Impact of Continuous Low Level Heatwrap Therapy in Acute Low Back Pain Patients: Subjective and Objective Measurements

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

Objectives

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

Methods

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

Results and conclusion

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

[Non-specific low back pain: interpretation of North American Spine Society (NASS) guidelines for evidence-based medicine]

Low back pain is a common disease. In 2020, the North American Spine Society (NASS) formulated an evidence-based clinical guideline for the diagnosis and treatment of non-specific low back pain. The guidelines mainly addressed five aspects of non-specific low back pain: diagnosis, imaging examination, conservative treatment, interventional treatment, and surgical treatment. Based on an in-depth understanding of the guidelines, this article gives a brief explanation of the diagnosis and treatment of non-specific low back pain, so as to provide references for clinicians.

A Role for Superficial Heat Therapy in the Management of Non-Specific, Mild-to-Moderate Low Back Pain in Current Clinical Practice: A Narrative Review

Low back pain (LBP) is a leading cause of disability. It significantly impacts the patient's quality of life, limits their daily living activities, and reduces their work productivity. To reduce the burden of LBP, several pharmacological and non-pharmacological treatment options are available. This review summarizes the role of superficial heat therapy in the management of non-specific mild-to-moderate LBP. First, we outline the common causes of LBP, then discuss the general mechanisms of heat therapy on (LBP), and finally review the published evidence regarding the impact of superficial heat therapy in patients with acute or chronic non-specific LBP. This review demonstrates that continuous, low-level heat therapy provides pain relief, improves muscular strength, and increases flexibility. Therefore, this effective, safe, easy-to-use, and cost-effective non-pharmacological pain relief option is relevant for the management of non-specific mild or moderate low back pain in current clinical practice.

Local heat applications as a treatment of physical and functional parameters in acute and chronic musculoskeletal disorders or pain

OBJECTIVES

The aim of this systematic review and meta-analysis was to evaluate the effectiveness of local heat applications (LHA) in individuals with acute or chronic musculoskeletal disorders.

DATA SOURCES

An electronic search was conducted on MEDLINE, CENTRAL, CINHAL and the PEDro databases up to December 2019.

STUDY SELECTION

Studies incorporating adults suffering from any kind of musculoskeletal issues treated by LHA compared to any treatment other than heat were included.

QUALITY ASSESSMENT

Two authors independently performed the methodological quality assessment using the Cochrane Risk of Bias tool.

DATA SYNTHESIS

LHA showed beneficial immediate effects to reduce pain vs no treatment (p < 0.001), standard therapy (p = 0.020), pharmacological therapy (p < 0.001) and placebo/sham (p = 0.044). Physical function was restored after LHA compared to no treatment (p = 0.025) and standard therapy (p = 0.006) whilst disability improved directly after LHA compared to pharmacological therapy (p = 0.003) and placebo/sham (p < 0.028). Quality of life was improved directly after LHA treatment compared to exercise therapy (p < 0.021). Range of motion increased and stiffness decreased after LHA treatment compared to pharmacological therapy (p = 0.009., p < 0.001) and placebo/sham (p < 0.001, p = 0.023). The immediate superior effects of LHA on muscular strength could be observed compared to no treatment (p < 0.001), cold (p < 0.001) and placebo/sham (p = 0.023).

CONCLUSIONS

Individuals suffering from acute musculoskeletal disorders might benefit from using LHA as an adjunct therapy. However, the studies included in this meta-analysis demonstrated a high heterogeneity and mostly an unclear risk of bias.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN

This is a guideline summary review.

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of journal impact factor, reporting conflicts, and reporting funding sources, on standardized effect sizes in back pain trials: a systematic review and meta-regression

BACKGROUND

Low back pain is a common and costly health complaint for which there are several moderately effective treatments. In some fields there is evidence that funder and financial conflicts are associated with trial outcomes. It is not clear whether effect sizes in back pain trials relate to journal impact factor, reporting conflicts of interest, or reporting funding.

METHODS

We performed a systematic review of English-language papers reporting randomised controlled trials of treatments for non-specific low back pain, published between 2006-2012. We modelled the relationship using 5-year journal impact factor, and categories of reported of conflicts of interest, and categories of reported funding (reported none and reported some, compared to not reporting these) using meta-regression, adjusting for sample size, and publication year. We also considered whether impact factor could be predicted by the direction of outcome, or trial sample size.

RESULTS

We could abstract data to calculate effect size in 99 of 146 trials that met our inclusion criteria. Effect size is not associated with impact factor, reporting of funding source, or reporting of conflicts of interest. However, explicitly reporting 'no trial funding' is strongly associated with larger absolute values of effect size (adjusted β=1.02 (95 % CI 0.44 to 1.59), P=0.001). Impact factor increases by 0.008 (0.004 to 0.012) per unit increase in trial sample size (P<0.001), but does not differ by reported direction of the LBP trial outcome (P=0.270).

CONCLUSIONS

The absence of associations between effect size and impact factor, reporting sources of funding, and conflicts of interest reflects positively on research and publisher conduct in the field. Strong evidence of a large association between absolute magnitude of effect size and explicit reporting of 'no funding' suggests authors of unfunded trials are likely to report larger effect sizes, notwithstanding direction. This could relate in part to quality, resources, and/or how pragmatic a trial is.

Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury

Nonpharmacological treatment strategies for acute musculoskeletal injury revolve around pain reduction and promotion of healing in order to facilitate a return to normal function and activity. Heat and cold therapy modalities are often used to facilitate this outcome despite prevalent confusion about which modality (heat vs cold) to use and when to use it. Most recommendations for the use of heat and cold therapy are based on empirical experience, with limited evidence to support the efficacy of specific modalities. This literature review provides information for practitioners on the use of heat and cold therapies based on the mechanisms of action, physiological effects, and the medical evidence to support their clinical use. The physiological effects of cold therapy include reductions in pain, blood flow, edema, inflammation, muscle spasm, and metabolic demand. There is limited evidence from randomized clinical trials (RCTs) supporting the use of cold therapy following acute musculoskeletal injury and delayed-onset muscle soreness (DOMS). The physiological effects of heat therapy include pain relief and increases in blood flow, metabolism, and elasticity of connective tissues. There is limited overall evidence to support the use of topical heat in general; however, RCTs have shown that heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain and provides significantly greater pain relief of DOMS than does cold therapy. There remains an ongoing need for more sufficiently powered high-quality RCTs on the effects of cold and heat therapy on recovery from acute musculoskeletal injury and DOMS.

Continuous low-level heatwrap therapy relieves low back pain and reduces muscle stiffness

BACKGROUND

Low back pain is a common and costly health care problem. This pilot study evaluated the sensitivity of the 2-stopwatch and Paris plinth methodologies for assessing time-to-onset of pain relief and flexibility, respectively, with continuous, low-level heatwrap therapy.

RESEARCH DESIGN AND METHODS

Subjects aged 18 to 55 years with at least moderate baseline acute low back pain were randomly assigned to either heatwrap or oral placebo for 8 hours. Unheated wrap (sham) and oral ibuprofen were included for blinding purposes only.

RESULTS

Sixty-one subjects were randomly assigned to either heatwrap (n = 26), oral placebo (n = 25), sham wrap (n = 5), or oral ibuprofen (n = 5). Median time to confirmed first perceptible pain relief and to meaningful pain relief were significantly shorter for the heatwrap group compared with those assigned to oral placebo (96.5 vs > 240.0 min and 215.7 vs > 240.0 min, respectively; P < 0.05 for both). Among subjects receiving the heatwrap, 53.8% reported first perceptible and meaningful relief, compared with 28.0% receiving oral placebo. Subjective measures of pain relief, back stiffness, and global evaluation were more sensitive in detecting treatment differences than the plinth assessments of flexibility, range of motion, and pain. Three adverse events were reported as mild in severity and considered unrelated to study treatment.

CONCLUSIONS

The 2-stopwatch methodology is a viable approach for assessing onset of analgesia in low back pain; however, the plinth may not be a reliable method for assessing flexibility. Consistent with published studies involving much larger sample sizes, the heatwrap provided significantly faster and sustained pain relief than oral placebo in subjects with acute low back pain. Clinical Trial Identifier: NCT01045993.

Acute back pain: benefits and risks of current treatments

OBJECTIVE

To review the efficacy and safety of current treatments for acute low back pain.

RESEARCH DESIGN AND METHODS

PubMed was searched for clinical trials in which the words, acute, back, and pain all appeared in the study summary. The search was from the earliest references included in this database (1949) until 1 May 2009. This resulted in retrieval of 129 papers. Review of study summaries indicated that 36 provided information about either a topical treatment or oral therapy for acute low back pain. In addition, studies included as part of the evidence base for the Evidence Review of American Pain Society/American Academy of Pain Medicine Evidence Review for Evaluation and Management of Low Back Pain were reviewed.

RESULTS

Recommended topical and systemic pharmacologic treatments for acute low back pain include application of superficial heat, acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), skeletal muscle relaxants/benzodiazepines, and opioids including tramadol. Only a small number of studies compared different approaches to treatment of acute back pain and most failed to demonstrate significant differences among treatments. Available results support the view that both NSAIDs and low-level continuous heat treatment are more effective than acetaminophen and that heat treatment is also significantly more effective than ibuprofen. A potential limitation of this study is that information from trials published in journals not included in PubMed or reported only at meetings and not yet published was not included.

CONCLUSIONS

A wide range of treatments is currently recommended for the management of patients with acute back pain and all are supported by results from controlled clinical trials.