Effectiveness of treatments for acute and sub-acute mechanical non-specific low back pain: protocol for a systematic review and network meta-analysis

Physical Therapists' Prognosis of Outcomes After a Hip or Quadriceps Exercise Intervention in Patients With Patellofemoral Pain: A Secondary Analysis of a Randomized Trial

OBJECTIVE: Can physical therapists who are treating patients with patellofemoral pain (PFP) predict the outcome of a 12-week exercise intervention based on initial assessment, and what are the physical therapists' reasons for prediction? DESIGN: Secondary analysis of a randomized trial. METHODS: After the initial assessment, physical therapists were asked to predict the prognosis of 200 patients with PFP who were allocated to 12 weeks of quadriceps exercises (QEs) or hip exercises (HEs) on a 1-to-10 Likert scale, and to describe their reasoning for the prediction score. OUTCOMES: measures were changes from baseline to weeks 12 and 26 on the Anterior Knee Pain Scale (range 0-100) and a transition questionnaire (TransQ). Linear mixed-effects models were used to assess the prediction. Secondly, we used a qualitative approach to summarize the physical therapists' reasoning (written notes) when predicting the outcome. RESULTS: There was no association between physical therapists' prognosis and changes in Anterior Knee Pain Scale for QE or HE at weeks 12 and 26 (slopes: -0.14 to -0.51 with wide 95% confidence intervals). There was no association between physical therapists' assessment of prognosis using TransQ for QE or HE at weeks 12 and 26 (odds ratio: 0.99 to 1.17 with wide 95% confidence intervals). CONCLUSION: Physical therapists' prognosis based on initial assessment was not associated with outcomes after 12 weeks of either quadriceps or hip exercise therapy among patients with PFP. Physical therapists' prognoses were not useful as a source of information and to identify PFP patients with poor or good projected outcomes. J Orthop Sports Phys Ther 2024;54(8):541-550. Epub 6 June 2024. doi:10.2519/jospt.2024.12258.

Comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain: A systematic review with network meta-analysis

This network meta-analysis aimed to estimate the comparative effectiveness of non-pharmacological interventions on sleep in individuals with chronic musculoskeletal pain. Seven databases were systematically searched up to February 2023. A random-effects network meta-analysis in a frequentist framework was performed to synthesize continuous data as standardized mean differences (SMD) along with a 95% confidence interval (95% CI). A total of 15,641 records were identified, and 107 randomized controlled trials involving 8,121 participants were included. Of 14 identified interventions, eight were significantly more effective than passive control in improving sleep quality at immediate post-intervention (SMDs = 0.67-0.74), with cognitive behavioral therapy (CBT) being the most effective treatment (SMD = 0.74, 95% CI: 0.45-1.03). Only CBT demonstrated sustained effects at short-term (SMD = 1.56; 95% CI: 0.62-2.49) and mid-term (SMD = 1.23; 95% CI: 0.44-2.03) follow-ups. Furthermore, CBT significantly improved subjective (SMD = 0.64; 95% CI: 0.25-1.03) and objective (SMD = 0.30; 95% CI: 0.01-0.59) sleep efficiency compared with passive control at immediate post-intervention. Our findings support CBT as the first-line treatment for improving sleep in individuals with chronic musculoskeletal pain, given its superior effectiveness across multiple sleep outcomes and its sustainable effects until mid-term follow-up. However, the certainty of evidence for these interventions in improving sleep quality was very low to low.

Supervised exercise with or without laser-guided feedback for people with non-specific chronic low back pain. A randomized controlled clinical trial

BACKGROUND

Among the most effective therapeutic interventions in non-specific chronic low back pain (NSCLBP), clinical practice guidelines highlight exercise therapy and patient education; However, regarding the combined intervention of exercise and Pain Neuroscience Education (PNE), there is no consensus on the most effective form of exercise.

OBJETIVE

To find out what changes occurred after the application of two exercise modalities [Supervised Exercise (SE) and Laser-Guided Exercise (LGE)] and PNE on pain, pain pressure thresholds, disability, catastrophizing, kinesiophobia and lumbar proprioception in subjects with NSCLBP.

METHODS

Single-blind randomized clinical controlled trial. 60 subjects with NSCLBP. Both groups performed a a total of 16 therapeutic exercise sessions and 8 Pain Neuroscience Education sessions. With the Laser-Guided Exercise Therapy group performing laser-guided exercises.

RESULTS

A significant decrease was observed for pain intensity for both groups between baseline and post-intervention and the 3 month follow-up (p < 0.001). There was a significant between-group difference between baseline and post-intervention scores in terms of pain intensity and kinesiophobia in favour of the LGE group.

CONCLUSION

Supervised exercise with or without laser feedback, when combined with PNE, reduces pain intensity, disability, pain catastrophizing, kinesiophobia and improves proprioception and PPTs in patients with NSCLBP. At a 3-month follow-up, the combination of LGE plus PNE is most effective for reducing pain intensity.

Cross-cultural adaptation and validation of the Traditional Chinese version of the Core Outcome Measures Index in patients with low back pain

PURPOSE

This study aimed to carry out a cross-cultural adaptation of the Core Outcome Measures Index (COMI) for use in Traditional Chinese-speaking patients with low back pain (LBP) and to investigate its psychometric properties.

METHODS

A total of 224 patients with LBP > 6 weeks who visited our spine center from May 2018 to May 2019 were included in the study. Patients completed a booklet of questionnaires including the following: (1) pain Numeric Rating Scale, (2) Oswestry Disability Index, (3) Roland-Morris Disability Questionnaire, (4) EuroQol-five dimension (EQ-5D), and (5) COMI. Patients were sent a second booklet (also containing a transition question to indicate any change in condition) to be completed again within one month after the first. Fifty-two patients did not receive any intervening treatment (group 1), while the other 172 patients received medical treatment (group 2) between the two questionnaires.

RESULTS

The intraclass correlation coefficient (ICC) for the COMI summary score was 0.94 (95% CI 0.89-0.97); the standard error of measurement (SEM) was 0.41 and the minimum detectable change (MDC) score was 1.14. The COMI summary scores showed a low floor effect (1.8%) and ceiling effect (0.4%). All COMI item scores demonstrated the hypothesized correlations with their corresponding full-length questionnaires except for the pain item (correlation stronger than hypothesized). Standardized response means (SRM) for the COMI items in the treated group were between 0.58 and 1.30. Regarding the ability of the COMI change score to differentiate between good and poor outcomes, the area under the receiver operating characteristic (AUROC) curve was 0.77 [standard error (SE) 0.07, 95% confidence interval (CI) 0.68-0.84] and the minimal clinically important change (MCIC) score was ≥ 1.85 points.

CONCLUSION

The Traditional Chinese COMI represents a practical and reliable tool for the assessment of Traditional Chinese-speaking patients with back problems.

An International Multidisciplinary Delphi-Based Consensus on Heat Therapy in Musculoskeletal Pain

INTRODUCTION

Musculoskeletal pain (MP) is prevalent in our society, having a strong negative impact on physical and psychosocial quality of life. Heat therapy (HT) has been frequently described as a treatment strategy for musculoskeletal pain, but scientific evidence is still poor. The aim of the present Delphi method study is to gather a consensus among European experts on the role of HT in MP.

METHODS

To address this topic, a list of 54 statements was developed, concerning mechanism of action of heat on muscle, types of MP eligible for heat treatment, efficacy of HT, time and modalities of treatment, maximizing compliance to HT, safety (based on heat wraps), wrong beliefs and common errors in the prescription of HT and the role of HT in preventing muscular damage in athletes. The survey was distributed to 116 European experts, using a 5-point Likert scale to express agreement or disagreement with the statements; 66% concordance with the statements was needed to define a consensus.

RESULTS

Consensus was reached on 78% of statements. There was a strong consensus on the mechanism of action of heat on muscle, the indication in chronic MP, its effectiveness as part of a multimodal approach to MP and the safety and tolerability of superficial heat therapy. A low-level of consensus was obtained on the role of heat in preventing muscular damage and in acute MP.

CONCLUSION

This Delphi consensus recognizes the role of HT mostly in chronic MP and highlights the need for stronger scientific evidence to regulate the use of this therapy in clinical practice.

Regulatory roles of noncoding RNAs in intervertebral disc degeneration as potential therapeutic targets (Review)

Intervertebral disc degeneration (IDD) is the leading cause of lower back pain, which is one of the primary factors that lead to disability and pose a serious economic burden. The key pathological processes involved are extracellular matrix degradation, autophagy, apoptosis, and inflammation of nucleus pulposus cells. Non-coding RNAs (ncRNAs), including microRNAs, long ncRNAs and circular RNAs, are key regulators of the aforementioned processes. ncRNAs are differentially expressed in tissues of the intervertebral disc between healthy individuals and patients and participate in the pathological progression of IDD via a complex pattern of gene regulation. However, the regulatory mechanisms of ncRNAs in IDD remain unclear. The present review summarizes the latest insights into the regulatory role of ncRNAs in IDD and sheds light on potentially novel therapeutic strategies for IDD that may be implemented in the future.

Slacklining as therapy to address non-specific low back pain in the presence of multifidus arthrogenic muscle inhibition

Low back pain (LBP) represents the most prevalent, problematic and painful of musculoskeletal conditions that affects both the individual and society with health and economic concerns. LBP is a heterogeneous condition with multiple diagnoses and causes. In the absence of consensus definitions, partly because of terminology inconsistency, it is further referred to as non-specific LBP (NSLBP). In NSLBP patients, the lumbar multifidus (MF), a key stabilizing muscle, has a depleted role due to recognized myocellular lipid infiltration and wasting, with the potential primary cause hypothesized as arthrogenic muscle inhibition (AMI). This link between AMI and NSLBP continues to gain increasing recognition. To date there is no 'gold standard' or consensus treatment to alleviate symptoms and disability due to NSLBP, though the advocated interventions are numerous, with marked variations in costs and levels of supportive evidence. However, there is consensus that NSLBP management be cost-effective, self-administered, educational, exercise-based, and use multi-modal and multi-disciplinary approaches. An adjuvant therapy fulfilling these consensus criteria is 'slacklining', within an overall rehabilitation program. Slacklining, the neuromechanical action of balance retention on a tightened band, induces strategic indirect-involuntary therapeutic muscle activation exercise incorporating spinal motor control. Though several models have been proposed, understanding slacklining's neuro-motor mechanism of action remains incomplete. Slacklining has demonstrated clinical effects to overcome AMI in peripheral joints, particularly the knee, and is reported in clinical case-studies as showing promising results in reducing NSLBP related to MF deficiency induced through AMI (MF-AMI). Therefore, this paper aims to: rationalize why and how adjuvant, slacklining therapeutic exercise may positively affect patients with NSLBP, due to MF-AMI induced depletion of spinal stabilization; considers current understandings and interventions for NSLBP, including the contributing role of MF-AMI; and details the reasons why slacklining could be considered as a potential adjuvant intervention for NSLBP through its indirect-involuntary action. This action is hypothesized to occur through an over-ride or inhibition of central down-regulatory induced muscle insufficiency, present due to AMI. This subsequently allows neuroplasticity, normal neuro-motor sequencing and muscle re-activation, which facilitates innate advantageous spinal stabilization. This in-turn addresses and reduces NSLBP, its concurrent symptoms and functional disability. This process is hypothesized to occur through four neuro-physiological processing pathways: finite neural delay; movement-control phenotypes; inhibition of action and the innate primordial imperative; and accentuated corticospinal drive. Further research is recommended to investigate these hypotheses and the effect of slacklining as an adjuvant therapy in cohort and control studies of NSLBP populations.

Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis

Objective

To assess the effectiveness of interventions for acute and subacute non-specific low back pain (NS-LBP) based on pain and disability outcomes.

Design

A systematic review of the literature with network meta-analysis.

Data sources

Medline, Embase and CENTRAL databases were searched from inception until 17 October 2020.

Eligibility criteria for selecting studies

Randomised clinical trials (RCTs) involving adults with NS-LBP who experienced pain for less than 6 weeks (acute) or between 6 and 12 weeks (subacute).

Results

Forty-six RCTs (n=8765) were included; risk of bias was low in 9 trials (19.6%), unclear in 20 (43.5%), and high in 17 (36.9%). At immediate-term follow-up, for pain decrease, the most efficacious treatments against an inert therapy were: exercise (standardised mean difference (SMD) −1.40; 95% confidence interval (CI) −2.41 to –0.40), heat wrap (SMD −1.38; 95% CI −2.60 to –0.17), opioids (SMD −0.86; 95% CI −1.62 to –0.10), manual therapy (SMD −0.72; 95% CI −1.40 to –0.04) and non-steroidal anti-inflammatory drugs (NSAIDs) (SMD −0.53; 95% CI −0.97 to –0.09). Similar findings were confirmed for disability reduction in non-pharmacological and pharmacological networks, including muscle relaxants (SMD -0.24; 95% CI -0.43 to -0.04). Mild or moderate adverse events were reported in the opioids (65.7%), NSAIDs (54.3%) and steroids (46.9%) trial arms.

Conclusion

With uncertainty of evidence, NS-LBP should be managed with non-pharmacological treatments which seem to mitigate pain and disability at immediate-term. Among pharmacological interventions, NSAIDs and muscle relaxants appear to offer the best harm–benefit balance.

Vertical traction for lumbar radiculopathy: a systematic review

Background

Only low-quality evidence is currently available to support the effectiveness of different traction modalities in the treatment of lumbar radiculopathy (LR). Yet, traction is still very commonly used in clinical practice. Some authors have suggested that the subgroup of patients presenting signs and symptoms of nerve root compression and unresponsive to movements centralizing symptoms may benefit from lumbar traction. The aim of this study is to conduct a systematic review of randomized controlled trials (RCTs) on the effects of vertical traction (VT) on pain and activity limitation in patients affected by LR.

Methods

We searched the Cochrane Controlled Trials Register, PubMed, CINAHL, Scopus, ISI Web of Science and PEDro from their inception to March 31, 2019 to retrieve RCTs on adults with LR using VT to reduce pain and activity limitation. We considered only trials reporting complete data on outcomes. Two reviewers selected the studies, extracted the results, and performed the quality assessment using the Risk of Bias and GRADE tools.

Results

Three studies met the inclusion criteria. Meta-analysis was not possible due to the heterogeneity of the included studies. We found very low quality evidence for a large effect of VT added to bed rest when compared to bed rest alone (g = − 1.01; 95% CI = -2.00 to − 0.02). Similarly, VT added to medication may have a large effect on pain relief when compared to medication alone (g = − 1.13; 95% CI = -1.72 to − 0.54, low quality evidence). Effects of VT added to physical therapy on pain relief were very small when compared to physical therapy without VT (g = − 0.14; 95% CI = -1.03 to 0.76, low quality evidence). All reported effects concerned short-term effect up to 3 months post-intervention.

Conclusions

With respect to short-term effects, VT may have a positive effect on pain relief if added to medication or bed rest. Long-term effects of VT are currently unknown. Future higher quality research is very likely to have an important impact on our confidence in the estimate of effect and may change these conclusions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40945-021-00102-5.

Effectiveness of Mechanical Traction for Lumbar Radiculopathy: A Systematic Review and Meta-Analysis

OBJECTIVE

Lumbar radiculopathy (LR) is a pain syndrome caused by compression/irritation of the lumbar nerve root(s). Traction is a well-known and commonly used conservative treatment for LR, although its effectiveness is disputed. The purpose of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effects of different types of traction added to or compared with conservative treatments on pain and disability.

METHODS

Data were obtained from CENTRAL, PUBMED, CINAHL, Scopus, ISI Web of Science, and PEDro from their inception to April 2020. All randomized controlled trials on adults with LR, using mechanical traction, and without any restriction regarding publication time or language were considered. Two reviewers selected the studies, evaluated the quality assessment, and extracted the results. Meta-analysis used a random-effects model. Eight studies met the inclusion criteria, and 5 were meta-analyzed.

RESULTS

Meta-analyses of results from low-quality studies indicated that supine mechanical traction added to physical therapist treatments had significant effects on pain (g = -0.58 [95% confidence interval = -0.87 to -0.29]) and disability (g = -0.78 [95% confidence interval = -1.45 to -0.11]). Analyses of results from high-quality studies of prone mechanical traction added to physical therapist intervention for pain and disability were not significant. These results were also evident at short-term follow-up (up to 3 months after intervention).

CONCLUSION

The literature suggests that, for pain and disability in LR, there is short-term effectiveness of supine mechanical traction when added to physical therapist intervention.

IMPACT

This systematic review may be relevant for clinical practice due to its external validity because the treatments and the outcome measures are very similar to those commonly used in a clinical context.

Effect of Platelet-Rich Plasma on Intervertebral Disc Degeneration In Vivo and In Vitro: A Critical Review

Intervertebral disc degeneration (IDD) is a globally occurring disease that represents a significant cause of socioeconomic problems. Currently, the main method for treating IDD is surgery, including discectomy and vertebral fusion. Several in vitro experiments demonstrated that platelet-rich plasma (PRP) could stimulate cell proliferation and extracellular matrix regeneration. Additionally, in vivo experiments have proven that PRP injection could restore intervertebral disc height. Clinical studies demonstrated that PRP injection could significantly relieve patient pain. However, further studies are still required to clarify the roles of PRP in IDD prevention and treatment. This review is aimed at summarizing and critically analyzing the current evidence regarding IDD treatment with PRP.