Patient-Reported Physician Treatment Recommendations and Compliance Among U.S. Adults with Low Back Pain

The Effectiveness of Acupuncture for Low Back Pain: An Umbrella Review and Meta-Analysis

Recommendations on the use of acupuncture in managing low back pain (LBP) vary across different guidelines. The methodological quality of existing systematic reviews and meta-analyses on this topic also demonstrates considerable diversity, potentially leading to biased conclusions. Therefore, we comprehensively searched PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Chinese National Knowledge Infrastructure (CNKI) databases and conducted an umbrella review. Scrutiny was performed to ascertain whether primary studies within the systematic reviews and meta-analyses adhered to our inclusion criteria, followed by a meticulous reanalysis of pertinent data. Participant numbers, heterogeneity, publication bias, and excessive significance were taken into account when assessing the credibility of the evidence. For robustness, sensitivity analysis was performed using the leave-one-out method. The results of the umbrella review yielded highly suggestive evidence in favor of the immediate and short-term analgesic effects of acupuncture, with suggestive evidence supporting intermediate-term analgesic effects. However, the effectiveness of acupuncture on disability improvement has demonstrated weak to suggestive evidence. Evidence supporting the enhancement of quality of life by acupuncture is limited. The leave-one-out analysis corroborated the robustness of the meta-analysis, further confirming the credibility of the findings. This umbrella review indicated that the most significant advantage of acupuncture for LBP is its capacity to reduce pain.

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.

Development of a low back pain care pathway in an academic hospital system: results of a consensus process

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide and a significant component of healthcare expenditures. Clinical practice guidelines (CPGs) have been highlighted as a key resource to improve the quality of care. This study aimed to develop a clinical pathway for LBP based on CPGs in an academic health system.

METHODS

We conducted a modified Delphi study of clinicians caring for patients with LBP who were asked to rate 21 CPG-informed seed statements through an online survey. The goal was to identify statements that achieved a minimum of 80% consensus among panelists.

RESULTS

Thirty-five healthcare providers participated as panelists. The majority of participants were male (68.6%), had MD or DO (62.9%) degrees, and were clinicians (73.8%) working in neurosurgery (36.1%), orthopedics (25.7%), emergency medicine (14.3%), or physical therapy (11.4%). Initially, consensus was reached on 20 of 21 seed statements. One statement did not reach consensus in the initial round and was revised into two separate statements based on feedback from panelists. One of these statements achieved consensus in the second review round. All statements reaching consensus were incorporated into a care pathway consisting of diagnosis, evaluation, and treatment for LBP.

CONCLUSION

Healthcare providers across various disciplines supported statements interpreting current CPGs related to care for LBP. This study represents a step toward supporting guideline-concordant care for LBP. Additional research is needed to assess how such pathways impact actual clinical care.

Barriers and facilitators to reducing paracetamol use in low back pain: A qualitative study

BACKGROUND

Paracetamol is widely used for low back pain (LBP), but research questions its efficacy and safety. Patient education booklets have been explored for promoting deprescribing, but barriers and facilitators specific to LBP deprescribing remain unexamined.

OBJECTIVE

To identify contextual factors facilitating and obstructing successful deprescribing of paracetamol for LBP after receiving an educational booklet.

STUDY DESIGN

This study is part of an uncontrolled cohort feasibility study (CEASE NOW) in the community, recruiting from Musculoskeletal Australia and painaustralia.

PATIENT SAMPLE

Twenty-four participants with acute, sub-acute, or chronic LBP, self-reporting paracetamol consumption, were included.

METHODS

Thematic content analysis was used to analyze qualitative data on barriers and facilitators. Data were categorized by deprescribing outcomes: i) successful deprescribing, ii) attempted but failed, or iii) no attempt. Semi-structured telephone interviews were conducted within one week after each participant completed the one-month follow-up.

RESULTS

Successful deprescribing was facilitated by supportive healthcare professionals, willingness, high self-efficacy, fear of future illness, and diverse strategies for deprescribing plans. Barriers included unsupportive healthcare professionals and fear of flare-ups. Participants not attempting deprescribing believed it unnecessary, perceived it as effortful, unquestioningly trusted healthcare professionals, and lacked risk awareness.

CONCLUSIONS

Support from healthcare professionals, patient willingness, perceived necessity, risk awareness, effort, and varied strategies influence deprescribing outcomes for LBP patients using paracetamol. Addressing these factors is crucial when designing interventions to promote safe and effective deprescribing in LBP management.

Bibliometric Analysis of Research Trends on Manual Therapy for Low Back Pain Over Past 2 Decades

Purpose

Low back pain (LBP) is a prevalent musculoskeletal disorder, and manual therapy (MT) is frequently employed as a non-pharmacological treatment for LBP. This study aims to explore the research hotspots and trends in MT for LBP. MT has gained widespread acceptance in clinical practice due to its proven safety and effectiveness. The study aims to analyze the developments in the field of MT for LBP over the past 23 years, including leading countries, institutions, authoritative authors, journals, keywords, and references. It endeavors to provide a comprehensive summary of the existing research foundation and to analyze the current cutting-edge research trends.

Methods

Relevant articles between 2000 and 2023 were retrieved from the Web of Science Core Collection (WOSCC) database. We used the software VOSviewer and CiteSpace to perform the analysis and summarize current research hotspots and emerging trends.

Results

Through screening, we included 1643 papers from 2000 to 2023. In general, the number of articles published each year showed an upward trend. The United States had the highest number of publications and citations. Canadian Memorial Chiropractic College was the most published research institution. The University of Pittsburgh in the United States had the most collaboration with other research institutions. Long, Cynthia R. was the active author. Journal of Manipulative and Physiological Therapeutics was the most prolific journal with 234 publications.

Conclusion

This study provides an overview of the current status and trends of clinical studies on MT for LBP in the past 23 years using the visualization software, which may help researchers identify potential collaborators and collaborating institutions, hot topics, and new perspectives in research frontiers, while providing new clinical practice ideas for the treatment of LBP.

Association between chiropractic spinal manipulation and gabapentin prescription in adults with radicular low back pain: retrospective cohort study using US data

OBJECTIVES

Radicular low back pain (rLBP) is often treated off-label with gabapentin or by chiropractors using chiropractic spinal manipulative therapy (CSMT). To date, no studies have examined the association between these interventions. We hypothesised that adults under 50 years of age receiving CSMT for newly diagnosed rLBP would have reduced odds of receiving a gabapentin prescription over 1 year-follow-up.

DESIGN

Retrospective cohort study.

SETTING

US network including linked medical records, medical claims and pharmacy claims of >122 million patients attending large healthcare organisations (TriNetX), queried 15 June 2023, yielding data from 2017 to 2023.

PARTICIPANTS

Adults aged 18-49 were included at their first occurrence of rLBP diagnosis. Exclusions were severe pathology, other spinal conditions, on-label gabapentin indications and gabapentin contraindications. Propensity score matching controlled for variables associated with gabapentin use and receipt of prescription medication over the preceding year.

INTERVENTIONS

Patients were divided into CSMT or usual medical care cohorts based on the care received on the index date of rLBP diagnosis.

PRIMARY AND SECONDARY OUTCOME MEASURES

OR for gabapentin prescription.

RESULTS

After propensity matching, there were 1635 patients per cohort (mean age 36.3±8.6 years, 60% women). Gabapentin prescription over 1-year follow-up was significantly lower in the CSMT cohort compared with the usual medical care cohort, with an OR (95% CI) of 0.53 (0.40 to 0.71; p<0.0001). Sensitivity analyses revealed early divergence in cumulative incidence of prescription; and no significant between-cohort difference in a negative control outcome (gastrointestinal medication) suggesting adequate control for pharmacological care preference.

CONCLUSIONS

Our findings suggest that US adults receiving CSMT for newly diagnosed rLBP have significantly reduced odds of receiving a gabapentin prescription over 1-year follow-up compared with those receiving usual medical care. Results may not be generalisable and should be replicated in other healthcare settings and corroborated by a prospective study to reduce confounding.

(C)onsumer focused (E)ducation on p(A)racetamol (S)ide (E)ffects, i(N)adequate (O)utcomes and (W)eaning (CEASE NOW) for individuals with low back pain: results of a feasibility study

OBJECTIVES

To determine the feasibility of a patient-education booklet to support patients with low back pain (LBP) to reduce paracetamol intake.

DESIGN

Single group, repeated measures feasibility study.

SETTING

Community.

PARTICIPANTS

Adults experiencing LBP of any kind and self-reporting consumption of paracetamol for LBP weekly for at least 1 month were invited to participate.

INTERVENTION

Participants received a patient-education booklet 1 week after the baseline measures were collected. The intervention was designed to change beliefs, increase knowledge and self-efficacy to deprescribe paracetamol for their LBP and create discussion with a health professional through the mechanisms of motivation, capacity and opportunity.

PRIMARY OUTCOME MEASURES

Feasibility of recruitment procedures, data collection and acceptability of the intervention.

SECONDARY OUTCOME MEASURES

Changes in motivation, self-efficacy, opportunity to deprescribe paracetamol for their LBP, paracetamol usage and LBP clinical outcomes at baseline, 1-week and 1-month follow-up.

RESULTS

A total of 24 participants were recruited into the study within the timeframe of 3 months from study advertisement and all completed the study follow-up. There were no missing data for any outcome measure across all follow-up points, 22 (91.6%) participants were willing to participate in a future randomised control trial (RCT) and over 60% of participants responded positively to questions regarding acceptability of the patient-educational booklet. Overall, at the 1-month follow-up, approximately two thirds (15/24) of participants had an increase in motivation and self-efficacy scores and had discussed or intended to discuss their paracetamol use for LBP with a health professional.

CONCLUSIONS

The results of this study demonstrate that the patient-education booklet is feasible to implement, and both the intervention and study design were well-received by participants. This study supports the undertaking an RCT to assess the effects of the patient-education booklet on deprescribing paracetamol in people with LBP.

Discussion on Collection of Clinical Questions in International Clinical Practice Guidelines of Acupuncture-Moxibustion

The clinical questions of acupuncture-moxibustion (Acup-Mox) guidelines are complicated, including not only the curative effect of Acup-Mox intervention measures, but also the operational elements of Acup-Mox. This paper aimed to put forward the idea and process of collecting clinical questions in developing international acupuncture clinical practice guidelines. The experience was collected and the idea of collecting clinical questions of Acup-Mox was formed through expert consultation and discussion in combination with expert opinions. Based on the characteristics of Acup-Mox discipline. This paper put forward the thinking of collecting elements of clinical questions following the intervention-population-outcome-control (I-P-O-C) inquiry process, according to the discipline of Acup-Mox. It was emphasized that in the process of collecting clinical questions, "treatable population" and "alleviable outcome indicators" for a specific Acup-Mox intervention with certain therapeutic effect should be focused on, so as to highlight the pertinence of clinical questions of Acup-Mox guidelines in terms of population and outcome elements.

Physician Office Visits That Included Complementary Health Approaches in U.S. Adults: 2005-2015

Introduction: The Institute of Medicine has described the need for comparing models of care delivery involving complementary health approaches and conventional medical practitioners. As a step toward addressing this need, we used a nationally representative 11-year sample of office-based visits to physicians from the National Ambulatory Medical Care Survey (NAMCS), to examine a comprehensive list of factors believed to be associated with visits where complementary health approaches were recommended or provided. Methods: NAMCS is a national health care survey designed to collect data on the provision and use of ambulatory medical care services provided by office-based physicians in the United States. Patient medical records were abstracted from a random sample of office-based physician visits. We examined several visit characteristics, including patient demographics, physician specialty, documented health conditions, and reasons for health visit. We ran chi-square analyses to test bivariate associations between visit factors and whether complementary health approaches were recommended or provided to guide development of logistic regression models. Results: Of the 550,114 office visits abstracted, 4.43% contained a report that complementary health approaches were ordered, supplied, administered, or continued. Among complementary health visits, 87% of patient charts mentioned nonvitamin nonmineral dietary supplements. The prevalence of complementary health visits significantly increased from 2% in 2005 to almost 8% in 2015. Returning patient status, survey year, physician specialty and degree, menopause, cardiovascular, and musculoskeletal diagnoses were significantly associated with complementary health visits, as was seeking preventative care or care for a chronic problem. Conclusion: We present an overview of the first study of office-based physician visits where complementary health approaches were recommended or ordered to their patients. These data confirm the growing popularity of complementary health approaches in the United States, provide a baseline for further studies, and inform subsequent investigations of integrative health care.

Association between chiropractic spinal manipulative therapy and benzodiazepine prescription in patients with radicular low back pain: a retrospective cohort study using real-world data from the USA

OBJECTIVES

Although chiropractic spinal manipulative therapy (CSMT) and prescription benzodiazepines are common treatments for radicular low back pain (rLBP), no research has examined the relationship between these interventions. We hypothesise that utilisation of CSMT for newly diagnosed rLBP is associated with reduced odds of benzodiazepine prescription through 12 months' follow-up.

DESIGN

Retrospective cohort study.

SETTING

National, multicentre 73-million-patient electronic health records-based network (TriNetX) in the USA, queried on 30 July 2021, yielding data from 2003 to the date of query.

PARTICIPANTS

Adults aged 18-49 with an index diagnosis of rLBP were included. Serious aetiologies of low back pain, structural deformities, alternative neurological lesions and absolute benzodiazepine contraindications were excluded. Patients were assigned to cohorts according to CSMT receipt or absence. Propensity score matching was used to control for covariates that could influence the likelihood of benzodiazepine utilisation.

OUTCOME MEASURES

The number, percentage and OR of patients receiving a benzodiazepine prescription over 3, 6 and 12 months' follow-up prematching and postmatching.

RESULTS

After matching, there were 9206 patients (mean (SD) age, 37.6 (8.3) years, 54% male) per cohort. Odds of receiving a benzodiazepine prescription were significantly lower in the CSMT cohort over all follow-up windows prematching and postmatching (p<0.0001). After matching, the OR (95% CI) of benzodiazepine prescription at 3 months was 0.56 (0.50 to 0.64), at 6 months 0.61 (0.55 to 0.68) and 12 months 0.67 (0.62 to 0.74). Sensitivity analysis suggested a patient preference to avoid prescription medications did not explain the study findings.

CONCLUSIONS

These findings suggest that receiving CSMT for newly diagnosed rLBP is associated with reduced odds of receiving a benzodiazepine prescription during follow-up. These results provide real-world evidence of practice guideline-concordance among patients entering this care pathway. Benzodiazepine prescription for rLBP should be further examined in a randomised trial including patients receiving chiropractic or usual medical care, to reduce residual confounding.

The impact of different intensities and domains of physical activity on analgesic use and activity limitation in people with low back pain: a prospective cohort study with a one-year follow-up

BACKGROUND

Analgesics are the most common form of managing low back pain (LBP). No previous study has examined which domains and intensities of physical activity are most beneficial in reducing the frequency of analgesic use for LBP, and its related activity limitation.

METHODS

This cohort study forms part of the AUstralian Twin low BACK pain study, investigating the impact of physical activity on LBP. Information on demographics, LBP and health-related factors, including physical activity were collected at baseline. Data on the total counts of analgesic use and activity limitation for LBP were collected weekly for one-year. Negative binomial regression models were conducted separately for each type of physical activity. Results were presented as Incidence Rate Ratios (IRR) and 95% Confidence Intervals (CI).

RESULTS

From an initial sample of 366 participants, 86 participants reported counts of analgesic use and 140 recorded counts of activity limitation across the follow up period. The negative binomial regression models for analgesic use counts indicated moderate-vigorous physical activity (IRR 0·97, 95% C.I 0·96-0·99) and physical workload (IRR 1·02, 95% C.I 1·01-1·05) to be significant. For activity limitation counts, significant associations were shown for sedentary time (IRR 1·04, 95% C.I 1·01-1·09) and leisure activity (IRR 0·94, 95% C.I 0·81-0·99).

CONCLUSIONS

Our findings highlight the potential importance of supporting engagement in moderate-vigorous and leisure physical activity, as well as minimising sedentary time and physical workload to reduce the risk of activity limitation and the need for analgesic use in people with LBP.

Systematic review of guideline-recommended medications prescribed for treatment of low back pain

OBJECTIVE

To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG).

METHODS

We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP.

RESULTS

316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids.

CONCLUSIONS

Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.

Exposure reasons, other substance use, and medical outcomes of poison control center cases aged 50+ involving opioids, 2015-2020

CONTEXT

Rates of prescription opioid (PO) prescribing and filling remain high, and illicit opioid (IO) use has increased among late middle-aged and older adults. Research on PO and IO poisoning and their impacts among these age groups is needed.

METHODS

Data came from 2015 to 2020 poison control center cases aged 50+ (N = 83,135). We used χ2 tests to examine changes over the study period in the numbers of PO and IO cases, type of opioids used, exposure reasons, and medical outcomes. We fit multinomial logistic regression models to examine the associations of medical outcomes with exposure reasons and other medication/substance involvement.

RESULTS

Between 2015/2016 and 2020, the numbers and shares of PO-only cases steadily declined, but IO cases, with or without PO, nearly tripled, constituting almost 10% of all PCC opioid cases aged 50+ in 2020. The rates of intentional misuse/abuse increased among both PO-only and IO (with/without PO) cases during the study period, and the death rate among IO cases sharply increased in 2020. Compared to adverse reactions or other unintentional exposures, intentional misuse/abuse and suspected suicides were associated with significantly higher risks of serious outcomes (e.g., risk of death from intentional misuse/abuse: RRR = 22.11, 95% CI = 16.74-29.20 in PO-only cases and RRR = 6.95, 95% CI = 2.37-20.39 in IO cases with/without PO). The use of most other medications and substances was also significantly associated with serious outcomes.

DISCUSSION

Among older adults, medical outcomes in opioid poisoning cases have become more serious in recent years as intentional misuse/abuse became more common. Opioid use disorder treatment should be readily available and accessible, and alternatives to PO prescribing should be considered.

CONCLUSIONS

Among individuals aged 50+, PO poisoning cases decreased, but IO cases increased sharply from 2015 to 2020 with concomitant increases in intentional misuse/abuse and serious medical outcomes.

Back and neck pain: in support of routine delivery of non-pharmacologic treatments as a way to improve individual and population health

Chronic back and neck pain are highly prevalent conditions that are among the largest drivers of physical disability and cost in the world. Recent clinical practice guidelines recommend use of non-pharmacologic treatments to decrease pain and improve physical function for individuals with back and neck pain. However, delivery of these treatments remains a challenge because common care delivery models for back and neck pain incentivize treatments that are not in the best interests of patients, the overall health system, or society. This narrative review focuses on the need to increase use of non-pharmacologic treatment as part of routine care for back and neck pain. First, we present the evidence base and summarize recommendations from clinical practice guidelines regarding non-pharmacologic treatments. Second, we characterize current use patterns for non-pharmacologic treatments and identify potential barriers to their delivery. Addressing these barriers will require coordinated efforts from multiple stakeholders to prioritize evidence-based non-pharmacologic treatment approaches over low value care for back and neck pain. These stakeholders include patients, health care providers, health care organizations, administrators, payers, policymakers and researchers.