Chronic low back pain: evaluation and management

Exploring the role of respiratory intervention as an effective adjunct tool in the management of chronic low back pain: A scoping systematic review

BACKGROUND

Individuals with chronic low back pain (CLBP) are usually prescribed manual therapy and exercise programs. Respiratory exercise interventions are also recommended by some researchers for CLBP. However, the evidence for the relative effectiveness of these treatments is limited, and the question of which sort of intervention is most suited remains unanswered.

OBJECTIVE

This systematic review aims to evaluate the effectiveness of respiratory interventions in CLBP.

METHODS

A systematic search was performed using databases: PubMed, Web of Science, PEDro, Cochrane Library, and Science Direct. The review was registered in PROSPERO (CRD42021233739).

RESULTS

Seven studies met the inclusion criteria. Out of these, one was of poor, three were of fair, and three were of good qualities. A total of 293 subjects were included in seven studies, the mean age of subjects ranged from 21 to 53 years. The largest effect size was reported for pain (d = 1.5) and maximum inspiratory pressure (d = 1.38). No detrimental effects were reported for any of the intervention programs.

CONCLUSIONS

Since most of the research has been done on pain and MIP, and both of these parameters have revealed significant changes with large effect size, therefore it can be concluded that respiratory interventions improve pain and MIP in CLBP. Owing to the limited number of studies available, a definitive outcome could not be documented for other parameters. Thus, further research is needed to provide a more robust piece of evidence and understanding.

Spinal Cord Stimulation in Chronic Low Back Pain Syndrome: Mechanisms of Modulation, Technical Features and Clinical Application

Chronic low-back pain (CLBP) is a common disease with several negative consequences on the quality of life, work and activity ability and increased costs to the health-care system. When pharmacological, psychological, physical and occupational therapies or surgery fail to reduce CLBP, patients may be a candidate for Spinal Cord Stimulation (SCS). SCS consists of the transcutaneous or surgical implantation of different types of electrodes in the epidural space; electrodes are then connected to an Implanted Pulse Generator (IPG) that generates stimulating currents. Through spinal and supraspinal mechanisms based on the “gate control theory for pain transmission”, SCS reduces symptoms of CLBP in the almost totality of well-selected patients and its effect lasts up to eight years in around 75% of patients. However, the evidence in favor of SCS still remains weak, mainly due to poor trial methodology and design. This narrative review is mainly addressed to those professionals that may encounter patients with CLBP failing conventional treatments. For this reason, we report the mechanisms of pain relief during SCS, the technical features and some clinical considerations about the application of SCS in patients with CLBP.

Effects of combined hip exercise and passive stretching on muscle stiffness, pain perception and painrelated disability, and physical function in older adults with low back pain

[Purpose] This study aimed to examine the effects of combined hip exercise and passive stretching as a novel treatment method for low back pain (LBP) in older adults.[Methods] Altogether, 20 Koreans with LBP aged 60–79 years (67.3 ± 5.92 years) were randomly assigned to undertake combined exercise (CE; n = 10) or lumbar stabilization exercise (LSE; n = 10). All participants performed their respective exercise program for 25–30 min with an OMNI scale of 6–8 for 8 weeks, three times a week. Body composition, muscle stiffness, pain-visual analog scale (P-VAS), Oswestry disability index, and physical function were evaluated before and after the exercise intervention.[Results] The CE group demonstrated greater improvements in lean body mass (<i>η²</i> = 0.402, <i>p</i> = 0.003) and percent body fat (<i>η²</i> = 0.222, <i>p</i> = 0.036) than the LSE group. Both groups demonstrated significant improvements in muscle stiffness, P-VAS scores, and Oswestry disability index scores, although no significant differences were observed between the interventions. All physical function parameters demonstrated a significant improvement in both groups, and the CE group demonstrated greater improvement in the YMCA sit-and-reach (<i>η²</i> = 0.338, <i>p</i> = 0.007) and straight leg raise tests (<i>η²</i> = 0.283, p = 0.016) than the LSE group.[Conclusion] CE is comparable to LSE as an effective and successful exercise intervention that reduces muscle stiffness and P-VAS scores. Moreover, CE is more effective than LSE in enhancing the physical function of older adults with LBP.

Validity of a Screening Tool for Patients with a Sub-Threshold Level of Lumbar Instability: A Cross-Sectional Study

Lumbar instability (LI) comprises one subgroup of those with chronic low back pain (CLBP); it indicates the impairment of at least one of the spinal stabilizing systems, and radiographic criteria of translation and rotation are used for its diagnosis. Previous studies have developed and tested a screening tool for LI where patients with sub-threshold lumbar instability (STLI) were detected in the initial stage of lumbar pathology using radiographs as a gold standard for diagnosis. The radiographic measurement in STLI lies between the range of translation and rotation of the LI and asymptomatic lumbar motion. However, there are no studies indicating the validity and cut-off points of the screening tool for STLI. The current study aimed to determine the validity of an LI screening tool to support the diagnostic process in patients with STLI. This study design was cross-sectional in nature. A total of 135 participants with CLBP, aged between 20 and 60 years, who had undergone flexion and extension radiographs, answered a screening tool with 14 questions. The cut-off score for identifying STLI using the screening tool was at least 6/14 positive responses to the LI questions. The findings suggested that the LI screening tool we tested is effective for the detection of STLI. The tool can be used in outpatient settings.

Functional Disruptions of the Brain in Low Back Pain: A Potential Imaging Biomarker of Functional Disability

Chronic low back pain (LBP) is one of the leading causes of disability worldwide. While LBP research has largely focused on the spine, many studies have demonstrated a restructuring of human brain architecture accompanying LBP and other chronic pain states. Brain imaging presents a promising source for discovering noninvasive biomarkers that can improve diagnostic and prognostication outcomes for chronic LBP. This study evaluated graph theory measures derived from brain resting-state functional connectivity (rsFC) as prospective noninvasive biomarkers of LBP. We also proposed and tested a hybrid feature selection method (Enet-subset) that combines Elastic Net and an optimal subset selection method. We collected resting-state functional MRI scans from 24 LBP patients and 27 age-matched healthy controls (HC). We then derived graph-theoretical features and trained a support vector machine (SVM) to classify patient group. The degree centrality (DC), clustering coefficient (CC), and betweenness centrality (BC) were found to be significant predictors of patient group. We achieved an average classification accuracy of 83.1% (p < 0.004) and AUC of 0.937 (p < 0.002), respectively. Similarly, we achieved a sensitivity and specificity of 87.0 and 79.7%. The classification results from this study suggest that graph matrices derived from rsFC can be used as biomarkers of LBP. In addition, our findings suggest that the proposed feature selection method, Enet-subset, might act as a better technique to remove redundant variables and improve the performance of the machine learning classifier.

Cognitive-Evaluative Dimension of Pain in Neuropathic Pain Relapse in Sciatica: A Case Report

The cognitive-evaluative (C-E) dimension of pain is commonly observed in patients with a relatively long duration of pain. However, little is known about the effects of pain relapse on the C-E dimension of pain. Moreover, the improvement process of the C-E dimension of pain following treatment is unknown. The objective of this case report was to (a) demonstrate that the C-E dimension was affected in the acute phase of neuropathic pain in cases of pain relapse, and (b) demonstrate the improvement process of the C-E dimension of pain. A woman was diagnosed with low back pain (LBP) and sciatica. The patient had previously experienced symptoms of LBP and sciatica; thus, this episode was a case of pain relapse. At the beginning of rehabilitation, the C-E dimension of pain was present in addition to the sensory-discriminative (S-D) dimension of pain. It was observed that improvement of the C-E dimension of pain was delayed in comparison with that of the S-D dimension of pain. The C-E dimension of pain was observed with pain relapse even though it was in the acute phase of pain. This case provides a novel insight into the C-E dimension of pain. Moreover, the delay in improving the C-E dimension of pain indicates a difference in the improvement process for each pain dimension.

Management of Chronic and Neuropathic Pain with 10 kHz Spinal Cord Stimulation Technology: Summary of Findings from Preclinical and Clinical Studies

Since the inception of spinal cord stimulation (SCS) in 1967, the technology has evolved dramatically with important advancements in waveforms and frequencies. One such advancement is Nevro’s Senza^® SCS System for HF10, which received Food and Drug and Administration (FDA) approval in 2015. Low-frequency SCS works by activating large-diameter Aβ fibers in the lateral discriminatory pathway (pain location, intensity, quality) at the dorsal column (DC), creating paresthesia-based stimulation at lower-frequencies (30–120 Hz), high-amplitude (3.5–8.5 mA), and longer-duration/pulse-width (100–500 μs). In contrast, high-frequency 10 kHz SCS works with a proposed different mechanism of action that is paresthesia-free with programming at a frequency of 10,000 Hz, low amplitude (1–5 mA), and short-duration/pulse-width (30 μS). This stimulation pattern selectively activates inhibitory interneurons in the dorsal horn (DH) at low stimulation intensities, which do not activate the dorsal column fibers. This ostensibly leads to suppression of hyperexcitable wide dynamic range neurons (WDR), which are sensitized and hyperactive in chronic pain states. It has also been reported to act on the medial pathway (drives attention and pain perception), in addition to the lateral pathways. Other theories include a reversible depolarization blockade, desynchronization of neural signals, membrane integration, glial–neuronal interaction, and induced temporal summation. The body of clinical evidence regarding 10 kHz SCS treatment for chronic back pain and neuropathic pain continues to grow. There is high-quality evidence supporting its use in patients with persistent back and radicular pain, particularly after spinal surgery. High-frequency 10 kHz SCS studies have demonstrated robust statistically and clinically significant superiority in pain control, compared to paresthesia-based SCS, supported by level I clinical evidence. Yet, as the field continues to grow with the technological advancements of multiple waveforms and programming stimulation algorithms, we encourage further research to focus on the ability to modulate pain with precision and efficacy, as the field of neuromodulation continues to adapt to the modern healthcare era.

Ultrasound-Guided Lumbar Spine Injection for Axial and Radicular Pain: A Single Institution Early Experience

STUDY DESIGN

Clinical audit via retrospective review of a database.

PURPOSE

To report an early experience using ultrasound-guided lumbar spinal injection for axial and radicular pain in an Asian multiethnic cohort.

OVERVIEW OF LITERATURE

Ultrasound-guided spine injection therapy is a comparatively new technique in the management of axial and radicular pain from degenerative lumbar spinal conditions, which may be a reasonable alternative to conventional fluoroscopic or computed tomography-guided injection.

METHODS

A retrospective review was conducted, involving all patients who underwent ultrasound-guided lumbar spine injection therapy at a single institution over 1 year. Patients were evaluated by two interventionists, who then performed standardized ultrasound-guided lumbar facet joint and pararadicular spinal injections.

RESULTS

There were 42 patients treated at our Sports Medicine Centre; with 27 patients (64.3%) receiving facet joint injections and 18 patients (42.9%) receiving nerve root injections. The majority (90.5%) of patients experienced an improvement of >30% in pain intensity at 3 months post-injection, using the Numerical Rating Scale pain score (p<0.001); with 40 patients (95.2%) reporting a reduction in Oswestry Disability Index score (p<0.001). No complications were reported.

CONCLUSIONS

Our initial experience confirms the safety, feasibility, and effectiveness of ultrasound-guided lumbar spinal injection for the treatment of axial and radicular pain in an Asian multiethnic cohort.

Categorisation of lumbar spine MRI referrals in Denmark as compliant or non-compliant to international imaging guidelines: an inter-rater reliability study

BACKGROUND

Managing low back pain (LBP) often involves MRI despite the fact that international guidelines do not recommend routine imaging. To allow us to explore the topic and use this knowledge in further research, a reliable method to review the MRI referrals is needed. Consequently, this study aimed to assess the inter-rater reliability of a method evaluating lumbar spine MRI referrals' appropriateness.

METHODS

Four inexperienced students (chiropractic master's students) and a senior clinician (chiropractor) were included as independent raters in this inter-rater reliability study. Lumbar spine MRI referrals from primary care on patients (> 18 years) with LBP with or without leg pain were included. The referrals were classified using a modified version of the American College of Radiology (ACR) imaging appropriateness criteria for LBP. Categories of appropriate referrals included; fractures, cancer, previous surgery, candidate for surgery or suspicion of cauda equina. Inappropriate referrals included lacking information on previous non-surgical treatment, no word on non-surgical treatment duration, or "other reasons" for inappropriate referrals. After two rounds of training and consensus sessions, 50 lumbar spine MRI referrals were reviewed independently by the five raters. Inter-rater reliability was quantified using unweighted Kappa statistics, and the observed agreement was calculated with both a pairwise comparison and an overall five-rater comparison.

RESULTS

Inter-rater reliability was substantial, with a Kappa value for appropriate vs. inappropriate referrals of 0.76 (95% CI: 0.55-0.89). When six and eight subcategories were evaluated, the Kappa values were 0.77 (95% CI: 0.58-0.91) and 0.82 (95% CI: 0.72-0.92), respectively. The overall percentage of agreement for appropriate and inappropriate referrals was 92% and ranged from 88 to 98% for the pairwise comparisons of the five raters' results. For the six and eight subcategories, the overall agreement was 92 and 88%, respectively, ranging from 88 to 98% and 84-92%, respectively, for the pairwise comparisons.

CONCLUSION

The inter-rater reliability of the evaluation of the appropriateness of lumbar spine MRI referrals, according to the modified ACR-appropriateness criteria, was found to range from substantial to almost perfect and can be used for research and quality assurance purposes.

Prevalence and Associated Factors of Depressive Symptoms Among Patients With Chronic Low Back Pain: A Cross-Sectional Study

Background: Few studies have focused on depressive symptoms among patients with chronic low back pain in China. The aim of this cross-sectional study was to assess the prevalence and associated factors of depressive symptoms in patients with chronic low back pain. Methods: From May to August 2021, 1,172 patients with chronic low back pain were recruited in China. Depressive symptoms were assessed through the Patient Health Questionnaire. Associations of demographic characteristics, clinical characters and social-psychological factors with depressive symptoms were investigated among patients with chronic low back pain. Results: The prevalence of depressive symptoms was 25.00%. Logistic regression analysis found that duration of pain in 1-5 years (1-3 years: OR = 2.91, 95%CI: 1.65-5.14, 3-5 years: OR = 3.09, 95%CI: 1.55-6.15) and more severe pain (OR = 1.13, 95%CI: 1.10-1.17) were associated with higher risks of depressive symptoms. Better family function (good family function: OR = 0.25, 95%CI: 0.15-0.41, moderate family dysfunction: OR = 0.47, 95%CI: 0.29-0.77) and higher pain self-efficacy (OR = 0.94, 95%CI: 0.93-0.95) were associated with lower risks of depressive symptoms. Conclusion: Patients with chronic low back pain have a high prevalence of depressive symptoms in China. Duration of pain, pain severity, family function and pain self-efficacy were predictors of depressive symptoms among chronic low back pain patients in China. Early identification of the associated factors may be helpful for the timely management of depressive symptoms.

Concurrent Use of Lumbar Total Disc Arthroplasty and Anterior Lumbar Interbody Fusion: The Lumbar Hybrid Procedure for the Treatment of Multilevel Symptomatic Degenerative Disc Disease: A Prospective Study

STUDY DESIGN

A prospective study.

OBJECTIVE

The aim of this study was to evaluate clinical and patient outcomes post combined total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF), known as hybrid surgery for the treatment of multilevel symptomatic degenerative disc disease (DDD).

SUMMARY OF BACKGROUND DATA

Class I studies comparing the treatment of one-level lumbar DDD with TDA and ALIF have confirmed the effectiveness of those treatments through clinical and patient outcomes. Although the success of single-level disease is well documented, the evidence relating to the treatment of multilevel DDD with these modalities is emerging. With the evolution of the TDA technology, a combined approach to multilevel disease has developed in the form of the hybrid procedure.

METHODS

A total of 617 patients underwent hybrid surgery for chronic back pain between July 1998 and February 2012. Visual Analog Pain Scale for the back and leg were recorded along with the Oswestry Disability Index and Roland Morris Disability Questionnaire.

RESULTS

Both statistically and clinically significant (p < 0.005) reductions were seen in back and leg pain, which were sustained for at least 8 years postsurgery. In addition, significant improvements (P < 0.001) in self-rated disability and function were also maintained for at least 8 years. Patient satisfaction was rated as good or excellent in >90% of cases.

CONCLUSION

The results of this research indicate that improvements in both back and leg pain and function can be achieved using the hybrid lumbar reconstructive technique.

LEVEL OF EVIDENCE

4.