will provide written informed consent. This trial will be conducted in accordance with the principles outlined in the Declaration of Helsinki and its amendments. This work will be disseminated through the publication of peer-reviewed manuscripts.

TRIAL REGISTRATION NUMBER

ChiCTR2400082428.

Effect of asymptomatic intervertebral flexion patterns on lumbar disc pressure: A finite element analysis study

Movement patterns may be a factor for manipulating the lumbar load, although little information is yet available in the literature about the relationship between this variable and intervertebral disc pressure (IDP). A finite element model of the lumbar spine (49-year-old asymptomatic female) was used to simulate intervertebral movements (L2-L5) of 127 asymptomatic participants. The data from participants that at least completed a simulation of lumbar vertebral movement during the first 53% of a movement cycle (flexion phase) were used for further analyses. Then, for each vertebral angular motion curve with constant spatial peaks, different temporal patterns were simulated in two stages: (1) in lumbar pattern exchange (LPE), each vertebral angle was simulated by the corresponding vertebrae of other participants data; (2) in vertebral pattern exchange (VPE), vertebral angles were simulated by each other. The k-mean algorithm was used to cluster two groups of variables; peak and cumulative IDP, in both stages of simulations (i.e., LPE and VPE). In the second stage of the simulation (VPE), Kendall's tau was utilized to consider the relationship between different temporal patterns and IDPs for each individual lumbar level. Cluster analyses showed that the temporal movement pattern did not exhibit any effect on the peak IDP while the cumulative IDP changed significantly for some patterns. Earlier involvement in lumbar motion at any level led to higher IDP in the majority of simulations. There is therefore a possibility of manipulating lumbar IDP by changing the temporal pattern with the same ROM, in which optimal distribution of the loads among lumbar levels may be applied as preventive or treatment interventions. Evaluating load benefits, such as load, on biomechanically relevant lumbar levels, dynamically measured by quantitative fluoroscopy, may help inform interventional exercises.

Conservative nonsurgical knowledge of German orthopedic and trauma surgeons-Present state of affairs

BACKGROUND

After the fusion of the fields of orthopedics and trauma surgery in 2006 the educational content significantly increased. The acquisition of non-surgical diagnostic and treatment skills seems to fall behind in the classical operatively focused residency programs. This study presents a status quo of the non-surgical education and knowledge in the field of orthopedics and traumatology in Germany.

METHODS

An online-based voluntary and anonymous questionnaire was conducted between June and August 2023. The questionnaire was distributed through the email lists of the German Society for Orthopedics and Traumatology (DGOU) and the German Professional Association for Orthopedics and Traumatology (BVOU).

RESULTS

A total of 486 German orthopedic and trauma surgeons answered the online questionnaire (77.9% male; mean age 50.2 ± 11.8 years) and 11.5% were residents. Only 27.1% spent part of the residency training in the outpatient sector. In total 84.2% wish for an increased focus on non-operative treatment options during further education, 81.1% agreed that they have a good general understanding of non-operative treatment options and 81.0% felt confident to apply them in the daily clinical routine (residents 35.4% and 41.7%, respectively). The highest self-assessed competences were knowledge on the application of splints and casts and physiotherapy, ergotherapy and sports therapy, the lowest were knowledge on acupuncture, magnetic field therapy and nutritional aspects after trauma. In total, 77.7% stated non-surgical research projects are not supported at their institution.

CONCLUSION

Orthopedic and trauma surgeons in Germany subjectively have solid knowledge on treatment options while resident physicians still need to strengthen their skills. Rotation into the outpatient sector and rehabilitation facilities as well as supporting research in the field could further improve the non-surgical skills.

Lower cross syndrome: specific treatment protocol versus generalized treatment protocol. A randomized single-blinded trial

INTRODUCTION

Lower crossed syndrome (LCS) is a biomechanical muscle imbalance causing low back pain.

Quantitative evaluation of risk factors for low back pain in young patients using synthetic magnetic resonance imaging and proton density fat fraction analyses

Background

Lumbar intervertebral disc and paravertebral muscle degeneration are common causes of chronic low back pain (CLBP). However, the exact etiology of CLBP in young patients remains unclear. Identifying the risk factors for CLBP in young patients could expedite the development of effective preventive recommendations.

Objectives

To identify the factors influencing the presence and severity of CLBP in young patients by analyzing the associations between the fat content of the paravertebral muscles, T2 value of the lumbar intervertebral disc (LIVD), and visual analog scale (VAS) score.

Design

Data for 23 patients diagnosed with CLBP were compared to those of 20 healthy young individuals.

Methods

The T2 values of the LIVD and fat content of the psoas major (PM), multifidus (MF), and erector spinae (ES) muscles for 23 young patients with CLBP and 20 healthy individuals were measured and compared using synthetic magnetic resonance imaging and proton density fat fraction analyses. Moreover, the factors (T2 values and fat content) associated with severe CLBP (assessed using the VAS score) were analyzed.

Results

The fat content of the right MF and ES was higher in patients with CLBP than in healthy individuals (p < 0.05). The T2 values of each LIVD in the CLBP and control groups were not significantly different (p > 0.05). Moreover, the VAS scores did not correlate with the T2 values of the patients (p > 0.05). The fat content of the bilateral MF and ES muscles was positively associated with the VAS score in young patients with CLBP (left MF: r = 0.506, p = 0.01; right MF: r = 0.532, p = 0.01; left ES: r = 0.636, p < 0.01; and right ES: r = 0.716, p < 0.01).

Conclusion

Degeneration of the MF and ES may contribute to CLBP in young patients. In addition, the severity of CLBP is positively correlated with the degree of fat infiltration in the MF and ES.

Canadian Association of Radiologists Spine Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Spine Expert Panel is made up of physicians from the disciplines of radiology, emergency medicine, neurology, neurosurgery, physiatry, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 10 clinical/diagnostic scenarios, a rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 23 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 22 recommendation statements across the 8 scenarios (one scenario points to the CAR Trauma Referral Guideline and one scenario points to the CAR Musculoskeletal Guideline). This guideline presents the methods of development and the referral recommendations for myelopathy, suspected spinal infection, possible atlanto-axial instability (non-traumatic), axial pain (non-traumatic), radicular pain (non-traumatic), cauda equina syndrome, suspected spinal tumour, and suspected compression fracture. Spondyloarthropathies and spine trauma point to other CAR Diagnostic Imaging Referral Guidelines, Musculoskeletal and Trauma, respectively.

Self-acknowledged limitations in exercise therapy trials for low back pain

RATIONALE

Despite the widespread recommendation to engage in therapeutic exercise for the treatment of low back pain (LBP), there is conflicting evidence regarding clinical outcomes and effectiveness. Poor methodological quality may be to blame for reducing the overall strength of evidence for this intervention, yet little is known about the difficulties researchers encounter when designing and implementing their study methods.

AIMS AND OBJECTIVES

The aim of this study was to characterize the extent and type of self-acknowledged limitations (SALs) in exercise therapy trials for LBP to gain a better understanding of challenges encountered when conducting this research.

METHODS

This is a methodological review of clinical trials in which SALs were extracted, categorized by theme and subcategorized within each theme. Counts and prevalence rates were tabulated for the number of SALs in each category and subcategory.

RESULTS

There were 914 SALs among the 312 included trials, with a mean of 2.93 (95% confidence interval [CI], 2.77-3.09) per trial. Analysis of the data resulted in the development of 13 distinct categories of limitations, among which were 37 subcategories. The top three categories pertained to statistical power (14.3% of total SALs), study length and/or follow-up (14.3%) and inclusion criteria (14.2%). The top three subcategories were lack of long-term follow-up (13.8% of total SALs), inadequate sample size (13.3%) and inclusion of specific populations (12.3%).

CONCLUSION

Statistical power, study length and/or follow-up, and inclusion criteria were the three most commonly reported categories of SALs in exercise trials for LBP. Lack of long-term follow-up, inadequate sample size and inclusion of specific populations were the most common subcategories. Research protocols recognizing and avoiding these limitations will enhance the overall quality of evidence of exercise therapy trials for LBP.

Redesigning the Care of Musculoskeletal Conditions With Lifestyle Medicine

Value-based health care has been accelerated by alternative payment models and has catalyzed the redesign of care delivery across the nation. Lifestyle medicine (LM) is one of the fastest growing medical specialties and has emerged as a high-value solution for root cause treatment of chronic disease. This review detailed a large integrated health care delivery system's value transformation efforts in the nonoperative treatment of musculoskeletal (MSK) conditions by placing patient-centric, team-based, lifestyle-focused care at the foundation. With an economic and treatment imperative to reimagine care, recognizing more intervention is not always better, a collaborative approach was designed, which placed functional improvement of the patient at the center. This article described the process of implementing LM into an MSK model of care. The change management process impacted clinical, operational, and benefit plan design to facilitate an integrated care model. A new understanding of patients' co-occurring physical impairments, medical comorbidities, and behavioral health needs was necessary for clinicians to make the shift from a pathoanatomic, transactional model of care to a biopsychosocial, longitudinal model of care. The authors explored the novel intersection of the implementation of a biopsychosocial model of care using LM principles to achieve greater value for the MSK patient population.

Medication recommendations for treatment of lumbosacral radiculopathy: A systematic review of clinical practice guidelines

OBJECTIVE

The purpose of this systematic review was to ascertain guideline-recommended pharmaceutical approaches to lumbosacral radicular symptoms, assess the quality of the clinical practice guidelines (CPGs) with the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool, and qualitatively synthesize the guideline recommendations.

LITERATURE SURVEY

Literature searches were performed in PubMed, Cochrane Database of Systematic Reviews, Index to Chiropractic Literature, Allied and Complementary Medicine Database (AMED), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and Physiotherapy Evidence Database (PEDro). We included guidelines published between January 1, 2017, and January 9, 2022, written in the English language, related to radiculopathy, sciatica, and/or low back pain with leg pain, and that provided recommendations on oral medication.

METHODOLOGY

The review was performed in accordance with Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) and the protocol was pre-registered with the International Prospective Register of Systematic Reviews (PROSPERO). Eligibility screening, full-text review, extraction of information pertaining to pharmacological management, and synthesis of results were performed independently by two authors and a third investigator was recruited to arbitrate any disagreements. The AGREE II tool was administered by four authors to appraise CPG quality.

SYNTHESIS

After screening 413 citations and assessing 37 full-text articles, 11 CPGs met the inclusion criteria. They represented seven countries (Belgium, Canada, England, France, Japan, Korea, and United States) and three continents (Asia, Europe, and North America), as well as the Global Spine Care Initiative aimed at a worldwide presence. The mean overall AGREE II score was 87.1% (standard deviation [SD] 12.6%), generally reflecting high-quality CPGs. The highest domain mean score was for Clarity of Presentation (96.7%, SD 4.4%), and the lowest was Applicability (75.6%, SD 22.8%). Five classes of medications were recommended by at least one CPG: anticonvulsants, antidepressants, oral corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), and opioids.

CONCLUSIONS

The most common medication class recommended by the CPGs for lumbar radiculopathy was antidepressants. No CPGs recommended prescribing acetaminophen, benzodiazepines, muscle relaxants, or antibiotics. There was very little agreement between the CPGs, and all the medication classes had at least one CPG recommended against its use. Three guidelines reviewed did not recommend any medications due to lack of supporting literature, and instead recommended nonpharmacologic therapy.

Chiropractic and Spinal Manipulation: A Review of Research Trends, Evidence Gaps, and Guideline Recommendations

Chiropractors diagnose and manage musculoskeletal disorders, commonly using spinal manipulative therapy (SMT). Over the past half-century, the chiropractic profession has seen increased utilization in the United States following Medicare authorization for payment of chiropractic SMT in 1972. We reviewed chiropractic research trends since that year and recent clinical practice guideline (CPG) recommendations regarding SMT. We searched Scopus for articles associated with chiropractic (spanning 1972-2024), analyzing publication trends and keywords, and searched PubMed, Scopus, and Web of Science for CPGs addressing SMT use (spanning 2013-2024). We identified 6286 articles on chiropractic. The rate of publication trended upward. Keywords initially related to historical evolution, scope of practice, medicolegal, and regulatory aspects evolved to include randomized controlled trials and systematic reviews. We identified 33 CPGs, providing a total of 59 SMT-related recommendations. The recommendations primarily targeted low back pain (n = 21) and neck pain (n = 14); of these, 90% favored SMT for low back pain while 100% favored SMT for neck pain. Recent CPG recommendations favored SMT for tension-type and cervicogenic headaches. There has been substantial growth in the number and quality of chiropractic research articles over the past 50 years, resulting in multiple CPG recommendations favoring SMT. These findings reinforce the utility of SMT for spine-related disorders.

The Physical and Psychological Effects of Telerehabilitation-Based Exercise for Patients With Nonspecific Low Back Pain: Prospective Randomized Controlled Trial

Background

Physical therapy has demonstrated efficacy in managing nonspecific low back pain (NLBP) among patients. Nevertheless, the prevalence of NLBP poses a challenge, as the existing medical infrastructure may be insufficient to care for the large patient population, particularly in geographically remote regions. Telerehabilitation emerges as a promising method to address this concern by offering a method to deliver superior medical care to a greater number of patients with NLBP.

Objective

The purpose of this study is to demonstrate the physical and psychological effectiveness of a user-centered telerehabilitation program, consisting of a smartphone app and integrated sensors, for patients with NLBP.

Methods

This was a single-center, prospective, randomized controlled trial for individuals with NLBP for a duration exceeding 3 months. All participants were assigned randomly to either the telerehabilitation-based exercise group (TBEG) or the outpatient-based exercise group (OBEG). All participants completed a 30-minute regimen of strength and stretching exercises 3 times per week, for a total of 8 weeks, and were required to complete assessment questionnaires at 0, 2, 4, and 8 weeks. The TBEG completed home-based exercises and questionnaires using a telerehabilitation program, while the OBEG completed them in outpatient rehabilitation. The Oswestry Disability Index (ODI) served as the primary outcome measure, assessing physical disability. Secondary outcomes included the Numeric Pain Rating Scale, Fear-Avoidance Beliefs Questionnaire, and 36-item Short-Form Health Survey.

Results

In total, 54 of 129 eligible patients were enrolled and randomly assigned to the study. The completion of all the interventions and assessments in the TBEG and OBEG was 89% (24/27) and 81% (22/27). The findings indicate that no statistical significance was found in the difference of ODI scores between the TBEG and the OBEG at 2 weeks (mean difference -0.91; odds ratio [OR] 0.78, 95% CI -5.96 to 4.14; P=.72), 4 weeks (mean difference -3.80; OR 1.33, 95% CI -9.86 to -2.25; P=.21), and 8 weeks (mean difference -3.24; OR 0.92, 95% CI -8.65 to 2.17; P=.24). The improvement of the ODI in the TBEG (mean -16.42, SD 7.30) and OBEG (mean -13.18, SD 8.48) was higher than 10 after an 8-week intervention. No statistically significant differences were observed between the 2 groups at the 8-week mark regarding the Fear-Avoidance Beliefs Questionnaire (mean difference 8.88; OR 1.04, 95% CI -2.29 to 20.06; P=.12) and Numeric Pain Rating Scale (mean difference -0.39; OR 0.44, 95% CI -2.10 to 1.31; P=.64). In the subgroup analysis, there was no statistically significant difference in outcomes between the 2 groups.

Conclusions

Telerehabilitation interventions demonstrate comparable therapeutic efficacy for individuals with NLBP when compared to conventional outpatient-based physical therapy, yielding comparable outcomes in pain reduction and improvement in functional limitations.

Focused extracorporeal shockwave therapy for the treatment of low back pain: a systematic review

Introduction

Low back pain (LBP) is a common condition affecting up to 84% of people in their lifetime, with a prevalence of 11.9% and a high recurrence rate within the first year. Furthermore, chronic low back pain syndrome has been described in up to 7%, making it a significant health and socioeconomic problem. Among nonoperative treatment options, the recently used focused extracorporeal shockwave therapy (ESWT) devices generate waves that converge at a precise depth in the body, thereby revealing the potential to affect pathology remotely from the contact surface. The article aims to present a systematic literature review with a critical discussion on treating low back pain using this modality.

Methods

A search for randomized controlled trials (RCT) of focused ESWT for low back pain published before April 1, 2024, in PubMed, Web of Science, Scopus, Google Scholar, and trial registries (WHO International Clinical Trials Registry Platform and ClinicaTrials.gov) was performed.

Results

Only three studies against conservative treatment comprising 94 patients met the selection criteria and were further analyzed. Comparative clinical studies regarding the effectiveness of radial and focused ESWT for low back pain were missing. The results revealed that all treated patients had significantly reduced pain and improved functional impairment immediately after the procedures and 1 month later. At the third month time point, the pain levels remained better in the experimental than in the control group without achieving statistical significance. None of the studies had a long-term follow-up.

Conclusion

Focused ESWT is a modern physiotherapeutic method that can potentially treat a broad spectrum of conditions responsible for low back pain. Despite the small number of low-evidence studies, there is sufficient data on the effectiveness and safety of this therapeutic modality. With future well-designed trials, the bias risks would be diminished, the indications for its use would expand, and the treatment protocols would be clarified.

The association of physical activity and sedentary behaviour with low back pain disability trajectories: A prospective cohort study

BACKGROUND

Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of risk factors might contribute to a better understanding of the course of LBP.

OBJECTIVES

To investigate the association of habitual physical activity (PA) and sedentary behaviour (SB), measured at baseline, with disability trajectories in adults with LBP.

METHODS

A prospective cohort study where habitual PA levels were measured using the Short QUestionnaire to ASsess Health enhancing physical activity (SQUASH), SB was calculated as average sedentary hours per day, and LBP disability using the Oswestry Disability Index (ODI). Participants completed the questionnaires at one and a half, three, six, and twelve months. Linear mixed models were estimated to describe the association of habitual PA levels SB measured at baseline with disability trajectories. Other predictors were gender, education level, age, pain, number of previous episodes of LBP, and duration of LBP.

RESULTS

Habitual SB measured at baseline in adults (n = 347) with LBP were not associated with disability trajectories. For PA, participants with one metabolic equivalent of task (MET) hour per day above average recovered 0.04 [95% CI 0.004 to 0.076] points on the ODI per month faster than participants with an average amount of MET hours per day.

CONCLUSIONS

Habitual SB was not associated with LBP disability trajectories over a one-year follow-up. High levels of habitual PA at baseline were associated with improved recovery in LBP disability trajectory, but the finding is not clinically relevant.

Effect of exercise and manual therapy or kinesiotaping on sEMG and pain perception in chronic low back pain: a randomized trial

The importance of incorporating lumbo-pelvic stability core and controlling motor exercises in patients with chronic low back pain (CLBP) reinforces the use of strategies to improve biopsychosocial beliefs by reducing biomedical postulations. However, clinical practice guidelines recommend multimodal approaches incorporating exercise and manual therapy (MT), and instead reject the application of kinesiotape (KT) in isolation. Therefore, the objectives of this study were to analyze the effects of 12 weeks of exercises combined with MT or KT on perceived low back pain using the visual analog scale (VAS) and muscle electric activity measured with electromyography (EMG) of the rectus abdominis and multifidus in CLBP (mild disability) and to explore the relationship between the rectus abdominis and multifidus ratios and pain perception after intervention. A blinded, 12-week randomized controlled trial (RCT) was carried out, involving three parallel groups of patients with CLBP. The study was registered at Clinicaltrial.gov and assigned the identification number NCT05544890 (19/09/22). The trial underwent an intention-to-treat analysis. The primary outcome revealed a multimodal treatment program supplemented by additional therapies such as MT and KT, resulting in significant reductions in perceived low back pain. The subjective assessment of individuals with CLBP indicated no discernible distinction between exclusive core stability exercises and control-motor training when combined with MT or KT. Notably, our findings demonstrated positive alterations in both the mean and peak EMG values of the right rectus abdominis in the exercise group, suggesting a beneficial impact on muscle activation. This study focused on assessing the activation levels of the trunk musculature, specifically the rectus abdominis (RA) and multifidus (MF), in individuals with CLBP exhibiting mild disability according to the Oswestry Disability Index. Importantly, improvements in the VAS values were observed independently of changes in muscle electrical activity.

Acute back pain: The role of medication, physical medicine and rehabilitation: WFNS spine committee recommendations

Objectives

To formulate the most current, evidence-based recommendations for the role of medication, physical medicine, and rehabilitation in the management of acute low back pain lasting <4 weeks.

Methods

A systematic literature search in PubMed and Google Scholar databases was performed from 2012 to 2022 using the search terms "acute low back pain," "drugs," "bed rest," "physical medicine," rehabilitation." Standardized screening criteria resulted in a total of 39 articles that were analyzed, including 16 RCTs, 8 prospective studies, 6 retrospective studies, and 9 systematic reviews. This up-to-date information was reviewed and presented at two separate meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Two rounds of the Delphi method were utilized to vote on the statements and arrive at a positive or negative consensus.

Results and conclusion

The WFNS Spine Committee finalized twelve recommendation guidelines on the role of medication, physical medicine and rehabilitation in the management of acute LBP. We advocate for a uniform approach to the treatment of these patients, including proper patient education and utilizing drugs with proven efficacy and minimal side effects. First-line pharmacologic agents are acetaminophen and NSAIDs; muscle relaxants can be used for spasms and pain reduction, and opioids should be minimized. Continued activity, rather than bed rest, is recommended, and lumbar spine orthotics may be used to reduce pain and augment functional status. Thermotherapy, cryotherapy, TENs, spinal manipulative therapy, and acupuncture may all be used as adjuncts to improve acute LBP.

The pain attitudes and beliefs scale for physiotherapists: development and psychometric assessment of the Spanish version among physiotherapy students

INTRODUCTION

Pain might be approached from a biomedical or biopsychosocial perspective. There is a lack of research on the attitudes and beliefs about pain among physiotherapy students. In this context, the Pain Attitudes and Belief Scale for Physiotherapists (PABS-PT) is an instrument widely used from a clinical and educational perspective, but its psychometric properties have not yet been tested in a student-based population.

OBJECTIVE

To develop the Spanish version of the PABS-PT scale and to assess its psychometric properties among students in physiotherapy.

METHODS

The study was carried out among 103 students in their final years of academic studies in the Degree in Physiotherapy in the University of Murcia (Spain). Sociodemographic and PABS-PT related variables were collected. The instrument was translated into Spanish and tested through factor analysis, internal consistency, test-retest reliability, and known-groups validity. The 95% minimal detectable change of the instrument was also calculated.

RESULTS

The factor analysis revealed two factors within the instrument: Biomedical (9 items) and Biopsychosocial (7 items) factors, with Cronbach's alpha values of 0.730 and 0.708, respectively. The Intraclass Correlation Coefficient (3,2) was 0.851 for the Biomedical factor and 0.699 for the Biopsychosocial factor. The minimal detectable changes (95% CI) for the Biomedical and Biopsychosocial factors were 6.01 and 5.56, respectively. The pre-specified hypothesis for the known-groups validity test was met and revealed large effect sizes (d = 1.24).

CONCLUSION

The Spanish version of the instrument PABS-PT-SP covers two factors. It shows satisfactory psychometric properties and it is therefore an effective framework to discriminate between the biomedical and/or biopsychosocial thoughts and attitudes toward pain in physiotherapy.

Comparing the Efficacy and Safety of Unilateral Biportal Endoscopic Decompression with Percutaneous Endoscopic Lumbar Decompression for Lumbar Degenerative Diseases: A Meta-Analysis

OBJECTIVE

Unilateral biportal endoscopic decompression (UBED) offers the advantages of minimal tissue damage, operational flexibility, and clear visualization, positioning it as an innovative and minimally invasive endoscopic technique. Nevertheless, the clinical evidence supporting the use of UBED in the treatment of degenerative lumbar diseases is limited and conflicting.

METHODS

As of October 1, 2023, a comprehensive search was conducted across databases including Web of Science, PubMed, Embase, and the Cochrane Library to identify all published studies on minimally invasive UBED for the treatment of degenerative lumbar diseases. Data pertaining to patient demographics, fluoroscopy time, operative duration, intraoperative hemorrhage, hospitalization length, visual analog scale (VAS) score for back and leg pain, MacNab criteria, Oswestry Disability Index (ODI), and complication rates were extracted. The Newcastle-Ottawa scale was utilized to assess the quality.

RESULTS

Twelve articles were included, involving 816 patients. The back VAS score (95% confidence interval [CI]: -0.09-0.07, P = 0.75), MacNab criteria (95% CI: 0.52-2.3, P = 0.82), fluoroscopy time (95% CI: -7.03 to -0.4, P = 0.08), and the incidence of complications (95% CI: 0.5-1.73, P = 0.82) were not significantly different, while the leg VAS score (95% CI: 0.01-0.18, P = 0.03), ODI score (95% CI: -1.03 to -0.09, P = 0.02), operation time (95% CI: 5.76-20.62, P = 0.0005), hospitalization length (95% CI: 0.41-2.76, P = 0.008), and intraoperative hemorrhage (95% CI: 21.92-72.44, P = 0.0003) were significantly different.

CONCLUSIONS

UBED offers superiority in ODI, flexibility, and visual field clarity. Conversely, percutaneous endoscopic lumbar decompression presents advantages in terms of operation duration, blood loss, hospitalization length, and leg VAS score. These factors should be thoroughly considered when selecting a surgical approach.

Five-Year Longitudinal Follow-Up of Restorative Neurostimulation Shows Durability of Effectiveness in Patients With Refractory Chronic Low Back Pain Associated With Multifidus Muscle Dysfunction

BACKGROUND

Adults with refractory, mechanical chronic low back pain associated with impaired neuromuscular control of the lumbar multifidus muscle have few treatment options that provide long-term clinical benefit. This study hypothesized that restorative neurostimulation, a rehabilitative treatment that activates the lumbar multifidus muscles to overcome underlying dysfunction, is safe and provides relevant and durable clinical benefit to patients with this specific etiology.

MATERIALS AND METHODS

In this prospective five-year longitudinal follow-up of the ReActiv8-B pivotal trial, participants (N = 204) had activity-limiting, moderate-to-severe, refractory, mechanical chronic low back pain, a positive prone instability test result indicating impaired multifidus muscle control, and no indications for spine surgery. Low back pain intensity (10-cm visual analog scale [VAS]), disability (Oswestry Disability Index), and quality of life (EuroQol's "EQ-5D-5L" index) were compared with baseline and following the intent-to-treat principle, with a supporting mixed-effects model for repeated measures that accounted for missing data.

RESULTS

At five years (n = 126), low back pain VAS had improved from 7.3 to 2.4 cm (-4.9; 95% CI, -5.3 to -4.5 cm; p < 0.0001), and 71.8% of participants had a reduction of ≥50%. The Oswestry Disability Index improved from 39.1 to 16.5 (-22.7; 95% CI, -25.4 to -20.8; p < 0.0001), and 61.1% of participants had reduction of ≥20 points. The EQ-5D-5L index improved from 0.585 to 0.807 (0.231; 95% CI, 0.195-0.267; p < 0.0001). Although the mixed-effects model attenuated completed-case results, conclusions and statistical significance were maintained. Of 52 subjects who were on opioids at baseline and had a five-year visit, 46% discontinued, and 23% decreased intake. The safety profile compared favorably with neurostimulator treatments for other types of back pain. No lead migrations were observed.

CONCLUSION

Over a five-year period, restorative neurostimulation provided clinically substantial and durable benefits with a favorable safety profile in patients with refractory chronic low back pain associated with multifidus muscle dysfunction.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT02577354; registration date: October 15, 2016; principal investigator: Christopher Gilligan, MD, Brigham and Women's Hospital, Boston, MA, USA. The study was conducted in Australia (Broadmeadow, New South Wales; Noosa Heads, Queensland; Welland, South Australia; Clayton, Victoria), Belgium (Sint-Niklaas; Wilrijk), The Netherlands (Rotterdam), UK (Leeds, London, Middlesbrough), and USA (La Jolla, CA; Santa Monica, CA; Aurora, CO; Carmel, IN; Indianapolis, IN; Kansas City, KS; Boston, MA; Royal Oak, MI; Durham, NC; Winston-Salem, NC; Cleveland, OH; Providence, RI; Spartanburg, SC; Spokane, WA; Charleston, WV).

Chronic Low Back Pain: History, Symptoms, Pain Mechanisms, and Treatment

Chronic low back pain (cLBP) is the most frequently reported cause of years lived with disability. Identifying the anatomical structures or dysfunction contributing to patients' symptoms is critical to guiding treatment. The etiology of back pain and differential diagnosis is often broad, ranging from non-degenerative cLBP (trauma, tumor, inflammation, infection, etc.) to degenerative (also described as nonspecific) cLBP. After eliminating suspicion for more insidious causes of cLBP, a thorough investigation can be conducted in an attempt to identify a source of degenerative cLBP. Degenerative cLBP can originate from many sources, and a detailed understanding of the structures potentially involved is invaluable for an accurate diagnosis. This review article aims to provide a broad overview of the utility of clinical history, physical exam findings, imaging findings, and diagnostic procedures in identifying the cause of patients' cLBP. We provide a framework to help guide clinicians by dividing the structures into groups as follows: anterior vertebral column, posterior vertebral column, and extra-vertebral pain. For each condition listed, we touch on the treatment options that can be considered.

The effect of EMS, IFC, and TENS on patient-reported outcome measures for chronic low back pain: a systematic review and meta-analysis

Introduction

Chronic low back pain (CLBP) is the leading cause of years lived with disability worldwide. Transcutaneous electrotherapies have been widely used to treat CLBP but, with the partial exception of transcutaneous electrical nerve stimulation (TENS), their effect on pain, disability, quality-of-life, and psychosocial outcomes have not been systematically reviewed. The purpose of this systematic review and meta-analysis was to clarify the overall effect of transcutaneous electrotherapies on patient-reported outcome measures (PROMs) in CLBP patients.

Methods

Four databases and two study registries were searched for studies that utilized transcutaneous electrotherapies as a primary intervention for CLBP, compared against active or passive controls. Two reviewers independently extracted study data and assessed risk of bias. Studies were grouped by intervention vs. comparison, and by time of follow-up. Meta-analyses were conducted where appropriate.

Results

A total of 89 full-text were assessed for eligibility; 14 studies were included, with 6 in the meta-analyses (all TENS or mixed TENS). Pain: meta-analyses revealed no significant difference for TENS vs. active control, TENS vs. passive control, or mixed TENS vs. active control at post-intervention, nor for mixed TENS vs. active control at 1-month post-intervention. Interferential current (IFC) was more effective than active control (2 studies), while electromyostimulation (EMS) was generally superior to passive, but not active, controls (6 studies).

Disability

Meta-analyses revealed no significant difference for TENS vs. active control at post-intervention, mixed TENS vs. active control at post-intervention, or mixed TENS vs. active control at 1-month post-intervention. IFC was more effective than active control (2 studies), while the EMS results were mixed (6 studies). We were unable to perform meta-analyses for quality-of-life or psychosocial outcomes.

Conclusion

There is moderate evidence that TENS is similar to all controls for improving pain and disability. There is limited evidence that IFC is superior to active controls for improving pain and disability. There is limited evidence that EMS is superior to passive but not active controls for improving pain, and similar to all controls for improving disability.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=452851, Identifier (CRD42023452851).

Do we really apply evidence-based-recommendations to spine surgery? Results of an international survey

OBJECTIVE

This international survey investigated Evidence-Based Medicine (EBM) in spine surgery by measuring its acceptance among spine surgeons. It assessed their understanding of EBM and how they apply it in practice by analyzing responses to various clinical scenarios..

MATERIALS AND METHODS

Following the CHERRIES guidelines, an e-survey was distributed to multiple social media forums for neurosurgeons and orthopedic surgeons on Facebook, LinkedIn, and Telegram and circulated further through email via the authors' network. Three hundred participants from Africa, Asia, Europe, North America, and Oceania completed the survey.

RESULTS

Our study revealed that 67.7% (n = 203) of respondents used EBM in their practice, and 97.3% (n = 292) believed training in research methodology and EBM was necessary for the practice of spine surgery. Despite this endorsement of using EBM in spine surgery, we observed varied responses to how EBM is applied in practice based on example scenarios. The responders who had additional training tended to obey EBM guidelines more than those who had no additional training. Most surgeons responded as always or sometimes prescribing methylprednisolone to patients with acute spinal cord injury. Other significant differences were identified between geographical regions, training, practice settings, and other factors.

CONCLUSIONS

Most respondents used EBM in practice and believed training in research methodology and EBM is necessary for spine surgery; however, there were significant variations on how to use them per case. Thus, the appropriate application of EBM in clinical settings for spinal surgery must be further studied.

Precision Rehabilitation After Neurostimulation Implantation for Multifidus Dysfunction in Nociceptive Mechanical Chronic Low Back Pain

Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.

Performance of ChatGPT on NASS Clinical Guidelines for the Diagnosis and Treatment of Low Back Pain: A Comparison Study

STUDY DESIGN

Comparative analysis.

OBJECTIVE

To evaluate Chat Generative Pre-trained Transformer (ChatGPT's) ability to predict appropriate clinical recommendations based on the most recent clinical guidelines for the diagnosis and treatment of low back pain.

BACKGROUND

Low back pain is a very common and often debilitating condition that affects many people globally. ChatGPT is an artificial intelligence model that may be able to generate recommendations for low back pain.

MATERIALS AND METHODS

Using the North American Spine Society Evidence-Based Clinical Guidelines as the gold standard, 82 clinical questions relating to low back pain were entered into ChatGPT (GPT-3.5) independently. For each question, we recorded ChatGPT's answer, then used a point-answer system-the point being the guideline recommendation and the answer being ChatGPT's response-and asked ChatGPT if the point was mentioned in the answer to assess for accuracy. This response accuracy was repeated with one caveat-a prior prompt is given in ChatGPT to answer as an experienced orthopedic surgeon-for each question by guideline category. A two-sample proportion z test was used to assess any differences between the preprompt and postprompt scenarios with alpha=0.05.

RESULTS

ChatGPT's response was accurate 65% (72% postprompt, P =0.41) for guidelines with clinical recommendations, 46% (58% postprompt, P =0.11) for guidelines with insufficient or conflicting data, and 49% (16% postprompt, P =0.003*) for guidelines with no adequate study to address the clinical question. For guidelines with insufficient or conflicting data, 44% (25% postprompt, P =0.01*) of ChatGPT responses wrongly suggested that sufficient evidence existed.

CONCLUSION

ChatGPT was able to produce a sufficient clinical guideline recommendation for low back pain, with overall improvements if initially prompted. However, it tended to wrongly suggest evidence and often failed to mention, especially postprompt, when there is not enough evidence to adequately give an accurate recommendation.

The effects of osteopathic manipulative treatment on pain and disability in patients with chronic low back pain: a single-blinded randomized controlled trial

CONTEXT

The evidence for the efficacy of osteopathic manipulative treatment (OMT) in the management of low back pain (LBP) is considered weak by systematic reviews, because it is generally based on low-quality studies. Consequently, there is a need for more randomized controlled trials (RCTs) with a low risk of bias.

OBJECTIVES

The objective of this study is to evaluate the efficacy of an OMT intervention for reducing pain and disability in patients with chronic LBP.

METHODS

A single-blinded, crossover, RCT was conducted at a university-based health system. Participants were adults, 21-65 years old, with nonspecific LBP. Eligible participants (n=80) were randomized to two trial arms: an immediate OMT intervention group and a delayed OMT (waiting period) group. The intervention consisted of three to four OMT sessions over 4-6 weeks, after which the participants switched (crossed-over) groups. The primary clinical outcomes were average pain, current pain, Patient-Reported Outcomes Measurement Information System (PROMIS) 29 v1.0 pain interference and physical function, and modified Oswestry Disability Index (ODI). Secondary outcomes included the remaining PROMIS health domains and the Fear Avoidance Beliefs Questionnaire (FABQ). These measures were taken at baseline (T0), after one OMT session (T1), at the crossover point (T2), and at the end of the trial (T3). Due to the carryover effects of OMT intervention, only the outcomes obtained prior to T2 were evaluated utilizing mixed-effects models and after adjusting for baseline values.

RESULTS

Totals of 35 and 36 participants with chronic LBP were available for the analysis at T1 in the immediate OMT and waiting period groups, respectively, whereas 31 and 33 participants were available for the analysis at T2 in the immediate OMT and waiting period groups, respectively. After one session of OMT (T1), the analysis showed a significant reduction in the secondary outcomes of sleep disturbance and anxiety compared to the waiting period group. Following the entire intervention period (T2), the immediate OMT group demonstrated a significantly better average pain outcome. The effect size was a 0.8 standard deviation (SD), rendering the reduction in pain clinically significant. Further, the improvement in anxiety remained statistically significant. No study-related serious adverse events (AEs) were reported.

CONCLUSIONS

OMT intervention is safe and effective in reducing pain along with improving sleep and anxiety profiles in patients with chronic LBP.

Chiropractic spinal manipulation and likelihood of tramadol prescription in adults with radicular low back pain: a retrospective cohort study using US data

OBJECTIVES

Patients receiving chiropractic spinal manipulation (CSM) for low back pain (LBP) are less likely to receive any opioid prescription for subsequent pain management. However, the likelihood of specifically being prescribed tramadol, a less potent opioid, has not been explored. We hypothesised that adults receiving CSM for newly diagnosed radicular LBP would be less likely to receive a tramadol prescription over 1-year follow-up, compared with those receiving usual medical care.

DESIGN

Retrospective cohort study.

SETTING

US medical records-based dataset including >115 million patients attending academic health centres (TriNetX, Inc), queried 9 November 2023.

PARTICIPANTS

Opioid-naive adults aged 18-50 with a new diagnosis of radicular LBP were included. Patients with serious pathology and tramadol use contraindications were excluded. Variables associated with tramadol prescription were controlled via propensity matching.

INTERVENTIONS

Patients were divided into two cohorts dependent on treatment received on the index date of radicular LBP diagnosis (CSM or usual medical care).

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk ratio (RR) for tramadol prescription (primary); markers of usual medical care utilisation (secondary).

RESULTS

After propensity matching, there were 1171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the CSM cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p<0.0001). A cumulative incidence graph demonstrated that the reduced incidence of tramadol prescription in the CSM cohort relative to the usual medical care cohort was maintained throughout 1-year follow-up. Utilisation of NSAIDs, physical therapy evaluation and lumbar imaging was similar between cohorts.

CONCLUSIONS

This study found that US adults initially receiving CSM for radicular LBP had a reduced likelihood of receiving a tramadol prescription over 1-year follow-up. These findings should be corroborated by a prospective study to minimise residual confounding.

The effects of Core Stability Exercises and Mulligan's mobilization with movement techniques on sacroiliac joint dysfunction

Purpose

Sacroiliac joint dysfunction (SIJD), while being the primary contributor to low back pain, is still disregarded and treated as low back pain. Mulligan's Mobilization with Movement (MWM) Techniques and Core Stability Exercises (CSE) are often used to treat low back pain. There is not much evidence that it is effective in SIJD. To evaluate the effectiveness of CSE coupled with MWM (CSE + MWM) in the treatment of SIJD.

Methods

39 patients with SIJD were recruited and randomly divided into distinct groups as follows: control group (n = 13), CSE group (n = 13) and CSE + MWM group (n = 13). The Numerical Pain Rating Scale (NPRS), the Roland Morris Disability Questionnaire (RMDQ), the Range of Motion (ROM), the Pressure Pain Threshold (PPT) and the pelvic tilt angle asymmetry ratio in the sagittal plane (PTAR) were used to gauge the intervention's success both before (M0) and after (M1) it. All experimental data were statistically analyzed.

Results

The SIJ-related pain metric significantly decreased in both the CSE + MWM group and the CSE group between M0 and M1, as determined by the NPRS and RMDQ. Between M0 and M1, The CSE group's left axial rotation ROM and lumbar flexion ROM were significantly decreased. The CSE + MWM group's extension ROM and left lateral flexion ROM both significantly increased between M0 and M1. In the difference variable (M1-M0), the CSE + MWM group substantially outperformed control group in the left lateral flexion ROM and outperformed the CSE group in the left axial rotation ROM.

Conclusion

In individuals with SIJD, CSE + MWM is beneficial in lowering pain, disability, and function. Treatment with CSE and MWM approaches for SIJ appears to boost this efficacy.

The Role of p38 Mitogen-Activated Protein Kinase-Mediated F-Actin in the Acupuncture-Induced Mitigation of Inflammatory Pain in Arthritic Rats

The analgesic efficacy of acupuncture has been widely recognized. However, the mechanism by which manual acupuncture-generated mechanical stimuli translate into biological signals remains unclear. This study employed a CFA-induced inflammatory pain rat model. Acupuncture intervention was then performed following standardized procedures. Enzyme-linked immunosorbent assay (ELISA) assessed inflammatory cytokines levels, while immunofluorescence and qRT-PCR screened the level of p38 and F-actin expression in the ST36 acupoint area of rats. Results indicated increased inflammatory factors, including IL-1β and TNFα, with reduced paw withdrawal mechanical threshold (PWMT) and paw withdrawal thermal latency (PWTL) in CFA rats compared to unmodeled rats. After acupuncture intervention, the heightened expression level of F-actin and p38 mRNA and the phosphorylation of p38 in the acupoint area was observed alongside decreased inflammatory factors in diseased ankle joints. The application of lifting and thrusting manipulations further enhanced the effect of acupuncture, in which the molecular expression level of muscle and connective tissue increased most significantly, indicating that these two tissues play a major role in the transformation of acupuncture stimulation. Moreover, antagonizing p38 expression hindered acupuncture efficacy, supporting the hypothesis that p38 MAPK-mediated F-actin transduces mechanical signals generated by acupuncture and related manipulation into biological signals.

Acute low back pain: Epidemiology, etiology, and prevention: WFNS spine committee recommendations

Objective

Acute low back pain is a highly prevalent condition that poses significant challenges to healthcare systems worldwide. In this manuscript, we present the most current, evidence-based guidelines from the World Federation of Neurosurgical Societies (WFNS) Spine Committee on the epidemiology, etiology, and prevention of acute low back pain (LBP) lasting ≤ 4 weeks.

Methods

We performed a literature review 2012-2022 using the PubMed, Medline, and CENTRAL databases with the keywords "acute low back pain", "acute back pain", "low back pain", "epidemiology", "etiology", "costs", "risk factor", "cultural", "developed", "developing" and "prevention". Systematic screening criteria were applied, resulting in 13 final articles on epidemiology and etiology of LBP, 2 manuscripts on costs, 5 articles on risk factors, and 23 articles on prevention strategies for acute LBP. These were presented at two separate international meetings, where members of the WFNS Spine Committee voted on five final consensus statements presented here.

Results

and Conclusions: There is a high incidence and prevalence of acute LBP, particularly in high-income countries, which is felt to be at least partially due to demographic shifts with an aging population and lifestyle changes including higher rates of obesity and physical inactivity. Acute LBP has a significant impact on quality of life and ability to work, resulting in high direct and indirect costs worldwide. Early diagnosis and appropriate management of acute LBP is recommended to prevent this pain from turning into chronic LBP. The WFNS Spine Committee's recommendations respresent the latest guidelies to help improve patient care for acute LBP worldwide.

Clinical guidelines are silent on the recommendation of physical activity and exercise therapy for low back pain: A systematic review

OBJECTIVES

To synthesise and evaluate the quality of the recommendations for exercise therapy and physical activity from guidelines for the prevention and/or management of low back pain.

DESIGN

Systematic review.

METHODS

Included clinical practice guidelines for the management of low back pain published between 2014 and 2022 and searched in 9 databases until September 2022. The quality of evidence was evaluated with the Appraisal of Guidelines, Research and Evaluation tool (AGREE-II instrument).

RESULTS

After screening 3448 studies, 18 clinical practice guidelines were included in this review. Only five (27 %) guidelines were judged as having a satisfactory quality of evidence (i.e., rigour of development and applicability), and 13 (72 %) of guidelines are discussed and rated as critical. Regarding physical activity, no guidelines provided recommendations for the primary prevention of low back pain or incorporated adequate physical activity aspects considering type, dosage, frequency, and intensity. For exercises, all (100 %) guidelines recommended at least one type of supervised exercise in the management of low back pain, and 16 (88 %) provided an overall recommendation for people to stay active.

CONCLUSIONS

Guidelines offer minimal or, sometimes, no detail regarding physical activity or specific exercise regimens for the management and prevention of low back pain. When some guidance is provided, the recommendations typically lack specificity concerning the type, intensity, duration, and frequency of exercise and, in many cases, they represent a combination of scarce available evidence and stakeholder perspectives.

The Clinical Efficacy of Platelet-Rich Plasma Injection Therapy versus Different Control Groups for Chronic Low Back Pain: A Network Meta-Analysis of Randomized Controlled Trials

Objective

Low back pain is one of the main causes of disability in the world. Although regenerative medicine may represent breakthroughs in the management of low back pain, its use remains controversial. Therefore, we conducted a meta-analysis to evaluate the clinical efficacy of platelet-rich plasma (PRP) injection therapy versus different control groups for chronic low back pain during 4 weeks, 3 months, and 6 months.

Methods

Different electronic databases were searched for randomized controlled trials up to August 2023. Mean changes from baseline in pain and Oswestry Disability Index (ODI) scores at 4 weeks, 3 months, and 6 months and standard deviations of outcome were recorded.

Results

Four articles with 154 cases were finally included in this meta-analysis. After 4 weeks, corticosteroid (CS) was the optimal treatment option for chronic low back pain in terms of improvement in pain and disability index (surface under the cumulative ranking curve [SUCRA]=71.3%, SUCRA=57.8%, respectively). After 3 months, radiofrequency (RF) emerged as the best therapy in pain (SUCRA=100%) and disability index (SUCRA=98.5%), followed by PRP (SUCRA=62.3%, SUCRA=64.3%, respectively), CS (SUCRA=24.6%, SUCRA=25.9%, respectively) and lidocaine (SUCRA=13.1%, SUCRA=11.3%, respectively). At 6 months, RF was most likely to be the best treatment in pain (SUCRA=94.9%) and disability index (SUCRA=77.3%), followed by PRP (SUCRA=71.2%, SUCRA=79.6%, respectively). However, compared with the last follow-up, there was a slight downward trend in improvement pain and disability index with RF, while PRP was still an upward trend.

Conclusion

This study demonstrated better short-term improvement of chronic low back pain with CS after 4 weeks. PRP and RF improvement effects matched, but follow-up of at least 6 months showed that PRP seemed to be more advantageous in improvement in disability indices. Considering the limitations of this study, these conclusions still need to be verified by more comparative RCTs and a longer follow-up period.

Non-Surgical Approaches to the Management of Lumbar Disc Herniation Associated with Radiculopathy: A Narrative Review

Lumbar disc herniation associated with radiculopathy (LDHR) is among the most frequent causes of spine-related disorders. This condition is triggered by irritation of the nerve root caused by a herniated disc. Many non-surgical and surgical approaches are available for managing this prevalent disorder. Non-surgical treatment approaches are considered the preferred initial management methods as they are proven to be efficient in reducing both pain and disability in the absence of any red flags. The methodology employed in this review involves an extensive exploration of recent clinical research, focusing on various non-surgical approaches for LDHR. By exploring the effectiveness and patient-related outcomes of various conservative approaches, including physical therapy modalities and alternative therapies, therapists gain valuable insights that can inform clinical decision-making, ultimately contributing to enhanced patient care and improved outcomes in the treatment of LDHR. The objective of this article is to introduce advanced and new treatment techniques, supplementing existing knowledge on various conservative treatments. It provides a comprehensive overview of the current therapeutic landscape, thereby suggesting pathways for future research to fill the gaps in knowledge. Specific to our detailed review, we identified the following interventions to yield moderate evidence (Level B) of effectiveness for the conservative treatment of LDHR: patient education and self-management, McKenzie method, mobilization and manipulation, exercise therapy, traction (short-term outcomes), neural mobilization, and epidural injections. Two interventions were identified to have weak evidence of effectiveness (Level C): traction for long-term outcomes and dry needling. Three interventions were identified to have conflicting or no evidence (Level D) of effectiveness: electro-diagnostic-based management, laser and ultrasound, and electrotherapy.

What a pain in the … back: a review of current treatment options with a focus on naproxen sodium

Non-specific low back pain (LBP) represents a challenging and prevalent condition that is one of the most common symptoms leading to primary care physician visits. While established guidelines recommend prioritizing non-pharmacological approaches as the primary course of action, pharmacological treatments are advised when non-pharmacological approaches are ineffective or based on patient preference. These guidelines recommend non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxers (SMRs) as the first-line pharmacological options for acute or subacute LBP, while NSAIDs are the exclusive first-line pharmacological option for chronic LBP. Although SMRs are generally effective for acute LBP, the available evidence does not support the view that they improve functional recovery, and their comparative efficacy to NSAIDs and other analgesics remains unknown, while studies have shown them to introduce adverse events without significantly reducing LBP. Moreover, opioids continue to be widely prescribed for LBP, despite limited evidence for effectiveness and known risks of addiction and overdose. Broader use of non-opioid pharmacotherapy, including the appropriate use of OTC options, is critical to addressing the opioid crisis. The balance of evidence indicates that NSAIDs have a favorable benefit-risk profile when compared to other available pharmacological treatment options for non-specific LBP, a condition that is primarily acute in nature and well-suited for self-treatment with OTC analgesics. While clinical guidelines do not differentiate between NSAIDs, evidence indicates that OTC naproxen sodium effectively relieves pain across multiple types of pain models, and furthermore, the 14-h half-life of naproxen sodium allows sustained, all day pain relief with reduced patient pill burden as compared to shorter acting options. Choosing the most appropriate approach for managing LBP, including non-pharmacological options, should be based on the patient's condition, severity of pain, potential risks, and individual patient preference and needs.

Evidence-based rehabilitation medicine: definition, foundation, practice and development

To determine the definition, foundation, practice, and development of evidence-based rehabilitation medicine (EBRM) and point out the development direction for EBRM. Retrieve the database of PubMed, Cochrane Library, Embase, China national knowledge infrastructure (CNKI), Wanfang, and China science and technology journal database (CSTJ). The search was conducted from the establishment of the database to June 2023. The key words are "rehabilitation medicine and evidence based" in Chinese and English. After reading the abstract or full text of the literature, a summary analysis is conducted to determine the definition, foundation, practice, and development of EBRM. A total of 127 articles were included. The development of 14 sub majors in EBRM are not balanced, evidence-based musculoskeletal rehabilitation medicine (EBMRM) (31 articles, mainly focuses on osteoarthritis, osteoporosis and musculoskeletal pain), evidence-based neurorehabilitation medicine (EBNM) (34 articles, mainly concentrated in stroke, traumatic brain injury and spinal cord injury) and evidence-based education rehabilitation medicine (EBEDRM) (17 articles, mainly focuses on educational methodology), evidence-based nursing rehabilitation medicine (EBNRM) (2 articles), evidence-based engineering rehabilitation medicine (EBENRM) (7 articles), evidence-based traditional Chinese rehabilitation medicine (EBTCRM) (3 articles), evidence-based internal rehabilitation medicine (EBIRM) (11 articles), evidence-based intensive care rehabilitation medicine (EBICRM) (4 articles), evidence-based oncology rehabilitation medicine (EBORM) (6 articles), evidence-based physical therapy medicine (EBPTM) (3 articles), evidence-based cardiopulmonary rehabilitation medicine (EBCRM) (6 articles), evidence-based speech therapy medicine (EBSTM)/evidence-based occupation therapy medicine (EBOTM)/evidence-based geriatric rehabilitation medicine (EBGRM) (1 article). The EBMRM, EBNM and EBEDRM are relatively well developed. The development of EBNRM, EBENRM, EBTCRM, EBIRM, EBICRM, EBGRM, EBORM, EBCRM, EBPTM, EBSTM and EBOTM is relatively slow, indicating these eleven fields should be pay more attention in future.

Future of low back pain: unravelling IVD components and MSCs' potential

Low back pain (LBP) mainly emerges from intervertebral disc (IVD) degeneration. However, the failing mechanism of IVD ́s components, like the annulus fibrosus (AF) and nucleus pulposus (NP), leading to IVD degeneration/herniation is still poorly understood. Moreover, the specific role of cellular populations and molecular pathways involved in the inflammatory process associated with IVD herniation remains to be highlighted. The limited knowledge of inflammation associated with the initial steps of herniation and the lack of suitable models to mimic human IVD ́s complexity are some of the reasons for that. It has become essential to enhance the knowledge of cellular and molecular key players for AF and NP cells during inflammatory-driven degeneration. Due to unique properties of immunomodulation and pluripotency, mesenchymal stem cells (MSCs) have attained diverse recognition in this field of bone and cartilage regeneration. MSCs therapy has been particularly valuable in facilitating repair of damaged tissues and may benefit in mitigating inflammation' degenerative events. Therefore, this review article conducts comprehensive research to further understand the intertwine between the mechanisms of action of IVD components and therapeutic potential of MSCs, exploring their characteristics, how to optimize their use and establish them safely in distinct settings for LPB treatment.

Efficacy of Core-Strengthening and Intensive Dynamic Back Exercises on Pain, Core Muscle Endurance, and Functional Disability in Patients with Chronic Non-Specific Low Back Pain: A Randomized Comparative Study

BACKGROUND

Chronic back pains are progressively disabling working individuals, including 60-80% of the general population, for which their diagnosis is challenging to healthcare workers worldwide, thereby becoming a burden to nations.

PURPOSE

The study aimed to investigate the efficacy of core strengthening exercise (CSE) and intensive dynamic back exercise (IDBE) on pain, core muscle endurance, and functional disability in patients with chronic non-specific low back pain (LBP).

METHODS

The study was based on a three-arm parallel-group randomized control design. Forty-five participants with chronic non-specific LBP were recruited and randomly divided into the CSE, IDBE, and Control groups. The CSE and IDBE groups received CSE and IDBE, respectively. However, the Control group received no intervention. Numeric pain rating scale, Oswestry Disability Index, core flexors, extensors, and side bridge tests assessed pain intensity, functional disability, and endurance of core muscles. Outcome scores for the dependent variables were collected at baseline (pre-intervention) and six-week post-intervention. There were no follow-up measurements in this study. A one-way multivariate analysis of covariance (MANCOVA) was used to analyze the intervention effects on the outcomes within groups and between groups, respectively; keeping the significance-level alpha at 95%, i.e., p < 0.05. A univariate F-test was performed to observe the superiority of one treatment over another. Pearson's correlation coefficient test was conducted to determine a relation between the dependent variables. In all statistical analyses, the level of significance α was kept at 0.05.

RESULTS

All forty-five out of sixty-three participants with chronic non-specific low back pain (male, 32 and female, 23; average age, 20.24 ± 1.46 years; average pain duration, 19.6 ± 5.42 weeks) completed the study and their data were analyzed. The MANCOVA test showed a significant difference between the treatment groups on the combined multiple endurance tests for the core muscles (flexors, extensors, side bridge tests to the right and left), Visual Analog Scale (VAS), and Oswestry Disability Index (ODI) scores after controlling for baseline scores of all the dependent variables: F (6, 12) = 23.381; p < 0.05; Wilks' Λ = 0.033; partial η2 = 0.819. A post hoc pair-wise comparison followed by a univariate F-test indicated that a significant improvement was found between the CSE vs. IDBE vs. Control groups on the post-test scores of all the dependent variables except VAS and EET (CSE vs. IDBE only). A Pearson's correlation coefficient test revealed a notable relation between the dependent variables.

CONCLUSIONS

The experimental group CSE was found to be more effective than IDBE on improving functional disability, cores' flexors, and side bridges' endurance tests than IDBE. The magnitude of this improvement exceeded the minimal clinically important difference (MCID), suggesting a clinically relevant enhancement in functional disability, core flexors, and side bridge endurance for participants engaged in CSE. However, CSE vs. IDBE revealed non-significant differences on reducing pain and core extensors' endurance. The absence of statistically significant differences suggests that the observed changes did not exceed the established MCID for pain intensity and core extensors' endurance. In addition, partial eta-squared value revealed the superiority of CSE over IDBE and Control groups. This suggests that the observed differences between the two interventions are not only statistically significant, but also clinically relevant, surpassing the established MCID.

Short-term effects of cupping and scraping therapy for chronic nonspecific low-back pain: A prospective, multicenter randomized trial

BACKGROUND

As one of the most common musculoskeletal ailments, chronic nonspecific low-back pain (CNLBP) causes persistent disability and substantial medical expenses. Epidemiological evidence shows that the incidence rate of CNLBP in young and middle-aged people who are demanded rapidly recovery and social contribution is rising. Recent guidelines indicate a reduced role for medicines in the management of CNLBP.

OBJECTIVE

The present study investigates the short-term effects of cupping and scraping therapy using a medicated balm, compared to nonsteroidal anti-inflammatory drug (NSAID) with a capsaicin plaster, in the treatment of CNLBP.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

We designed a prospective multicenter randomized clinical trial enrolling patients from January 1, 2022 to December 31, 2022. A total of 156 patients with CNLBP were randomized into two parallel groups. Diclofenac sodium-sustained release tablets were administered orally to participants in the control group for one week while a capsaicin plaster was applied externally. Patients in the test group were treated with cupping and scraping using a medical device and medicated balm.

MAIN OUTCOME MEASURES

Primary outcome was pain recorded using the visual analogue scale (VAS). Two secondary outcomes were recorded using the Japanese Orthopedic Association low-back pain scale (JOA) and the traditional Chinese medicine (TCM) syndrome integral scale (TCMS) as assessment tools.

RESULTS

Between baseline and postintervention, all changes in outcome metric scales were statistically significant (P < 0.001). Compared to the control group, patients in the test group had a significantly greater treatment effect in all outcome variables, as indicated by lower VAS and TCMS scores and higher JOA scores, after the one-week intervention period (P < 0.001). Further, according to the findings of multivariate linear regression analysis, the participants' pain (VAS score) was related to their marital status, age, smoking habits and body mass index. No adverse reactions were reported for any participants in this trial.

CONCLUSION

The effectiveness of TCM combined with the new physiotherapy tool is superior to that of NSAID combined with topical plasters, regarding to pain intensity, TCM symptoms and quality of life. The TCM plus physiotherapy also showed more stable and long-lasting therapeutic effects.

TRIAL REGISTRATION

This study was registered at Chinese Clinical Trial Registry (ChiCTR2200055655). Please cite this article as: He JY, Tu XY, Yin ZF, Mu H, Luo MJ, Chen XY, Cai WB, Zhao X, Peng C, Fang FF, Lü C, Li B. Short-term effects of cupping and scraping therapy for chronic nonspecific low-back pain: A prospective, multicenter randomized trial. J Integr Med. 2024; 22(1): 39-45.

Development of Preliminary Integrated Health Care Clinical Competencies for United States Doctor of Chiropractic Programs: A Modified Delphi Consensus Process

Background

There has been rapid growth of chiropractors pursuing career opportunities in both public and private hospitals and other integrated care settings. Chiropractors that prosper in integrated care settings deliver patient-centered care, focus on the institutional mission, understand and adhere to organizational rules, and are proficient in navigating complex systems. The Council on Chiropractic Education Accreditation Standards do not outline specific meta-competencies for integrated care clinical training.

Objective

The purpose of this study was to develop preliminary integrated health care competencies for DC programs to guide the advancement of clinical chiropractic education.

Methods

A systematic literature search was performed. Articles were screened for eligibility and extracted in duplicate. Domains and seed statements were generated from this literature, piloted at a conference workshop, and evaluated via a modified Delphi consensus process. Of 42 invited, 36 chiropractors participated as panelists. Public comment period yielded 20 comments, none resulting in substantive changes to the competencies.

Results

Of 1718 citations, 23 articles met eligibility criteria. After 2 modified Delphi rounds, consensus was reached on all competency statements. A total of 78 competency statements were agreed upon, which encompassed 4 domains and 11 subdomains. The 4 domains were: 1) Collaboration, (2) Clinical Excellence, (3) Communication, and (4) Systems Administration.

Conclusion

We identified 78 preliminary competencies appropriate for preparing DC students and early career chiropractors for clinical practice in integrated healthcare settings. Educational programs may consider these competencies for curricular design and reform to strengthen DC program graduates for integrated practice, advanced training, and employment.

Navigating the Landscape of Herniated Discs: A Rare Case of Herniated Disc Regression

A herniated disc is a condition in which the nucleus pulposus is displaced from the intervertebral space. It usually leads to back pain, thus being the most common reason for it. Patients often describe the first symptoms of a herniated disc as extreme and decisive pain. Unlike the usual mechanical back pain, a herniated disc is often related to a stinging or burning sensation that often spreads to the lower extremities and proves to be continuous at lower temperatures. We present a case of a 58-year-old male patient who visited the Acibadem City Clinic with complaints of pain initially starting from his hip, which in time extended to his left leg (L5 radiculopathy) and a few days later to his right leg (L5 radiculopathy). Before visiting the clinic, he had been treated in Germany with physiotherapy and supplements, which had proved ineffective. After an MRI, which revealed an L4-L5 herniated disc, he underwent conservative treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs) for 14 days in addition to Medrol 4mg tablets (3x1 per day for 10 days). On the third day of the treatment, 60% of the symptoms had subsided. Seven months later, he came in for a scheduled checkup, and 95% of the symptoms were gone. A controlled MRI was done, and the herniated disc had completely vanished. We hope that this type of research will benefit medical professionals, patients, researchers, doctors, and students, among others. Such cases also contribute to the quality of care for such patients and help set regulated factual guidelines regarding their treatment as a whole.

A randomized controlled trial investigating the impact of a single flash cupping session on patients with chronic lower back pain using multichannel surface electromyographic assessment

BACKGROUND

Chronic lower back pain (CLBP) is one of the most common disorders worldwide. Flash cupping has the ability to relieve CLBP; nevertheless, its impact on CLBP and the likely mechanism of action have not been studied.

OBJECTIVE

The goal of this study was to assess the impact of a single, brief cupping session on CLBP and low back muscle activity using multichannel surface electromyography (sEMG).

METHODS

In this randomized controlled trial, 24 patients with CLBP were enrolled and randomly assigned to the control group (treated by acupuncture) and cupping group (treated by acupuncture and flash cupping). Acupuncture was applied on the shen shu (BL23), dachang shu (BL25), and wei zhong (BL40) acupoints in both the groups. A brief cupping treatment was applied to the shen shu (BL23), qihai shu (BL24), dachang shu (BL25), guanyuan shu (BL26), and xiaochang shu (BL27) acupoints on both sides of the lower back in the cupping group. The numeric rating scale (NRS) was used to assess therapy efficacy for lower back pain (LBP) before and after treatment. Surface EMG data collected during symmetrical trunk flexion-extension movements were utilized to measure lower back muscle activity and the effectiveness of LBP therapy.

RESULTS

There was no statistically significant difference (P= 0.63) in pain intensity between the two groups before and after treatment. There was a statistically significant difference (P= 0.04) between the control group and the cupping group in the sEMG topographic map parameter CoGx-To-Midline.

CONCLUSION

This study established a connection between the action mechanism of flash cupping and enhanced horizontal synchronization of lower back muscular activity.