1
|
Baroncini A, Maffulli N, Mian M, Vaishya R, Simeone F, Migliorini F. Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review. J Orthop Surg Res 2024; 19:248. [PMID: 38637804 PMCID: PMC11025267 DOI: 10.1186/s13018-024-04741-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 04/14/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point. METHODS In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used. RESULTS Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001). CONCLUSION Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ. LEVEL OF EVIDENCE I systematic review of RCTs.
Collapse
Affiliation(s)
- Alice Baroncini
- GSpine4, IRCCS Ospedale Galeazzi - Sant'Ambrogio, Milan, Italy
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine and Psychology, University La Sapienza, 00185, Rome, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, London, E1 4DG, England
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Thornburrow Drive, Stoke on Trent, England
| | - Michael Mian
- Innovation Research Teaching Service (IRTS), Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Raju Vaishya
- Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi, 110076, India
| | - Francesco Simeone
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy
| | - Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
- Department of Orthopaedic, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| |
Collapse
|
2
|
Neilson BD, Dickerson C, Young JL, Shepherd MH, Rhon DI. Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials. J Clin Sleep Med 2023; 19:1961-1970. [PMID: 37259893 PMCID: PMC10620655 DOI: 10.5664/jcsm.10672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/25/2023] [Accepted: 05/26/2023] [Indexed: 06/02/2023]
Abstract
STUDY OBJECTIVES To investigate the extent to which sleep measures are reported in intervention trials for chronic low back pain. METHODS A systematic scoping review was conducted. Ovid MEDLINE, Cochrane CENTRAL, and CINAHL were queried for trials published between January 2010 and December 2022 using keywords related to chronic low back pain. Two reviewers screened and reviewed abstracts and full texts for eligibility criteria and extracted data. Randomized intervention trials with the aim to treat pain or disability related to chronic low back pain in adults were included. Data were pooled and synthesized from trials that included a measure of sleep. RESULTS Two hundred eighty-two trials conducted in 40 different countries were included in the final review. Twenty-six trials (9.2%) assessed any sleep measure, and 13 (4.6%) collected a formal sleep disturbance measure at multiple time points. Three trials analyzed the mediating effects of sleep disturbance on pain. Reporting of sleep measures was no better in more recently published trials; trials published in 2010 (22%; n = 2/9) and 2022 (23%; n = 3/13) had the highest reporting rates. CONCLUSIONS The poor adherence to guideline recommendations for capturing measures of sleep quality or disturbance limits clinicians' and researchers' understanding of how sleep may influence treatment effects for chronic low back pain. There is an opportunity to improve the understanding of the relationship between sleep and pain with improved collection and reporting of sleep disturbance measures. CITATION Neilson BD, Dickerson C, Young JL, Shepherd MH, Rhon DI. Measures of sleep disturbance are not routinely captured in trials for chronic low back pain: a systematic scoping review of 282 trials. J Clin Sleep Med. 2023;19(11):1961-1970.
Collapse
Affiliation(s)
- Brett D Neilson
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
- Doctor of Physical Therapy Program, Hawai'i Pacific University, Honolulu, Hawaii
| | - Chris Dickerson
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Jodi L Young
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Mark H Shepherd
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
| | - Daniel I Rhon
- Doctor of Science Program in Physical Therapy, Bellin College, Green Bay, Wisconsin
- Department of Rehab Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| |
Collapse
|
3
|
Migliorini F, Vaishya R, Pappalardo G, Schneider M, Bell A, Maffulli N. Between guidelines and clinical trials: evidence-based advice on the pharmacological management of non-specific chronic low back pain. BMC Musculoskelet Disord 2023; 24:432. [PMID: 37254090 DOI: 10.1186/s12891-023-06537-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 05/16/2023] [Indexed: 06/01/2023] Open
Abstract
The pharmacological management of nonspecific chronic low back pain (NCLBP) aims to restore patients' daily activities and improve their quality of life. The management of NCLBP is not well codified and extremely heterogeneous, and residual symptoms are common. Pharmacological management should be considered as co-adjuvant to non-pharmacological therapy, and should be guided by the symptoms reported by the patients. Depending on the individual severity of NCLPB, pharmacological management may range from nonopioid to opioid analgesics. It is important to identify patients with generalized sensory hypersensitivity, who may benefit from dedicated therapy. This article provides an evidence-based overview of the principles of pharmacological management of NCLPB.
Collapse
Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital of Aachen, 52064, Aachen, Germany.
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Bolzano, 39100, Italy.
| | - Raju Vaishya
- Department of Orthopedics, Indraprastha Apollo Hospitals Institutes of Orthopaedics, New Delhi, India
| | | | - Marco Schneider
- Department of Medicine and Dentistry, University of Witten/Herdecke, 58455, Witten, Germany
- Department of Arthroscopy and Joint Replacement, MVZ Praxisklinik Orthopädie Aachen, RWTH University Hospital Aachen, 52074, Aachen, Germany
| | - Andreas Bell
- Department of Orthopedics, Eifelklinik St. Brigida, Simmerath, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, 84081, Italy
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Mile End Hospital, London, E1 4DG, England
- School of Pharmacy and Bioengineering, Stoke on Trent, Keele University Faculty of Medicine, Keele, England
| |
Collapse
|
4
|
Combination pharmacotherapy for the treatment of neuropathic pain in adults: systematic review and meta-analysis. Pain 2023; 164:230-251. [PMID: 35588148 DOI: 10.1097/j.pain.0000000000002688] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 03/07/2022] [Indexed: 02/06/2023]
Abstract
ABSTRACT Neuropathic pain causes substantial morbidity and healthcare utilization. Monotherapy with antidepressants or anticonvulsants often fails to provide relief. Combining different drugs sometimes provides improved analgesia and/or tolerability. More than half of patients receive 2 or more analgesics, and combination trials continue to emerge. This review comprehensively searched CENTRAL, MEDLINE, and EMBASE for relevant trials. Included studies are double-blind randomized controlled trials evaluating combinations of 2 or more drugs vs placebo or at least one monotherapy in adults with neuropathic pain. Outcomes included measures of efficacy and adverse effects. Risk of bias was assessed. Meta-analyses compared combination to monotherapy wherever 2 or more similar studies were available. Forty studies (4741 participants) were included. Studies were heterogenous with respect to various characteristics, including dose titration methods and administration (ie, simultaneous vs sequential) of the combination. Few combinations involved a nonsedating drug, and several methodological problems were identified. For opioid-antidepressant, opioid-gabapentinoid, and gabapentinoid-antidepressant combinations, meta-analyses failed to demonstrate superiority over both monotherapies. In general, adverse event profiles were not substantially different for combination therapy compared with monotherapy. Despite widespread use and a growing number of trials, convincing evidence has not yet emerged to suggest superiority of any combination over its respective monotherapies. Therefore, implementing combination therapy-as second- or third-line treatment-in situations where monotherapy is insufficient, should involve closely monitored individual dosing trials to confirm safety and overall added benefit. Further research is needed, including trials of combinations involving nonsedating agents, and to identify clinical settings and specific combinations that safely provide added benefit.
Collapse
|
5
|
Alshehri FS. Tapentadol: A Review of Experimental Pharmacology Studies, Clinical Trials, and Recent Findings. Drug Des Devel Ther 2023; 17:851-861. [PMID: 36974332 PMCID: PMC10039632 DOI: 10.2147/dddt.s402362] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
Tapentadol is an analgesic compound that acts centrally to attenuate pain. Previous studies have shown that tapentadol has dual mechanisms of action as a mu-opioid receptor agonist and noradrenaline re-uptake inhibition. Therefore, tapentadol provides a great advantage over classic opioids in pain management from nociceptive to neuropathic. Cumulative evidence from in vitro data suggests that tapentadol effect of norepinephrine re-uptake could be a new target that overcomes other classic opioids in chronic neuropathic pain. Compared to tramadol and other opioids, tapentadol is associated with fewer adverse effects than tramadol. Tapentadol is a new alternative to treat acute, chronic, and neuropathic pain. Thus, this review article was focused on understanding the studies that led to the development of tapentadol as a novel analgesic drug and its advantages over conventional opioids. Thus, tapentadol is a good alternative with fewer adverse effects and is available for human use.
Collapse
Affiliation(s)
- Fahad S Alshehri
- Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
- Correspondence: Fahad S Alshehri, Department of Pharmacology and Toxicology, College of Pharmacy, Umm Al‑ Qura University, Makkah, 24382, Saudi Arabia, Email
| |
Collapse
|
6
|
Fu JL, Perloff MD. Pharmacotherapy for Spine-Related Pain in Older Adults. Drugs Aging 2022; 39:523-550. [PMID: 35754070 DOI: 10.1007/s40266-022-00946-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 12/12/2022]
Abstract
As the population ages, spine-related pain is increasingly common in older adults. While medications play an important role in pain management, their use has limitations in geriatric patients due to reduced liver and renal function, comorbid medical problems, and polypharmacy. This review will assess the evidence basis for medications used for spine-related pain in older adults, with a focus on drug metabolism and adverse drug reactions. A PubMed/OVID search crossing common spine, neck, and back pain terms with key words for older adults and geriatrics was combined with common drug classes and common drug names and limited to clinical trials and age over 65 years. The results were then reviewed with identification of commonly used drugs and drug categories: nonsteroidal anti-inflammatories (NSAIDs), acetaminophen, corticosteroids, gabapentin and pregabalin, antispastic and antispasmodic muscle relaxants, tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs), tramadol, and opioids. Collectively, 138 double-blind, placebo-controlled trials were the focus of the review. The review found a variable contribution of high-quality studies examining the efficacy of medications for spine pain primarily in the geriatric population. There was strong evidence for NSAID use with adjustments for gastrointestinal and renal risk factors. Gabapentin and pregabalin had mixed evidence for neuropathic pain. SNRIs had good evidence for neuropathic pain and a more favorable safety profile than TCAs. Tramadol had some evidence in older patients, but more so in persons aged < 65 years. Rational therapeutic choices based on geriatric spine pain diagnosis are helpful, such as NSAIDs and acetaminophen for arthritic and myofascial-based pain, gabapentinoids or duloxetine for neuropathic and radicular pain, antispastic agents for myofascial-based pain, and combination therapy for mixed etiologies. Tramadol can be well tolerated in older patients, but has risks of cognitive and classic opioid side effects. Otherwise, opioids are typically avoided in the treatment of spine-related pain in older adults due to their morbidity and mortality risk and are reserved for refractory severe pain. Whenever possible, beneficial geriatric spine pain pharmacotherapy should employ the lowest therapeutic doses with consideration of polypharmacy, potentially decreased renal and hepatic metabolism, and co-morbid medical disorders.
Collapse
Affiliation(s)
- Jonathan L Fu
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, 85 E. Concord St, 1122, Boston, MA, 02118, USA
| | - Michael D Perloff
- Department of Neurology, Boston University School of Medicine, Boston Medical Center, 85 E. Concord St, 1122, Boston, MA, 02118, USA.
| |
Collapse
|
7
|
Pergolizzi J, Magnusson P, Coluzzi F, Breve F, LeQuang JAK, Varrassi G. Multimechanistic Single-Entity Combinations for Chronic Pain Control: A Narrative Review. Cureus 2022; 14:e26000. [PMID: 35855248 PMCID: PMC9286298 DOI: 10.7759/cureus.26000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 06/15/2022] [Indexed: 11/05/2022] Open
|
8
|
Samolsky Dekel BG, Sorella MC, Vasarri A, Melotti RM. Evidence for the BUAS-test ability to diagnose lumbar radicular pain. Br J Pain 2022; 16:23-33. [PMID: 35111311 PMCID: PMC8801693 DOI: 10.1177/20494637211005794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Differential diagnosis of low back pain (LBP) is complex and a prominent issue at all health-care levels; guidance may come from patients' history cues and clinical examination signs. Human and animal studies report that diagnosis of lumbar radicular pain (LRP) may come from evaluating subjective responses of injured lumbar nerves to a strain applied at the buttock. The Buttock Applied Strain (BUAS-test) test may guide the differential diagnosis of LBP. Following an ex-adiuvantibus criterion, clinical improvement of LRP, diagnosed with the BUAS-test and congruently treated, may support this test diagnostic ability. METHODS Among 258 LRP patients, who, upon first visit (V1), tested positive on the BUAS-test (with/without positive Straight Leg Raising Test, SLRT), the effect of gabapentin prescription on painDETECT (PD) questionnaire and Brief Pain Inventory (BPI) outcomes was quantified in the follow-up visit (V2). To support BUAS-test diagnostic ability, we hypothesized that, at V2, >50% of the sample would present negative PD outcome, significant (t-test) and ⩾2 points V2-V1 differences for each of the BPI-item's score. We used multinomial logistic regression (MLR) and χ2 analyses to evaluate the PD-V2 outcomes' dependence upon independent variables. RESULTS Of the sample, 77% reported a negative PD-V2 outcome. V2-V1 differences of all BPI items were significant and >2 points. PD-V2 outcomes showed significant associations with SLRT-V1 and PD-V1, respectively, but not with gender, age group or pain site. MLR showed a significant relationship between SLRT-V1 and PD-V2 outcomes. CONCLUSION Among LRP patients, diagnosed by the BUAS-test and treated with gabapentin, all prespecified endpoints were reached. These results may be considered a piece of ex-adiuvantibus evidence for the BUAS-test ability to diagnose LRP. While positive BUAS-test implies potential LRP, the co-presence with positive SLRT may imply a severer LRP condition. Further prospective research, in different settings and direct clinical measures, is needed.
Collapse
Affiliation(s)
- Boaz Gedaliahu Samolsky Dekel
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
- Anesthesia and Pain Therapy Unit, Bologna’s Teaching Hospital, S. Orsola-Malpighi policlinic, Bologna, Italy
- Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
- Boaz Gedaliahu Samolsky Dekel, Department of Medicine and Surgery Sciences, University of Bologna, Via Massarenti n. 9, 40138 Bologna, Italy.
| | - Maria Cristina Sorella
- Anesthesia and Pain Therapy Unit, Bologna’s Teaching Hospital, S. Orsola-Malpighi policlinic, Bologna, Italy
| | - Alessio Vasarri
- Anesthesia and Pain Therapy Unit, Bologna’s Teaching Hospital, S. Orsola-Malpighi policlinic, Bologna, Italy
| | - Rita Maria Melotti
- Department of Medicine and Surgery Sciences, University of Bologna, Bologna, Italy
- Anesthesia and Pain Therapy Unit, Bologna’s Teaching Hospital, S. Orsola-Malpighi policlinic, Bologna, Italy
- Post Graduate School of Anaesthesia and Intensive Care, University of Bologna, Bologna, Italy
| |
Collapse
|
9
|
Giménez-Campos MS, Pimenta-Fermisson-Ramos P, Díaz-Cambronero JI, Carbonell-Sanchís R, López-Briz E, Ruíz-García V. A systematic review and meta-analysis of the effectiveness and adverse events of gabapentin and pregabalin for sciatica pain. Aten Primaria 2021; 54:102144. [PMID: 34637958 PMCID: PMC8515246 DOI: 10.1016/j.aprim.2021.102144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/06/2021] [Accepted: 05/31/2021] [Indexed: 11/26/2022] Open
Abstract
Aim This SR aims to assess the effectiveness of pregabalin and gabapentin on pain and disability caused by acute sciatica and the adverse events associated with their clinical use. Design Systematic review. Databases Electronic databases of Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Clinical Trials.gov were searched from their inception until March 1st of 2021. Selection criteria Randomized trials (RCT) with adults > 18 years old with acute sciatica for a minimum of 1 week and a maximum of 1 year (at least moderate pain). Data treatment The outcomes were pain, disability and adverse events. Data was summarized using odds ratio and mean difference. GRADE was used to calculate the level of evidence. Results Eight RCT involving 747 participants were included. The effect of pregabalin was assessed in 3 RCT and in one three-arm trial (pregabalin vs limaprost vs a combination of limaprost and pregabalin). Two trials assessed the effect of gabapentin compared with placebo and one compared with tramadol. One study assessed the effect of gabapentin vs pregabalin in a crossover head-to-head trial. A statistically significant improvement on leg pain at 2 weeks and leg pain with movement at 3 and 4 months was found in a RCT comparing gabapentin with placebo. There were no statistically differences on the remaining time periods assessed for leg pain, low back pain and functional disability. Conclusions This SR provides clear evidence for lack of effectiveness of pregabalin and gabapentin for sciatica pain management. In view of this, its routine clinical use cannot be supported.
Collapse
|
10
|
Serrano Afonso A, Carnaval T, Videla Cés S. Combination Therapy for Neuropathic Pain: A Review of Recent Evidence. J Clin Med 2021; 10:jcm10163533. [PMID: 34441829 PMCID: PMC8396869 DOI: 10.3390/jcm10163533] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 12/19/2022] Open
Abstract
Pharmacological treatment is not very effective for neuropathic pain (NP). A progressive decrease in the estimated effect of NP drugs has been reported, giving rise to an increase in the use of the multimodal analgesic approach. We performed a new independent review to assess whether more and better-quality evidence has become available since the last systematic review. We evaluated the efficacy, tolerability, and safety of double-blinded randomized controlled trials involving only adult participants and comparing combination therapy (CT: ≥2 drugs) with a placebo and/or at least one other comparator with an NP indication. The primary outcome assessed was the proportion of participants reporting ≥50% pain reductions from baseline. The secondary outcome assessed was the proportion of drop-outs due to treatment-emergent adverse events. After removing duplicates, 2323 citations were screened, with 164 articles assessed for eligibility, from which 16 were included for qualitative analysis. From the latter, only five lasted for at least 12 weeks and only six complied with the required data for complete analysis. CT has been adopted for years without robust evidence. Efforts have been made to achieve better-quality evidence, but the quality has not improved over the years. In this regard, guidelines for NP should attempt to make recommendations about CT research, prioritizing which combinations to analyze.
Collapse
Affiliation(s)
- Ancor Serrano Afonso
- Department of Anesthesiology, Resuscitation and Pain Management, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain
- Correspondence:
| | - Thiago Carnaval
- Department of Clinical Pharmacology, Hospital Universitari de Bellvitge, 08907 L’Hospitalet de Llobregat, Spain;
| | - Sebastià Videla Cés
- Pharmacology Unit, Department of Pathology and Experimental Therapeutics, School of Medicine and Health Sciences, IDIBELL, University of Barcelona, 08907 L’Hospitalet de Llobregat, Spain;
| |
Collapse
|
11
|
Jovanovic F, Pirvulescu I, Knezevic E, Candido KD, Knezevic NN. Comparative safety review of current treatment options for chronic low back pain and unmet needs: a narrative review. Expert Opin Drug Saf 2021; 20:1005-1033. [PMID: 33945371 DOI: 10.1080/14740338.2021.1921142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The healthcare expenditures in the United States are substantial for the management of refractory, chronic low back pain (CLBP). The objective of this review is to summarize and evaluate the safety profiles of different pharmacological treatment options used in the management of CLBP.Areas covered: The authors conducted a search of randomized controlled trials (RCTs) assessing the safety profiles of different pharmacological agents used in the management of CLBP. This narrative review covered corticosteroids, opioids, antidepressants, gabapentinoids, nonsteroidal anti-inflammatory drugs, muscle relaxants, anti-nerve growth factor antibodies and topical agents, as monotherapy or in combination.Expert opinion: The risk-benefit ratio of a particular treatment is a subject driving the ongoing development of pharmaceuticals. The most commonly reported AEs across all drug classes are of gastrointestinal nature, followed by neurological and skin-related. These AEs include nausea, dizziness, constipation, arthralgia, headache, dry mouth, pruritus, etc. The majority of the AEs reported are not life-threatening, although they may lower patients' quality of life, thus, affecting their compliance. One of the biggest limitations of our review stems from the paucity of safety assessments in published RCTs. Advances in our understanding of the neurobiology of pain will promote development of new therapeutic strategies.
Collapse
Affiliation(s)
- Filip Jovanovic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Iulia Pirvulescu
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
| | - Emilija Knezevic
- College of Liberal Arts & Sciences, University of Illinois at Urbana Champaign, IL, United States
| | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, College of Medicine, University of Illinois, Chicago, IL, United States.,Department of Surgery, College of Medicine, University of Illinois, Chicago, IL, United States
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States.,Department of Anesthesiology, College of Medicine, University of Illinois, Chicago, IL, United States.,Department of Surgery, College of Medicine, University of Illinois, Chicago, IL, United States
| |
Collapse
|
12
|
Migliorini F, Maffulli N, Baroncini A, Eschweiler J, Tingart M, Quack V. Opioids for chronic low back pain management: a Bayesian network meta-analysis. Expert Rev Clin Pharmacol 2021; 14:635-641. [PMID: 33706636 DOI: 10.1080/17512433.2021.1903316] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Introduction: Chronic low back pain (LBP) is common, and some patients require opiates therapy. This Bayesian network meta-analysis (NMA) analyzed available randomized clinical trials (RCTs) on the use of opioids for LBP.Methods: All RCTs comparing two or more opioids for chronic LBP and reporting results under the Numeric Rating Scale were included. The following drugs were analyzed: fentanyl, morphine, tapentadol, oxycodone, buprenorphine, oxymorphone, tramadol. The NMA was performed through the STATA routine for Bayesian hierarchical random-effects model analysis, with standardized mean difference (SMD) effect measure. Data regarding the rate of adverse events and different drug formulations were also reported.Results: Data from 2933 patients were obtained, with a mean age of 53.30 ± 6.95 years. The mean duration of symptoms prior to beginning the trial was 95.16 ± 47.29 months. The mean follow-up was 3.29 ± 1.72 months. Among the analyzed compounds, oxymorphone, tapentadol and fentanyl showed the highest efficacy in terms of pain reduction.Conclusion: According to published level I evidence, oxymorphone, tapentadol and fentanyl were the most effective drugs in the treatment of chronic LBP. However, different formulation and pharmacokinetic characteristics need to be taken into consideration when choosing the ideal compound for a given patient.
Collapse
Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, via S. Allende, Baronissi (SA), Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent, UK.,Centre for Sports and Exercise Medicine, Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Mile End Hospital, London, UK
| | - Alice Baroncini
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Markus Tingart
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| | - Valentin Quack
- Department of Orthopaedics and Trauma Surgery, University Clinic Aachen, RWTH Aachen University Clinic, Aachen, Germany
| |
Collapse
|
13
|
Haji K, Muthu S, Banakh I, Tiruvoipati R. Prolonged encephalopathy and associated nonconvulsive seizures from suspected pregabalin and tapentadol: Two case reports and review of literature. Clin Case Rep 2021; 9:1362-1366. [PMID: 33768845 PMCID: PMC7981720 DOI: 10.1002/ccr3.3772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 05/17/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
A combination of pregabalin and tapentadol may be associated with prolonged encephalopathy.
Collapse
Affiliation(s)
- Kavi Haji
- Department of Intensive Care MedicineFrankston HospitalFrankstonVic.Australia
- School of Public HealthFaculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVic.Australia
- Faculty of SurgeryUniversity of MelbourneMelbourneVic.Australia
| | - Sachin Muthu
- Department of Intensive Care MedicineFrankston HospitalFrankstonVic.Australia
| | - Iouri Banakh
- Department of PharmacyFrankston HospitalFrankstonVic.Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care MedicineFrankston HospitalFrankstonVic.Australia
- School of Public HealthFaculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVic.Australia
| |
Collapse
|
14
|
Tapentadol, Buprenorphine, and Levorphanol for the Treatment of Neuropathic Pain: a Systematic Review. Curr Pain Headache Rep 2021; 25:18. [PMID: 33630185 DOI: 10.1007/s11916-020-00934-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW The objective of this systematic review is to present the available evidence for the utilization of the atypical opioids tapentadol, buprenorphine, and levorphanol for the treatment of neuropathic pain. RECENT FINDINGS In total, 1619 articles were retrieved of which 10 studies were included. Of 5 included studies pertaining to tapentadol, 4 studies show tapentadol monotherapy to be effective for the treatment of diabetic peripheral neuropathy or chronic, radiating low back pain. Of the 3 studies included for buprenorphine, only one was a randomized controlled trial found not to have a statistically significant reduction in pain with TD buprenorphine likely due to very high withdrawal rates during the trial. Only 2 case reports were included from the available literature for levorphanol providing low-quality anecdotal evidence. The role of tapentadol, buprenorphine, and levorphanol for neuropathic pain conditions requires robust research including randomized controlled trials to evaluate their efficacy and safety.
Collapse
|
15
|
Abstract
There is tremendous interpatient variability in the response to analgesic therapy
(even for efficacious treatments), which can be the source of great frustration
in clinical practice. This has led to calls for “precision
medicine” or personalized pain therapeutics (ie, empirically based
algorithms that determine the optimal treatments, or treatment combinations, for
individual patients) that would presumably improve both the clinical care of
patients with pain and the success rates for putative analgesic drugs in phase 2
and 3 clinical trials. However, before implementing this approach, the
characteristics of individual patients or subgroups of patients that increase or
decrease the response to a specific treatment need to be identified. The
challenge is to identify the measurable phenotypic characteristics of patients
that are most predictive of individual variation in analgesic treatment
outcomes, and the measurement tools that are best suited to evaluate these
characteristics. In this article, we present evidence on the most promising of
these phenotypic characteristics for use in future research, including
psychosocial factors, symptom characteristics, sleep patterns, responses to
noxious stimulation, endogenous pain-modulatory processes, and response to
pharmacologic challenge. We provide evidence-based recommendations for core
phenotyping domains and recommend measures of each domain.
Collapse
|
16
|
The early influence of COVID-19 pandemic-associated restrictions on pain, mood, and everyday life of patients with painful polyneuropathy. Pain Rep 2020; 5:e858. [PMID: 33134753 PMCID: PMC7566868 DOI: 10.1097/pr9.0000000000000858] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022] Open
Abstract
Supplemental Digital Content is Available in the Text. Validated questionnaires revealed a shift of attention from chronic pain towards the COVID-19 pandemic in patients with chronic painful polyneuropathy. Introduction: The SARS-Cov-2 pandemic requires special attention on its psychological effects and the impact on patients with chronic pain. Objectives: This study aimed at examining the influence of the COVID-19 pandemic-associated regulations initiated by the German government on pain intensity and characteristics, emotional well-being, and everyday life of patients with painful polyneuropathy. Methods: Forty-three patients (well assessed with questionnaires before the pandemic and without change of their health status between baseline and current assessment) were investigated with validated, self-reported questionnaires and COVID-19-specific items 2 weeks after the regulations came into effect. Results: Pain intensity remained stable or even improved like the neuropathic pain symptom inventory total score (t0: 33.54 ± 20.48 vs t1: 27.38 ± 16.16, P = 0.008). Only 11.6% reported a pandemic-associated pain worsening. Rumination scores of the Pain Catastrophizing Scale were lower during t1 compared to before the pandemic regulations (t0: 7.81 ± 4.70, t1: 6.49 ± 4.39; P = 0.030). Interestingly, pain ratings for the last 7 days were higher in patients with a changed social life compared to those without (−1.63 ± 1.60 vs 0.31 ± 1.83; P = 0.01). Quality of life was decreased and helplessness increased in those with higher pain ratings. Conclusion: Results suggest a shift of attention from the chronic pain condition towards the imminent threat of a global pandemic. As the impacts of the pandemic are persistent and evolving, the development of the measured parameters in the forthcoming weeks will be of great interest.
Collapse
|
17
|
The Potential Role of Dual Mechanistic Opioids in Combating Opioid Misuse. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00414-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
18
|
Caraci F, Coluzzi F, Marinangeli F, Mercadante S, Rinonapoli G, Romualdi P, Nicora M, Dickenson AH. Modulation of sensitization processes in the management of pain and the importance of descending pathways: a role for tapentadol? Curr Med Res Opin 2020; 36:1015-1024. [PMID: 32216591 DOI: 10.1080/03007995.2020.1748876] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Objective: This paper presents and discusses recent evidence on the pathophysiological mechanisms of pain. The role of tapentadol - an opioid characterized by an innovative mechanism of action (i.e. µ-opioid receptor [MOR] agonism and inhibition of noradrenaline [NA] reuptake [NRI]) - in the modulation of pain, and the most recent pharmacological evidence on this molecule (e.g. the µ-load concept) are also presented and commented upon.Methods: Narrative review.Results: Solid evidence has highlighted the importance of central sensitization in the transition from acute to chronic pain. In particular, the noradrenergic system holds a major role in limiting central sensitization and the progression to chronic pain. Therefore, pharmacological modulation of the noradrenergic system appears to be a well-grounded strategy for the control of chronic pain. Tapentadol is characterized by a to-date-unique mechanism of action, since it acts both as a MOR agonist and as an inhibitor of NA reuptake. The synergistic interaction of these two mechanisms allows a strong analgesic effect by acting on both ascending and descending pathways. Of note, the reduced µ-load of tapentadol limits the risk of opioid-related adverse events, such as gastrointestinal disturbances. Moreover, the NA component becomes predominant, at least, in some types of pain, with consequent specific clinical efficacy in the treatment of neuropathic and chronic pain.Conclusions: According to these characteristics, tapentadol appears suitable in the treatment of severe uncontrolled chronic pain characterized by both a nociceptive and a neuropathic component, such as osteoarthritis or back pain.
Collapse
Affiliation(s)
- Filippo Caraci
- Department of Drug Sciences, University of Catania, Catania, Italy
- Oasi Research Institute - IRCCS, Troina, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Anesthesiology and Intensive Care, University of L'Aquila, L'Aquila, Italy
| | - Sebastiano Mercadante
- Supportive Care Center, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | | | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | | | |
Collapse
|
19
|
Caraci F, Coluzzi F, Marinangeli F, Mercadante S, Rinonapoli G, Romualdi P, Nicora M, Dickenson AH. Modulation of sensitization processes in the management of pain and the importance of descending pathways: a role for tapentadol? Curr Med Res Opin 2020; 36:I-XVII. [PMID: 31822137 DOI: 10.1080/03007995.2019.1703664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: This paper presents and discusses recent evidence on the pathophysiological mechanisms of pain. The role of tapentadol - an analgesic molecule characterized by an innovative mechanism of action (i.e. µ-opioid receptor [MOR] agonism and inhibition of noradrenaline [NA] reuptake [NRI]) - in the modulation of pain, and the most recent pharmacological evidence on this molecule (e.g. the µ-load concept) are also presented and commented upon.Methods: Narrative review.Results: Solid evidence has highlighted the importance of central sensitization in the transition from acute to chronic pain. In particular, the noradrenergic system holds a major role in limiting central sensitization and the progression to chronic pain. Therefore, pharmacological modulation of the noradrenergic system appears to be a well-grounded strategy for the control of chronic pain. Tapentadol is characterized by a to-date-unique mechanism of action since it acts both as a MOR agonist and as an inhibitor of NA reuptake. The synergistic interaction of these two mechanisms allows a strong analgesic effect by acting on both ascending and descending pathways. Of note, the reduced µ-load of tapentadol has two important consequences: first, it limits the risk of opioid-related adverse events, as well as the risk of dependence; second, the NA component becomes predominant at least in some types of pain with consequent specific clinical efficacy in the treatment of neuropathic and chronic pain.Conclusions: According to these characteristics, tapentadol appears suitable in the treatment of chronic pain conditions characterized by both a nociceptive and a neuropathic component, such as osteoarthritis or back pain.
Collapse
Affiliation(s)
- Filippo Caraci
- Department of Drug Sciences, University of Catania, Catania, Italy
- Oasi Research Institute - IRCCS, Troina, Italy
| | - Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Franco Marinangeli
- Anesthesiology and Intensive Care, University of L'Aquila, L'Aquila, Italy
| | - Sebastiano Mercadante
- Supportive Care Center, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
- Main Regional Center for Pain Relief and Supportive/Palliative Care, La Maddalena Cancer Center, Palermo, Italy
| | | | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | | | | |
Collapse
|
20
|
Moisset X, Bouhassira D, Avez Couturier J, Alchaar H, Conradi S, Delmotte MH, Lanteri-Minet M, Lefaucheur JP, Mick G, Piano V, Pickering G, Piquet E, Regis C, Salvat E, Attal N. Pharmacological and non-pharmacological treatments for neuropathic pain: Systematic review and French recommendations. Rev Neurol (Paris) 2020; 176:325-352. [PMID: 32276788 DOI: 10.1016/j.neurol.2020.01.361] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 01/07/2020] [Indexed: 02/08/2023]
Abstract
Neuropathic pain remains a significant unmet medical need. Several recommendations have recently been proposed concerning pharmacotherapy, neurostimulation techniques and interventional management, but no comprehensive guideline encompassing all these treatments has yet been issued. We performed a systematic review of pharmacotherapy, neurostimulation, surgery, psychotherapies and other types of therapy for peripheral or central neuropathic pain, based on studies published in peer-reviewed journals before January 2018. The main inclusion criteria were chronic neuropathic pain for at least three months, a randomized controlled methodology, at least three weeks of follow-up, at least 10 patients per group, and a double-blind design for drug therapy. Based on the GRADE system, we provide weak-to-strong recommendations for use and proposal as a first-line treatment for SNRIs (duloxetine and venlafaxine), gabapentin and tricyclic antidepressants and, for topical lidocaine and transcutaneous electrical nerve stimulation specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a second-line treatment for pregabalin, tramadol, combination therapy (antidepressant combined with gabapentinoids), and for high-concentration capsaicin patches and botulinum toxin A specifically for peripheral neuropathic pain; a weak recommendation for use and proposal as a third-line treatment for high-frequency rTMS of the motor cortex, spinal cord stimulation (failed back surgery syndrome and painful diabetic polyneuropathy) and strong opioids (in the absence of an alternative). Psychotherapy (cognitive behavioral therapy and mindfulness) is recommended as a second-line therapy, as an add-on to other therapies. An algorithm encompassing all the recommended treatments is proposed.
Collapse
Affiliation(s)
- X Moisset
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France.
| | - D Bouhassira
- INSERM U987, CETD, Ambroise-Paré Hospital, AP-HP, Boulogne-Billancourt, France; Université Versailles - Saint-Quentin-en-Yvelines, Versailles, France
| | - J Avez Couturier
- Service de Neuropédiatrie, Consultation Douleur Enfant, CIC-IT 1403, CHU de Lille, Lille, France
| | - H Alchaar
- 73, boulevard de Cimiez, Nice, France
| | - S Conradi
- CETD, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - M H Delmotte
- GHU, Paris site Ste-Anne, Structure Douleurs, 1, rue Cabanis, Paris 14, France
| | - M Lanteri-Minet
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; Département d'Évaluation et Traitement de la Douleur, Centre Hospitalier Universitaire (CHU) de Nice, Fédération Hospitalo-Universitaire InovPain, Université Côte d'Azur, Nice, France
| | - J P Lefaucheur
- EA 4391, Faculté de Médecine, Université Paris Est Créteil, Créteil, France; Service de Physiologie, Explorations Fonctionnelles, Hôpital Henri-Mondor, Assistance publique-Hôpitaux de Paris, Créteil, France
| | - G Mick
- Centre d'Évaluation et Traitement de la Douleur du Voironnais, Centre Hospitalier de Voiron, Laboratoire P2S, Université de Lyon, Lyon, France
| | - V Piano
- Centre Hospitalier de Draguignan, Service Algologie 4(e), route de Montferrat, 83007 Draguignan cedex, France
| | - G Pickering
- Université Clermont Auvergne, Inserm, Neuro-Dol, 63000 Clermont-Ferrand, France; Clinical Pharmacology Department, CPC/CIC Inserm 1405, University Hospital CHU, Clermont-Ferrand, France
| | - E Piquet
- Département d'Évaluation et Traitement de la Douleur, Centre Hospitalier Universitaire (CHU) de Nice, Fédération Hospitalo-Universitaire InovPain, Université Côte d'Azur, Nice, France
| | - C Regis
- CETD, CHU Montpellier, Montpellier, France
| | - E Salvat
- Centre d'Évaluation et de Traitement de la Douleur, Hôpitaux Universitaires de Strasbourg, Université de Strasbourg, Institut des Neurosciences Cellulaires et Intégratives, Centre National de la Recherche Scientifique, Strasbourg, France
| | - N Attal
- INSERM U987, CETD, Ambroise-Paré Hospital, AP-HP, Boulogne-Billancourt, France; Université Versailles - Saint-Quentin-en-Yvelines, Versailles, France
| |
Collapse
|
21
|
Tampin B, Royle J, Bharat C, Trevenen M, Olsen L, Goucke R. Psychological factors can cause false pain classification on painDETECT. Scand J Pain 2020; 19:501-512. [PMID: 30901319 DOI: 10.1515/sjpain-2018-0355] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 02/15/2019] [Indexed: 01/04/2023]
Abstract
Background and aims The painDETECT questionnaire (PD-Q) has been widely used as a screening tool for the identification of neuropathic pain (NeP) as well as a tool for the characterization of patients' pain profile. In contrast to other NeP screening tools, the PD-Q is the only screening tool with weighted sensory descriptors. It is possible that responses to the PD-Q sensory descriptors are influenced by psychological factors, such as catastrophizing or anxiety, which potentially might contribute to an overall higher score of PD-Q and a false positive identification of NeP. This study aimed to explore (i) the relationship between psychological factors (catastrophizing, anxiety, depression and stress) and the total PD-Q score and (ii) if psychological factors are associated with false positive identifications of NeP on the PD-Q compared to clinically diagnosed NeP. Methods The study was a retrospective review of 1,101 patients attending an outpatient pain centre. Patients were asked to complete the PD-Q, the Pain Catastrophizing Scale (PCS), the Depression, Anxiety and Stress Scale (DASS) and the Brief Pain Inventory (BPI). For patients who were identified by PD-Q as having NeP, their medical records were reviewed to establish if they had a clinical diagnosis of NeP. Results Accounting for missing data, complete datasets of 652 patients (mean age 51 (SD14) years, range 18-88; 57% females) were available for analysis. Based on PD-Q scoring, NeP was likely present in 285 (44%) patients. Depression, anxiety, stress, catastrophizing, BPI pain and BPI interference were all significantly related to each other (p < 0.0001) and patients displaying these traits were significantly more likely to have a positive PD-Q score (p < 0.0001). For patients classified by PD-Q as having NeP, only 50% of patients had a clinical diagnosis of NeP. Anxiety was significantly associated with a false positive classification of NeP on PD-Q (p = 0.0036). Conclusions Our retrospective study showed that psychological factors including catastrophizing, depression, anxiety, and stress were all influential in producing a higher score on the PD-Q. We observed a high rate of false positive NeP classification which was associated with the presence of anxiety. Implications Clinicians and researchers should be aware that a patient's psychological state may influence the responses to PD-Q and consequently the final PD-Q score and its NeP classification.
Collapse
Affiliation(s)
- Brigitte Tampin
- Department of Physiotherapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.,Faculty of Business Management and Social Sciences, Hochschule Osnabrück, University of Applied Sciences, Osnabrück, Germany
| | - Jane Royle
- Department of Pain Management, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Chrianna Bharat
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia
| | - Michelle Trevenen
- Department of Research, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Applied Statistics, University of Western Australia, Perth, Western Australia, Australia
| | - Lisa Olsen
- Department of Pain Management, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Roger Goucke
- Department of Pain Management, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| |
Collapse
|
22
|
Otto JC, Forstenpointner J, Sachau J, Hüllemann P, Hukauf M, Keller T, Gierthmühlen J, Baron R. A Novel Algorithm to Identify Predictors of Treatment Response: Tapentadol Monotherapy or Tapentadol/Pregabalin Combination Therapy in Chronic Low Back Pain? Front Neurol 2019; 10:979. [PMID: 31572292 PMCID: PMC6753214 DOI: 10.3389/fneur.2019.00979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/27/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose: High dose monotherapies or drug combinations are used to achieve sufficient analgesia for the treatment of severe chronic low back pain, before invasive therapy options are considered. In order to demonstrate an alternative for an empirical treatment approach, the authors' primary aim was to present an algorithm for the objective identification of treatment predictors. Additionally, the study identified baseline-characteristics in chronic low back pain patients prior to tapentadol PR treatment, as well as scrutinized those patients, either benefitting from a medium/high dose tapentadol PR monotherapy or a combination therapy (medium dose tapentadol PR + pregabalin). Patients and Methods: The statistical approach included data of a previously published randomized, double blind, phase 3b study which compared the effectiveness and safety of tapentadol PR vs. a combination of tapentadol PR and pregabalin. In total, 46 clinical parameters were included in the statistical prediction models which were applied separately either to 50 patients who already responded well during the titration period (i.e., medium dose tapentadol PR) or to 261 patients with in the comparative treatment period [i.e., monotherapy (high dose tapentadol PR) or combination therapy (medium dose tapentadol PR/pregabalin)]. Results: The first statistical model identified three co-variables (NRS-3, PDQ, SQ) with predictive effects on patients responding well (“optimal responders”) to a medium dose tapentadol PR titration. Those patients presented low baseline pain intensity scores, good sleep quality and high painDETECT scores. The second statistical model identified eight co-variables (PDQ, numbness, SF-12 MCS, SF-12 PCS, VAS, HADS-A, HADS-D, SQ) with predictive effects on patients responding to high dose tapentadol PR monotherapy vs. a combination therapy (tapentadol PR + pregabalin). The high dose tapentadol PR responders indicated high painDETECT scores, little numbness and a good mental health status. Whereas, the combination therapy (tapentadol PR + pregabalin) responders were characterized by severe sleep disturbances and little anxiety. Conclusion: The statistical analysis characterized chronic low back pain patients and identified factors contributing to a treatment response. Thus, this retrospective statistical algorithm represents an elegant method, which may contribute to future strategies toward a more individualized and improved mechanism based pain therapy.
Collapse
Affiliation(s)
- Jan C Otto
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Julia Forstenpointner
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Juliane Sachau
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Philipp Hüllemann
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | | | | | - Janne Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| |
Collapse
|
23
|
Lee JH, Choi KH, Kang S, Kim DH, Kim DH, Kim BR, Kim W, Kim JH, Do KH, Do JG, Ryu JS, Min K, Bahk SG, Park YH, Bang HJ, Shin KH, Yang S, Yang HS, Yoo SD, Yoo JS, Yoon KJ, Yoon SJ, Lee GJ, Lee SY, Lee SC, Lee SY, Lee IS, Lee JS, Lee CH, Lim JY, Han JY, Han SH, Sung DH, Cho KH, Kim SY, Kim HJ, Ju W. Nonsurgical treatments for patients with radicular pain from lumbosacral disc herniation. Spine J 2019; 19:1478-1489. [PMID: 31201860 DOI: 10.1016/j.spinee.2019.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/02/2019] [Accepted: 06/04/2019] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Lumbosacral disc herniation (LDH) is one of the most frequent musculoskeletal diseases causative of sick leave in the workplace and morbidity in daily activities. Nonsurgical managements are considered as first line treatment before surgical treatment. PURPOSE This clinical practice guideline (CPG) is intended to provide physicians who treat patients diagnosed with LDH with a guideline supported by scientific evidence to assist in decision-making for appropriate and reasonable treatments. STUDY DESIGN/SETTING A systematic review. PATIENT SAMPLE Studies of human subjects written in Korean or English that met the following criteria were selected: patients aged ≥18 years, clinical presentation of low back and radicular leg pain, diagnosis of LDH on radiological evaluation including computed tomography or magnetic resonance imaging. OUTCOMES MEASURES Pain and functional evaluation scales such as visual analogue scale, numeric rating scale, and Oswestry disability index METHODS: The MEDLINE (PubMed), EMBASE, Cochrane Review, and KoreaMed databases were searched for articles regarding non-surgical treatments for LDH published up to July 2017. Of the studies fulfilling these criteria, those investigating clinical results after non-surgical treatment including physical and behavioral therapy, medication, and interventional treatment in terms of pain control and functional improvements were chosen for this study. RESULTS Nonsurgical treatments were determined to be clinically effective with regards to pain reduction and functional improvement in patients with LDH. Nevertheless, the evidence level was generally not evaluated as high degree, which might be attributed to the paucity of well-designed randomized controlled trials. Exercise and traction were strongly recommended despite moderate level of evidence. Epidural injection was strongly recommended with high degree of evidence and transforaminal approach was more strongly recommended than caudal approach. CONCLUSIONS This CPG provides new and updated evidence-based recommendations for treatment of the patients with LDH, which suggested that, despite an absence of high degrees of evidence level, non-surgical treatments were clinically effective.
Collapse
Affiliation(s)
- Jung Hwan Lee
- Namdarun Rehabilitation Clinic, Yongin-si, Gyeongg-do, South korea
| | - Kyoung Hyo Choi
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.
| | - Seok Kang
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, South Korea
| | - Dong Hwan Kim
- Department of Physical and Rehabilitation Medicine, College of Medicine, Kyung Hee University Hospital, South Korea
| | - Du Hwan Kim
- Department of Physical and Rehabilitation Medicine, Dongsan Medical Center, School of Medicine, Keimyung University, Daegu, South Korea
| | - Bo Ryun Kim
- Department of Rehabilitation Medicine, School of Medicine, Jeju National University, Jeju, South Korea
| | - Won Kim
- Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jung Hwan Kim
- Rehabilitation Hospital and Research Institute, National Rehabilitation Center, Seoul, South Korea
| | - Kyung Hee Do
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, South Korea
| | - Jong Geol Do
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ju Seok Ryu
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundnang Hospital, Seoul, South Korea
| | - Kyunghoon Min
- Department of Rehabilitation Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Sung Gin Bahk
- Department of Physical Medicine & Rehabilitation, Seocho Se Barun Hospital, Seoul, South Korea
| | - Yun Hee Park
- Department of Physical Medicine and Rehabilitation, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Heui Je Bang
- Department of Rehabilitation Medicine, College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Kyoung-Ho Shin
- Heal & Tun Rehabilitation Medicine Clinic, Seongnam-si, Gyeonggi-do, South Korea
| | - Seoyon Yang
- Department of Physical and Rehabilitation Medicine, Seoul Hyundai Hospital, Seoul, South Korea
| | - Hee Seung Yang
- Department of Physical and Rehabilitation Medicine, Veterans medical center, Seoul, South Korea
| | - Seung Don Yoo
- Department of Physical and Rehabilitation Medicine, Kyung Hee university, College of Medicine, Seoul, South Korea
| | - Ji Sung Yoo
- Department of Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, South Korea
| | - Kyung Jae Yoon
- Department of Physical and Rehabilitation Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Jin Yoon
- Department of Physical and Rehabilitation Medicine, Danam Rehabilitation Hospital, South Korea
| | - Goo Joo Lee
- Department of Rehabilitation Medicine, Chungbuk National University Hospital, Cheongju, South Korea
| | - Sang Yoon Lee
- Department of Rehabilitation Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Sang Chul Lee
- Department and Research Institute of Rehabilitation Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Yeol Lee
- Department of Physical Medicine and Rehabilitation, College of Medicine, Soonchunhyang University Hospital, Seoul, South Korea
| | - In-Sik Lee
- Department of Rehabilitation Medicine, Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, South Korea
| | - Jung-Soo Lee
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chang-Hyung Lee
- Department of Physical and Rehabilitation Medicine, Pusan National University Yangsan Hospital, School of Medicine, Pusan National University, Busan, South Korea
| | - Jae-Young Lim
- Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae-Young Han
- Department of Physical and Rehabilitation Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Seung Hoon Han
- Department of Rehabilitation Medicine, Hanyang University Guri Hospital, Seoul, South Korea
| | - Duk Hyun Sung
- Department of Physical Medicine and Rehabilitation, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kang Hee Cho
- Department of Physical and Rehabilitation Medicine, Chungnam National University, Daejeon, South Korea
| | - Soo Young Kim
- Department of Family Medicine, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Institute for Evidence-based Medicine, Cochrane Korea, College of Medicine, Korea University, Seoul, South Korea
| | - Woong Ju
- Department of Obstetrics and Gynecology, Ewha Womans University, Seoul, South Korea
| |
Collapse
|
24
|
Abstract
Tapentadol prolonged release (tapentadol PR) [Palexia® SR in EU] is a long-acting tablet formulation of the strong central analgesic tapentadol, which acts as both a μ-opioid receptor (MOR) agonist and a noradrenaline reuptake inhibitor. Tapentadol PR is approved for chronic pain in various countries, with its EU indication (severe chronic pain manageable only with opioid analgesics) being the focus here. Well-designed trials and clinical practice data support tapentadol PR use in this setting. Short term, tapentadol PR was an effective and generally well tolerated analgesic for moderate to severe pain of varying aetiologies, including neuropathic pain. It provided analgesia at least as good as that of conventional strong opioids and appeared more favourable in terms of gastrointestinal tolerability, likely due to less potent MOR binding. Severe back pain with a neuropathic component responded well to moderate-dose tapentadol PR in some patients, while for others, an increase to the maximum recommended tapentadol PR dosage provided analgesia at least as good as that of moderate-dose tapentadol PR plus pregabalin and appeared to have some CNS tolerability benefits. Data also support the use of tapentadol PR in opioid rotation, including when conventional opioids are intolerable. Longer-term data in musculoskeletal pain conditions indicate continued benefit over up to 2 years’ treatment with tapentadol PR with no evidence of tolerance. Thus, tapentadol PR is a useful option for the management of severe chronic pain.
Collapse
Affiliation(s)
- Emma D Deeks
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
| |
Collapse
|
25
|
Coluzzi F, Polati E, Freo U, Grilli M. Tapentadol: an effective option for the treatment of back pain. J Pain Res 2019; 12:1521-1528. [PMID: 31190963 PMCID: PMC6526923 DOI: 10.2147/jpr.s190176] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Back pain, including low back pain and neck pain, is the leading cause of disability worldwide. This type of pain is challenging to treat, since it presents both a nociceptive and a neuropathic component. The latter also contributes to the evolution of pain toward chronification. Treatment selection should therefore consider the ability to prevent this event. Tapentadol is characterized by a unique and innovative peculiar mechanism of action that makes it the first representative of a new class of central strong analgesics referred to as MOR-NRI. This molecule acts both on the nociceptive and neuropathic components of pain, and it can therefore be effective in the treatment of a mixed pain condition such as back pain. This narrative review discusses the rationale for the use of tapentadol in both low back pain and neck pain and presents available clinical data. Overall, data show that tapentadol prolonged release is a well-grounded treatment for chronic back pain, sustained by a strong mechanistic rationale and robust evidence. Given also the availability of long-term efficacy and safety data, we believe that this molecule should be considered as an elective therapy for chronic back pain.
Collapse
Affiliation(s)
- Flaminia Coluzzi
- Department of Medical and Surgical Sciences and Biotechnologies, Unit of Anesthesia, Intensive Care and Pain Medicine, SAPIENZA University of Rome - Polo Pontino, Latina, Italy,
| | - Enrico Polati
- Anesthesia and Intensive Care, Pain Relief Center, Ospedale Policlinico GB Rossi, Verona, Italy
| | - Ulderico Freo
- Anesthesiology and Intensive Medicine, Department of Medicine DIMED University of Padua, 35100 Padua, Italy
| | - Mariagrazia Grilli
- Laboratory of Neuroplasticity, Department of Pharmaceutical Sciences, University of Piemonte Orientale, 28100 Novara, Italy
| |
Collapse
|
26
|
Huang L, Khakimova D, Pruskowski J. Opioids for Neuropathic Pain #363. J Palliat Med 2018. [DOI: 10.1089/jpm.2018.0542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
27
|
Song L, Qiu P, Xu J, Lv J, Wang S, Xia C, Chen P, Fan S, Fang X, Lin X. The Effect of Combination Pharmacotherapy on Low Back Pain. Clin J Pain 2018; 34:1039-1046. [DOI: 10.1097/ajp.0000000000000622] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
28
|
Mathieson S, Kasch R, Maher CG, Pinto RZ, McLachlan AJ, Koes BW, Lin CWC. Combination Drug Therapy for the Management of Low Back Pain and Sciatica: Systematic Review and Meta-Analysis. THE JOURNAL OF PAIN 2018; 20:1-15. [PMID: 30585164 DOI: 10.1016/j.jpain.2018.06.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 06/07/2018] [Accepted: 06/25/2018] [Indexed: 12/27/2022]
Abstract
Combining medicines may give greater pain relief and/or improved tolerability. We conducted a systematic review to investigate the effects of combination drug therapy in patients with low back pain and/or sciatica on pain, disability, and adverse events. Databases and trial registers were searched from inception to July 27, 2017, for randomized trials of (sub)acute or chronic back pain or sciatica participants that were administered combination drug therapy compared with monotherapy or placebo. Of the 27 studies included, most combinations (21 of 23) consisted of single trials. Most combinations had no or small effect on pain and disability. A clinically important difference was found in one combination, buprenorphine plus pregabalin versus buprenorphine for chronic back pain at immediate (mean difference = -23.30; 95% confidence interval = -27.68 to -18.92) and short (mean difference = -27.60; 95% confidence interval = -31.70 to -23.50) terms; however, the quality of evidence was low. There was no statistically significant increased risk of serious adverse events. When the risk of adverse events was statistically significant, it favored monotherapy or placebo. There is no clear evidence to support any combination drug therapy for the management of low back pain and sciatica due to the limited number of studies and overall low quality of evidence. Perspective: Combining medicines may give greater pain relief and/or improved tolerability compared with single-ingredient medicines. However, the lack of studies and overall low quality of evidence limit the recommendation of combination drug therapy for the management of low back pain and sciatica.
Collapse
Affiliation(s)
- Stephanie Mathieson
- Sydney School of Public Health, University of Sydney and Institute for Musculoskeletal Health, Sydney, Australia..
| | - Richard Kasch
- Center for Orthopedics, Trauma Surgery and Rehabilitation Medicine; Clinic and Outpatient Clinic for Orthopedics and Orthopedic Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Christopher G Maher
- Sydney School of Public Health, University of Sydney and Institute for Musculoskeletal Health, Sydney, Australia
| | - Rafael Zambelli Pinto
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Bart W Koes
- Department of General Practice, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Chung-Wei Christine Lin
- Sydney School of Public Health, University of Sydney and Institute for Musculoskeletal Health, Sydney, Australia
| |
Collapse
|
29
|
Attal N, Bouhassira D, Baron R. Diagnosis and assessment of neuropathic pain through questionnaires. Lancet Neurol 2018; 17:456-466. [DOI: 10.1016/s1474-4422(18)30071-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/15/2022]
|
30
|
Abstract
Introduction Tapentadol is a centrally acting analgesic that has been available for the management of acute and chronic pain in routine clinical practice since 2009. Methods This is the first integrated descriptive analysis of post-marketing safety data following the use of tapentadol in a broad range of pain conditions relating to the topics overall safety, dose administration above approved dosages, administration during pregnancy, serotonin syndrome, respiratory depression, and convulsion. The data analyzed pertain to spontaneous reports from healthcare and non-healthcare professionals and were put in the context of safety information known from interventional and non-interventional trials. Results The first years of routine clinical practice experience with tapentadol have confirmed the tolerability profile that emerged from the clinical trials. Moreover, the reporting of expected side effects such as respiratory depression and convulsion was low and no major risks were identified. The evaluation of available post-marketing data did not confirm the theoretical risk of serotonin syndrome nor did it reveal unexpected side effects with administration of higher than recommended doses. Conclusion More than 8 years after its first introduction, the favorable overall safety profile of tapentadol in the treatment of various pain conditions is maintained in the general population. Funding Grünenthal GmbH. Electronic supplementary material The online version of this article (10.1007/s12325-017-0654-0) contains supplementary material, which is available to authorized users.
Collapse
|
31
|
Nicol AL, Hurley RW, Benzon HT. Alternatives to Opioids in the Pharmacologic Management of Chronic Pain Syndromes: A Narrative Review of Randomized, Controlled, and Blinded Clinical Trials. Anesth Analg 2017; 125:1682-1703. [PMID: 29049114 DOI: 10.1213/ane.0000000000002426] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic pain exerts a tremendous burden on individuals and societies. If one views chronic pain as a single disease entity, then it is the most common and costly medical condition. At present, medical professionals who treat patients in chronic pain are recommended to provide comprehensive and multidisciplinary treatments, which may include pharmacotherapy. Many providers use nonopioid medications to treat chronic pain; however, for some patients, opioid analgesics are the exclusive treatment of chronic pain. However, there is currently an epidemic of opioid use in the United States, and recent guidelines from the Centers for Disease Control (CDC) have recommended that the use of opioids for nonmalignant chronic pain be used only in certain circumstances. The goal of this review was to report the current body of evidence-based medicine gained from prospective, randomized-controlled, blinded studies on the use of nonopioid analgesics for the most common noncancer chronic pain conditions. A total of 9566 studies were obtained during literature searches, and 271 of these met inclusion for this review. Overall, while many nonopioid analgesics have been found to be effective in reducing pain for many chronic pain conditions, it is evident that the number of high-quality studies is lacking, and the effect sizes noted in many studies are not considered to be clinically significant despite statistical significance. More research is needed to determine effective and mechanism-based treatments for the chronic pain syndromes discussed in this review. Utilization of rigorous and homogeneous research methodology would likely allow for better consistency and reproducibility, which is of utmost importance in guiding evidence-based care.
Collapse
Affiliation(s)
- Andrea L Nicol
- From the *Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas; †Department of Anesthesiology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina; and ‡Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | |
Collapse
|
32
|
Palmitoylethanolamide in the Treatment of Failed Back Surgery Syndrome. PAIN RESEARCH AND TREATMENT 2017; 2017:1486010. [PMID: 28875041 PMCID: PMC5569747 DOI: 10.1155/2017/1486010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/07/2017] [Accepted: 05/16/2017] [Indexed: 01/09/2023]
Abstract
Introduction This observational study was designed to evaluate the efficacy of ultramicronized palmitoylethanolamide (um-PEA) (Normast®) administration, as add-on therapy for chronic pain, in the management of pain-resistant patients affected by failed back surgery syndrome. Methods A total of 35 patients were treated with tapentadol (TPD) and pregabalin (PGB). One month after the start of standard treatment, um-PEA was added for the next two months. Pain was evaluated by the Visual Analogue Scale (VAS) at the time of enrollment (T0) and after one (T1), two (T2), and three (T3) months. Results After the first month with TDP + PGB treatment only, VAS score decreased significantly from 5.7 ± 0.12 at the time of enrollment (T0) to 4.3 ± 0.11 (T1) (p < 0.0001); however, it failed to provide significant subjective improvement in pain symptoms. Addition of um-PEA led to a further and significant decrease in pain intensity, reaching VAS scores of 2.7 ± 0.09 (T2) and 1.7 ± 0.11 (T3, end of treatment) (p < 0.0001) without showing any side effects. Conclusions This observational study provides evidence, albeit preliminary, for the efficacy and safety of um-PEA (Normast) as part of a multimodal therapeutic regimen in the treatment of pain-resistant patients suffering from failed back surgery syndrome.
Collapse
|
33
|
Shanthanna H, Gilron I, Rajarathinam M, AlAmri R, Kamath S, Thabane L, Devereaux PJ, Bhandari M. Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. PLoS Med 2017; 14:e1002369. [PMID: 28809936 PMCID: PMC5557428 DOI: 10.1371/journal.pmed.1002369] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 07/06/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Chronic Low Back Pain (CLBP) is very common, with a lifetime prevalence between 51% and 80%. In majority, it is nonspecific in nature and multifactorial in etiology. Pregabalin (PG) and Gabapentin (GB) are gabapentinoids that have demonstrated benefit in neuropathic pain conditions. Despite no clear rationale, they are increasingly used for nonspecific CLBP. They necessitate prolonged use and are associated with adverse effects and increased cost. Recent guidelines from the National Health Service (NHS), England, expressed concerns on their off-label use, in addition to the risk of misuse. We aimed to assess the effectiveness and safety of gabapentinoids in adult CLBP patients. METHODS Electronic databases of MEDLINE, EMBASE, and Cochrane were searched from their inception until December 20th, 2016. We included randomized control trials reporting the use of gabapentinoids for the treatment of CLBP of >3 months duration, in adult patients. Study selection and data extraction was performed independently by paired reviewers. Outcomes were guided by Initiative on Methods, Measurement and Pain Assessment in Clinical Trials guidelines, with pain relief and safety as the primary outcomes. Meta-analyses were performed for outcomes reported in 3 or more studies. Outcomes were reported as mean differences (MDs) or risk ratios (RRs) with their corresponding 95% confidence intervals (CIs), and I2 in percentage representing the percentage variability in effect estimates that could be explained by heterogeneity. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to assess the quality of evidence. RESULTS Out of 1,385 citations, eight studies were included. Based on the interventions and comparators, studies were analyzed in 3 different groups. GB compared with placebo (3 studies, n = 185) showed minimal improvement of pain (MD = 0.22 units, 95% CI [-0.5 to 0.07] I2 = 0%; GRADE: very low). Three studies compared PG with other types of analgesic medication (n = 332) and showed greater improvement in the other analgesic group (MD = 0.42 units, 95% CI [0.20 to 0.64] I2 = 0; GRADE: very low). Studies using PG as an adjuvant (n = 423) were not pooled due to heterogeneity, but the largest of them showed no benefit of adding PG to tapentadol. There were no deaths or hospitalizations reported. Compared with placebo, the following adverse events were more commonly reported with GB: dizziness-(RR = 1.99, 95% CI [1.17 to 3.37], I2 = 49); fatigue (RR = 1.85, 95% CI [1.12 to 3.05], I2 = 0); difficulties with mentation (RR = 3.34, 95% CI [1.54 to 7.25], I2 = 0); and visual disturbances (RR = 5.72, 95% CI [1.94 to 16.91], I2 = 0). The number needed to harm with 95% CI for dizziness, fatigue, difficulties with mentation, and visual disturbances were 7 (4 to 30), 8 (4 to 44), 6 (4 to 15), and 6 (4 to 13) respectively. The GRADE evidence quality was noted to be very low for dizziness and fatigue, low for difficulties with mentation, and moderate for visual disturbances. Functional and emotional improvements were reported by few studies and showed no significant improvements. CONCLUSIONS AND RELEVANCE Existing evidence on the use of gabapentinoids in CLBP is limited and demonstrates significant risk of adverse effects without any demonstrated benefit. Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for CLBP merits caution. There is need for large high-quality trials to more definitively inform this issue. TRIAL REGISTRATION PROSPERO CRD42016034040.
Collapse
Affiliation(s)
- Harsha Shanthanna
- Department of Anesthesiology, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ian Gilron
- Departments of Anesthesiology & Perioperative Medicine and Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Manikandan Rajarathinam
- Department of Anesthesiology, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Rizq AlAmri
- Department of Anesthesiology, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada
| | - Sriganesh Kamath
- Department of Anesthesiology, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,Department of Neuroanesthesia, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Lehana Thabane
- Department of Anesthesiology, St Joseph's Healthcare, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Biostatistics Unit, St Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Philip J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mohit Bhandari
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.,Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
34
|
Dolor en el herpes zóster: prevención y tratamiento. Semergen 2017; 43:318-327. [DOI: 10.1016/j.semerg.2016.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/28/2016] [Accepted: 02/07/2016] [Indexed: 12/30/2022]
|
35
|
Abstract
There is tremendous interpatient variability in the response to analgesic therapy (even for efficacious treatments), which can be the source of great frustration in clinical practice. This has led to calls for "precision medicine" or personalized pain therapeutics (ie, empirically based algorithms that determine the optimal treatments, or treatment combinations, for individual patients) that would presumably improve both the clinical care of patients with pain and the success rates for putative analgesic drugs in phase 2 and 3 clinical trials. However, before implementing this approach, the characteristics of individual patients or subgroups of patients that increase or decrease the response to a specific treatment need to be identified. The challenge is to identify the measurable phenotypic characteristics of patients that are most predictive of individual variation in analgesic treatment outcomes, and the measurement tools that are best suited to evaluate these characteristics. In this article, we present evidence on the most promising of these phenotypic characteristics for use in future research, including psychosocial factors, symptom characteristics, sleep patterns, responses to noxious stimulation, endogenous pain-modulatory processes, and response to pharmacologic challenge. We provide evidence-based recommendations for core phenotyping domains and recommend measures of each domain.
Collapse
|
36
|
Buoli M, Caldiroli A, Serati M. Pharmacokinetic evaluation of pregabalin for the treatment of generalized anxiety disorder. Expert Opin Drug Metab Toxicol 2017; 13:351-359. [DOI: 10.1080/17425255.2017.1281247] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Massimiliano Buoli
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Caldiroli
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Serati
- Department of Psychiatry, University of Milan, Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
37
|
Baron R, Eberhart L, Kern KU, Regner S, Rolke R, Simanski C, Tölle T. Tapentadol Prolonged Release for Chronic Pain: A Review of Clinical Trials and 5 Years of Routine Clinical Practice Data. Pain Pract 2016; 17:678-700. [PMID: 27611642 DOI: 10.1111/papr.12515] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 07/08/2016] [Indexed: 01/07/2023]
Abstract
Tapentadol prolonged release (PR) for the treatment of moderate to severe chronic pain combines 2 modes of action. These are μ-opioid receptor agonism and noradrenaline reuptake inhibition in a single molecule that allow higher analgesic potency through modulation of different pharmacological targets within the pain transmitting systems. At the same time, this can also serve as a clue for modulation of different pain-generating mechanisms according to nociceptive, neuropathic, or mixed pain conditions. Tapentadol PR has now been on the market for 5 years, with over 4.6 million people treated worldwide. A panel of pain specialists convened in Germany to review the clinical program and to discuss the role of tapentadol PR in the management of chronic pain. The clinical study program demonstrated effective and generally well-tolerated treatment for up to 2 years in a broad range of chronic pain conditions, including those with neuropathic pain components. This was confirmed in routine clinical practice observations. Head-to-head studies with World Health Organization (WHO) III opioids such as oxycodone controlled release and oxycodone/naloxone PR showed at least comparable pain relief in the treatment of moderate-to-severe musculoskeletal pain. Rotation from poorly tolerated WHO III opioids to tapentadol PR provided effective pain relief and better symptom control for musculoskeletal pain compared to previous medication. Functionality, health status and quality of life also improved under tapentadol PR treatment. The gastrointestinal tolerability profile was more favorable compared to other tested WHO III opioids. Tapentadol PR has a good safety profile and no evidence of acquired tolerance from the long-term data so far collected. Overall, tapentadol PR represents an effective and generally well-tolerated alternative to "classical" opioidergic drugs.
Collapse
Affiliation(s)
- Ralf Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Leopold Eberhart
- Department of Anesthesiology and Critical Care Medicine, Philipps-University, Marburg, Germany
| | | | | | - Roman Rolke
- Department of Palliative Medicine, Medical Faculty RWTH Aachen University, Aachen, Germany
| | - Christian Simanski
- Department of Trauma, Hand and Foot Surgery, St. Martinus Hospital, Langenfeld, Germany
| | - Thomas Tölle
- Department of Neurology, Technische Universität, Munich, Germany
| |
Collapse
|
38
|
Förster M, Helfert S, Dierschke R, Großkopf M, Hüllemann P, Keller T, Baron R, Binder A. Evaluation of the antihyperalgesic effect of tapentadol in two human evoked pain models – the TapCapMentho pilot trial. Expert Opin Pharmacother 2016; 17:1717-25. [DOI: 10.1080/14656566.2016.1201071] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- M. Förster
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| | - S. Helfert
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| | - R. Dierschke
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| | - M. Großkopf
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| | - P. Hüllemann
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| | | | - R. Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| | - A. Binder
- Division of Neurological Pain Research and Therapy, Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany
| |
Collapse
|
39
|
Rosario M, Francesco R, Sergio F, Niccolò GL, Alba F, Maurizio N, Sergio A, Stefania G, Filippo A. Effectiveness of tapentadol prolonged release for the management of painful mucositis in head and neck cancers during intensity modulated radiation therapy. Support Care Cancer 2016; 24:4451-5. [PMID: 27448104 DOI: 10.1007/s00520-016-3351-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 07/10/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the effectiveness and tolerability profile of tapentadol prolonged release (PR) in a cohort of head and neck cancer (HNC) patients affected by background pain due to painful mucositis during intensity modulated radiation therapy with or without cisplatin with definitive and adjuvant intent. MATERIALS AND METHODS Tapentadol PR was administered at the moment of pain onset in opioid-naive patients at the dosage of 50 mg BID. The dosage was increased 50 mg twice a day until the optimal dose of no more than 500 mg/day of tapentadol PR. Primary endpoint of the analysis was the evaluation of improved assessment using the numerical rating scale (NRS). Secondary endpoints were as follows: (1) assessment of the treatment received using the patients' global impression of change (PGIC) scale; (2) weight increase/stability; (3) sleep quality; and (4) tolerability. The period of observation was 90 days from the start of antineoplastic treatment. RESULTS Between September 2014 and May 2015, 30 HNC patients were observed. The average age was 64.9 years (range, 36-80). Twenty-two days after the start of antineoplastic treatment, tapentadol PR was administered to 25 % of patients. This percentage was increased to 50 % after 39 days and to 75 % after 43 days. Considering the efficacy of tapentadol PR on daily pain, there was a reduction of 30 % (95 % C.I. 69.3 ÷ 96.2 %) in the pain score in 26 patients (86.7 %), and a reduction of 50 % (95 % C.I. 57.7 ÷ 90.1 %) in 23 patients (76.7 %). CONCLUSION The use of tapentadol PR is feasible and well tolerated in HNC patients affected by background pain due to painful mucositis during intensity modulated radiotherapy with or without cisplatin. Further studies are needed to enhance current findings.
Collapse
Affiliation(s)
- Mazzola Rosario
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy.
| | - Ricchetti Francesco
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Fersino Sergio
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Giaj Levra Niccolò
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Fiorentino Alba
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Nicodemo Maurizio
- Medical Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Albanese Sergio
- Head Neck Surgery, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Gori Stefania
- Medical Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| | - Alongi Filippo
- Radiation Oncology, Sacro Cuore Don Calabria Cancer Care Center, Negrar-Verona, Italy
| |
Collapse
|
40
|
In Reply. Anesthesiology 2016; 125:256-7. [DOI: 10.1097/aln.0000000000001148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
41
|
Bhatia A. Questions Regarding "Efficacy of Duloxetine in Chronic Low Back Pain with a Neuropathic Component". Anesthesiology 2016; 125:255-6. [PMID: 27326500 DOI: 10.1097/aln.0000000000001147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Anuj Bhatia
- Toronto Western Hospital, University of Toronto, Ontario, Canada.
| |
Collapse
|
42
|
Abstract
Background and objectives The painDETECT questionnaire (PD-Q), a simple and reliable screening questionnaire of neuropathic pain, was developed in 2004 in cooperation with the German Research Network on Neuropathic Pain. The initial aim was to implement quality management and to improve the situation of neuropathic pain (NeP) patients in Germany. The PD-Q proved immediately successful and was translated into and validated in multiple languages. Subsequently a comprehensive electronic system (PD) comprising various validated questionnaires with regard to pain typical comorbidities, such as function, sleep, mood or anxiety, was implemented Germany wide. We aimed to provide a comprehensive overview about the development and validation as well as the application of the PD-Q in various clinical conditions. Methods This overview is based on a literature search on English full-text papers using the term 'painDETECT' in Medline and PubMed covering the time period from 2006 to September 2015, amended with further publications cited in the retrieved publications or provided by the questionnaire developers. Results PD-Q as screening tool for NeP described in patients with lower back pain (8 studies), rheumatoid arthritis and osteoarthritis (10), thoracotomy (2 studies), tumor diseases (4 studies), fibromyalgia (4 studies), diverse musculoskeletal conditions (12 studies) and diverse other conditions (10 studies). In addition, the PD-Q was used in 9 studies that investigated the effect of drugs for the treatment of patients with a NeP component. Conclusion To date more than 300,000 patients were assessed, providing the basis for one of the world's largest datasets for chronic pain. Among others the extensive pool of PD-Q data triggered the idea of subgrouping patients on the basis of their individual sensory profiles which might in the future lead to a stratified treatment approach and ultimately to personalized therapy. Started as a healthcare utilization project in Germany, the PD-Q is nowadays used for clinical and research purposes around the world.
Collapse
Affiliation(s)
- Rainer Freynhagen
- a Zentrum für Anästhesiologie, Intensivmedizin, Schmerztherapie & Palliativmedizin, Benedictus Krankenhaus , Tutzing , Germany
- b Technische Universität, Klinik für Anästhesiologie , München , Germany
| | - Thomas R Tölle
- c Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität , München , Germany
| | | | - Ralf Baron
- e Neurologische Klinik und Poliklink, Christians-Albrechts-Universität , Kiel , Germany
| |
Collapse
|
43
|
Efficacy of Duloxetine in Chronic Low Back Pain with a Neuropathic Component: A Randomized, Double-blind, Placebo-controlled Crossover Trial. Anesthesiology 2016; 124:150-8. [PMID: 26517858 DOI: 10.1097/aln.0000000000000902] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Among patients with chronic low back pain (CLBP), approximately 37% show signs of a neuropathic pain component (radicular pain). Treatment of this condition remains challenging. Therefore, the current study aimed to investigate the efficacy of duloxetine in the treatment of CLBP patients with neuropathic leg pain. METHODS The study was conducted as a prospective, randomized, placebo-controlled, double-blind crossover trial. CLBP with a visual analog scale (VAS) score greater than 5 and a neuropathic component that was assessed clinically and by the painDETECT questionnaire (score > 12) were required for inclusion. Patients were randomly assigned to either duloxetine or placebo for 4 weeks followed by a 2-week washout period before they crossed over to the alternate phase that lasted another 4 weeks. Duloxetine was titrated up to 120 mg/day. The primary outcome parameter was mean VAS score during the last week of treatment in each phase (VAS(week4)). RESULTS Of 41 patients, 21 patients completed both treatment phases. In the intention-to-treat analysis (n = 25), VAS(week4) was significantly lower in the duloxetine phase compared with placebo (4.1 ± 2.9 vs. 6.0 ± 2.7; P = 0.001), corresponding to an average pain reduction of 32%. The painDETECT score at the end of each treatment phase was significantly lower in the duloxetine phase compared with placebo (17.7 ± 5.7 vs. 21.3 ± 3.6 points; P = 0.0023). Adverse events were distributed equally between the duloxetine (65%) and placebo phases (62%) (P = 0.5). CONCLUSION In this crossover study, duloxetine proved to be superior to placebo for the treatment of CLBP with a neuropathic leg pain.
Collapse
|
44
|
Baron R, Binder A, Attal N, Casale R, Dickenson AH, Treede RD. Neuropathic low back pain in clinical practice. Eur J Pain 2016; 20:861-73. [PMID: 26935254 PMCID: PMC5069616 DOI: 10.1002/ejp.838] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background and objective Low back pain (LBP) is one of the most common chronic pain conditions. This paper reviews the available literature on the role of neuropathic mechanisms in chronic LBP and discusses implications for its clinical management, with a particular focus on pharmacological treatments. Databases and data treatment Literature searches were performed in PubMed, key pain congresses and ProQuest Dialog to identify published evidence on neuropathic back pain and its management. All titles were assessed for relevant literature. Results Chronic LBP comprises both nociceptive and neuropathic components, however, the neuropathic component appears under‐recognized and undertreated. Neuropathic pain (NP) is challenging to manage. Many patients with chronic LBP have pain that is refractory to existing treatments. Typically, less than half of patients experience clinically meaningful analgesia with oral pharmacotherapies; these are also associated with risks of adverse effects. Paracetamol and NSAIDs, although widely used for LBP, are unlikely to ameliorate the neuropathic component and data on the use of NP medications such as antidepressants and gabapentin/pregabalin are limited. While there is an unmet need for improved treatment options, recent data have shown tapentadol to have efficacy in the neuropathic component of LBP, and studies suggest that the capsaicin 8% patch and lidocaine 5% medicated plaster, topical analgesics available for the treatment of peripheral NP, may be a valuable additional approach for the management of neuropathic LBP. Conclusions Chronic LBP often has an under‐recognized neuropathic component, which can be challenging to manage, and requires improved understanding and better diagnosis and treatment. What does this review add? Increased recognition and improved understanding of the neuropathic component of low back pain raises the potential for the development of mechanism‐based therapies. Open and retrospective studies suggest that agents like tapentadol and topical analgesics — such as the capsaicin 8% patch and the lidocaine 5% medicated plaster — may be effective options for the treatment of neuropathic low back pain in defined patient groups.
Collapse
Affiliation(s)
- R Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - A Binder
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - N Attal
- INSERM U 987 and Centre d'Evaluation et de Traitement De La Douleur, APHP, Boulogne-Billancourt, France
| | - R Casale
- Habilita Care & Research Hospitals, 24040, Zingonia di Ciserano, Italy
| | - A H Dickenson
- Department of Neuroscience, Physiology and Pharmacology, University College London, UK
| | - R-D Treede
- Centre of Biomedicine and Medical Technology Mannheim, Heidelberg University, Mannheim, Germany
| |
Collapse
|
45
|
Akinci A, Al Shaker M, Chang MH, Cheung CW, Danilov A, José Dueñas H, Kim YC, Guillen R, Tassanawipas W, Treuer T, Wang Y. Predictive factors and clinical biomarkers for treatment in patients with chronic pain caused by osteoarthritis with a central sensitisation component. Int J Clin Pract 2016; 70:31-44. [PMID: 26558538 PMCID: PMC4738415 DOI: 10.1111/ijcp.12749] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIMS The aim of this non-systematic review was to provide a practical guide for clinicians on the evidence for central sensitisation in chronic osteoarthritis (OA) pain and how this pain mechanism can be addressed in terms of clinical diagnosis, investigation and treatment. METHODS The authors undertook a non-systematic review of the literature including a MEDLINE search (search terms included central sensitisation, osteoarthritis, osteoarthrosis) for relevant and current clinical studies, systematic reviews and narrative reviews. Case reports, letters to the editor and similar literature sources were excluded. Information was organised to allow a pragmatic approach to the discussion of the evidence and generation of practical recommendations. RESULTS There is good evidence for a role of central sensitisation in chronic OA pain in a subgroup of patients. Clinically, a central sensitisation component in chronic OA pain can be suspected based on characteristic pain features and non-pain features seen in other conditions involving central sensitisation. However, there are currently no diagnostic inventories for central sensitisation specific to OA. Biomarkers may be helpful for confirming the presence of central sensitisation, especially when there is diagnostic uncertainty. Several non-pharmacological and pharmacological treatments may be effective in OA patients with central sensitisation features. Multimodal therapy may be required to achieve control of symptoms. DISCUSSION Clinicians should be aware of central sensitisation in patients with chronic OA pain, especially in patients presenting with severe pain with unusual features.
Collapse
Affiliation(s)
- A Akinci
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Hacettepe University, Ankara, Turkey
| | - M Al Shaker
- King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia
| | - M H Chang
- Taichung Veterans General Hospital, Taichung, Taiwan
| | - C W Cheung
- Department of Anaesthesiology, Laboratory and Clinical Research Institute for Pain, The University of Hong Kong, Hong Kong, China
| | - A Danilov
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Y C Kim
- Seoul National University School of Medicine, Pain Management Center of the Seoul National University Hospital, Seoul, Korea
| | - R Guillen
- Pain Clinic, National Cancer Institute, México DF, México
| | - W Tassanawipas
- Department of Orthopaedics, Phramongkutklao Army Hospital, Bangkok, Thailand
| | - T Treuer
- Eli Lilly and Co, Budapest, Hungary
| | - Y Wang
- Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
46
|
Cohen SP, Hanling S, Bicket MC, White RL, Veizi E, Kurihara C, Zhao Z, Hayek S, Guthmiller KB, Griffith SR, Gordin V, White MA, Vorobeychik Y, Pasquina PF. Epidural steroid injections compared with gabapentin for lumbosacral radicular pain: multicenter randomized double blind comparative efficacy study. BMJ 2015; 350:h1748. [PMID: 25883095 PMCID: PMC4410617 DOI: 10.1136/bmj.h1748] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate whether an epidural steroid injection or gabapentin is a better treatment for lumbosacral radiculopathy. DESIGN A multicenter randomized study conducted between 2011 and 2014. Computer generated randomization was stratified by site. Patients and evaluating physicians were blinded to treatment outcomes. SETTINGS Eight military, Veterans Administration, and civilian hospitals. PARTICIPANTS 145 people with lumbosacral radicular pain secondary to herniated disc or spinal stenosis for less than four years in duration and in whom leg pain is as severe or more severe than back pain. INTERVENTIONS Participants received either epidural steroid injection plus placebo pills or sham injection plus gabapentin. MAIN OUTCOME MEASURES Average leg pain one and three months after the injection on a 0-10 numerical rating scale. A positive outcome was defined as a ≥ 2 point decrease in leg pain coupled with a positive global perceived effect. All patients had one month follow-up visits; patients whose condition improved remained blinded for their three month visit. RESULTS There were no significant differences for the primary outcome measure at one month (mean pain score 3.3 (SD 2.6) and mean change from baseline -2.2 (SD 2.4) in epidural steroid injection group versus 3.7 (SD 2.6) and -1.7 (SD 2.6) in gabapentin group; adjusted difference 0.4, 95% confidence interval -0.3 to 1.2; P=0.25) and three months (mean pain score 3.4 (SD 2.7) and mean change from baseline -2.0 (SD 2.6) versus 3.7 (SD 2.8) and -1.6 (SD 2.7), respectively; adjusted difference 0.3, -0.5 to 1.2; P=0.43). Among secondary outcomes, one month after treatment those who received epidural steroid injection had greater reductions in worst leg pain (-3.0, SD 2.8) than those treated with gabapentin (-2.0, SD 2.9; P=0.04) and were more likely to experience a positive successful outcome (66% v 46%; number needed to treat=5.0, 95% confidence interval 2.8 to 27.0; P=0.02). At three months, there were no significant differences between treatments. CONCLUSIONS Although epidural steroid injection might provide greater benefit than gabapentin for some outcome measures, the differences are modest and are transient for most people.Trial registration ClinicalTrials.gov Identifier: NCT01495923.
Collapse
Affiliation(s)
- Steven P Cohen
- Blaustein Pain Treatment Center, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, MD, USA Walter Reed National Military Medical Center, Bethesda, MD, USA Blaustein Pain Treatment Center, Department of Anesthesiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven Hanling
- Pain Medicine Division, Department of Anesthesiology, Naval Medical Center-San Diego, USA
| | - Mark C Bicket
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA, USA
| | - Ronald L White
- Interdisciplinary Pain Medicine, Department of Surgery, Landstuhl, Regional Medical Center, Landstuhl, Germany
| | - Elias Veizi
- Pain Medicine Service Department of Anesthesiology, Louis Stokes Cleveland VA Medical Center, Case Western University, Cleveland, OH, USA
| | - Connie Kurihara
- Anesthesia Service, Department of Surgery, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Zirong Zhao
- Department of Neurology, District of Columbia VA Hospital, Washington DC, MD, USA Department of Medicine, George Washington University, Washington DC, MD, USA
| | - Salim Hayek
- Pain Medicine Division, Department of Anesthesiology, Case Western Reserve School of Medicine, Cleveland, OH, USA
| | - Kevin B Guthmiller
- Interdisciplinary Pain Management Clinic, Department of Anesthesiology, San Antonio Military Medical Center, San Antonio, TX, USA Pain Medicine Fellowship Program, Department of Anesthesiology, San Antonio Military Medical Center, San Antonio, TX, USA
| | | | - Vitaly Gordin
- Pain Medicine Division, Department of Anesthesiology, Penn State Hershey Medical Center, Hershey, PA, USA
| | | | - Yakov Vorobeychik
- Departments of Anesthesiology and Neurology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Paul F Pasquina
- Department of Physical Medicine and Rehabilitation, Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| |
Collapse
|
47
|
Lasting Prolonged-Release Tapentadol for Moderate/Severe Non-Cancer Musculoskeletal Chronic Pain. Pain Ther 2015; 4:107-17. [PMID: 25558866 PMCID: PMC4470964 DOI: 10.1007/s40122-014-0030-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Indexed: 12/12/2022] Open
Abstract
Introduction Despite opioids’ recognized role in the treatment of moderate/severe musculoskeletal chronic pain, their long-term benefits need investigation. We explored the lasting analgesic efficacy, tolerability, influence on life quality, and chronicity stage of the novel prolonged release (PR) opioid, tapentadol, in 30 outpatients. Methods We evaluated patients’ pain intensity and relief (Numerical Rating Scale; NRS), adverse effects, sleep quality, treatment satisfaction, health status (12-questions Health-Survey; SF-12), chronicity stage (Italian Mainz Pain-Staging System; I-MPSS) at 10, 30, 60, and 90 days after tapentadol prescription. Results At follow-ups, the investigated outcomes showed an overall statistically significant (Wilcoxon signed-rank test) improvement and remained stable over time, as did the health status and chronicity stage. Adverse effects were limited, transitory, and tolerable. Conclusions Twelve weeks of PR tapentadol in outpatients with moderate/severe chronic musculoskeletal pain showed satisfactory analgesic efficacy and tolerability, and had a positive influence on life quality and chronicity stage. The results are robust enough to warrant a subsequent study with a larger sample and a longer observation period.
Collapse
|
48
|
Freynhagen R, Serpell M, Emir B, Whalen E, Parsons B, Clair A, Latymer M. A comprehensive drug safety evaluation of pregabalin in peripheral neuropathic pain. Pain Pract 2015; 15:47-57. [PMID: 24279736 PMCID: PMC4320770 DOI: 10.1111/papr.12146] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/07/2013] [Indexed: 12/12/2022]
Abstract
Pregabalin is a commonly used therapy currently recommended as first-line treatment for a number of neuropathic pain (NeP) conditions. Since licensure, a number of clinical trials of pregabalin in different NeP conditions have been completed from which additional data on safety and tolerability can be drawn. In this analysis, patient-level data from 31 randomized clinical trials of pregabalin in peripheral NeP sponsored by Pfizer were pooled and assessed for incidence of adverse events (AEs). Incidence by age, disease condition, and race, together with risk differences and time to onset and resolution of AEs, was assessed. In total, 7,510 patients were included: 4,884 on pregabalin (representing 805 patient-years treatment) and 2,626 on placebo. Pregabalin vs. placebo risk analysis identified 9 AEs with a risk difference, for which the lower limit of the 95% confidence interval (CI) was > 1%: dizziness (risk difference [95% CI]: (17.0 [15.4 to 18.6]), somnolence (10.8 [9.5 to 12.1]), peripheral edema (5.4 [4.3 to 6.4]), weight increase (4.7 [3.9 to 5.5]), dry mouth (2.9 [2.1 to 3.8]), constipation (2.3 [1.5 to 3.2]), blurred vision (2.2 [1.6 to 2.9]), balance disorder (2.0 [1.5 to 2.5]), and euphoric mood (1.6 [1.2 to 2.0]). The most common AEs, dizziness and somnolence, typically emerged within the first 1 to 2 weeks of treatment and resolved 1 to 2 weeks later, without resulting in cessation of treatment. The data from this review provide information, indicating which AEs may be expected in patients treated with pregabalin, and suggest that careful dose titration to the highest tolerable dose is the most appropriate approach in clinical practice.
Collapse
Affiliation(s)
- Rainer Freynhagen
- Zentrum für Anästhesiologie, Intensivmedizin, Schmerztherapie & Palliativmedizin, Benedictus Krankenhaus, Tutzing and Klinik für Anästhesiologie, Technische Universität MünchenMünchen, Germany
| | - Michael Serpell
- Gartnavel General Hospital and Glasgow UniversityGlasgow, U.K
| | - Birol Emir
- Pfizer IncNew York City, New York, U.S.A
| | - Ed Whalen
- Pfizer IncNew York City, New York, U.S.A
| | | | | | | |
Collapse
|
49
|
Markman JD, Frazer ME, Rast SA, McDermott MP, Gewandter JS, Chowdhry AK, Czerniecka K, Pilcher WH, Simon LS, Dworkin RH. Double-blind, randomized, controlled, crossover trial of pregabalin for neurogenic claudication. Neurology 2014; 84:265-72. [PMID: 25503625 PMCID: PMC4335998 DOI: 10.1212/wnl.0000000000001168] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives: To test the effects of pregabalin on the induction of neurogenic claudication. Methods: This study was a randomized, double-blind, active placebo-controlled, 2-period, crossover trial. Twenty-nine subjects were randomized to receive pregabalin followed by active placebo (i.e., diphenhydramine) or active placebo followed by pregabalin. Each treatment period lasted 10 days, including a 2-step titration. Periods were separated by a 10-day washout period, including a 3-day taper phase after the first period. The primary outcome variable was the time to first moderate pain symptom (Numeric Rating Scale score ≥4) during a 15-minute treadmill test (Tfirst). Secondary outcome measures included pain intensity at rest, pain intensity at the end of the treadmill test, distance walked, and validated self-report measures of pain and functional limitation including the Roland-Morris Disability Questionnaire, modified Brief Pain Inventory–Short Form, Oswestry Disability Index, and Swiss Spinal Stenosis Questionnaire. Results: No significant difference was found between pregabalin and active placebo for the time to first moderate pain symptom (difference in median Tfirst = −1.08 [95% confidence interval −2.25 to 0.08], p = 0.61). In addition, none of the secondary outcome measures of pain or functional limitation were significantly improved by pregabalin compared with active placebo. Conclusions: Pregabalin was not more effective than active placebo in reducing painful symptoms or functional limitations in patients with neurogenic claudication associated with lumbar spinal stenosis. Classification of evidence: This study provides Class I evidence that for patients with neurogenic claudication, compared with diphenhydramine, pregabalin does not increase the time to moderate pain during a treadmill test.
Collapse
Affiliation(s)
- John D Markman
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA.
| | - Maria E Frazer
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Shirley A Rast
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Michael P McDermott
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Jennifer S Gewandter
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Amit K Chowdhry
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Kate Czerniecka
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Webster H Pilcher
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Lee S Simon
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| | - Robert H Dworkin
- From the Department of Neurosurgery, Translational Pain Research Program (J.D.M., M.E.F., S.A.R., K.C., W.H.P.), and Departments of Biostatistics and Computational Biology (M.P.M., A.K.C.), Neurology (M.P.M., A.K.C.), and Anesthesiology (J.S.G., R.H.D.), University of Rochester School of Medicine and Dentistry, Rochester, NY; and SDG LLC (L.S.S.), Cambridge, MA
| |
Collapse
|
50
|
Yavuz F, Guzelkucuk U. Diagnosis and pharmacologic management of neuropathic pain among patients with chronic low back pain. World J Rheumatol 2014; 4:54-61. [DOI: 10.5499/wjr.v4.i3.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 06/29/2014] [Accepted: 10/16/2014] [Indexed: 02/06/2023] Open
Abstract
Chronic low back pain consists of both nociceptive and neuropathic mechanisms and can be classified as a mixed pain syndrome. Neuropathic component of chronic low back pain has often been under-recognized and under-treated by the physicians. Recent studies have demonstrated that approximately 20%-55% of chronic low back pain patients have neuropathic pain symptoms. An altered peripheral, spinal, and supraspinal processing of pain arising as a result of a lesion affecting the nerves system are the major contributor to neuropathic low back pain. The clinical evaluation is still the gold standard for assessment and diagnosis of neuropathic low back pain. Although diagnosis can be difficult due to the lack of reliable gold standard diagnostic test for neuropathic low back pain, screening tools may help non-specialists, in particular, to identify potential patients with neuropathic low back pain who require further diagnostic evaluation and pain management. Several screening tools for neuropathic pain have been developed and tested with different patient populations. Among the screening tools, the painDETECT questionnaire and the Standardized Evaluation of Pain are validated in patients with low back pain. The Standardized Evaluation of Pain may lead to more effective in discriminating between neuropathic and nociceptive pain in patients with low back pain according to the higher rate of sensitivity and its validity in patients with low back pain. However, the most appropriate approach is still to combine findings on physical and neurologic examinations and patient’s report in distinguishing neuropathic pain from nociceptive pain. The clinical examination including bedside sensory tests is still the best available tool for assessment and diagnosis neuropathic pain among patients with chronic low back pain. Due to the fact that chronic low back pain consists of both nociceptive and neuropathic mechanisms, a multimodal treatment approach is more rational in the management of patients with chronic low back pain. Therefore, combination therapy including drugs with different mechanisms of action should be given to the patients with chronic low back pain.
Collapse
|