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Van den Heuvel SAS, Cohen SPC, de Andrès Ares J, Van Boxem K, Kallewaard JW, Van Zundert J. 3. Pain originating from the lumbar facet joints. Pain Pract 2024; 24:160-176. [PMID: 37640913 DOI: 10.1111/papr.13287] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Pain originating from the lumbar facets can be defined as pain that arises from the innervated structures comprising the joint: the subchondral bone, synovium, synovial folds, and joint capsule. Reported prevalence rates range from 4.8% to over 50% among patients with mechanical low back pain, with diagnosis heavily dependent on the criteria employed. In well-designed studies, the prevalence is generally between 10% and 20%, increasing with age. METHODS The literature on the diagnosis and treatment of lumbar facet joint pain was retrieved and summarized. RESULTS There are no pathognomic signs or symptoms of pain originating from the lumbar facet joints. The most common reported symptom is uni- or bilateral (in more advanced cases) axial low back pain, which often radiates into the upper legs in a non-dermatomal distribution. Most patients report an aching type of pain exacerbated by activity, sometimes with morning stiffness. The diagnostic value of abnormal radiologic findings is poor owing to the low specificity. SPECT can accurately identify joint inflammation and has a predictive value for diagnostic lumbar facet injections. After "red flags" are ruled out, conservatives should be considered. In those unresponsive to conservative therapy with symptoms and physical examination suggesting lumbar facet joint pain, a diagnostic/prognostic medial branch block can be performed which remains the most reliable way to select patients for radiofrequency ablation. CONCLUSIONS Well-selected individuals with chronic low back originating from the facet joints may benefit from lumbar medial branch radiofrequency ablation.
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Affiliation(s)
- Sandra A S Van den Heuvel
- Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Steven P C Cohen
- Anesthesiology, Pain Medicine Division, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | | | - Koen Van Boxem
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan Willem Kallewaard
- Anesthesiology and Pain Medicine, Rijnstate Ziekenhuis, Velp, The Netherlands
- Anesthesiology and Pain Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jan Van Zundert
- Anesthesiology, Critical Care and Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium
- Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
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Olivier TJ, Baltich Nelson B, Pham T, Trivedi K, Patel A, Sharma GS, Konda C, Annaswamy TM. Quality of clinical practice guidelines on interventional management of low back pain: A systematic review. PM R 2023; 15:1038-1051. [PMID: 35014199 DOI: 10.1002/pmrj.12760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 10/21/2021] [Accepted: 12/06/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To appraise the quality of low back pain (LBP) clinical practice guidelines (CPG) that include interventional management recommendations and to associate their quality with characteristics including publication year and creating organization. TYPE: Systematic Review. LITERATURE SURVEY LBP (subacute or chronic) CPGs in English (symptom based, governmental or professional society created, January 1990-May 2020) were found using MEDLINE, EMBASE, CINAHL, Ortho Guidelines, CPG Infobase, ECRI, Guidelines International Network, NICE, and SIGN. METHODOLOGY In this third order systematic review, search results were deduplicated, title and abstract screened by two independent reviewers, and full texts reviewed by four reviewers. Discrepancies were resolved by a third reviewer. Resulted CPGs were appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Tool by four appraisers each. Association of their quality with creating organization, geographical region, and year of creation was calculated. SYNTHESIS Seven hundred fourteen screened documents resulted in 21 final CPGs. On appraisal, average overall CPG quality was 5.2 (range 2.5-6.75). Domain 5 (applicability) had the lowest average (44%) and domain 4 (clarity of presentation) had the highest average score (82%). For overall recommendation, 16 received "yes" or "yes with modifications," six received unanimous "yes" and two unanimous "no" votes. The interrater agreement of domain scoring was excellent (0.8-1.0; p < .001). There was no association found between quality of CPG and (1) year of publication (R2 = 0.0006), (2) whether the CPG was updated or new (p = .17), and (3) region of publication (p = .37). CONCLUSIONS The majority of the 21 CPGs identified in this systematic review were of high quality, but overall quality and recommendation ratings were variable. The quality of appraised CPGs showed no association with their characteristics. Some domains such as "applicability" scored uniformly lower, revealing opportunity for improvement in future CPG development. LBP CPGs should be scrutinized before adopting their recommendations.
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Affiliation(s)
- Timothy J Olivier
- University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | | | - Tri Pham
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Kavita Trivedi
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ankit Patel
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - G Sunny Sharma
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Chaitanya Konda
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
- Physical Medicine & Rehabilitation Service, VA North Texas Health Care System, Dallas, Texas, USA
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Olivier TJ, Konda C, Pham T, Baltich Nelson B, Patel A, Sharma GS, Trivedi K, Annaswamy TM. Clinical practice guidelines on interventional management of low back pain: A synthesis of recommendations. PM R 2023; 15:1052-1063. [PMID: 36507598 DOI: 10.1002/pmrj.12930] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Revised: 11/14/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To summarize the recommendations on the interventional management of subacute and chronic nonradicular low back pain (LBP) from the 21 quality-appraised clinical practice guidelines (CPGs) identified in a previously published paper: "Quality of Clinical Practice Guidelines on Interventional Management of Low Back Pain: A Systematic Review." By disseminating this information, we aimed to facilitate the implementation of these recommendations into clinical practice. TYPE: Systematic Review LITERATURE SURVEY: Electronic bibliographic databases, guideline databases, and gray literature were searched from January 2016 to January 2020 to identify CPGs that met study criteria. METHODOLOGY A total of 21 CPGs were quality appraised and interventional management recommendations were extracted and organized into several treatment categories including epidural steroid injections, radiofrequency procedures (RF), facet injections, sacroiliac injections, and prolotherapy. Within each treatment category, the recommendations were organized based on two factors: quality of CPG and strength of recommendation. SYNTHESIS Overall, there was no consistency in recommendations for or against any interventional procedure, even when accounting for the quality of the CPG. In all of the CPGs reviewed, the most common strength of recommendation was weakly for. The second, third, and fourth most common strength of recommendations were inconclusive, weakly against, and strongly against, respectively, and the least common was strongly for. The treatment categories with the greatest number of recommendations were RF procedures (most common strength of recommendation was weakly for) and facet procedures. Among the high-quality CPGs, the most common strength of recommendation was inconclusive. CONCLUSIONS Most of the interventional management recommendations for management of nonradicular LBP in the 21 CPGs appraised in this review were either weakly for, weakly against, or inconclusive, with several recommendations within each treatment category contradicting each other. Appraisal of Guidelines for Research & Evaluation Instrument quality appraisals of CPGs on interventional management of LBP were of unclear utility in guiding clinical implementation.
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Affiliation(s)
- Timothy J Olivier
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Chaitanya Konda
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Tri Pham
- University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Becky Baltich Nelson
- Clinical Library, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Ankit Patel
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - G Sunny Sharma
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kavita Trivedi
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thiru M Annaswamy
- Department of Physical Medicine & Rehabilitation, UT Southwestern Medical Center, Dallas, Texas, USA
- Physical Medicine & Rehabilitation Service, VA North Texas Health Care System, Dallas, Texas, USA
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Farooque M. Specific and Nonspecific Low Back Pain-Mind the Gap and its Impact in Clinical Practice: Opinion of a Recovering Interventional Spine Physiatrist. Spine J 2023:S1529-9430(23)00170-5. [PMID: 37116719 DOI: 10.1016/j.spinee.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/18/2023] [Indexed: 04/30/2023]
Affiliation(s)
- Mustafa Farooque
- Department of Medicine at the University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA; Back & Spine Program at Aurora St. Luke's Medical Center, Milwaukee, WI, 2901 W Kinnickinnic River Pkwy, Suite 310, Milwaukee, WI.
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Sarvilina IV, Danilov AB. [Comparative analysis of the use of symptomatic slow acting drugs for osteoarthritis containing chondroitin sulfate or affecting its biosynthesis in patients with non-specific low back pain]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:81-96. [PMID: 36719123 DOI: 10.17116/jnevro202312301181] [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: 02/01/2023]
Abstract
OBJECTIVE Retrospective comparative analysis of the use of SYSADOA preparations containing chondroitin sulfate (Chondroguard, 2 ml, 25 amp., glycosaminoglycan-peptide complex, 1 ml 25 amp., bioactive concentrate of small marine fish, 2 ml, 10 amp.) in patients with chronic non-specific low back pain (LBP) of lumbar and sacral localization caused by spondylosis and osteochondrosis of the lumbar spine, at the stage of outpatient care. MATERIAL AND METHODS Data of medical records of patients (n=120; men - 32, women - 88, age - 54.1±7.6 years, duration of disease exacerbation 4.0±1.7 months) with nonspecific LBP were systematized according to the inclusion/exclusion criteria. All patients were divided into 4 groups: Group 1 (n=30) received Chondroguard im., 2 ml every other day, the course of treatment was 25 injections, 25 days; Group 2 (n=30) received glycosaminoglycan-peptide complex on the 1st day - 0.3 ml, on the 2nd day - 0.5 ml, and then 3 times a week for 1 ml, course of treatment - 25 injections, 25 days; Group 3 (n=30) received bioactive concentrate of small marine fish, 2 ml im., every other day, the course of treatment was 10 injections; repeated courses of treatment - after 6 months; Group 4 (n=30) received Amelotex (meloxicam) at a dose of 15 mg once a day for 15 days. All patients of the first 3 groups received Amelotex at a dose of 15 mg with the possibility of reducing the dose to 7.5 mg or completely discontinuing the drug if necessary. Retrospectively, dynamic monitoring was performed in the medical records of outpatients after 50 days and 6 months from the start of therapy according to the following parameters: intensity of pain according to VAS, short form of the McGill pain questionnaire, vital signs of patients (Oswestry Disability Index, version 2.1a [Oswestry Disability Index], and Roland-Morris questionnaire), propensity to chronic pain syndrome according to the STarT Back Screening Tool questionnaire, the presence and severity of comorbid fibromyalgia according to the Fibromyalgia Rapid Screening Tool questionnaire, the level of pain catastrophization according to the Pain Catastrophizing Scale, the severity of comorbid anxiety and depression according to the Hospital Anxiety and Depression Scale, the severity comorbid insomnia (Insomnia Severity Index), quality of life according to the SF-36 scale, the effectiveness of drugs according to the patient on a 5-point scale, the need to take NSAIDs and analgesics, tolerability on a 4-point system. The safety of therapy was monitored using the WHO and Naranjo scales. RESULTS In patients with nonspecific LBP, a greater degree of reduction in the intensity of the pain syndrome, a smaller number of exacerbations of the pain syndrome over 6 months of observation, an improvement in the functional status and life activity, a tendency to a decrease in the severity of anxiety and depression, sleep disturbances and comorbid fibromyalgia, limiting the risk of chronicity and catastrophization of pain, the presence of a structure-modifying effect on IVD and degenerative changes in the facet joints, a significant improvement in the physical and mental components of health, high satisfaction and safety of therapy, which included taking Chondroguard with meloxicam, with a decrease in the need to take the latter by the 50th day observation period compared to other regimens. The effects of Chondroguard and meloxicam turned out to be long-term and were recorded by the 6th month in the absence of Chondroguard, which indicated the preservation of the influence of highly purified cholesterol on the pathogenetic mechanisms of the formation of LBP. CONCLUSION The study allows us to recommend the use of a parenteral form of cholesterol (Chondroguard, CJSC «PharmFirma «Sotex», Russia) for the treatment of nonspecific LBP with moderate or severe pain, chronic relapsing or persistent course, in combination with NSAIDs and their subsequent cancellation or administration on demand.
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Affiliation(s)
- I V Sarvilina
- LLC «Medical Center «Novomedicina», Rostov-on-Don, Russia
| | - A B Danilov
- First Moscow State Medical University named after I.M. Sechenov, Moscow, Russia
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de Witte PB, van Bergen CJA, de Geest BL, Willeboordse F, van Linge JH, den Hartog YM, Margret M H P Foreman-van Drongelen M, Pereboom RM, Robben SGF, Burger BJ, Witlox MA, Witbreuk MMEH. Treatment of decentered developmental dysplasia of the hip under the age of 1 year: an evidence-based clinical practice guideline - Part 2. EFORT Open Rev 2022; 7:542-553. [PMID: 35924650 PMCID: PMC9458947 DOI: 10.1530/eor-21-0126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background and purpose Materials and methods Results Interpretation
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Affiliation(s)
| | | | | | | | - Joost H van Linge
- Juliana Children's Hospital, The Hague & Reinier HAGA Orthopaedic Centre, Zoetermeer and Delft, the Netherlands
| | | | | | - Renske M Pereboom
- Dutch Hip Patient Association "Vereniging Afwijkende Heupontwikkeling", Nijkerk, the Netherlands
| | - Simon G F Robben
- Department Radiology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Bart J Burger
- Department Orthopedic Surgery, North West Hospital Group, Alkmaar, the Netherlands
| | - M Adhiambo Witlox
- Department Orthopedic Surgery, CAPHRI Care and Public Health Research Institute, Maastricht University Medical Center, Maastricht, the Netherlands
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Gianola S, Bargeri S, Cinquini M, Iannicelli V, Meroni R, Castellini G. More than one third of clinical practice guidelines on low back pain overlap in AGREE II appraisals. Research wasted? BMC Med Res Methodol 2022; 22:184. [PMID: 35790902 PMCID: PMC9254584 DOI: 10.1186/s12874-022-01621-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 04/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Systematic reviews can apply the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool to critically appraise clinical practice guidelines (CPGs) for treating low back pain (LBP); however, when appraisals differ in CPG quality rating, stakeholders, clinicians, and policy-makers will find it difficult to discern a unique judgement of CPG quality. We wanted to determine the proportion of overlapping CPGs for LBP in appraisals that applied AGREE II. We also compared inter-rater reliability and variability across appraisals. Methods For this meta-epidemiological study we searched six databases for appraisals of CPGs for LBP. The general characteristics of the appraisals were collected; the unit of analysis was the CPG evaluated in each appraisal. The inter-rater reliability and the variability of AGREE II domain scores for overall assessment were measured using the intraclass correlation coefficient and descriptive statistics. Results Overall, 43 CPGs out of 106 (40.6%) overlapped in seventeen appraisals. Half of the appraisals (53%) reported a protocol registration. Reporting of AGREE II assessment was heterogeneous and generally of poor quality: overall assessment 1 (overall CPG quality) was rated in 11 appraisals (64.7%) and overall assessment 2 (recommendation for use) in four (23.5%). Inter-rater reliability was substantial/perfect in 78.3% of overlapping CPGs. The domains with most variability were Domain 6 (mean interquartile range [IQR] 38.6), Domain 5 (mean IQR 28.9), and Domain 2 (mean IQR 27.7). Conclusions More than one third of CPGs for LBP have been re-appraised in the last six years with CPGs quality confirmed in most assessments. Our findings suggest that before conducting a new appraisal, researchers should check systematic review registers for existing appraisals. Clinicians need to rely on updated CPGs of high quality and confirmed by perfect agreement in multiple appraisals. Trial Registration Protocol Registration OSF: https://osf.io/rz7nh/ Supplementary Information The online version contains supplementary material available at 10.1186/s12874-022-01621-w.
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Price MR, Cupler Z, Hawk C, Bednarz EM, Walters SA, Daniels CJ. Systematic review of guideline-recommended medications prescribed for treatment of low back pain. Chiropr Man Therap 2022; 30:26. [PMID: 35562756 PMCID: PMC9101938 DOI: 10.1186/s12998-022-00435-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To identify and descriptively compare medication recommendations among low back pain (LBP) clinical practice guidelines (CPG). METHODS We searched PubMed, Cochrane Database of Systematic Review, Index to Chiropractic Literature, AMED, CINAHL, and PEDro to identify CPGs that described the management of mechanical LBP in the prior five years. Two investigators independently screened titles and abstracts and potentially relevant full text were considered for eligibility. Four investigators independently applied the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument for critical appraisal. Data were extracted for pharmaceutical intervention, the strength of recommendation, and appropriateness for the duration of LBP. RESULTS 316 citations were identified, 50 full-text articles were assessed, and nine guidelines with global representation met the eligibility criteria. These CPGs addressed pharmacological treatments with or without non-pharmacological treatments. All CPGS focused on the management of acute, chronic, or unspecified duration of LBP. The mean overall AGREE II score was 89.3% (SD 3.5%). The lowest domain mean score was for applicability, 80.4% (SD 5.2%), and the highest was Scope and Purpose, 94.0% (SD 2.4%). There were ten classifications of medications described in the included CPGs: acetaminophen, antibiotics, anticonvulsants, antidepressants, benzodiazepines, non-steroidal anti-inflammatory drugs (NSAIDs), opioids, oral corticosteroids, skeletal muscle relaxants (SMRs), and atypical opioids. CONCLUSIONS Nine CPGs, included ten medication classes for the management of LBP. NSAIDs were the most frequently recommended medication for the treatment of both acute and chronic LBP as a first line pharmacological therapy. Acetaminophen and SMRs were inconsistently recommended for acute LBP. Meanwhile, with less consensus among CPGs, acetaminophen and antidepressants were proposed as second-choice therapies for chronic LBP. There was significant heterogeneity of recommendations within many medication classes, although oral corticosteroids, benzodiazepines, anticonvulsants, and antibiotics were not recommended by any CPGs for acute or chronic LBP.
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Affiliation(s)
| | | | - Cheryl Hawk
- Texas Chiropractic College, Pasadena, TX USA
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What can we learn from long-term studies on chronic low back pain? A scoping review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:901-916. [PMID: 35044534 DOI: 10.1007/s00586-022-07111-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE A scoping review was conducted with the objective to identify and map the available evidence from long-term studies on chronic non-specific low back pain (LBP), to examine how these studies are conducted, and to address potential knowledge gaps. METHOD We searched MEDLINE and EMBASE up to march 2021, not restricted by date or language. Experimental and observational study types were included. Inclusion criteria were: participants between 18 and 65 years old with non-specific sub-acute or chronic LBP, minimum average follow-up of > 2 years, and studies had to report at least one of the following outcome measures: disability, quality of life, work participation, or health care utilization. Methodological quality was assessed using the Effective Public Health Practice Project quality assessment. Data were extracted, tabulated, and reported thematically. RESULTS Ninety studies met the inclusion criteria. Studies examined invasive treatments (72%), conservative (21%), or a comparison of both (7%). No natural cohorts were included. Methodological quality was weak (16% of studies), moderate (63%), or strong (21%) and generally improved after 2010. Disability (92%) and pain (86%) outcomes were most commonly reported, followed by work (25%), quality of life (15%), and health care utilization (4%). Most studies reported significant improvement at long-term follow-up (median 51 months, range 26 months-18 years). Only 10 (11%) studies took more than one measurement > 2 year after baseline. CONCLUSION Patients with persistent non-specific LBP seem to experience improvement in pain, disability and quality of life years after seeking treatment. However, it remains unclear what factors might have influenced these improvements, and whether they are treatment-related. Studies varied greatly in design, patient population, and methods of data collection. There is still little insight into the long-term natural course of LBP. Additionally, few studies perform repeated measurements during long-term follow-up or report on patient-centered outcomes other than pain or disability.
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Ng JY, Mohiuddin U, Azizudin AM. Clinical practice guidelines for the treatment and management of low back pain: A systematic review of quantity and quality. Musculoskelet Sci Pract 2021; 51:102295. [PMID: 33444892 DOI: 10.1016/j.msksp.2020.102295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Low back pain (LBP) is highly prevalent in the general population and is responsible for increased health-care costs, pain, impairment of activity, and if chronic, is associated with a range of comorbidities. OBJECTIVES The purpose of this review was to identify the quantity and assess the quality of evidence-based clinical practice guidelines (CPGs) for the treatment and/or management of LBP in adults. METHODS MEDLINE, EMBASE, CINAHL, and the Guidelines International Network were systematically searched from 2008 to 2018 to identify LBP CPGs. Eligible CPGs were assessed in duplicate using the Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument across 6 domains: scope and purpose, stakeholder involvement, rigour of development, clarity of presentation, applicability, and editorial independence. RESULTS Of 181 unique search results, 22 CPGs for the treatment and/or management of LBP were eligible. Scaled domain percentages from highest to lowest were: scope and purpose (90.0%), clarity of presentation (84.0%), stakeholder involvement (54.0%), rigour of development (51.2%), editorial independence (39.6%) and applicability (28.5%). Quality varied within and across CPGs. CONCLUSIONS CPGs varied in quality, with most scoring the highest in the scope and purpose and clarity of presentation domains. CPGs achieved variable and lower scores in the stakeholder involvement, rigour of development, applicability, and editorial independence domains. CPGs with higher AGREE II scores can serve as suitable evidence-based resources for clinicians involved in LBP care; CPGs with lower scores could be improved in future updates using the AGREE II instrument, among other guideline development resources, as a guide.
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Affiliation(s)
- Jeremy Y Ng
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| | - Uzair Mohiuddin
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| | - Ashlee M Azizudin
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
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Castellini G, Iannicelli V, Briguglio M, Corbetta D, Sconfienza LM, Banfi G, Gianola S. Are clinical practice guidelines for low back pain interventions of high quality and updated? A systematic review using the AGREE II instrument. BMC Health Serv Res 2020; 20:970. [PMID: 33092579 PMCID: PMC7583191 DOI: 10.1186/s12913-020-05827-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/15/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Clinical practice guidelines (CPGs) provide recommendations for practice, but the proliferation of CPGs issued by multiple organisations in recent years has raised concern about their quality. The aim of this study was to systematically appraise CPGs quality for low back pain (LBP) interventions and to explore inter-rater reliability (IRR) between quality appraisers. The time between systematic review search and publication of CPGs was recorded. METHODS Electronic databases (PubMed, Embase, PEDro, TRIP), guideline organisation databases, websites, and grey literature were searched from January 2016 to January 2020 to identify GPCs on rehabilitative, pharmacological or surgical intervention for LBP management. Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool to evaluate CPGs quality and record the year the CPGs were published and the year the search strategies were conducted. RESULTS A total of 21 CPGs met the inclusion criteria and were appraised. Seven (33%) were broad in scope and involved surgery, rehabilitation or pharmacological intervention. The score for each AGREE II item was: Editorial Independence (median 67%, interquartile range [IQR] 31-84%), Scope and Purpose (median 64%, IQR 22-83%), Rigour of Development (median 50%, IQR 21-72%), Clarity and Presentation (median 50%, IQR 28-79%), Stakeholder Involvement (median 36%, IQR 10-74%), and Applicability (median 11%, IQR 0-46%). The IRR between the assessors was nearly perfect (interclass correlation 0.90; 95% confidence interval 0.88-0.91). The median time span was 2 years (range, 1-4), however, 38% of the CPGs did not report the coverage dates for systematic searches. CONCLUSIONS We found methodological limitations that affect CPGs quality. In our opinion, a universal database is needed in which guidelines can be registered and recommendations dynamically developed through a living systematic reviews approach to ensure that guidelines are based on updated evidence. LEVEL OF EVIDENCE 1 TRIAL REGISTRATION: REGISTRATION PROSPERO DETAILS: CRD42019127619 .
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Affiliation(s)
- G Castellini
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - V Iannicelli
- Vita-Salute San Raffaele University, Milan, Italy
| | - M Briguglio
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - D Corbetta
- Vita-Salute San Raffaele University, Milan, Italy.,Rehabilitation and Functional Recovery Department, IRCCS Ospedale San Raffaele, Milan, Italy
| | - L M Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.,Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - G Banfi
- Vita-Salute San Raffaele University, Milan, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - S Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
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Baronio M, Sadia H, Paolacci S, Prestamburgo D, Miotti D, Guardamagna VA, Natalini G, Bertelli M. Etiopathogenesis of sacroiliitis: implications for assessment and management. Korean J Pain 2020; 33:294-304. [PMID: 32989194 PMCID: PMC7532300 DOI: 10.3344/kjp.2020.33.4.294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/17/2020] [Accepted: 04/16/2020] [Indexed: 12/24/2022] Open
Abstract
The sacroiliac joints connect the base of the sacrum to the ilium. When inflamed, they are suspected to cause low back pain. Inflammation of the sacroiliac joints is called sacroiliitis. The severity of the pain varies and depends on the degree of inflammation. Sacroiliitis is a hallmark of seronegative spondyloarthropathies. The presence or absence of chronic sacroiliitis is an important clue in the diagnosis of low back pain. This article aims to provide a concise overview of the anatomy, physiology, and molecular biology of sacroiliitis to aid clinicians in the assessment and management of sacroiliitis. For this narrative review, we evaluated articles in English published before August 2019 in PubMed. Then, we selected articles related to the painful manifestations of the sacroiliac joint. From the retrieved articles, we found that chronic sacroiliitis may be caused by various forms of spondyloarthritis, such as ankylosing spondyloarthritis. Sacroiliitis can also be associated with inflammatory bowel disease, Crohn’s disease, gout, tuberculosis, brucellosis, and osteoarthritis, indicating common underlying etiological factors. The pathophysiology of sacroiliitis is complex and may involve internal, environmental, immunological, and genetic factors. Finally, genetic factors may also play a central role in progression of the disease. Knowing the genetic pre-disposition for sacroiliitis can be useful for diagnosis and for formulating treatment regimens, and may lead to a substantial reduction in disease severity and duration and to improved patient performance.
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Affiliation(s)
- Manuela Baronio
- Dipartimento di Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Fondazione Poliambulanza, Brescia, Italy
| | - Hajra Sadia
- Atta-ur-Rahman School of Applied Biosciences, National University of Science and Technology, Islamabad, Pakistan
| | | | | | - Danilo Miotti
- Cure Palliative e Terapia del Dolore, ICS Maugeri, Pavia, Italy
| | | | - Giuseppe Natalini
- Dipartimento di Anestesia, Rianimazione, Terapia Intensiva e del Dolore, Fondazione Poliambulanza, Brescia, Italy
| | - Matteo Bertelli
- MAGI's Lab, Rovereto, Italy.,MAGI Euregio, Bolzano, Italy.,EBTNA-LAB, Rovereto, Italy
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Maas ET, Juch JNS, Ostelo RWJG, Groeneweg JG, Kallewaard JW, Koes BW, Verhagen AP, van Dongen JM, van Tulder MW, Huygen FJPM. Cost-Effectiveness of Radiofrequency Denervation for Patients With Chronic Low Back Pain: The MINT Randomized Clinical Trials. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:585-594. [PMID: 32389224 DOI: 10.1016/j.jval.2019.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 10/15/2019] [Accepted: 12/09/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To evaluate the cost-effectiveness of radiofrequency denervation when added to a standardized exercise program for patients with chronic low back pain. METHODS An economic evaluation was conducted alongside 3 pragmatic multicenter, nonblinded randomized clinical trials (RCTs) in The Netherlands with a follow up of 52 weeks. Eligible participants were included between January 1, 2013, and October 24, 2014, and had chronic low back pain; a positive diagnostic block at the facet joints (n = 251), sacroiliac (SI) joints (n = 228), or a combination of facet joints, SI joints, and intervertebral discs (n = 202); and were unresponsive to initial conservative care. Quality-adjusted life-years (QALYs) and societal costs were measured using self-reported questionnaires. Missing data were imputed using multiple imputation. Bootstrapping was used to estimate statistical uncertainty. RESULTS After 52 weeks, no difference in costs between groups was found in the facet joint or combination RCT. The total costs were significantly higher for the intervention group in the SI joint RCT. The maximum probability of radiofrequency denervation being cost-effective when added to a standardized exercise program ranged from 0.10 in the facet joint RCT to 0.17 in the SI joint RCT irrespective of the ceiling ratio, and 0.65 at a ceiling ratio of €30 000 per QALY in the combination RCT. CONCLUSIONS Although equivocal among patients with symptoms in a combination of the facet joints, SI joints, and intervertebral discs, evidence suggests that radiofrequency denervation combined with a standardized exercise program cannot be considered cost-effective from a societal perspective for patients with chronic low back pain originating from either facet or SI joints in a Dutch healthcare setting.
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Affiliation(s)
- Esther T Maas
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Movement Science Research Institute, Amsterdam, The Netherlands.
| | - Johan N S Juch
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Raymond W J G Ostelo
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Movement Science Research Institute, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - J George Groeneweg
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | | | - Bart W Koes
- Department of General Practice, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Arianne P Verhagen
- Department of General Practice, Erasmus University Medical Centre, Rotterdam, The Netherlands; Graduate School of Health, Discipline of Physiotherapy, University of Technology Sydney, Ultimo, Australia
| | - Johanna M van Dongen
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Movement Science Research Institute, Amsterdam, The Netherlands
| | - Maurits W van Tulder
- Department of Health Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Movement Science Research Institute, Amsterdam, The Netherlands; Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Frank J P M Huygen
- Department of Anesthesiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
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Ng JY, Mohiuddin U. Quality of complementary and alternative medicine recommendations in low back pain guidelines: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2020; 29:1833-1844. [DOI: 10.1007/s00586-020-06393-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/23/2020] [Accepted: 03/22/2020] [Indexed: 11/24/2022]
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15
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Schneider BJ, Doan L, Maes MK, Martinez KR, Gonzalez Cota A, Bogduk N. Systematic Review of the Effectiveness of Lumbar Medial Branch Thermal Radiofrequency Neurotomy, Stratified for Diagnostic Methods and Procedural Technique. PAIN MEDICINE 2020; 21:1122-1141. [DOI: 10.1093/pm/pnz349] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
Objective
To determine the effectiveness of lumbar medial branch thermal radiofrequency neurotomy based on different selection criteria and procedural techniques.
Design
Comprehensive systematic review.
Methods
A comprehensive literature search was conducted, and all authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies.
Outcome Measures
The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief, as well as procedural technique with perpendicular or parallel placement of electrodes.
Results
Results varied by selection criteria and procedural technique. At six months, 26% of patients selected via single medial branch block with 50% pain relief and treated via perpendicular technique achieved at least 50% pain relief; 49% of patients selected via dual medial branch blocks with 50% pain relief and treated via parallel technique achieved at least 50% pain relief. The most rigorous patient selection and technique—two diagnostic medial branch blocks with 100% pain relief and parallel electrode placement—resulted in 56% of patients experiencing 100% relief of pain at six months.
Conclusions
This comprehensive systematic review found differences in the effectiveness of lumbar medial branch radiofrequency neurotomy when studies were stratified by patient selection criteria and procedural technique. The best outcomes are achieved when patients are selected based on high degrees of pain relief from dual medial branch blocks with a technique employing parallel electrode placement.
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Affiliation(s)
- Byron J Schneider
- Department of Physical Medicine and Rehabilitation, Vanderbilt University, Nashville, Tennessee
| | - Lisa Doan
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU School of Medicine, New York, New York, USA
| | - Marc K Maes
- Department of Anesthesia, Pain Clinic, A.Z. Jan Portaels, Vilvoorde, Belgium, Rugpoli Brabant/Kliniek, Tilburg, the Netherlands
| | | | | | - Nikolai Bogduk
- Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
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Parfenov VA, Yakhno NN, Davydov OS, Kukushkin ML, Churyukanov MV, Golovacheva VA, Isaikin AI, Achkasov EE, Evzikov GY, Karateev AE, Khabirov FA, Shirokov VA, Yakupov EZ. Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP). NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2019. [DOI: 10.14412/2074-2711-2019-2s-7-16] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Examination of a patient with chronic low back pain (LBP) is aimed at eliminating its specific cause and assessing the social and psychological factors of chronic pain. The diagnosis of chronic nonspecific (musculoskeletal) LBP is based on the exclusion of a specific cause of pain, discogenic radiculopathy, and lumbar stenosis. It is advisable to identify possible pain sources: pathology of intervertebral disc pathology, facet joints, and sacroiliac joint and myofascial syndrome.An integrated multidisciplinary approach (a high level of evidence), including therapeutic exercises, physical activity optimization, psychological treatments (cognitive behavioral therapy), an educational program (back pain school for patients), and manual therapy, is effective in treating chronic musculoskeletal LBP. For pain relief, one may use nonsteroidal anti-inflammatory drugs in minimally effective doses and in a short cycle, muscle relaxants, and a capsaicin patch, and, if there is depressive disorder, antidepressants (a medium level of evidence). Radiofrequency denervation or therapeutic blockages with anesthetics and glucocorticoids (damage to the facet joints, sacroiliac joint), back massage, and acupuncture (a low level of evidence) may be used in some patients.Therapeutic exercises and an educational program (the prevention of excessive loads and prolonged static and uncomfortable postures and the use of correct methods for lifting weights, etc.) are recommended for preventive purposes.
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Affiliation(s)
- V. A. Parfenov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - N. N. Yakhno
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - O. S. Davydov
- Z.P. Solovyev Research and Practical Center of Psychoneurology, Moscow Healthcare Department
| | - M. L. Kukushkin
- Research Institute of General Pathology and Pathophysiology, Russian Academy of Sciences
| | - M. V. Churyukanov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia; Acad. B.V. Petrovsky Russian Research Center of Surgery
| | - V. A. Golovacheva
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - A. I. Isaikin
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - E. E. Achkasov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | - G. Yu. Evzikov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
| | | | - F. A. Khabirov
- Kazan State Medical Academy, Branch, Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia
| | - V. A. Shirokov
- Ural State Medical University, Ministry of Health of Russia
| | - E. Z. Yakupov
- Kazan State Medical University, Ministry of Health of Russia
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Parreira PCS, Maher CG, Traeger AC, Hancock MJ, Downie A, Koes BW, Ferreira ML. Evaluation of guideline-endorsed red flags to screen for fracture in patients presenting with low back pain. Br J Sports Med 2018; 53:648-654. [PMID: 30337350 DOI: 10.1136/bjsports-2018-099525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES (1) Describe the evolution of guideline-endorsed red flags for fracture in patients presenting with low back pain; (2) evaluate agreement between guidelines; and (3) evaluate the extent to which recommendations are accompanied by information on diagnostic accuracy of endorsed red flags. DESIGN Systematic review. DATA SOURCES MEDLINE and PubMed, PEDro, CINAHL and EMBASE electronic databases. We also searched in guideline databases, including the National Guideline Clearinghouse and Canadian Medical Association Infobase. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Evidence-based clinical practice guidelines. DATA EXTRACTION Two review authors independently extracted the following data: health professional association or society producing guideline, year of publication, the precise wording of endorsed red flag for vertebral fracture, recommendations for diagnostic workup if fracture is suspected, if the guidelines substantiate the recommendation with citation to a primary diagnostic study or diagnostic review, if the guideline provides any diagnostic accuracy data. RESULTS 78 guidelines from 28 countries were included. A total of 12 discrete red flags were reported. The most commonly recommended red flags were older age, use of steroids, trauma and osteoporosis. Regarding the evolution of red flags, older age, trauma and osteoporosis were the first red flags endorsed (in 1994); and previous fracture was the last red flag endorsed (in 2003). Agreement between guidelines in endorsing red flags was only fair; kappa=0.32. Only 9 of the 78 guidelines substantiated their red flag recommendations by research and only nine provided information on diagnostic accuracy. SUMMARY/CONCLUSION The number of red flags endorsed in guidelines to screen for fracture has risen over time; most guidelines do not endorse the same set of red flags and most recommendations are not supported by research or accompanied by diagnostic accuracy data.
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Affiliation(s)
- Patricia C S Parreira
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Christopher G Maher
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Adrian C Traeger
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Mark J Hancock
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
| | - Aron Downie
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Bart W Koes
- Department of General Practice, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Manuela L Ferreira
- Institute of Bone and Joint Research, The Kolling Institute, Sydney Medical School, Sydney, Australia
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18
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Spinal Cord Stimulation for Peripheral Neuropathic Pain. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00049-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Müller-Schwefe G, Morlion B, Ahlbeck K, Alon E, Coaccioli S, Coluzzi F, Huygen F, Jaksch W, Kalso E, Kocot-Kępska M, Kress HG, Mangas AC, Margarit Ferri C, Mavrocordatos P, Nicolaou A, Hernández CP, Pergolizzi J, Schäfer M, Sichère P. Treatment for chronic low back pain: the focus should change to multimodal management that reflects the underlying pain mechanisms. Curr Med Res Opin 2017; 33:1199-1210. [PMID: 28277866 DOI: 10.1080/03007995.2017.1298521] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
UNLABELLED Chronic low back pain: Chronic pain is the most common cause for people to utilize healthcare resources and has a considerable impact upon patients' lives. The most prevalent chronic pain condition is chronic low back pain (CLBP). CLBP may be nociceptive or neuropathic, or may incorporate both components. The presence of a neuropathic component is associated with more intense pain of longer duration, and a higher prevalence of co-morbidities. However, many physicians' knowledge of chronic pain mechanisms is currently limited and there are no universally accepted treatment guidelines, so the condition is not particularly well managed. DIAGNOSIS Diagnosis should begin with a focused medical history and physical examination, to exclude serious spinal pathology that may require evaluation by an appropriate specialist. Most patients have non-specific CLBP, which cannot be attributed to a particular cause. It is important to try and establish whether a neuropathic component is present, by combining the findings of physical and neurological examinations with the patient's history. This may prove difficult, however, even when using screening instruments. Multimodal management: The multifactorial nature of CLBP indicates that the most logical treatment approach is multimodal: i.e. integrated multidisciplinary therapy with co-ordinated somatic and psychotherapeutic elements. As both nociceptive and neuropathic components may be present, combining analgesic agents with different mechanisms of action is a rational treatment modality. Individually tailored combination therapy can improve analgesia whilst reducing the doses of constituent agents, thereby lessening the incidence of side effects. CONCLUSIONS This paper outlines the development of CLBP and the underlying mechanisms involved, as well as providing information on diagnosis and the use of a wide range of pharmaceutical agents in managing the condition (including NSAIDs, COX-2 inhibitors, tricyclic antidepressants, opioids and anticonvulsants), supplemented by appropriate non-pharmacological measures such as exercise programs, manual therapies, behavioral therapies, interventional pain management and traction. Surgery may be appropriate in carefully selected patients.
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Affiliation(s)
| | | | | | - Eli Alon
- d Universitätsspital Zurich , Zurich , Switzerland
| | | | - Flaminia Coluzzi
- f Department of Medical and Surgical Sciences and Biotechnologies , Sapienza University of Rome , Italy
| | - Frank Huygen
- g University Hospital , Rotterdam , The Netherlands
| | | | - Eija Kalso
- i Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine , University of Helsinki, and Helsinki University Hospital , Finland
| | - Magdalena Kocot-Kępska
- j Department of Pain Research and Treatment , Collegium Medicum Jagiellonian University , Kraków , Poland
| | - Hans-Georg Kress
- k Department of Special Anaesthesia and Pain Therapy , Medizinische Universität/AKH Wien , Vienna , Austria
| | | | | | | | | | | | | | - Michael Schäfer
- r Department of Anaesthesiology and Intensive Care Medicine , Charité University Berlin, Campus Virchow Klinikum , Berlin , Germany
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Mohamed AA, Salama AK, Essam Salem A, El Gallad A. Management for failed back surgery syndrome: three-in-one procedure versus percutaneous spinal fixation alone. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2017. [DOI: 10.1080/22201181.2017.1287835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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22
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Itz CJ, Ramaekers BLT, van Kleef M, Dirksen CD. Medical specialists care and hospital costs for low back pain in the Netherlands. Eur J Pain 2016; 21:705-715. [PMID: 27860026 DOI: 10.1002/ejp.974] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND To examine the organization of medical specialist care and hospital costs for low back pain (LBP) in the Netherlands. METHODS Aggregated health insurance claims data were provided on all diagnosis treatment combination (DTC) declarations for LBP patients first referred to the hospital in the 2nd half of 2008 and retrieved from Vektis, an organization that collects health insurance claims data. Data were available up to 1 January 2012. The data included patient characteristics, DTC-specific information including: neurology, neurosurgery, orthopaedic surgery, anaesthesiology and radiology. RESULTS In total 80,652 LBP patients were referred to the hospital for the first time in the second half of 2008 accumulating to a total of 173,620 DTC's with total costs of €194 million. Of these patients, 56% were female and 61% aged above 50 years at first referral to the hospital. The average number of DTC's and costs per patient were 2.15 and €2410, respectively (during the follow-up period of 3.0-3.5 year). Moreover, 51% of the patients needed only one DTC; less than 10% of patients needed 5 DTC's. Following the DTC number, the share of consultations to the neurologist decreased, whereas that of the anaesthesiology specialism increased. The largest portion of costs was allocated to the anaesthesiology and neurosurgery specialisms. CONCLUSIONS In the Netherlands, LBP patients consult a variety of medical specialists, in particular, the neurology, hospital costs for LBP patients are expected to increase given the rising incidence. Optimal diagnosis and tailored treatment plans might result in reduced costs and improved patient outcomes. SIGNIFICANCE Low back pain patients consult various specialists, with the majority first referred to the neurologist. More than half of the LBD patients require only one DTC and less than 10% needed five DTC's or more. The largest portion of the hospital costs for LBP patients is allocated to the anaesthesiology and neurosurgery specialisms.
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Affiliation(s)
- C J Itz
- Department of Health Service Research, Maastricht University, The Netherlands
| | - B L T Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, The Netherlands
| | - M van Kleef
- Department of Anesthesiology and Pain Medicine, Maastricht University Medical Centre, The Netherlands
| | - C D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, The Netherlands
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Maas E, Juch J, Ostelo R, Groeneweg J, Kallewaard J, Koes B, Verhagen A, Huygen F, van Tulder M. Systematic review of patient history and physical examination to diagnose chronic low back pain originating from the facet joints. Eur J Pain 2016; 21:403-414. [DOI: 10.1002/ejp.963] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2016] [Indexed: 01/09/2023]
Affiliation(s)
- E.T. Maas
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research; Faculty of Earth and Life Sciences; VU University Amsterdam; The Netherlands
| | - J.N.S. Juch
- Department of Anaesthesiology; Erasmus Medical Centre; Rotterdam The Netherlands
| | - R.W.J.G. Ostelo
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research; Faculty of Earth and Life Sciences; VU University Amsterdam; The Netherlands
- Department of Epidemiology and Biostatistics; VU University Medical Centre Amsterdam; The Netherlands
| | - J.G. Groeneweg
- Department of Anaesthesiology; Erasmus Medical Centre; Rotterdam The Netherlands
| | | | - B.W. Koes
- Department of General Practice; Erasmus Medical Centre; Rotterdam The Netherlands
| | - A.P. Verhagen
- Department of General Practice; Erasmus Medical Centre; Rotterdam The Netherlands
| | - F.J.P.M. Huygen
- Department of Anaesthesiology; Erasmus Medical Centre; Rotterdam The Netherlands
| | - M.W. van Tulder
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research; Faculty of Earth and Life Sciences; VU University Amsterdam; The Netherlands
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