Medication use for low back pain in primary care

Description and initial validation of a novel measure of pain intensity: the Numeric Rating Scale of Underlying Pain without concurrent Analgesic use

ABSTRACT

Although many individuals with chronic pain use analgesics, the methods used in many randomized controlled trials (RCTs) do not sufficiently account for confounding by differential post-randomization analgesic use. This may lead to underestimation of average treatment effects and diminished power. We introduce (1) a new measure-the Numeric Rating Scale of Underlying Pain without concurrent Analgesic use (NRS-UP (A) )-which can shift the estimand of interest in an RCT to target effects of a treatment on pain intensity in the hypothetical situation where analgesic use was not occurring at the time of outcome assessment; and (2) a new pain construct-an individuals' perceived effect of analgesic use on pain intensity (E A ). The NRS-UP (A) may be used as a secondary outcome in RCTs of point treatments or nonpharmacologic treatments. Among 662 adults with back pain in primary care, participants' mean value of the NRS-UP (A) among those using analgesics was 1.2 NRS points higher than their value on the conventional pain intensity NRS, reflecting a mean E A value of -1.2 NRS points and a perceived beneficial effect of analgesics. More negative values of E A (ie, greater perceived benefit) were associated with a greater number of analgesics used but not with pain intensity, analgesic type, or opioid dose. The NRS-UP (A) and E A were significantly associated with future analgesic use 6 months later, but the conventional pain NRS was not. Future research is needed to determine whether the NRS-UP (A), used as a secondary outcome may allow pain RCTs to target alternative estimands with clinical relevance.

Improving Power and Accuracy in Randomized Controlled Trials of Pain Treatments by Accounting for Concurrent Analgesic Use

The 0 to 10 numeric rating scale of pain intensity is a standard outcome in randomized controlled trials (RCTs) of pain treatments. For individuals taking analgesics, there may be a disparity between "observed" pain intensity (pain intensity with concurrent analgesic use) and pain intensity without concurrent analgesic use (what the numeric rating scale would be had analgesics not been taken). Using a contemporary causal inference framework, we compare analytic methods that can potentially account for concurrent analgesic use, first in statistical simulations, and second in analyses of real (non-simulated) data from an RCT of lumbar epidural steroid injections. The default analytic method was ignoring analgesic use, which is the most common approach in pain RCTs. Compared to ignoring analgesic use and other analytic methods, simulations showed that a quantitative pain and analgesia composite outcome based on adding 1.5 points to pain intensity for those who were taking an analgesic (the QPAC1.5) optimized power and minimized bias. Analyses of real RCT data supported the results of the simulations, showing greater power with analysis of the QPAC1.5 as compared to ignoring analgesic use and most other methods examined. We propose alternative methods that should be considered in the analysis of pain RCTs. PERSPECTIVE: This article presents the conceptual framework behind a new quantitative pain and analgesia composite outcome, the QPAC1.5, and the results of statistical simulations and analyses of trial data supporting improvements in power and bias using the QPAC1.5. Methods of this type should be considered in the analysis of pain RCTs.

Assessment and nonsurgical management of low back pain: a narrative review

Low back pain (LBP) is a common condition that affects people of all ages and income levels worldwide. The etiology of LBP may be mechanical, neuropathic, systemic, referred visceral, or secondary to other causes. Despite numerous studies, the diagnosis and management of LBP remain challenging due to the complex biomechanics of the spine and confounding factors, such as trivial degenerative imaging findings irrelevant to symptoms and psychological and emotional factors. However, it is imperative to identify the crucial signs ("red flags") indicating a serious underlying condition. While many recent guidelines emphasize non-pharmacologic management approaches, such as education, reassurance, and physical and psychological care, as the first option, LBP patients in many countries, including South Korea, are prescribed medications. Multidisciplinary rehabilitation combined with prudent use of medications is required in patients unresponsive to first-line therapy. The development of practical guidelines apposite for South Korea is needed with multidisciplinary discussion.

Evaluating Different Measures of Low Back Pain Among U.S. Manual Materials Handling Workers: Comparisons of Demographic, Psychosocial, and Job Physical Exposure

OBJECTIVE

To examine differences in demographic, psychosocial, and job physical exposure risk factors between multiple low back pain (LBP) outcomes in a prospective cohort of industrial workers.

BACKGROUND

LBP remains a leading cause of lost industrial productivity. Different case definitions involving pain (general LBP), medication use (M-LBP), seeking healthcare (H-LBP), and lost time (L-LBP) are often used to study LBP outcomes. However, the relationship between these outcomes remains unclear.

METHOD

Demographic, health status, psychosocial, and job physical exposure risk factors were quantified for 635 incident-eligible industrial workers. Incident cases of LBP outcomes and pain symptoms were quantified and compared across the four outcomes.

RESULTS

Differences in age, gender, medical history, and LBP history were found between the four outcomes. Most incident-eligible workers (67%) suffered an LBP outcome during follow-up. Cases decreased from 420 for LBP (25.4 cases/100 person-years) to 303 for M-LBP (22.0 cases/100 person-years), to 151 for H-LBP (15.6 cases/100 person-years), and finally to 56 for L-LBP (8.7 cases/100 person-years). Conversely, pain intensity and duration increased from LBP to H-LBP. However, pain duration was relatively lower for L-LBP than for H-LBP.

CONCLUSION

Patterns of cases, pain intensity, and pain duration suggest the influence of the four outcomes. However, few differences in apparent risk factors were observed between the outcomes. Further research is needed to establish consistent case definitions.

APPLICATION

Knowledge of patterns between different LBP outcomes can improve interpretation of research and guide future research and intervention studies in industry.

NSAIDs in sciatica (NIS): study protocol for an investigator-initiated multicentre, randomized placebo-controlled trial of naproxen in patients with sciatica

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely used to treat sciatica, despite insufficient evidence from placebo-controlled trials. NSAIDs may cause serious side effects; hence, there is a strong need to clarify their potential beneficial effects in patients with sciatica.

METHODS

This is a multicentre, randomized, placebo-controlled, parallel-group superiority trial. Participants will be recruited among sciatica patients referred to outpatient clinics at hospitals in Norway who have radiating pain below the knee with a severity score of ≥ 4 on a 0-10 numeric rating scale and clinical signs of nerve root or spinal nerve involvement. The intervention consists of oral naproxen 500 mg or placebo twice daily for 10 days. Participants will report the outcomes and adverse events daily using an electronic case report form. The primary endpoint is change in leg pain intensity from baseline to day 10 based on daily observations. The secondary outcomes are back pain intensity, disability, sciatica symptom severity, rescue medication (paracetamol) consumption, opioid use, ability to work or study, 30% and 50% improvement in leg pain, and global perceived change of sciatica/back problem. The outcomes will be analysed using mixed effects models for repeated measurements. The total duration of follow-up is 12 (± 2) days.

DISCUSSION

This trial aims to evaluate the benefits of naproxen, a non-selective NSAID, in patients with sciatica. No important differences in efficacy have been demonstrated between different NSAIDs in the management of musculoskeletal disorders; hence, the results of this trial will likely be applicable to other NSAIDs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03347929 . Registered on November 20, 2017.

Primary care providers' experiences treating low back pain

CONTEXT

Our original work addresses the biological sex impact on low back pain (LBP) management and prognosis in primary care settings. To our knowledge, our study is the first in the United States to evaluate the differences in clinicians' approaches to LBP in the ambulatory setting specifically based on patient gender. Our findings suggest that there is a knowledge gap among primary care providers (PCPs) toward the potential impact of biological sex on LBP and a bias toward gender roles when counseling patients for home chores or occupational tasks. Further evaluation of this knowledge gap and its impact on LBP management and prognosis is recommended in US healthcare settings.

OBJECTIVES

This study aims to explore PCP experiences and practice patterns regarding LBP in females compared to males in US healthcare settings.

METHODS

We utilized a cross-sectional study design and convenience sampling. Data were collected anonymously utilizing a 27-item online survey sent periodically via email to PCPs working in Ohio. We had 58 responses for analysis; data were analyzed utilizing bivariate and multivariate analyses.

RESULTS

On average, approximately 9 out of 10 responding clinicians reported experiencing LBP. PCPs were not in agreement that LBP is different in women than men. Clinicians with a women's health, osteopathic, or sport's medicine background were more likely to agree that LBP is different in women than in men. PCPs were more likely to counsel female patients about pelvic floor exercises; however, their intake of present pelvic symptoms in LBP female patients is suboptimal. PCPs were more likely to counsel females for home chores than males, which is aligned with the perceived traditional gender roles among PCPs.

CONCLUSIONS

There may be a knowledge gap among PCPs toward the potential impact of biological sex on LBP and a bias toward gender roles when counseling patients for home chores or occupational tasks. Further investigation of this knowledge gap and counseling approaches is recommended to better bridge the gender disparity.

Low Back Pain: A Comprehensive Review on the Diagnosis, Treatment Options, and the Role of Other Contributing Factors

BACKGROUND: In recent years, low back pain (LBP) is a growing major health issue around the world and mostly addressed in primary healthcare settings. This may be due to changing work environment including the nature of long sitting work hours, especially in the booming information and technology (IT) and Business Process Outsourcing (BPO) industry. LBP is normally considered as a combination of various types of pain and its related conditions, which eventually lead to disabilities. AIM: In this article, the aim is to discuss the current and future perspectives of LBP mainly on diagnosis and therapeutic front of LBP. METHODS: A search was performed using electronic databases, which include PubMed Central and Google Scholar, using the related key words “back pain and low back pain.” All related peer reviewed published articles were included regardless of the language, region, or the publication date. RESULTS: Although the management of LBP both in terms of diagnosis as well as in the therapeutic options has witnessed considerable progress but challenges are still exist not only within countries but also in the regions and continents among various medical professionals. However, in the past few years, a huge array of coordinated but randomized multi-center clinical studies were performed and various detailed insight investigations have been done, and substantial clinical guidelines have become available. Hence, a new view on evidence-based management approach for LBP has significantly improved recently and discussed here. CONCLUSION: Based on the available evidence and literature, this comprehensive review discusses the present and future perspectives of LBP mainly on diagnosis and therapeutic front for LBP. In addition, current intervention and prevention plans have failed to lessen the considerable burden of LBP and hence several areas which require more details, which deserves additional discussion to augment us through an understanding of this very important topic on improvements of multi tasked outcomes to benefit the affected patients.

Factors associated with care-seeking for low back pain when genetics and the familial environment are considered

BACKGROUND

Low back pain (LBP) is the leading cause of disability worldwide. Care-seekers for LBP cause substantial economic burden to governments and the healthcare system.

OBJECTIVE

To investigate lifestyle and health-related factors associated with care-seeking (including pain medication use) in individuals experiencing LBP, after controlling for important genetic and early environmental confounders through the use of a within-twin pair case-control design.

DESIGN

A secondary analysis of observational longitudinal data, derived from the Australian Twin low BACK pain (AUTBACK) study, was performed on 66 twin pairs that presented with similar symptoms of LBP at baseline but became discordant for care-seeking behaviour over one month.

METHODS

Subjective and objective assessment of pain intensity, disability, depression, sleep quality, physical activity and body mass index were performed. Data was analysed using stepwise conditional logistic regression in two stages: within-pair case-control for monozygotic and dizygotic twins together; and within-pair case-control analysis of monozygotic twins only. Results were expressed as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Higher LBP intensity (OR 2.9; 95% CI 1.3-6.8) and poorer sleep quality (OR 10.9; 95% CI 1.5-77.7) were the main factors that increased the likelihood of care-seeking for LBP. These associations remained significant and increased in magnitude after adjusting for genetic confounding.

CONCLUSIONS

Individuals with higher LBP intensity and worse sleep quality are more likely to seek care for LBP, and this relationship is likely to be causal after adjustment of familial and genetic confounding.

How do contraindications to non-opioid analgesics and opioids affect the likelihood that patients with back pain diagnoses in the primary care setting receive an opioid prescription? An observational cross-sectional study

BACKGROUND

Given the risks of opioids, clinicians are under growing pressure to treat pain with non-opioid medications. Yet non-opioid analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) have their own risks: patients with kidney disease or gastrointestinal diseases can experience serious adverse events. We examined the likelihood that patients with back pain diagnoses and contraindications to NSAIDs and opioids received an opioid prescription in primary care.

METHODS

We identified office visits for back pain from 2012 to 2017 and sampled the first office visit per patient per year (N = 24,543 visits). We created indicators reflecting contraindications for NSAIDs (kidney, liver, cardiovascular/cerebrovascular, and gastrointestinal diseases; concurrent or chronic use of anticoagulants/antiplatelets, chronic corticosteroid use) and opioids (depression, anxiety, substance use (SUD) and bipolar disorders, and concurrent benzodiazepines) and estimated four logistic regression models, with the one model including all patient visits and models 2-4 stratifying for previous opioid use. We estimated the population attributable risk for each contraindication.

RESULTS

In our model with all patients-visits, patients received an opioid prescription at 4% of visits. The predicted probability (PP) of receiving an opioid was 4% without kidney disease vs. 7% with kidney disease; marginal effect (ME): 3%; 95%CI: 1-4%). For chronic or concurrent anticoagulant/antiplatelet prescriptions, the PPs were 4% vs. 6% (ME: 2%; 95%CI: 1-3%). For concurrent benzodiazepines, the PPs were 4% vs. 11% (ME: 7%, 95%CI: 5-9%) and for SUD, the PPs were 4% vs. 5% (ME: 1%, 95%CI: 0-3%). For the model including patients with previous long-term opioid use, the PPs for concurrent benzodiazepines were 25% vs. 24% (ME: -1%; 95%CI: - 18-16%). The population attributable risk (PAR) for NSAID and opioid contraindications was small. For kidney disease, the PAR was 0.16% (95%CI: 0.08-0.23%), 0.44% (95%CI: 0.30-0.58%) for anticoagulants and antiplatelets, 0.13% for substance use (95%CI: 0.03-0.22%) and 0.20% for concurrent benzodiazepine use (95%CI: 0.13-0.26%).

CONCLUSIONS

Patients with diagnoses of kidney disease and concurrent use of anticoagulants/antiplatelet medications had a higher probability of receiving an opioid prescription at a primary care visit for low back pain, but these conditions do not explain a large proportion of the opioid prescriptions.

Cell-based strategies for IVD repair: clinical progress and translational obstacles

Intervertebral disc (IVD) degeneration is a major cause of low back pain, a prevalent and chronic condition that has a striking effect on quality of life. Currently, no approved pharmacological interventions or therapies are available that prevent the progressive destruction of the IVD; however, regenerative strategies are emerging that aim to modify the disease. Progress has been made in defining promising new treatments for disc disease, but considerable challenges remain along the entire translational spectrum, from understanding disease mechanism to useful interpretation of clinical trials, which make it difficult to achieve a unified understanding. These challenges include: an incomplete appreciation of the mechanisms of disc degeneration; a lack of standardized approaches in preclinical testing; in the context of cell therapy, a distinct lack of cohesion regarding the cell types being tested, the tissue source, expansion conditions and dose; the absence of guidelines regarding disease classification and patient stratification for clinical trial inclusion; and an incomplete understanding of the mechanisms underpinning therapeutic responses to cell delivery. This Review discusses current approaches to disc regeneration, with a particular focus on cell-based therapeutic strategies, including ongoing challenges, and attempts to provide a framework to interpret current data and guide future investigational studies.

Site-Directed Differentiation of Human Adipose-Derived Mesenchymal Stem Cells to Nucleus Pulposus Cells Using an Injectable Hydroxyl-Functional Diblock Copolymer Worm Gel

Adipose-derived mesenchymal stem cells (ASCs) have been identified for their promising therapeutic potential to regenerate and repopulate the degenerate intervertebral disk (IVD), which is a major cause of lower back pain. The optimal cell delivery system remains elusive but encapsulation of cells within scaffolds is likely to offer a decisive advantage over the delivery of cells in solution by ensuring successful retention within the tissue. Herein, we evaluate the use of a fully synthetic, thermoresponsive poly(glycerol monomethacrylate)-poly(2-hydroxypropyl methacrylate) (PGMA-PHPMA) diblock copolymer worm gel that mimics the structure of hydrophilic glycosaminoglycans. The objective was to use this gel to direct differentiation of human ASCs toward a nucleus pulposus (NP) phenotype, with or without the addition of discogenic growth factors TGFβ or GDF6. Accordingly, human ASCs were incorporated into a cold, free-flowing aqueous dispersion of the diblock copolymer, gelation induced by warming to 37 °C and cell culture was conducted for 14 days with or without such growth factors to assess the expression of characteristic NP markers compared to those produced when using collagen gels. In principle, the shear-thinning nature of the biocompatible worm gel enables encapsulated human ASCs to be injected into the IVD using a 21G needle. Moreover, we find significantly higher gene expression levels of ACAN, SOX-9, KRT8, and KR18 for ASCs encapsulated within worm gels compared to collagen scaffolds, regardless of the growth factors employed. In summary, such wholly synthetic worm gels offer considerable potential as an injectable cell delivery scaffold for the treatment of degenerate disk disease by promoting the transition of ASCs toward an NP-phenotype.

Transcutaneous electrical nerve stimulation and heat to reduce pain in a chronic low back pain population: a randomized controlled clinical trial

BACKGROUND

Low back pain is the leading cause of disability worldwide. The therapeutic management of patients with chronic LBP is challenging.

OBJECTIVES

The aim of this study is to evaluate the effects of heat and transcutaneous electrical nerve stimulation combined on pain relief in participants with chronic low back pain.

METHODS

Fifty participants with chronic (≥3 months) low back pain were randomly assigned to two groups: HeatTens (n=25) and control group (n=25). Primary outcome was pain. Secondary outcomes were pressure pain thresholds, temporal summation, conditioned pain modulation, fear-avoidance and beliefs questionnaire, central sensitization inventory, quality of life, and medication use. The control group received no treatment and continued usual care. After four weeks of treatment, all measurements were repeated.

RESULTS

Fifty individuals participated in this study. Significant higher pressure pain threshold measures after both 30min and 4 weeks for the lower back region and the second plantar toe were found only in the experimental group.

CONCLUSION

The combination of heat and transcutaneous electrical nerve stimulation does not reduce pain scores in patients with chronic low back pain. Pressure pain threshold values significantly improved, showing beneficial effects of the experimental treatment. ClinicalTrials.gov: NCT03643731 (https://clinicaltrials.gov/ct2/show/NCT03643731).

Factors associated with early opioid dispensing compared with NSAID and muscle relaxant dispensing after a work-related low back injury

OBJECTIVES

The objective of this historical cohort study was to determine the claimant and prescriber factors associated with receiving opioids at first postinjury dispense compared with non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) in a sample of workers' compensation claimants with low back pain (LBP) claims between 1998 and 2009 in British Columbia, Canada.

METHODS

Administrative workers' compensation, prescription and healthcare data were linked. The association between claimant factors (sociodemographics, occupation, diagnosis, comorbidities, pre-injury prescriptions and healthcare) and prescriber factors (sex, birth year, specialty) with drug class(es) at first dispense (opioids vs NSAIDs/SMRs) was examined with multilevel multinomial logistic regression.

RESULTS

Increasing days supplied with opioids in the previous year was associated with increased odds of receiving opioids only (1-14 days OR 1.62, 95% CI 1.51 to 1.75; ≥15 days OR 5.12, 95% CI 4.65 to 5.64) and opioids with NSAIDs/SMRs (1-14 days OR 1.49, 95% CI 1.39 to 1.60; ≥15 days OR 2.82, 95% CI 2.56 to 3.12). Other significant claimant factors included: pre-injury dispenses for NSAIDs, SMRs, antidepressants, anticonvulsants and sedative-hypnotics/anxiolytics; International Statistical Classification of Diseases and Related Health Problems, 9th Revision diagnosis; various pre-existing comorbidities; prior physician visits and hospitalisations; and year of injury, age, sex, health authority and occupation. Prescribers accounted for 25%-36% of the variability in the drug class(es) received, but prescriber sex, specialty and birth year did not explain observed between-prescriber variation.

CONCLUSIONS

During this period in the opioid crisis, early postinjury dispensing was multifactorial, with several claimant factors associated with receiving opioids at first prescription. Prescriber variation in drug class choice appears particularly important, but was not explained by basic prescriber characteristics.

Steroids and L-Lysine Aescinate for Acute Radiculopathy Due to a Herniated Lumbar Disk

Background and objectives. The efficacy of commonly prescribed analgesic and adjuvant drugs for the management of patients with radiculopathy has not been well established. Oral steroids are commonly used to treat sciatica or radiculopathy due to a herniated disk but the effect remains controversial. L-lysine aescinate showed superiority over placebo or baseline therapy with NSAIDs alone in treating sciatica, but have not been evaluated in an appropriately powered clinical trial. Materials and Methods. Randomized, double-blind clinical trial conducted in two health centers in collaboration with Uzhhorod Natioanl University in Ukraine. Adults (N = 90) with acute radicular pain and a herniated disk confirmed by MRI were eligible. Participants were randomly assigned to three groups (N = 30 in each) to receive a baseline therapy with lornoxicam (16 mg per day) and adjunctive 5-day course of IV dexamethasone (first group: 8 mg per day/40 mg total) or 0,1% solution of L-lysine aescinate (5 mL and 10 mL for group 2 and 3 respectively). Primary outcomes were Visual Analogue Scale changes and the straight leg raise angle at 15th and 30th day. Results. The level of pain improvement at 15th days after initiation of therapy with dexamethasone or solution of L-lysine aescinate at doses of 5 or 10 mL was not significantly different. The lowest levels of pain were achieved in patients who received the L-lysine aescinate 10 mL, but the range of decrease in pain was slightly greater in the group administered dexamethasone. Conclusions. Among patients with acute radiculopathy due to a herniated lumbar disk a short course of IV dexamethasone or L-lysine aescinate resulted in pain improvement at 15th and 30th day. Dexamethasone may be preferable if a longer-term analgesic effect is needed. Taking into account side effects of dexamethasone, a solution of L-lysine aescinate can be used to relieve pain symptoms.

Botulinum toxins for the prevention of migraine in adults

BACKGROUND

Migraine occurs in around 15% of adults and is ranked as the seventh most disabling disease amongst all diseases globally. Despite the available treatments many people suffer prolonged and frequent attacks which have a major impact on their quality of life. Chronic migraine is defined as 15 or more days of headache per month, at least eight of those days being migraine. People with episodic migraine have fewer than 15 headache days per month. Botulinum toxin type A has been licensed in some countries for chronic migraine treatment, due to the results of just two trials.

OBJECTIVES

To assess the effects of botulinum toxins versus placebo or active treatment for the prevention or reduction in frequency of chronic or episodic migraine in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE & MEDLINE in Process, Embase, ClinicalTrials.gov and World Health Organization International Clinical Trials Registry (to December 2017). We examined reference lists and carried out citation searches on key publications. We sent correspondence to major manufacturers of botulinum toxin.

SELECTION CRITERIA

Randomised, double-blind, controlled trials of botulinum toxin (any sero-type) injections into the head and neck for prophylaxis of chronic or episodic migraine in adults. Eligible comparators were placebo, alternative prophylactic agent or different dose of botulinum toxin.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data. For continuous outcomes we used mean change data when available. For dichotomous data we calculated risk ratios (RRs). We used data from the 12-week post-treatment follow-up time point. We assessed the evidence using GRADE and created two 'Summary of findings' tables.

MAIN RESULTS

Description of trialsWe found 90 articles describing 28 trials (4190 participants), which were eligible for inclusion. The longest treatment duration was three rounds of injections with three months between treatments, so we could not analyse long-term effects. For the primary analyses, we pooled data from both chronic and episodic participant populations. Where possible, we also separated data into chronic migraine, episodic migraine and 'mixed group' classification subgroups. Most trials (21 out of 28) were small (fewer than 50 participants per trial arm). The risk of bias for included trials was low or unclear across most domains, with some trials reporting a high risk of bias for incomplete outcome data and selective outcome reporting.Botulinum toxin versus placeboTwenty-three trials compared botulinum toxin with placebo. Botulinum toxin may reduce the number of migraine days per month in the chronic migraine population by 3.1 days (95% confidence interval (CI) -4.7 to -1.4, 4 trials, 1497 participants, low-quality evidence). This was reduced to -2 days (95% CI -2.8 to -1.1, 2 trials, 1384 participants; moderate-quality evidence) when we removed small trials.A single trial of people with episodic migraine (N = 418) showed no difference between groups for this outcome measure (P = 0.49).In the chronic migraine population, botulinum toxin reduces the number of headache days per month by 1.9 days (95% CI -2.7 to -1.0, 2 trials, 1384 participants, high-quality evidence). We did not find evidence of a difference in the number of migraine attacks for both chronic and episodic migraine participants (6 trials, N = 2004, P = 0.30, low-quality evidence). For the population of both chronic and episodic migraine participants a reduction in severity of migraine rated during clinical visits, on a 10 cm visual analogue scale (VAS) of 3.3 cm (95% CI -4.2 to -2.5, very low-quality evidence) in favour of botulinum toxin treatment came from four small trials (N = 209); better reporting of this outcome measure from the additional eight trials that recorded it may have improved our confidence in the pooled estimate. Global assessment and quality-of-life measures were poorly reported and it was not possible to carry out statistical analysis of these outcome measures. Analysis of adverse events showed an increase in the risk ratio with treatment with botulinum toxin over placebo 30% (RR 1.28, 95% CI 1.12 to 1.47, moderate-quality evidence). For every 100 participants 60 experienced an adverse event in the botulinum toxin group compared with 47 in the placebo group.Botulinum toxin versus other prophylactic agentThree trials studied comparisons with alternative oral prophylactic medications. Meta-analyses were not possible for number of migraine days, number of headache days or number of migraine attacks due to insufficient data, but individually trials reported no differences between groups for a variety of efficacy measures in the population of both chronic and episodic migraine participants. The global impression of disease measured using Migraine Disability Assessment (MIDAS) scores were reported from two trials that showed no difference between groups. Compared with oral treatments, botulinum toxin showed no between-group difference in the risk of adverse events (2 trials, N = 114, very low-quality evidence). The relative risk reduction (RRR) for withdrawing from botulinum toxin due to adverse events compared with the alternative prophylactic agent was 72% (P = 0.02, 2 trials, N = 119).Dosing trialsThere were insufficient data available for the comparison of different doses.Quality of the evidenceThe quality of the evidence assessed using GRADE methods was varied but mostly very low; the quality of the evidence for the placebo and active control comparisons was low and very low, respectively for the primary outcome measure. Small trial size, high risk of bias and unexplained heterogeneity were common reasons for downgrading the quality of the evidence.

AUTHORS' CONCLUSIONS

In chronic migraine, botulinum toxin type A may reduce the number of migraine days per month by 2 days compared with placebo treatment. Non-serious adverse events were probably experienced by 60/100 participants in the treated group compared with 47/100 in the placebo group. For people with episodic migraine, we remain uncertain whether or not this treatment is effective because the quality of this limited evidence is very low. Better reporting of outcome measures in published trials would provide a more complete evidence base on which to draw conclusions.

Efficacy of Bee Venom Acupuncture for Chronic Low Back Pain: A Randomized, Double-Blinded, Sham-Controlled Trial

Bee venom acupuncture (BVA) is an effective treatment for chronic low back pain (CLBP) through the pharmacological effects of bee venom and the simultaneous stimulation of acupoints. However, evidence of its efficacy and safety in humans remains unclear. Using a double-blind, randomized study, 54 patients with non-specific CLBP were assigned to the BVA and sham groups. All participants underwent six sessions of real or sham BVA for 3 weeks, in addition to administration of 180 mg of loxonin per day. The primary outcome, that is, “bothersomeness” derived from back pain, was assessed using the visual analog scale. Secondary outcomes included pain intensity, dysfunction related to back pain (Oswestry Disability Index), quality of life (EuroQol 5-Dimension), and depressive mood (Beck’s depression inventory). Outcomes were evaluated every week during the treatment period and followed up at weeks 4, 8, and 12. After 3 weeks of the treatment, significant improvements were observed in the bothersomeness, pain intensity, and functional status in the BVA group compared with the sham group. Although minimal adverse events were observed in both groups, subsequent recovery was achieved without treatment. Consequently, our results suggest that it can be used along with conventional pharmacological therapies for the treatment of CLBP.

Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis

BACKGROUND

While it is now clear that paracetamol is ineffective for spinal pain, there is not consensus on the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for this condition. We performed a systematic review with meta-analysis to determine the efficacy and safety of NSAIDs for spinal pain.

METHODS

We searched MEDLINE, EMBASE, CINAHL, CENTRAL and LILACS for randomised controlled trials comparing the efficacy and safety of NSAIDs with placebo for spinal pain. Reviewers extracted data, assessed risk of bias and evaluated the quality of evidence using the Grade of Recommendations Assessment, Development and Evaluation approach. A between-group difference of 10 points (on a 0-100 scale) was used for pain and disability as the smallest worthwhile effect, as well as to calculate numbers needed to treat. Random-effects models were used to calculate mean differences or risk ratios with 95% CIs.

RESULTS

We included 35 randomised placebo-controlled trials. NSAIDs reduced pain and disability, but provided clinically unimportant effects over placebo. Six participants (95% CI 4 to 10) needed to be treated with NSAIDs, rather than placebo, for one additional participant to achieve clinically important pain reduction. When looking at different types of spinal pain, outcomes or time points, in only 3 of the 14 analyses were the pooled treatment effects marginally above our threshold for clinical importance. NSAIDs increased the risk of gastrointestinal reactions by 2.5 times (95% CI 1.2 to 5.2), although the median duration of included trials was 7 days.

CONCLUSIONS

NSAIDs are effective for spinal pain, but the magnitude of the difference in outcomes between the intervention and placebo groups is not clinically important. At present, there are no simple analgesics that provide clinically important effects for spinal pain over placebo. There is an urgent need to develop new drug therapies for this condition.

Non-steroidal anti-inflammatory drugs for sciatica

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most frequently prescribed drugs for the treatment of sciatica. A previous Cochrane review on the efficacy of NSAIDs summarised findings for acute and chronic low back pain (LBP) and sciatica. This is an update of the original review (2008) focusing on people suffering from sciatica.

OBJECTIVES

To determine the efficacy of NSAIDs in pain reduction, overall improvement, and reported side effects in people with sciatica.

SEARCH METHODS

We performed electronic searches up to 24 June 2015 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PubMed, and two trials registers. We searched reference lists of included studies and relevant reviews on the topics for additional trials.

SELECTION CRITERIA

We included randomised controlled trials (double-blind, single-blind, and open-label) that assessed the efficacy of NSAIDs in sciatica. We included all trials that compared NSAIDs to placebo, to other NSAIDs, or to other medication. Additional interventions were allowed if there was a clear contrast for the treatment with NSAIDs in the trial.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the risk of bias and extracted the data. Where feasible we calculated pooled results using Review Manager 5.3. We reported pain relief outcomes using mean difference (MD) with 95% confidence intervals (95% CI). We used risk ratios (RR) with 95% CI to report global improvement of treatment, adverse effects, and additional medication. We performed a meta-analysis if possible. We assessed level of evidence using the GRADE approach. We used standard methodological procedures recommended by The Cochrane Collaboration.

MAIN RESULTS

We included 10 trials reported in 9 publications (N = 1651). Only one trial out of 10 was assessed at low risk of bias. Five trials used the currently recommended daily dose for the drug, and two trials used lower daily doses available over the counter. Three trials investigated NSAIDs no longer approved for human use. The follow-up duration was short in all studies but one.Three trials (n = 918) compared the effects of NSAIDs to those of placebo on pain reduction. The pooled mean difference showed comparable pain reduction (visual analogue scale, 0 to 100) in the NSAIDs and placebo groups (MD -4.56, 95% CI -11.11 to 1.99). Heterogeneity was high (I2 = 82%), and the quality of the evidence was very low. When we excluded one trial with a short follow-up of eight hours, the mean difference further decreased (MD -0.09, 95% CI -9.89 to 9.71). Three trials (n = 753) compared NSAIDs to placebo regarding global improvement. We found low-quality evidence that NSAIDs are more effective than placebo with a risk ratio of 1.14 (95% CI 1.03 to 1.27). One trial (n = 214) studied the effect of NSAIDs on disability, finding very low-quality evidence that NSAIDs are no more effective than placebo on disability. Four trials (n = 967) comparing NSAIDs to placebo reported adverse effects, with low-quality evidence that the risk for adverse effects is higher in the NSAID group than in the placebo group (RR 1.40, 95% CI 1.02 to 1.93). The adverse effects reported in this review are consistent with those previously reported in the literature.

AUTHORS' CONCLUSIONS

This updated systematic review including 10 trials evaluating the efficacy of NSAIDs versus placebo or other drugs in people with sciatica reports low- to very low-level evidence using the GRADE criteria. The efficacy of NSAIDs for pain reduction was not significant. NSAIDs showed a better global improvement compared to placebo. These findings must be interpreted with caution, as the level of evidence according to the GRADE classification was very low for the outcome pain reduction and low for global improvement due to small study samples, inconsistent results, imprecision, and a high risk of bias in the included trials. While the trials included in the analysis were not powered to detect potential rare side effects, we found an increased risk for side effects in the short-term NSAIDs use. As NSAIDs are frequently prescribed, the risk-benefit ratio of prescribing the drug needs to be considered.

The relationship between overactivity and opioid use in chronic pain: a 5-day observational study

With increasing concerns about the potential harm of long-term opioid therapy, there is a need for the development and implementation of alternative treatment strategies for patients with chronic pain who have been using opioids for a prolonged period of time. Based on the findings from a recent qualitative investigation that suggested there may be a bidirectional association between opioid reliance and habitual overactivity behaviour (activity engagement that significantly exacerbates pain), this study was designed to quantitatively investigate the association between opioid use and habitual overactivity over a 5-day period in a group of chronic pain patients. Participants provided a list of their prescribed pain medication, completed a self-report measure of habitual overactivity, and then commenced 5 days of data collection. Data collection required participants to wear an activity monitor and to complete a diary that detailed their daily activities and the time at which they took medication. Individuals reporting higher levels of habitual overactivity were more likely to be prescribed opioids. In addition, higher levels of habitual overactivity were associated with more frequent pro re nata ("as needed") opioid use over the 5 days, and with a discrepancy between the prescribed and actual oral morphine-equivalent daily dose, where more medication was taken than was prescribed. There was no predominant context for pro re nata use. The results of this study support the idea that habitual overactivity behaviour may play a role in the development of reliance on opioid medication and that such an association may provide a potential treatment target for opioid therapy rationalisation.

Nanofibers used for the delivery of analgesics

Nanofibers are extremely advantageous for drug delivery because of their high surface area-to-volume ratios, high porosities and 3D open porous structures. Local delivery of analgesics by using nanofibers allows site-specificity and requires a lower overall drug dosage with lower adverse side effects. Different analgesics have been loaded onto various nanofibers, including those that are natural, synthetic and copolymer, for various medical applications. Analgesics can also be singly or coaxially loaded onto nanofibers to enhance clinical applications. In particular, analgesic-eluting nanofibers provide additional benefits to preventing wound adhesion and scar formation. This paper reviews current research and breakthrough discoveries on the innovative application of analgesic-loaded nanofibers that will alter the clinical therapy of pain.

Efficacy and Safety of Acupuncture for Acute Low Back Pain in Emergency Department: A Pilot Cohort Study

Introduction. Low back pain (LBP) is one of the most common complaints in the emergency department (ED). There are several research articles providing evidence for acupuncture for treating chronic LBP but few about treating acute LBP. This study assessed the efficacy and safety of acupuncture for the treatment of acute LBP in the ED. Materials and methods. A clinical pilot cohort study was conducted. 60 participants, recruited in the ED, were divided into experimental and control groups with 1 dropout during the study. Life-threatening conditions or severe neurological defects were excluded. The experimental group (n = 45) received a series of fixed points of acupuncture. The control group (n = 14) received sham acupuncture by pasting seed-patches near acupoints. Back pain was measured using the visual analog scale (VAS) at three time points: baseline and immediately after and 3 days after intervention as the primary outcome. The secondary outcomes were heart rate variability (HRV) and adverse events. Results. The VAS demonstrated a significant decrease (P value <0.001) for the experimental group after 15 minutes of acupuncture. The variation in HRV showed no significant difference in either group. No adverse event was reported. Conclusion. Acupuncture might provide immediate effect in reducing the pain of acute LBP safely.

What types of degenerative lumbar pathologies respond to nerve root injection? A retrospective review of six hundred and forty one cases

PURPOSE

Peri-radicular injection is a widely used procedure for treating lumbar radicular pain, but it remains unclear what types of lumbar pathologies respond well to this treatment. We aimed to investigate the efficacy of peri-radicular injection for degenerative lumbar disorders and to determine what types of pathologies respond well to this treatment.

METHODS

We reviewed the records of 641 consecutive patients who underwent peri-radicular injection for degenerative lumbar pathologies with mean follow-up of 23.4 months. The pathologies included herniated disc in 286 patients, spinal stenosis in 141, degenerative spondylolisthesis in 136, failed back surgery in 24, isthmic spondylolisthesis in 22, degenerative scoliosis in 18, and foraminal stenosis in 14. Outcome measure was whether or not surgery is avoided by using peri-radicular injection. The rate of obviating surgery was determined in each pathology.

RESULTS

Peri-radicular injection obviated surgeries in 331 patients (51.7%). There were no complications related to the procedure, including neurological deterioration, infection, and haematoma. The rate of obviating surgery was 42.0% in disc herniation, 52.9% in degenerative spondylolisthesis, 67.4% in spinal stenosis, 54.5% in isthmic spondylolisthesis, 57.1% in foraminal stenosis, 61.1% in degenerative scoliosis and 54.1% in failed back surgery. Poor outcomes were observed in herniated disc with spinal stenosis (17.9% success), foraminal disc herniation (33.3%), recurrent disc herniation (18.2%) and failed back surgery with instability (33.3%).

CONCLUSIONS

This study demonstrated that 51.7% of patients with degenerative lumbar pathologies were successfully treated by peri-radicular injection. Efficacy was limited in cases of herniated disc with spinal stenosis, foraminal disc herniation, recurrent disc herniation and failed back surgery with instability.

Delivery systems for the treatment of degenerated intervertebral discs

The intervertebral disc (IVD) is the most avascular and acellular tissue in the body and therefore prone to degeneration. During IVD degeneration, the balance between anabolic and catabolic processes in the disc is deregulated, amongst others leading to alteration of extracellular matrix production, abnormal enzyme activities and production of pro-inflammatory substances like cytokines. The established treatment strategy for IVD degeneration consists of physiotherapy, pain medication by drug therapy and if necessary surgery. This approach, however, has shown limited success. Alternative strategies to increase and prolong the effects of bioactive agents and to reverse the process of IVD degeneration include the use of delivery systems for drugs, proteins, cells and genes. In view of the specific anatomy and physiology of the IVD and depending on the strategy of the therapy, different delivery systems have been developed which are reviewed in this article.

Analgesic use in older adults with back pain: the BACE study

BACKGROUND

Older patients with back pain are more likely to visit their general practitioner (GP) and are more likely to be prescribed analgesics.

OBJECTIVE

To assess analgesic use in older adults with back pain in general practice.

METHODS

The BACE study in the Netherlands is a prospective cohort study. Patients (aged >55 years) with back complaints were recruited when consulting their GP or shortly thereafter. Measurements took place at baseline and at 3- and 6-month follow-up. For medication use, patients were asked if they had used any medication for their back pain in the previous 3 months and, if so, to specify the medication name, dosage used, frequency of usage, and whether the medication was prescribed or purchased over the counter.

RESULTS

Of the 1,402 patients who were approached to enter the study, 675 were included. Of these patients, 484 (72%) reported medication use at baseline. Nonsteroidal anti-inflammatory drugs (NSAIDs) (57%) were more often used than paracetamol (49%). Paracetamol was mostly obtained over the counter (69%), and NSAIDs were mostly obtained by prescription (85%). At baseline, patients with severe pain (numerical rating scale score ≥7) used more paracetamol, opioids, and muscle relaxants. Patients with chronic pain (back pain >3 months) used more paracetamol, while patients with a shorter duration of pain used more NSAIDs. During follow-up there was an overall decline in medication use; however, at 3- and 6-month follow-up, 36% and 30% of the patients, respectively, still used analgesics.

CONCLUSIONS

In these older adults consulting their GP with back pain, 72% used analgesics at baseline. Despite a decrease in medication use during follow-up, at 3 and 6 months a considerable proportion still used analgesics.

Anxiolytic medication as an adjunct to morphine analgesia for acute low back pain management in the emergency department: a prospective randomized trial

STUDY DESIGN

Prospective, single-blinded, and randomized clinical trial.

OBJECTIVE

This study evaluates the added benefit of promethazine administration as an anxiolytic adjunct to morphine analgesia in reducing acute low back pain (LBP) compared with morphine alone.

SUMMARY OF BACKGROUND DATA

Acute LBP is one of the most common reasons for emergency department (ED) visits. The optimal analgesic treatment for acute LBP remains controversial. Anxiety relief has been shown to improve pain management in the ED setting. We hypothesized that administration of the antihistamine promethazine as an anxiolytic adjunct to morphine analgesia will improve LBP management compared with morphine alone.

METHODS

Fifty-nine adults, who were treated in our ED for severe acute LBP (visual analogue scale ≥ 70 mm), were randomly enrolled in the study. Thirty patients received slow infusion of intravenous (IV) morphine 0.1 mg/kg in normal saline and 29 patients received an analgesic regimen of IV morphine 0.1 mg/kg with promethazine 25 mg administered similarly. Pain and anxiety levels were subjectively assessed by the patients on a 100-mm visual analogue scale before and after treatment. Adverse event related to analgesia were recorded in real time.

RESULTS

After analgesia administration patients' pain rating decreased by 43 mm in the morphine group and by 39 mm in the morphine/promethazine group (P = 0.26). Similarly, patients' anxiety decreased by 19 mm in the morphine group and by 13 mm in the morphine/promethazine group (P = 0.37). The average ED stay was 78 minutes longer in the morphine/promethazine group (P = 0.01), due to the strong sedative effect of promethazine. Patients' satisfaction and the rate of adverse events were similar in both groups.

CONCLUSION

IV administration of morphine-promethazine regimen for pain and anxiety relief associated with acute LBP showed no advantage compared with IV morphine alone and significantly lengthened the overall ED stay. Thus, we think that promethazine has no place in acute LBP management in the adult ED setting.

LEVEL OF EVIDENCE

1.

Translating evidence for low back pain management into a consumer-focussed resource for use in community pharmacies: a cluster-randomised controlled trial

Background

This cluster-randomised controlled trial determined the effectiveness of an evidence-based, pamphlet intervention in improving low back pain (LBP)-related beliefs among pharmacy consumers.

Methods

Thirty five community pharmacies were randomised to three groups: pamphlet+education intervention [n = 11]; pamphlet only intervention [n = 11]; control: usual care [n = 13]. Eligibility requirements for clusters included: community-based pharmacies and proprietor participation consent. Pharmacy consumers (N = 317) aged 18–65 years currently experiencing LBP participated. Intervention group allocation depended on the pharmacy attended. Individual-level outcomes were measured at pre-intervention (T0), at two (T1) and eight (T2) weeks post-intervention and included beliefs about LBP [Back Pain Beliefs Questionnaire (BBQ); Fear Avoidance Beliefs Questionnaire (FABQ)]. Secondary outcomes included pain severity, activity impairment and pamphlet perceived usefulness. Blinding to group allocation included primary investigators, outcome assessors and the statistician. Pharmacy staff and consumers were un-blinded.

Results

Of 35 pharmacies recruited (317 consumers), no clusters were lost to follow-up. Follow-up was available for n = 24 at 2 weeks only; n = 38 at 8 weeks only; n = 148 at both time points, with n = 148+24+38 = 210 analysed (107 excluded: no follow up). Adjusting for baseline scores demonstrated no significant differences in beliefs (2 or at 8 weeks) between pamphlet (with or without education) versus control, or between ‘pamphlet with’ versus ‘without’ education. Work-related fear (FABQ) was significantly lower in consumers receiving pamphlet (with or without education) versus control (difference −2.3, 95%CI: −4.4 to −0.2). There was no significant difference between “pamphlet with” versus “pamphlet without” groups. Consumers receiving the “pamphlet with” reported greater perceived usefulness than consumers receiving the “pamphlet without” (difference 0.9 (95%CI: 0.0 to 1.8)).

Conclusion

Community pharmacies provided a feasible primary care portal for implementing evidence-based information. The associated improvement in work-related LBP-beliefs for consumers receiving the pamphlet suggests this simple intervention may be a useful component of care.

Trial Registration

ACTR.org.au ACTRN12611000053921

Effects of concurrent low back conditions on depression outcomes

CONTEXT

Depression and low back problems are common issues in primary care.

OBJECTIVE

To compare 6-month depression outcomes (specifically, clinical results and number of outpatient visits) in patients with or without comorbid low back conditions (LBCs). The authors hypothesized that the presence of an LBC within 3 months of the diagnosis of depression would negatively affect clinical outcomes of depression treatment after 6 months.

DESIGN

Retrospective record review.

SETTING

Collaborative care management program in a large primary care practice.

PARTICIPANTS

Patients with a diagnosis of depression enrolled in collaborative care management (N=1326), including 172 with and 1154 without evidence of an LBC within 3 months of enrollment.

MAIN OUTCOME MEASURES

Clinical depression outcomes (remission and persistent depressive symptoms) and number of outpatient visits at 6 months.

RESULTS

Regression modeling for clinical remission and persistent depressive symptoms at 6 months demonstrated that LBCs were not an independent factor affecting clinical remission (P=.24) but were associated with persistent depressive symptoms (odds ratio, 1.559; 95% confidence interval, 1.065-2.282; P=.02); LBCs remained an independent predictor of outlier status for outpatient visits (≥8 clinical visits after 6 months of enrollment), with an odds ratio of 1.581 (95% confidence interval, 1.086-2.30; P=.02).

CONCLUSION

Increased odds of persistent depressive symptoms and increased number of outpatient visits were found in patients with depression and concomitant LBCs 6 months after enrollment into collaborative care management, compared with those in patients with depression and without LBCs. The data suggest that temporally related LBCs could lead to worse outcomes in primary care patients being treated for depression, encouraging closer observation and possible therapeutic changes in this cohort.

WITHDRAWN: Spinal manipulative therapy for low-back pain

BACKGROUND

Low-back pain is a costly illness for which spinal manipulative therapy is commonly recommended. Previous systematic reviews and practice guidelines have reached discordant results on the effectiveness of this therapy for low-back pain.

OBJECTIVES

To resolve the discrepancies related to the use of spinal manipulative therapy and to update previous estimates of effectiveness, by comparing spinal manipulative therapy with other therapies and then incorporating data from recent high-quality randomized, controlled trials (RCTs) into the analysis.

SEARCH METHODS

The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL were electronically searched from their respective beginning to January 2000, using the Back Group search strategy; references from previous systematic reviews were also screened.

SELECTION CRITERIA

Randomized, controlled trials (RCT) that evaluated spinal manipulative therapy for patients with low-back pain, with at least one day of follow-up, and at least one clinically-relevant outcome measure.

DATA COLLECTION AND ANALYSIS

Two authors, who served as the authors for all stages of the meta-analysis, independently extracted data from unmasked articles. Comparison treatments were classified into the following seven categories: sham, conventional general practitioner care, analgesics, physical therapy, exercises, back school, or a collection of therapies judged to be ineffective or even harmful (traction, corset, bed rest, home care, topical gel, no treatment, diathermy, and minimal massage).

MAIN RESULTS

Thirty-nine RCTs were identified. Meta-regression models were developed for acute or chronic pain and short-term and long-term pain and function. For patients with acute low-back pain, spinal manipulative therapy was superior only to sham therapy (10-mm difference [95% CI, 2 to 17 mm] on a 100-mm visual analogue scale) or therapies judged to be ineffective or even harmful. Spinal manipulative therapy had no statistically or clinically significant advantage over general practitioner care, analgesics, physical therapy, exercises, or back school. Results for patients with chronic low-back pain were similar. Radiation of pain, study quality, profession of manipulator, and use of manipulation alone or in combination with other therapies did not affect these results.

AUTHORS' CONCLUSIONS

There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low-back pain.

Tissue engineering approaches to degenerative disc disease--a meta-analysis of controlled animal trials

OBJECTIVE

The objective of this systematic review was to assess cell/biomaterial treatments of degenerative disc disease in controlled animal trails. The primary endpoints were restoration of disc height and T2 signal intensity.

METHOD

PubMed, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Cochrane Database of Systematic Reviews (CDSR) were searched for studies reporting on the use of tissue engineering treatments (cells/biomaterials/cells and biomaterials) for degenerative disc disease treatments in a controlled trial. Publication bias was assessed graphically using funnel plots and Egger's regression. Data were grouped by follow-up duration - early (<4 weeks), intermediate (4-12 weeks) and late (>12 weeks), and weighted mean differences (WMD) were calculated using DerSimonian-Laird Random Effect models.

RESULTS

Thirteen papers, published between 2004 and 2011, were included in this study. In comparison with the injured disc, all three treatments showed a positive effect in disc height, but none of the treatments restored disc height compared to the healthy disc. Overall, there seemed to be a better effect on disc height restoration for the treatment with cells and biomaterials. None of the treatments could achieve the same T2 signal intensity as the healthy disc, and compared to the injured disc, only the treatment with cells and biomaterials showed consistently better results.

CONCLUSION

Treatment of an injured/degenerating disc with cells, cells plus biomaterial or biomaterial alone has a potential for at least a partial regeneration of the disc. However, so far, none of the treatments is able to effectively restore the properties of a healthy disc.

Antineuropathic and antinociceptive drugs combination in patients with chronic low back pain: a systematic review

Purpose. Chronic low back pain (LBP) is often characterized by both nociceptive and neuropathic components. While various monotherapies have been reported of only limited efficacy, combining drugs with different mechanisms of action and targets appears a rational approach. Aim of this systematic review is to assess the efficacy and safety of different combined pharmacological treatments, compared to monotherapy or placebo, for the pharmacological treatment of chronic LBP. Methods. Published papers, written or abstracted in English from 1990 through 2011, comparing combined pharmacological treatments of chronic LBP to monotherapy or placebo were reviewed. Results. Six articles met the inclusion criteria. Pregabalin combined with celecoxib or opioids was shown to be more effective than either monotherapy. Oxycodone-paracetamol versus previous treatments and tramadol-paracetamol versus placebo were also reported as effective, while morphine-nortriptyline did not show any benefit over any single agent. Conclusions. In spite of theoretical advantages of combined pharmacological treatments of chronic LBP, clinical studies are remarkably few. Available data show that combined therapy, including antinociceptive and antineuropathic agents is more effective than monotherapy, with similar side effects.

Drugs for relief of pain in patients with sciatica: systematic review and meta-analysis

OBJECTIVE

To investigate the efficacy and tolerability of analgesic and adjuvant pain drugs typically administered in primary care for the management of patients with sciatica.

DESIGN

Systematic review. Data source International Pharmaceutical Abstracts, PsycINFO, Medline, Embase, Cochrane Central Register of Clinical Trials (CENTRAL), CINAHL, and LILACS.

STUDY SELECTION

Randomised controlled trials assessing the efficacy and tolerability of drugs versus placebo or other treatment for sciatica.

DATA EXTRACTION

Two independent reviewers extracted data and assessed methodological quality using the PEDro scale. Pain and disability outcomes were converted to a common 0 to 100 scale. Data were pooled with a random effects model, and the GRADE approach was used in summary conclusions.

RESULTS

Twenty three published reports met the inclusion criteria. The evidence to judge the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, antidepressants, anticonvulsants, muscle relaxants, and opioid analgesics ranged from moderate to low quality. Most of the pooled estimates did not favour the active treatment over placebo. The pooled results of two trials of corticosteroids (mean difference in overall and leg pain -12.2, 95% confidence interval -20.9 to -3.4) and a single trial of the anticonvulsant gabapentin for chronic sciatica (mean difference in overall pain relief -26.6, -38.3 to -14.9) showed some benefits but only in the short term. The median rate of adverse events was 17% (interquartile range 10-30%) for the active drugs and 11% (3-23%) for placebo. Trial limitations included failure to use validated outcome measures, lack of long term follow-up, and small sample size.

CONCLUSIONS

As the existing evidence from clinical trials is of low quality, the efficacy and tolerability of drugs commonly prescribed for the management of sciatica in primary care is unclear.

Adherence of Irish general practitioners to European guidelines for acute low back pain: A prospective pilot study

There are no national low back pain (LBP) clinical guidelines in Ireland, and neither the level of adherence of General Practitioners (GPs) to the European guidelines, nor the cost of LBP to the patient and the state, have been investigated. A prospective pilot study was conducted on 54 consenting patients (18M, 36F: mean age (SD): 40.5 (14.3) years) with a new episode of acute LBP (<3 months) attending one of nine participating GPs. Baseline demographic, LBP classification [i.e. simple back ache (SBA), nerve root pain (NRP), serious spinal pathology (SSP)] and primary care management data were recorded over a three month period. Adherence and costs were estimated based on: medication prescription, referral for investigations, treatment or consultations, and wage replacement costs (time signed off work). For both SBA and NRP, medication prescriptions were consistent with European guideline recommendations, but not for referral for further treatment (39% of SBA patients were referred on first visit), secondary care (54% of NRP patients were referred on first visit), or discontinuation of work (50% NRP patients on first GP visit). The average total cost (direct and wage replacement) for a single episode of LBP over 12 weeks was 20,531 Euros (20,300-20,762). Direct costs accounted for 43% [8874.36 Euros, (8643.37-9105.37 Euros)] and wage replacement costs 57% (11,657 Euros). In conclusion, management of acute LBP in a cohort of GPs in Ireland was not consistent with European clinical guideline recommendations, and warrants higher levels of postgraduate education among GPs, as well as restructuring of primary care services, which should improve patient outcome and reduce costs.

Ten-year survey reveals differences in GP management of neck and back pain

PURPOSE

Clinical guidelines provide similar recommendations for the management of new neck pain and low back pain (LBP) but it is unclear if general practitioner's (GP) care is similar. While GP's management of LBP is well documented, little is known about GP's management of neck pain. We aimed to describe GP's management of new neck pain and compare this to GP's management of new LBP in Australia between April 2000 and March 2010.

METHODS

All GP-patient encounters for a new (i.e. first visit to any medical practitioner) neck pain or LBP problem were compared in terms of treatment delivered, referral patterns and requests for laboratory and imaging investigations.

RESULTS

General practitioners in Australia have managed new neck pain and LBP problems at a rate of 3.1 and 5.8 per 1,000 GP-patient encounters, respectively. GP's primarily utilised medications, in particular non-steroidal anti-inflammatory drugs, to manage new neck and LBP problems and referred approximately 25% of all patients for imaging. Patients with new neck pain are more frequently managed using physical treatments and were referred more often to allied health professionals and specialists. In comparison, patients with new LBP were managed more frequently with medication, advice, provision of a sickness certificate and ordering of pathology tests.

CONCLUSIONS

This is the first time GP management of a new episode of neck pain has been documented using a nationally representative sample and it is also the first time that the management of back and neck pain has been compared. Despite guidelines endorsing a similar approach for the management of new neck pain and LBP, in actual clinical practice Australian GPs manage these two conditions differently.

Pharmacologic management of chronic low back pain: synthesis of the evidence

STUDY DESIGN

Systematic review of the literature with subgroup analysis for heterogeneous treatment effects.

OBJECTIVE

The objectives of this systematic review were to summarize prior Cochrane reports regarding the safety and effectiveness of opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), and antidepressants for treatment of chronic low back pain (LBP) and to evaluate whether certain subpopulations respond more favorably to pharmacological management.

SUMMARY OF BACKGROUND DATA

While medications are a mainstay of LBP management, there is uncertainty as to the optimal use of commonly prescribed medications such as opioids, antidepressants, and NSAIDS.

METHODS

To summarize the overall treatment effect and safety for each of the three pharmacological drug classes (opioids, NSAIDs, or antidepressants), we summarized existing Cochrane reviews. To evaluate whether the effects of treatment varied by specific subgroups of patients, we sought randomized controlled trials (RCTs) evaluating one of the three pharmacological drug classes versus an alternative management for chronic LBP.

RESULTS

Based on the Cochrane reviews, opioids are more effective than placebo with respect to pain and disability, with a much greater effect size for pain than disability. When compared with NSAIDs, opioids did not confer a greater benefit with regard to pain and disability. The rate of side effects from opioids is significantly greater than placebo with differences ranging between 2% and 9%. The systematic review of RCTs showed that antidepressants are not more effective than placebo with respect to pain, functional status, or depression. Certain subgroup treatment effects were identified, supporting our hypothesis that chronic LBP should be considered a heterogeneous set of disorders. As such, chronic LBP subgroups should be considered both when making clinical treatment decisions and when designing future research trials.

CONCLUSION

Opioids and NSAIDs are effective for chronic LBP, while antidepressants have no meaningful clinical benefit. Based on the significant rate of side effects with opioids and the lack of convincing superiority over NSAIDs, opioids are not recommended as a treatment for chronic LBP. Attention to subgroups of patients will likely help guide treatment, and will likely help increase the clinical impact of future research.

CLINICAL RECOMMENDATIONS

Recommendation 1: NSAIDs should be considered as a treatment of chronic LBP (Strength: Strong). There is evidence demonstrating favorable effectiveness, but also significant side effects that may have meaningful clinical consequences. Recommendation 2: Opioids may be considered in the treatment of chronic LBP but should be avoided if possible (Strength: Weak). There is evidence demonstrating favorable effectiveness compared to placebo, similar effectiveness compared to NSAIDs, and with significant side effects including decreasing effectiveness related to habituation when used long-term. Recommendation 3: Antidepressants should not be routinely used for the treatment of chronic LBP (Strength: Strong). There is evidence that they are not more effective than placebo with respect to pain, functional status, or depression. Based on the hypothesis that chronic LBP is a symptom reflective of a heterogeneous group of disorders, categorization of certain patient specific subgroups may be helpful in guiding future treatment decision making. It is likely that inclusion of subgroup factors in future RCTs will provide information needed to improve the strength and specificity of future clinical recommendations.

The impact of fentanyl matrix on pain and function in spinal disorder-related chronic pain: an open label trial in Korea

Study Design

This is a multicenter, open-label prospective, non interventional study.

Purpose

We wanted to evaluate the impact of fentanyl matrix on the pain and function of patients with spinal disorder-related chronic, non-malignant pain.

Overview of Literature

Patients with severe non-malignant chronic low back pain may require opioid analgesics for effective pain management.

Methods

A total of 1,576 patients with severe pain (numeric rating scale = 7) were evaluated for their pain intensity at the initial visit and at weeks 4 and 8 (Visits 1, 2, and 3, respectively). Disturbances in sleep, daily living and social activities, the Oswestry Disability Index (ODI), the researchers' and patients' global assessment and the patients' treatment preference were also assessed.

Results

The pain intensity score significantly decreased from 8.1 at Visit 1 to 5.4 and 4.4 at Visits 2 and 3, respectively. Sleep disturbance also significantly decreased and the extent of disturbance of daily and social activities was also significantly improved. The ODI significantly decreased from 61.9% to 45.8% and 38.2% at Visits 1, 2, and 3, respectively. Adverse events were reported by 197 (12.5%) patients and severe adverse events were reported by 12 (0.76%) patients. Overall, 76.3% of the patients and 78.4% of the investigators rated the test drug as effective.

Conclusions

The fentanyl matrix is believed to be effective for the treatment of pain, sleep disturbance and the impact upon daily and social activities, yet physicians should pay attention to the risks of abuse and the adverse events.

Botulinum toxin for shoulder pain: a cochrane systematic review

OBJECTIVE

To perform a Cochrane Systematic Review of benefits and harms of botulinum toxin for shoulder pain.

METHODS

We included clinical trials of adults with shoulder pain (population), comparing botulinum toxin (intervention) to placebo or other therapies (comparison), and reporting benefits or harms (outcomes). We calculated relative risk (RR) for categorical outcomes and mean differences (MD) for continuous outcomes.

RESULTS

Six randomized controlled trials (RCT) with 164 patients all comparing single botulinum toxin type A injections to placebo were included. Five RCT in patients with post-stroke shoulder pain found that an intramuscular injection of botulinum toxin type A significantly reduced pain at 3-6 months (MD -1.2 points on 0-10 scale, 95% CI -2.4 to -0.07) and improved shoulder external rotation at 1 month (MD 9.8°, 95% CI 0.2° to 19.4°). Number of adverse events did not differ between groups (RR 1.46, 95% CI 0.6 to 24.3). One RCT in arthritis-related shoulder pain showed that single intraarticular botulinum toxin type A injection reduced pain (MD -2.0 on 0-10 scale, 95% CI -3.7 to -0.3) and shoulder disability (MD -13.4 on 0-100 scale, 95% CI -24.9 to -1.9) and improved shoulder abduction (MD 13.8°, 95% CI 3.2° to 44.0°) at 1 month, compared with placebo. Serious adverse events did not differ between groups (RR 0.35, 95% CI 0.11, 1.12).

CONCLUSION

With evidence from few studies with small sample sizes and medium to high risk of bias, botulinum toxin type A injections decreased pain and improved shoulder function in patients with chronic shoulder pain due to spastic hemiplegia or arthritis.