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Schmidt H, Drusko A, Renz MP, Schlömp L, Tost H, Schuh-Hofer S, Tesarz J, Meyer-Lindenberg A, Treede RD. Application of the grading system for "nociplastic pain" in chronic primary and chronic secondary pain conditions: a field study. Pain 2024:00006396-990000000-00695. [PMID: 39190340 DOI: 10.1097/j.pain.0000000000003355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 06/15/2024] [Indexed: 08/28/2024]
Abstract
ABSTRACT The concept "nociplastic pain" has been developed for patients with features of nociceptive system sensitization that are not explained as nociceptive or neuropathic. Here, we tested how well the recently published grading system differentiates between chronic primary and secondary pain conditions. We recruited patients with fibromyalgia (FMS, n = 41), complex regional pain syndrome (CRPS, n = 11), osteoarthritis (OA, n = 21), or peripheral nerve injury (PNI, n = 8). We used clinical history, pain drawings, quantitative sensory testing (QST), and questionnaires to classify their pains as possibly or probably "nociplastic." All patients with chronic primary pain exhibited widespread/regional pain not explainable by either nociceptive or neuropathic mechanisms. Widespread pain occurred in 12 patients with OA but was identified as nociceptive in 11 of 12. Regional pain occurred in 4 patients with PNI but was identified as neuropathic in 3 of 4. At this step, the grading system had 100% sensitivity and 93% specificity. Clinical evidence for pain hypersensitivity by QST, and history of hypersensitivity and mental comorbidities did not differentiate between chronic primary pain (QST: 36/52 = 69%, history: 43/52 = 83%) and secondary pain conditions (QST: 20/29 = 69%, history: 24/29 83%). Based on these data, specificity remained excellent (93%), but sensitivity dropped substantially (60%) due to lacking evidence for pain hypersensitivity in many patients with FMS. This low sensitivity suggests that the published grading system is not suitable for screening purposes. We suggest structural and content modifications to improve sensitivity, including placement of patient history before clinical examination and addition of a high tender point count as evidence for widespread pain hypersensitivity.
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Affiliation(s)
- Hannah Schmidt
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Neurophysiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Armin Drusko
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Malika Pia Renz
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Lea Schlömp
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Heike Tost
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sigrid Schuh-Hofer
- Department of Neurophysiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Neurology, University Medical Center Tübingen, Tübingen, Germany
| | - Jonas Tesarz
- Department of General Internal Medicine and Psychosomatics, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Meyer-Lindenberg
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Rolf-Detlef Treede
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Neurophysiology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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Chen Y, Wang E, Sites BD, Cohen SP. Integrating mechanistic-based and classification-based concepts into perioperative pain management: an educational guide for acute pain physicians. Reg Anesth Pain Med 2024; 49:581-601. [PMID: 36707224 DOI: 10.1136/rapm-2022-104203] [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: 11/16/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
Chronic pain begins with acute pain. Physicians tend to classify pain by duration (acute vs chronic) and mechanism (nociceptive, neuropathic and nociplastic). Although this taxonomy may facilitate diagnosis and documentation, such categories are to some degree arbitrary constructs, with significant overlap in terms of mechanisms and treatments. In clinical practice, there are myriad different definitions for chronic pain and a substantial portion of chronic pain involves mixed phenotypes. Classification of pain based on acuity and mechanisms informs management at all levels and constitutes a critical part of guidelines and treatment for chronic pain care. Yet specialty care is often siloed, with advances in understanding lagging years behind in some areas in which these developments should be at the forefront of clinical practice. For example, in perioperative pain management, enhanced recovery protocols are not standardized and tend to drive treatment without consideration of mechanisms, which in many cases may be incongruent with personalized medicine and mechanism-based treatment. In this educational document, we discuss mechanisms and classification of pain as it pertains to commonly performed surgical procedures. Our goal is to provide a clinical reference for the acute pain physician to facilitate pain management decision-making (both diagnosis and therapy) in the perioperative period.
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Affiliation(s)
- Yian Chen
- Anesthesiology, Stanford University School of Medicine, Stanford, California, USA
| | - Eric Wang
- Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Brian D Sites
- Anesthesiology and Orthopaedics, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Steven P Cohen
- Anesthesiology, Neurology, Physical Medicine & Rehabilitation and Psychiatry & Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Carayannopoulos A, Johnson D, Lee D, Giuffrida A, Poply K, Mehta V, Amann M, Santillo D, Ghandour Y, Koch A, Langhorst M, Heros R. Precision Rehabilitation After Neurostimulation Implantation for Multifidus Dysfunction in Nociceptive Mechanical Chronic Low Back Pain. Arch Rehabil Res Clin Transl 2024; 6:100333. [PMID: 39006113 PMCID: PMC11240036 DOI: 10.1016/j.arrct.2024.100333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/16/2024] Open
Abstract
Chronic low back pain (CLBP) is a debilitating, painful, and costly condition. Implantable neuromuscular electrical stimulation targeting the multifidus musculature is growing as a non-pharmacologic option for patients with recalcitrant nociceptive mechanical CLBP who have failed conservative treatments (including medications and physical therapy) and for whom surgery is not indicated. Properly selecting patients who meet specific criteria (based on historical results from randomized controlled trials), who diligently adhere to implant usage and precisely implement neuromuscular rehabilitation, improve success of significant functional recovery, as well as pain medication reductions. Patients with nociceptive mechanical CLBP who underwent implanted multifidus neurostimulation have been treated by physicians and rehabilitation specialists who have honed their experience working with multifidus neurostimulation. They have collaborated on consensus and evidence-driven guidelines to improve quality outcomes and to assist providers when encountering patients with this device. Physicians and physical therapists together provide precision patient-centric medical management with quality neuromuscular rehabilitation to encourage patients to be experts of both their implants and quality spine motion to help override long-standing multifidus dysfunction related to their CLBP.
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Affiliation(s)
- Alexios Carayannopoulos
- Departments of Neurosurgery and Neurology, Brown University/Warren Alpert Medical School, Providence, RI
| | - David Johnson
- A City to Coast Neurosurgery, Brisbane, Queensland, Australia
| | - David Lee
- Fullerton Orthopedic Surgery Medical Group, Fullerton, CA
| | - Anthony Giuffrida
- Cantor Spine Center, Paley Orthopedic & Spine Institute, Fort Lauderdale, FL
| | - Kavita Poply
- Queen Mary University of London/St. Bartholomew's Hospital/Health NHS Trust, London, UK
| | - Vivek Mehta
- St. Bartholomew's Hospital/Health NHS Trust, London, UK
| | - Marco Amann
- Orthopädische Klinik Schloss Werneck, Germany
| | | | - Yousef Ghandour
- Physical Rehabilitation Network/University of St. Augustine for Health Sciences, San Diego, CA
| | - Amy Koch
- Methodist Health System, Omaha, NE
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Al Mohamad F, Rios Rodriguez V, Haibel H, Protopopov M, Rademacher J, Sieper J, Torgutalp M, Käding H, Proft F, Poddubnyy D. Association of nociplastic and neuropathic pain components with the presence of residual symptoms in patients with axial spondyloarthritis receiving biological disease-modifying antirheumatic drugs. RMD Open 2024; 10:e004009. [PMID: 38360039 PMCID: PMC10875534 DOI: 10.1136/rmdopen-2023-004009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 01/29/2024] [Indexed: 02/17/2024] Open
Abstract
OBJECTIVE To evaluate the association of nociplastic (NoP) and neuropathic pain (NP) components with residual symptoms in patients with radiographic axial spondyloarthritis (r-axSpA) receiving biological disease-modifying antirheumatic drugs (bDMARDs). METHODS 78 patients with r-axSpA from the GErman SPondyloarthritis Inception Cohort receiving a bDMARD for at least 3 months were included in this analysis. The Widespread Pain Index (WPI) and the PainDETECT (PD) questionnaire were used to quantify the NoP and the NP components, respectively. Axial Spondyloarthritis Disease Activity Score (ASDAS) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) were used as measures of residual symptoms. C reactive protein (CRP) was used as a measure of systemic inflammatory activity. Univariable and multivariable regression analyses of disease activity were performed. The regions of the WPI score and items of the PD score were used for cluster analyses. RESULTS Linear multivariable regression analysis showed that WPI and PD were independently associated with ASDAS (b=0.1, 95% CI 0.04 to 0.17, and b=0.05, 95% CI 0.02 to 0.08, respectively) and BASDAI (b=0.24, 95% CI 0.08 to 0.39, and b=0.17, 95% CI 0.1 to 0.25, respectively) in r-axSpA patients receiving stable treatment with bDMARDs. Furthermore, WPI and PD were found to be significantly associated with the presence of relevant residual symptoms as defined by BASDAI ≥4 (OR 1.93, 95% CI 1.09 to 4.15, and OR 1.32, 95% CI 1.04 to 1.85, respectively). The effects were present also in patients with normal level of CRP. Cluster analysis revealed three distinct pain distribution profiles and four specific sensory symptom constellations allowing differentiation of different pain subtypes. CONCLUSION Both NoP and NP components seem to be associated with residual symptoms in patients with r-axSpA receiving treatment with bDMARDs.
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Affiliation(s)
- Fares Al Mohamad
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Valeria Rios Rodriguez
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hildrun Haibel
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mikhail Protopopov
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Judith Rademacher
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Sieper
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Murat Torgutalp
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Henriette Käding
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fabian Proft
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Department of Gastroenterology, Infectious Diseases and Rheumatology (including Clinical Nutrition), Charité-Universitätsmedizin Berlin, Berlin, Germany
- Epidemiology Unit, German Rheumatism Research Centre Berlin, Berlin, Germany
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5
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Wirth B, Schweinhardt P. Personalized assessment and management of non-specific low back pain. Eur J Pain 2024; 28:181-198. [PMID: 37874300 DOI: 10.1002/ejp.2190] [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: 05/15/2023] [Revised: 08/22/2023] [Accepted: 09/27/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND AND OBJECTIVE Low back pain (LBP), and in particular non-specific low back pain (NSLBP), which accounts for approximately 90% of LBP, is the leading cause of years lived with disability worldwide. In clinical trials, LBP is often poorly categorized into 'specific' versus 'non-specific' and 'acute' versus 'chronic' pain. However, a better understanding of the underlying pain mechanisms might improve study results and reduce the number of NSLBP patients. DATABASES AND DATA TREATMENT Narrative review. RESULTS NSLBP is a multi-dimensional, biopsychosocial condition that requires all contributing dimensions to be assessed and prioritized. Thereby, the assessment of the contribution of nociceptive, neuropathic and nociplastic pain mechanisms forms the basis for personalized management. In addition, psychosocial (e.g. anxiety, catastrophizing) and contextual factors (e.g. work situation) as well as comorbidities need to be assessed and individually weighted. Personalized treatment of NSLBP further requires individually choosing treatment modalities, for example, exercising, patient education, cognitive-behavioural advice, pharmacotherapy, as well as tailoring treatment within these modalities, for example, the delivery of tailored psychological interventions or exercise programs. As the main pain mechanism and psychosocial factors may vary over time, re-assessment is necessary and treatment success should ideally be assessed quantitatively and qualitatively. CONCLUSIONS The identification of the main contributing pain mechanism and the integration of the patients' view on their condition, including beliefs, preferences, concerns and expectations, are key in the personalized clinical management of NSLBP. In research, particular importance should be placed on accurate characterization of patients and on including outcomes relevant to the individual patient. SIGNIFICANCE STATEMENT Here, a comprehensive review of the challenges associated with the diagnostic label 'non-specific low back pain' is given. It outlines what is lacking in current treatment guidelines and it is summarized what is currently known with respect to individual phenotyping. It becomes clear that more research on clinically meaningful subgroups is needed to best tailor treatment approaches.
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Affiliation(s)
- Brigitte Wirth
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Petra Schweinhardt
- Department of Chiropractic Medicine, Integrative Spinal Research Group, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Alkosha HM. Interventional non-operative management of low back and neck pain. EGYPTIAN JOURNAL OF NEUROSURGERY 2023. [DOI: 10.1186/s41984-023-00189-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Abstract
Background
Chronic neck and back pain are among the most commonly encountered health problems in neurosurgical practice. Many cases fail prolonged pharmacological and physical therapy and are not proper candidates for surgical interventions, or had refused proposed surgical treatment.
Objective
To provide an informative critical summary of the literature about the topic of interventional management of axial neck and low back pain and highlighting the new trends and pieces of evidence.
Methods
The English literature published over the last two decades was reviewed by the author for recent and relevant data about the principles of interventional management of chronic neck and low back pain. A PubMed search was performed through phrase searching and combined searching using Boolean operators. The articles thought to be most relevant to the study aim and the neurosurgeons’ practice were extracted.
Results
Neck and low back pain continue to be among the most common musculoskeletal health problems and the most common cause of disability worldwide. A detailed understanding of relevant spine anatomy is crucial for interventionists who should deal with the concept of “functional spine unit” with multiple potential pain generators. Chronic spinal pain is best managed through a dedicated multidisciplinary team in well-equipped healthcare facilities. An algorithmic approach for the diagnosis and management of spinal pain is the mainstay of providing the best patient care and should be based on the commonality and treatability of pain generators, values of patients and available resources.
Conclusion
Management of chronic neck and back pain can represent a clinical dilemma due to the multiplicity of pain generators that may coexist in the same individual resulting in a complex type and pattern of pain. Approach to these patients requires contributions from the members of a multidisciplinary team, implementing a standardized approach in a well-equipped healthcare facility.
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Guan J, Zhao D, Liu T, Yu X, Feng N, Jiang G, Li W, Yang K, Zhao H, Yang Y. Correlation between surgical segment mobility and paravertebral muscle fatty infiltration of upper adjacent segment in single-segment LDD patients: retrospective study at a minimum 2 years' follow-up. BMC Musculoskelet Disord 2023; 24:28. [PMID: 36635673 PMCID: PMC9835309 DOI: 10.1186/s12891-023-06137-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/05/2023] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the relationship between surgical segment mobility and fatty infiltration of the adjacent segment paravertebral muscles in patients with single-segment lumbar degenerative disease (LDD) who underwent decompression with fusion or dynamic stabilization. METHODS Retrospective analysis of patients who underwent lumbar decompression combined with titanium rod fixation intertransverse fusion (PITF group), Isobar TTL dynamic stabilization (TTL group) or Isobar EVO dynamic stabilization (EVO group) for single-segment lumbar degenerative disease, from March 2012 to July 2018. The preoperative and final follow-up clinical indexes C-LDSI and the measured imaging indexes (range of motion of the surgical segment and the upper adjacent segment, and Goutallier grade of the upper adjacent segment) were counted, and the differences between the preoperative and final follow-up indexes were compared. RESULTS According to the inclusion and exclusion criteria, 68 patients were included in this study, 21 in the PITF group, 24 in the TTL group, and 23 in the EVO group. At the final follow-up, the C-LSDI score had significantly higher in the PITF group than the TTL and EVO groups, and the C-LSDI score was a very strongly negatively correlated with ROM of surgical segment (r=-0.7968, p < 0.001). There was a strong negative correlation between surgical segment and upper adjacent segment mobility (r = -0.6959, p < 0.001). And there was a very strong negative correlation between ROM of surgical segment and upper adjacent segment paravertebral muscle Goutallier classification (r = -0.8092, p < 0.001), whereas the ROM of the upper adjacent segment was strong positive correlated with the Goutallier classification (r = 0.6703, P < 0.001). CONCLUSION Compared with decompression combined with rigid fusion, decompression combined with dynamic fixation for single-segment lumbar degenerative disease can significantly reduce postoperative low back stiffness. And a certain range of increased mobility of the dynamic stabilization device can effectively reduce the compensatory mobility of the upper adjacent segment and slow down the fatty infiltration of the paravertebral muscle in the adjacent segment.
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Affiliation(s)
- Jianbin Guan
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Dingyan Zhao
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Tao Liu
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Xing Yu
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Ningning Feng
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Guozheng Jiang
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Wenhao Li
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Kaitan Yang
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - He Zhao
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
| | - Yongdong Yang
- grid.24695.3c0000 0001 1431 9176Dongzhimen Hospital Beijing University of Chinese Medicine, Haiyuncang No.5, Dongcheng District 100700 Beijing, China
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Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Sayed D, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Schwab F, Maislin G, Heemels JP, Eldabe S. Three-Year Durability of Restorative Neurostimulation Effectiveness in Patients With Chronic Low Back Pain and Multifidus Muscle Dysfunction. Neuromodulation 2023; 26:98-108. [PMID: 36175320 DOI: 10.1016/j.neurom.2022.08.457] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/03/2022] [Accepted: 08/22/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Restorative neurostimulation is a rehabilitative treatment for patients with refractory chronic low back pain (CLBP) associated with dysfunction of the lumbar multifidus muscle resulting in impaired neuromuscular control. The ReActiv8-B randomized, sham-controlled trial provided evidence of the effectiveness and safety of an implanted, restorative neurostimulator. The two-year analysis previously published in this journal demonstrated accrual of clinical benefits and long-term durability. OBJECTIVE Evaluation of three-year effectiveness and safety in patients with refractory, disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery. MATERIALS AND METHODS Prospective, observational follow-up of the 204 implanted trial participants. Low back pain visual analog scale (VAS), Oswestry Disability Index (ODI), EuroQol quality of life survey, and opioid intake were assessed at baseline, six months, and one, two, and three years after activation. The mixed-effects model repeated measures approach was used to provide implicit imputations of missing data for continuous outcomes and multiple imputation for proportion estimates. RESULTS Data were collected from 133 participants, and 16 patients missed their three-year follow-up because of coronavirus disease restrictions but remain available for future follow-up. A total of 62% of participants had a ≥ 70% VAS reduction, and 67% reported CLBP resolution (VAS ≤ 2.5cm); 63% had a reduction in ODI of ≥ 20 points; 83% had improvements of ≥ 50% in VAS and/or ≥ 20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 71% (36/51) participants on opioids at baseline had voluntarily discontinued (49%) or reduced (22%) opioid intake. The attenuation of effectiveness in the imputed (N = 204) analyses was relatively small and did not affect the statistical significance and clinical relevance of these results. The safety profile remains favorable, and no lead migrations have been observed to date. CONCLUSION At three years, 83% of participants experienced clinically substantial improvements in pain, disability, or both. The results confirm the long-term effectiveness, durability, and safety of restorative neurostimulation in patients with disabling CLBP associated with multifidus muscle dysfunction. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT02577354.
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Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, USA
| | - Vivek Mehta
- Barts Neuromodulation Center, St. Bartholomew's Hospital, London, UK
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Dawood Sayed
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, USA
| | - Edgar Ross
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Alexios Carayannopoulos
- Departments of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, USA
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, USA
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, USA
| | - James Rathmell
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Frank Schwab
- Northwell Health Orthopaedic Institute, New York, NY, USA
| | - Greg Maislin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
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9
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Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Maislin G, Heemels JP, Eldabe S. Long-Term Outcomes of Restorative Neurostimulation in Patients With Refractory Chronic Low Back Pain Secondary to Multifidus Dysfunction: Two-Year Results of the ReActiv8-B Pivotal Trial. Neuromodulation 2023; 26:87-97. [PMID: 35088722 DOI: 10.1016/j.neurom.2021.10.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/22/2020] [Accepted: 10/12/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Impaired neuromuscular control and degeneration of the multifidus muscle have been linked to the development of refractory chronic low back pain (CLBP). An implantable restorative-neurostimulator system can override the underlying multifidus inhibition by eliciting episodic, isolated contractions. The ReActiv8-B randomized, active-sham-controlled trial provided effectiveness and safety evidence for this system, and all participants received therapeutic stimulation from four months onward. OBJECTIVE This study aimed to evaluate the two-year effectiveness of this restorative neurostimulator in patients with disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery. MATERIALS AND METHODS Open-label follow-up of 204 participants implanted with a restorative neurostimulation system (ReActiv8, Mainstay Medical, Dublin, Ireland) was performed. Pain intensity (visual analog scale [VAS]), disability (Oswestry disability index [ODI]), quality-of-life (EQ-5D-5L), and opioid intake were assessed at baseline, six months, one year, and two years after activation. RESULTS At two years (n = 156), the proportion of participants with ≥50% CLBP relief was 71%, and 65% reported CLBP resolution (VAS ≤ 2.5 cm); 61% had a reduction in ODI of ≥20 points, 76% had improvements of ≥50% in VAS and/or ≥20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 87% of participants had continued device use during the second year for a median of 43% of the maximum duration, and 60% (34 of 57) had voluntarily discontinued (39%) or reduced (21%) opioid intake. CONCLUSIONS At two years, 76% of participants experienced substantial, clinically meaningful improvements in pain, disability, or both. These results provide evidence of long-term effectiveness and durability of restorative neurostimulation in patients with disabling CLBP, secondary to multifidus muscle dysfunction. CLINICAL TRIAL REGISTRATION The study is registered on clinicaltrials.gov with identifier NCT02577354.
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Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA.
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, USA
| | - Vivek Mehta
- Barts Neuromodulation Centre, St. Bartholomew's Hospital, London, UK
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, USA
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, USA
| | - Edgar Ross
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, USA
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
| | | | | | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, USA
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, USA
| | - James Rathmell
- Division of Pain Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, USA
| | - Greg Maislin
- Biomedical Statistical Consulting, Wynnewood, PA, USA
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, UK
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10
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Chiarotto A, Koes BW. Nonspecific Low Back Pain. Reply. N Engl J Med 2022; 387:479-480. [PMID: 35921471 DOI: 10.1056/nejmc2207597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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11
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The Pain Intensity/Quality and Pain Site Association with Muscle Activity and Muscle Activity Distribution in Patients with Chronic Low Back Pain: Using a Generalized Linear Mixed Model Analysis. Pain Res Manag 2022; 2022:5751204. [PMID: 35663049 PMCID: PMC9159876 DOI: 10.1155/2022/5751204] [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: 01/04/2022] [Revised: 03/09/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
Abstract
Background Pain can alter muscle activity, although it is not clear how pain intensity and site location affect muscle activity. This study aimed to reveal the complex associations among the pain site, pain intensity/quality, muscle activity, and muscle activity distribution. Methods Electromyographic signals were recorded from above a bilateral lumbar erector spinae muscle with a four-channel electrode in 23 patients with chronic low back pain while they performed a lumbar bending and returning task. We calculated the average value of muscle activity during the extension phase (agonist activity) and the centroid of muscle activity, as well as the distance between the centroid of muscle activity and pain site. We also assessed the pain site and pain intensity/quality by the interview and questionnaire method. A generalized linear mixed model analysis was performed to determine the relationships among pain intensity/quality, pain site, and muscle activity. Results The results showed that muscle activity during the extension phase was significantly negatively associated with neuropathic pain and “pain caused by light touch.” In addition, the distance between the centroid of muscle activity and pain site during the extension phase was significantly positively associated with intermittent pain, “throbbing pain,” “splitting pain,” “punishing-cruel,” and “pain caused by light touch.” Conclusions Our findings suggest the existence of a motor adaptation that suppresses muscle activity near the painful area as the pain intensity increases. Furthermore, the present study indicates that the presence or absence of this motor adaptation depended on the pain quality.
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12
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Hiyama A, Katoh H, Nomura S, Sakai D, Watanabe M. The Effect of Preoperative Neuropathic Pain and Nociceptive Pain on Postoperative Pain Intensity in Patients with the Lumbar Degenerative Disease Following Lateral Lumbar Interbody Fusion. World Neurosurg 2022; 164:e814-e823. [PMID: 35598851 DOI: 10.1016/j.wneu.2022.05.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The purpose of this study was to analyze whether the type of preoperative pain affects the improvement in postoperative pain intensity in patients with a lumbar degenerative disease (LDD). METHODS We retrospectively reviewed 93 patients who underwent lateral lumbar interbody fusion (LLIF) without direct decompression. All patients were evaluated using Numeric Rating Scale (NRS) scores for low back pain (NRSLBP), leg pain (NRSLP), and leg numbness (NRSLN) and imaging data before and after LLIF surgery. Based on the Japanese version of the painDETECT scores, patients were classified into 3 groups: a neuropathic pain (NeP) group, a nociceptive pain (NocP) group, and an intermediate mixed pain group. RESULTS The Japanese version of the painDETECT identified NeP in 20.4% of patients with LDD prior to LLIF. Preoperative NRSLBP, NRSLP, and NRSLN scores were higher in the NeP group than those in the NocP group. All types of pain improved after LLIF surgery. The NRSLBP score 12 months after surgery was higher in the NeP group (3.8 ± 2.8) than that in the NocP group (1.9 ± 2.2) (P = 0.008). Similar results were obtained with NRSLP (NeP group = 3.1 ± 2.8, NocP group = 1.5 ± 2.0, P = 0.010). CONCLUSIONS Although LLIF was useful for relieving all types of preoperative pain in LDD patients, the NRS scores for preoperative pain were higher in the NeP group than those in the NocP group, and the postoperative NRSLBP and NRSLP score was significantly higher in the NeP group. Thus, controlling preoperative NeP may improve therapeutic efficacy.
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Affiliation(s)
- Akihiko Hiyama
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan.
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Satoshi Nomura
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Masahiko Watanabe
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
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13
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Tieppo Francio V, Westerhaus BD, Rupp A, Sayed D. Non-Spinal Neuromodulation of the Lumbar Medial Branch Nerve for Chronic Axial Low Back Pain: A Narrative Review. FRONTIERS IN PAIN RESEARCH 2022; 3:835519. [PMID: 35295793 PMCID: PMC8915554 DOI: 10.3389/fpain.2022.835519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/28/2022] [Indexed: 11/13/2022] Open
Abstract
Chronic low back pain remains highly prevalent, costly, and the leading cause of disability worldwide. Symptoms are complex and treatment involves an interdisciplinary approach. Due to diverse anatomical etiologies, treatment outcomes with interventional options are highly variable. A novel approach to treating chronic axial low back pain entails the use of peripheral nerve stimulation to the lumbar medial branch nerve, and this review examines the clinical data of the two different, commercially available, non-spinal neuromodulation systems. This review provides the clinician a succinct narrative that presents up-to-date data objectively. Our review found ten clinical studies, including one report of two cases, six prospective studies, and three randomized clinical trials published to date. Currently, there are different proposed mechanisms of action to address chronic axial low back pain with different implantation techniques. Evidence suggests that peripheral nerve stimulation of the lumbar medial branch nerve may be effective in improving pain and function in patients with chronic axial low back pain symptoms at short and long term follow up, with good safety profiles. Further long-term data is needed to consider this intervention earlier in the pain treatment algorithm, but initial data are promising.
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Affiliation(s)
- Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS, United States
| | - Benjamin D. Westerhaus
- Cantor Spine Center at the Paley Orthopedic and Spine Institute, Ft. Lauderdale, FL, United States
| | - Adam Rupp
- Department of Rehabilitation Medicine, The University of Kansas Medical Center (KUMC), Kansas City, KS, United States
| | - Dawood Sayed
- Department of Anesthesiology, The University of Kansas Medical Center (KUMC), Kansas City, KS, United States
- *Correspondence: Dawood Sayed
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14
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Williams C, Jerome M, Fausel C, Dodson E, Stemper I, Centeno C. Regenerative Injection Treatments Utilizing Platelet Products and Prolotherapy for Cervical Spine Pain: A Functional Spinal Unit Approach. Cureus 2021; 13:e18608. [PMID: 34659923 PMCID: PMC8500543 DOI: 10.7759/cureus.18608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2021] [Indexed: 11/19/2022] Open
Abstract
Background The increasing burden of musculoskeletal disorders combined with the high utilization of opiates and the relatively limited ability of traditional approaches to satisfactorily address many of these conditions has spurred an increased interest in alternative treatments such as regenerative medicine therapies. Evidence is growing to support the use of regenerative injection treatments, including prolotherapy, platelet-rich plasma (PRP), platelet lysate (PL), and mesenchymal stromal cells. This study aims to offer a proof of concept via a case series of patients with neck pain treated using a functional spinal unit (FSU) model with combination prolotherapy, PRP, and PL injections. Methodology A chart review identified patients with neck pain treated with a combination of cervical injections using concentrated platelets and prolotherapy. Results A total of 14 patients met the inclusion criteria. The average decrease in the Numeric Pain Score was 2.8 (p = 0.002). The mean decrease in the Functional Rating Index was 27.3 (p = 0.004) at 24 months. Two patients had mild adverse reactions. Conclusions This case series demonstrates basic safety and clinically significant improvements in patients treated for neck pain with autologous concentrated platelet products and prolotherapy utilizing an FSU treatment protocol. Additional clinical studies are warranted with a larger patient sample size and longer follow-up periods.
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Affiliation(s)
- Christopher Williams
- Physical Medicine and Rehabilitation, Interventional Orthopedics and Regenerative Medicine, Interventional Orthopedics of Atlanta, Atlanta, USA
| | - Mairin Jerome
- Physical Medicine and Rehabilitation, Regenerative SportsCare Institute, New York, USA
| | - Chaz Fausel
- Physical Medicine and Rehabilitation, Advanced Regenerative Health, Denver, USA
| | - Ehren Dodson
- Research and Development, Regenexx, LLC, Des Moines, USA
| | - Ian Stemper
- Research and Development, Regenexx, LLC, Des Moines, USA
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15
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Gilligan C, Volschenk W, Russo M, Green M, Gilmore C, Mehta V, Deckers K, De Smedt K, Latif U, Georgius P, Gentile J, Mitchell B, Langhorst M, Huygen F, Baranidharan G, Patel V, Mironer E, Ross E, Carayannopoulos A, Hayek S, Gulve A, Van Buyten JP, Tohmeh A, Fischgrund J, Lad S, Ahadian F, Deer T, Klemme W, Rauck R, Rathmell J, Levy R, Heemels JP, Eldabe S. An implantable restorative-neurostimulator for refractory mechanical chronic low back pain: a randomized sham-controlled clinical trial. Pain 2021; 162:2486-2498. [PMID: 34534176 PMCID: PMC8442741 DOI: 10.1097/j.pain.0000000000002258] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 12/19/2022]
Abstract
ABSTRACT Chronic low back pain can be caused by impaired control and degeneration of the multifidus muscles and consequent functional instability of the lumbar spine. Available treatment options have limited effectiveness and prognosis is unfavorable. We conducted an international randomized, double-blind, sham-controlled trial at 26 multidisciplinary centers to determine safety and efficacy of an implantable, restorative neurostimulator designed to restore multifidus neuromuscular control and facilitate relief of symptoms (clinicaltrials.gov identifier: NCT02577354). Two hundred four eligible participants with refractory mechanical (musculoskeletal) chronic LBP and a positive prone instability test indicating impaired multifidus control were implanted and randomized to therapeutic (N = 102) or low-level sham (N = 102) stimulation of the medial branch of the dorsal ramus nerve (multifidus nerve supply) for 30 minutes twice daily. The primary endpoint was the comparison of responder proportions (≥30% relief on the LBP visual analogue scale without analgesics increase) at 120 days. After the primary endpoint assessment, participants in the sham-control group switched to therapeutic stimulation and the combined cohort was assessed through 1 year for long-term outcomes and adverse events. The primary endpoint was inconclusive in terms of treatment superiority (57.1% vs 46.6%; difference: 10.4%; 95% confidence interval, -3.3% to 24.1%, P = 0.138). Prespecified secondary outcomes and analyses were consistent with a modest but clinically meaningful treatment benefit at 120 days. Improvements from baseline, which continued to accrue in all outcome measures after conclusion of the double-blind phase, were clinically important at 1 year. The incidence of serious procedure- or device-related adverse events (3.9%) compared favorably with other neuromodulation therapies for chronic pain.
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Affiliation(s)
- Christopher Gilligan
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, United States
| | | | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | | | - Christopher Gilmore
- Center for Clinical Research, Carolinas Pain Institute, Winston-Salem, NC, United States
| | - Vivek Mehta
- Barts Neuromodulation Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Kristiaan Deckers
- Department of Physical Medicine and Rehabilitation, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Kris De Smedt
- Department of Neurosurgery, GZA - Sint Augustinus Hospital, Wilrijk, Belgium
| | - Usman Latif
- Department of Anesthesiology, University of Kansas School of Medicine, Kansas City, KS, United States
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, Australia
| | | | | | | | - Frank Huygen
- Department of Anaesthesiology Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ganesan Baranidharan
- Leeds Pain and Neuromodulation Centre,Leeds Teaching Hopsitals NHS Trust, Leeds, United Kingdom
| | - Vikas Patel
- Department of Orthopedic Surgery, University of Colorado, Denver, CO, United States
| | - Eugene Mironer
- Carolinas Center for the Advanced Management of Pain, Spartanburg, NC, United States
| | - Edgar Ross
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, United States
| | - Alexios Carayannopoulos
- Departments of Physical Medicine and Rehabilitation, Rhode Island Hospital, Brown University Medical School, Providence, RI, United States
| | - Salim Hayek
- Division of Pain Medicine, University Hospitals, Cleveland Medical Center, Cleveland, OH, United States
| | - Ashish Gulve
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - Antoine Tohmeh
- Multicare Neuroscience Institute, Spokane, WA, United States
| | - Jeffrey Fischgrund
- Department of Orthopedic Surgery, Oakland University, Beaumont Hospital, Royal Oak, MI, United States
| | - Shivanand Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, United States
| | - Farshad Ahadian
- Center for Pain Medicine, University of California, San Diego, CA, United States
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, United States
| | - William Klemme
- Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Richard Rauck
- Carolinas Pain Institute, Wake Forest University, Winston-Salem, NC, United States
| | - James Rathmell
- Division of Pain Medicine, Brigham and Women's Hospital Harvard Medical School, Boston, MA, United States
| | - Robert Levy
- Anesthesia Pain Care Consultant, Tamarac, FL, United States
| | | | - Sam Eldabe
- Department of Pain Medicine, The James Cook University Hospital, Middlesbrough, United Kingdom
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16
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Hollenberg AM, Maqsoodi N, Phan A, Huber A, Jubril A, Baldwin AL, Yokogawa N, Eliseev RA, Mesfin A. Bone morphogenic protein-2 signaling in human disc degeneration and correlation to the Pfirrmann MRI grading system. Spine J 2021; 21:1205-1216. [PMID: 33677096 PMCID: PMC8356724 DOI: 10.1016/j.spinee.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 02/27/2021] [Accepted: 03/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Back and neck pain secondary to disc degeneration is a major public health burden. There is a need for therapeutic treatments to restore intervertebral disc (IVD) composition and function. PURPOSE To quantify ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression in IVD specimens collected from patients undergoing surgery for disc degeneration, to correlate ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression in IVD specimens to the 5-level Pfirrmann MRI grading system, and to compare ALK3, BMP-2, pSMAD1/5/8 and MMP-13 expression between cervical and lumbar degenerative disc specimens. STUDY DESIGN An immunohistochemical study assessing ALK3, BMP-2, pSMAD1/5/8, and MMP-13 expression levels in human control and degenerative IVD specimens. METHODS Human IVD specimens were collected from surgical patients who underwent discectomy and interbody fusion at our institution between 1/2015 and 8/2017. Each patient underwent MRI prior to surgery. The degree of disc degeneration was measured according to the 5-level Pfirrmann MRI grading system. Patients were categorized into either the 1) control group (Pfirrmann grades I-II) or 2) degenerative group (Pfirrmann grades III-V). Histology slides of the collected IVD specimens were prepared and immunohistochemical staining was performed to assess ALK3, BMP-2, pSMAD1/5/8, and MMP-13 expression levels in the control and degenerative specimens. Expression levels were also correlated to the Pfirrmann criteria. Lastly, the degenerative specimens were stratified according to their vertebral level and expression levels between the degenerative lumbar and cervical discs were compared. RESULTS Fifty-two patients were enrolled; however, 2 control and 2 degenerative patients were excluded due to incomplete data sets. Of the remaining 48 patients, there were 12 control and 36 degenerative specimens. Degenerative specimens had increased expression levels of BMP-2 (p=.0006) and pSMAD1/5/8 (p<.0001). Pfirrmann grade 3 (p=.0365) and grade 4 (p=.0008) discs had significantly higher BMP-2 expression as compared to grade 2 discs. Pfirrmann grade 4 discs had higher pSMAD1/5/8 expression as compared to grade 2 discs (p<.0001). There were no differences in ALK3 or MMP-13 expression between the control and degenerative discs (p>.05). Stratifying the degenerative specimens according to their vertebral level showed no significant differences in expression levels between the lumbar and cervical discs (p>.05). CONCLUSIONS BMP-2 and pSMAD1/5/8 signaling activity was significantly upregulated in the human degenerative specimens, while ALK3 and MMP-13 expression were not significantly changed. The expression levels of BMP-2 and pSMAD1/5/8 correlate positively with the degree of disc degeneration measured according to the Pfirrmann MRI grading system. CLINICAL SIGNIFICANCE BMP-SMAD signaling represents a promising therapeutic target to restore IVD composition and function in the setting of disc degeneration.
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Affiliation(s)
- Alex M Hollenberg
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Noorullah Maqsoodi
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Amy Phan
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Aric Huber
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Ayodeji Jubril
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Avionna L Baldwin
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Noriaki Yokogawa
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Roman A Eliseev
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Addisu Mesfin
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY 14642, USA.
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17
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Potru S, Tang YL. Chronic Pain, Opioid Use Disorder, and Clinical Management Among Older Adults. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:294-302. [PMID: 34690595 PMCID: PMC8475938 DOI: 10.1176/appi.focus.20210002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Because of unique factors related to physiological changes and altered metabolism in advanced age, special attention is needed concerning chronic pain, opioid use, and opioid use disorder among older adults. Clinicians need to follow the most updated clinical guidelines regarding opioid prescribing. Routine screening and awareness are the keys to identifying opioid use disorder. Comprehensive assessments often require both pain assessment (including functional status) and substance use assessment, including the use of urine toxicological testing and structured, validated screening tools and instruments. Comprehensive, interdisciplinary efforts are critical in managing the care of older adults with chronic pain and opioid use disorder. A collaborative approach that includes substance abuse treatment and pain management (including pain subspecialty care) is often recommended. Medications for opioid use disorder have been extensively studied and have the most convincing evidence to date, and psychosocial treatments may be beneficial in some circumstances.
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Affiliation(s)
- Sudheer Potru
- Department of Anesthesiology (Potru) and Department of Psychiatry and Behavioral Sciences (Tang), both at Emory University, Atlanta; Department of Anesthesiology (Potru) and Substance Abuse Treatment Program (Tang), both at Atlanta Veterans Affairs Medical Center, Decatur, Georgia
| | - Yi-Lang Tang
- Department of Anesthesiology (Potru) and Department of Psychiatry and Behavioral Sciences (Tang), both at Emory University, Atlanta; Department of Anesthesiology (Potru) and Substance Abuse Treatment Program (Tang), both at Atlanta Veterans Affairs Medical Center, Decatur, Georgia
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18
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Fitzcharles MA, Cohen SP, Clauw DJ, Littlejohn G, Usui C, Häuser W. Nociplastic pain: towards an understanding of prevalent pain conditions. Lancet 2021; 397:2098-2110. [PMID: 34062144 DOI: 10.1016/s0140-6736(21)00392-5] [Citation(s) in RCA: 424] [Impact Index Per Article: 141.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/26/2020] [Accepted: 09/24/2020] [Indexed: 12/26/2022]
Abstract
Nociplastic pain is the semantic term suggested by the international community of pain researchers to describe a third category of pain that is mechanistically distinct from nociceptive pain, which is caused by ongoing inflammation and damage of tissues, and neuropathic pain, which is caused by nerve damage. The mechanisms that underlie this type of pain are not entirely understood, but it is thought that augmented CNS pain and sensory processing and altered pain modulation play prominent roles. The symptoms observed in nociplastic pain include multifocal pain that is more widespread or intense, or both, than would be expected given the amount of identifiable tissue or nerve damage, as well as other CNS-derived symptoms, such as fatigue, sleep, memory, and mood problems. This type of pain can occur in isolation, as often occurs in conditions such as fibromyalgia or tension-type headache, or as part of a mixed-pain state in combination with ongoing nociceptive or neuropathic pain, as might occur in chronic low back pain. It is important to recognise this type of pain, since it will respond to different therapies than nociceptive pain, with a decreased responsiveness to peripherally directed therapies such as anti-inflammatory drugs and opioids, surgery, or injections.
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Affiliation(s)
- Mary-Ann Fitzcharles
- Department of Rheumatology and Alan Edwards Pain Management Unit, McGill University, Montreal, QC, Canada.
| | - Steven P Cohen
- Department of Psychiatry and Behavioral Sciences and Department of Anesthesiology and Critical Care Medicine, Neurology and Physical Medicine and Rehabilitation at Johns Hopkins Hospital, Baltimore, MD, USA; Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Daniel J Clauw
- Departments of Anesthesiology, Medicine, and Psychiatry, Chronic Pain and Fatigue Research Center, the University of Michigan Medical School, Ann Arbor, MI, USA
| | - Geoffrey Littlejohn
- Department of Rheumatology and Department of Medicine, Monash Health and Monash University, Clayton, Melbourne, VIC, Australia
| | - Chie Usui
- Department of Psychiatry, Juntendo University School of Medicine, Tokyo, Japan
| | - Winfried Häuser
- Department Internal Medicine I, Klinikum Saarbrücken, Saarbrücken, Germany; Department of Psychosomatic Medicine and Psychotherapy, Technische Universität München, München, Germany
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Gabel CP, Mokhtarinia HR, Melloh M, Mateo S. Slacklining as therapy to address non-specific low back pain in the presence of multifidus arthrogenic muscle inhibition. World J Orthop 2021; 12:178-196. [PMID: 33959482 PMCID: PMC8082507 DOI: 10.5312/wjo.v12.i4.178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/18/2021] [Accepted: 03/13/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Charles Philip Gabel
- Department of Physiotherapy, Access Physiotherapy, Coolum Beach 4573, QLD, Australia
| | - Hamid Reza Mokhtarinia
- Department of Ergonomics, University of Social Welfare and Rehabilitation Sciences, Tehran 0001, Iran
- Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran 0001, Iran
| | - Markus Melloh
- School of Health Professions, Zurich University of Applied Sciences, Winterthur 8310, Switzerland
| | - Sébastien Mateo
- INSERM U1028, CNRS UMR5292, Lyon Neuroscience Research Center, Université de Lyon, Lyon 69000, France
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Shraim MA, Massé-Alarie H, Hodges PW. Methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system: a systematic review. Pain 2021; 162:1007-1037. [PMID: 33136983 DOI: 10.1097/j.pain.0000000000002113] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/05/2020] [Indexed: 12/18/2022]
Abstract
ABSTRACT Mechanism-based classification of pain has been advocated widely to aid tailoring of interventions for individuals experiencing persistent musculoskeletal pain. Three pain mechanism categories (PMCs) are defined by the International Association for the Study of Pain: nociceptive, neuropathic, and nociplastic pain. Discrimination between them remains challenging. This study aimed to build on a framework developed to converge the diverse literature of PMCs to systematically review methods purported to discriminate between them; synthesise and thematically analyse these methods to identify the convergence and divergence of opinion; and report validation, psychometric properties, and strengths/weaknesses of these methods. The search strategy identified articles discussing methods to discriminate between mechanism-based categories of pain experienced in the musculoskeletal system. Studies that assessed the validity of methods to discriminate between categories were assessed for quality. Extraction and thematic analysis were undertaken on 184 articles. Data synthesis identified 200 methods in 5 themes: clinical examination, quantitative sensory testing, imaging, diagnostic and laboratory testing, and pain-type questionnaires. Few methods have been validated for discrimination between PMCs. There was general convergence but some disagreement regarding findings that discriminate between PMCs. A combination of features and methods, rather than a single method, was generally recommended to discriminate between PMCs. Two major limitations were identified: an overlap of findings of methods between categories due to mixed presentations and many methods considered discrimination between 2 PMCs but not others. The results of this review provide a foundation to refine methods to differentiate mechanisms for musculoskeletal pain.
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Affiliation(s)
- Muath A Shraim
- The University of Queensland, NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health & Rehabilitation Sciences, QLD, Australia
| | - Hugo Massé-Alarie
- The University of Queensland, NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health & Rehabilitation Sciences, QLD, Australia
- Centre Interdisciplinaire de recherche en réadaptation et Integration sociale (CIRRIS), Université Laval, Québec, QC, Canada
| | - Paul W Hodges
- The University of Queensland, NHMRC Centre of Clinical Research Excellence in Spinal Pain, Injury & Health, School of Health & Rehabilitation Sciences, QLD, Australia
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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.
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Ogunlade B, Fidelis OP, Adelakun SA, Adedotun OA. Grape seed extract inhibits nucleus pulposus cell apoptosis and attenuates annular puncture induced intervertebral disc degeneration in rabbit model. Anat Cell Biol 2020; 53:313-324. [PMID: 32782235 PMCID: PMC7527127 DOI: 10.5115/acb.20.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/14/2020] [Accepted: 06/24/2020] [Indexed: 11/27/2022] Open
Abstract
Low back pain is a musculoskeletal disorders implicated to disc degeneration. Grape seed extracts (GSEs) is a natural flavonoids rich compound with antioxidants and anti-inflammatory properties. This study is aimed at investigating the inhibitory and anabolic response of GSE on annular punctured induced disc degeneration in rabbit model. Twenty-Eight New Zealand white rabbits (weighing about 2.0-3.5 kg) were used with institutional animal care committee's approval. The animals were divided into four groups (n=7 per group). Group A (non-punctured group) received distilled water orally for 4 weeks. Group B (punctured group) received distilled water for 4 weeks. Group C (punctured treated group) received distilled water for 4 weeks and thereafter received 500 mg/kg of GSE for another 4 weeks. Group D received 500 mg/kg of GSE immediately after puncture for 4 weeks. At the end of the experiment, the animals were sacrificed with intramuscular injection of ketamine followed by intravenous injection of sodium pentobarbital. The percentage disc height index of the punctured group showed significant decrease compared to the control and treated groups. Histological and immunohistochemical studies showed distortion in the disc morphology, decrease in chondrocyte like cells, disorganization of collagen and elastic fibers, increase Bax expression levels in the punctured group compared to control and treated groups which was attenuated after GSE administration. GSE has preventive and restorative effects on punctured induced disc preventing the degradation of collagen fibrils within the disc tissues.
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Affiliation(s)
- B Ogunlade
- Department of Human Anatomy, Federal University of Technology, Akure, Ondo State, Nigeria
| | - O P Fidelis
- Department of Biomedical Technology, Federal University of Technology, Akure, Ondo State, Nigeria
| | - S A Adelakun
- Department of Human Anatomy, Federal University of Technology, Akure, Ondo State, Nigeria
| | - O A Adedotun
- Department of Human Anatomy, Federal University of Technology, Akure, Ondo State, Nigeria
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Schwarm FP, Ott M, Nagl J, Bender M, Stein M, Uhl E, Maxeiner H, Kolodziej MA. The Predictive Value of Transcutaneous Electrical Nerve Stimulation for Patient Selection in Peripheral Nerve Field Stimulation for Chronic Low Back Pain: A Prospective Study. Neuromodulation 2020; 24:1051-1058. [PMID: 32757257 DOI: 10.1111/ner.13244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/10/2020] [Accepted: 06/22/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Peripheral nerve field stimulation (PNFS) is an effective alternative treatment for patients with chronic low back pain. Transcutaneous electrical nerve stimulation (TENS) is frequently used in pain therapy. Aim of this prospective study was to examine the predictive value of TENS for later PNFS treatment. MATERIALS AND METHODS Between 2014 and 2019, a prospective cohort study of 41 patients with chronic lumbar pain was conducted. Pain intensity (NRS) was assessed before and after TENS use, preoperatively/postoperatively and in the follow-up after three and six months, SF12v2 questionnaires with physical (PCS) and mental component summary (MCS) scores, and Oswestry disability index (ODI) questionnaire at baseline as well as three and six months after PNFS implantation. Implantation of the PNFS-system with two percutaneous leads was performed after four to seven days of positive testing. Statistical analysis was performed using depending t-test, ANOVA, and Spearman correlation. RESULTS The cohort consisted of 41 patients (19 females, 22 males) with a median age of 60.5 years (IQR25-75 52-67). Two patients were lost to follow-up. After positive PNFS testing a pulse generator (IPG) was implanted in 15 patients with positive TENS effect and 15 patients without TENS effect. Leads were explanted in nine patients after negative PNFS trial phase. TENS positive patients showed significant correlation to a positive effect in the PNFS trial phase in NRS reduction (p = 0.042) indicating that TENS responders will also respond to PNFS (94% patients). After three and six months follow-up median NRS and SF12v2 (PCS) improved significantly in both cohorts, SF12v2 (MCS) and ODI only in the TENS positive cohort, respectively. CONCLUSION TENS can be predictive for patient selection in PNFS, as TENS positive patients showed significant correlation with a positive PNFS trial period. Therefore, TENS positive patients might be justifiable to be directly implanted with leads and IPG. TENS positive patients further tend to show a better improvement in the follow-up.
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Affiliation(s)
| | - Marc Ott
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Jasmin Nagl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Michael Bender
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Marco Stein
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University Giessen, Giessen, Germany
| | - Hagen Maxeiner
- Department of Anesthesiology, Intensive Care and Pain Therapy, Justus-Liebig-University Giessen, Giessen, Germany
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Systematic Review and Synthesis of Mechanism-based Classification Systems for Pain Experienced in the Musculoskeletal System. Clin J Pain 2020; 36:793-812. [DOI: 10.1097/ajp.0000000000000860] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
OBJECTIVES Assessment of neuropathic pain in chronic low back syndromes is important. However, there is currently no gold standard for its diagnosis. The aim of this observational cross-sectional study was to assess the neuropathic component of pain in various chronic low back pain syndromes using a range of diagnostic tests. MATERIALS AND METHODS Included in this study were 63 patients with chronic axial low back pain (ALBP), 48 patients with chronic radicular syndromes (CRS) comprising 23 with discogenic compression (CDRS) and 25 with lumbar spinal stenosis (LSS), and 74 controls. PainDETECT questionnaire (PDQ), quantitative sensory testing (QST), and skin biopsy with evaluation of intraepidermal nerve fiber density (IENFD) were used to assess the neuropathic pain component. RESULTS Positive PDQ (≥19) was obtained more frequently in patients with CDRS and LSS (26.1% and 12.0%, respectively) compared with patients with ALBP (1.6%, P<0.001). The proportion of patients with sensory loss confirmed by QST was lowest in the ALBP subgroup (23.8%) compared with CDRS (47.8%), and LSS (68.0%) subgroups (P<0.001). A reduction in IENFD was disclosed in a proportion of up to 52.0% of affected roots in patients with CRS. DISCUSSION Neuropathic pain is quite frequent in CRS, and QST reveals sensory loss as a frequent abnormality in patients with CRS. Using a cut-off value of 19, PDQ identified a neuropathic component in a relatively low proportion of patients with CRS. CRS may be associated with a reduction in IENFD.
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Al-Kaisy A, Royds J, Palmisani S, Pang D, Wesley S, Taylor RS, Cook A, Eldabe S, McCracken L, Duarte R, Fairbank J. Multicentre, double-blind, randomised, sham-controlled trial of 10 khz high-frequency spinal cord stimulation for chronic neuropathic low back pain (MODULATE-LBP): a trial protocol. Trials 2020; 21:111. [PMID: 31992344 PMCID: PMC6986091 DOI: 10.1186/s13063-019-3831-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 10/22/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Chronic neuropathic low back pain (CNLBP) is a debilitating condition in which established medical treatments seldom alleviate symptoms. Evidence demonstrates that high-frequency 10 kHz spinal cord stimulation (SCS) reduces pain and improves health-related quality of life in patients with failed back surgery syndrome (FBSS), but evidence of this effect is limited in individuals with CNLBP who have not had surgery. The aim of this multicentre randomised trial is to assess the clinical and cost-effectiveness of 10 kHz SCS for this population. METHODS This is a multicentre, double-blind, randomised, sham-controlled trial with a parallel economic evaluation. A total of 96 patients with CNLBP who have not had spinal surgery will be implanted with an epidural lead and a sham lead outside the epidural space without a screening trial. Patients will be randomised 1:1 to 10 kHz SCS plus usual care (intervention group) or to sham 10 kHz SCS plus usual care (control group) after receiving the full implant. The SCS devices will be programmed identically using a cathodal cascade. Participants will use their handheld programmer to alter the intensity of the stimulation as per routine practice. The primary outcome will be a 7-day daily pain diary. Secondary outcomes include the Oswestry Disability Index, complications, EQ-5D-5 L, and health and social care costs. Outcomes will be assessed at baseline (pre-randomisation) and at 1 month, 3 months and 6 months after device activation. The primary analyses will compare primary and secondary outcomes between groups at 6 months, while adjusting for baseline outcome scores. Incremental cost per quality-adjusted life year (QALY) will be calculated at 6 months and over the lifetime of the patient. DISCUSSION The outcomes of this trial will inform clinical practice and healthcare policy on the role of high-frequency 10 kHz SCS for use in patients with CNLBP who have not had surgery. TRIAL REGISTRATION Clinicaltrials.gov, NCT03470766. Registered on 20 March 2018. DISCLAIMER The views expressed here are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The NIHR had no role in the study design, writing of the manuscript or the decision to submit for publication. ROLES AND RESPONSIBILITIES AK, SP, DP, SW, RST, AC, SE, LM, RD and JF all contributed to the trial design and to securing trial funding. AK, JR, SP, DP, and SE are involved in the recruitment, the intervention and the follow-up. SW will perform data collection and analysis. RST will be responsible for the statistical analysis, and RD will be responsible for the health economic analysis. All authors read and approved the final manuscript.
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Affiliation(s)
- Adnan Al-Kaisy
- Pain Management & Neuromodulation Centre, St Thomas’ Hospital, Westminster Bridge Road, SE1 7EH London, UK
| | | | | | - David Pang
- Guys & St. Thomas NHS Foundation Trust, London, UK
| | | | - Rod S. Taylor
- Institute of Health and Well Being, University of Glasgow, Glasgow, UK
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sam Eldabe
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Lance McCracken
- Department of Psychology, Uppsala University, Uppsala, Sweden
| | - Rui Duarte
- Liverpool Reviews and Implementation Group, Health Services Research, University of Liverpool, Liverpool, UK
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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.
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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
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Park TSW, Khan N, Kuo A, Nicholson JR, Corradini L, Smith MT. J-2156, a somatostatin receptor type 4 agonist, alleviates mechanical hyperalgesia in a rat model of chronic low back pain. Biomed Pharmacother 2019; 117:109056. [PMID: 31181441 DOI: 10.1016/j.biopha.2019.109056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/22/2019] [Accepted: 05/31/2019] [Indexed: 01/23/2023] Open
Abstract
Chronic low back pain (LBP) ranks among the most common reasons for patient visits to healthcare providers. Drug treatments often provide only partial pain relief and are associated with considerable side-effects. J-2156 [(1'S,2S)-4amino-N-(1'-carbamoyl-2'-phenylethyl)-2-(4"-methyl-1"-naphthalenesulfonylamino)butanamide] is an agonist that binds with nanomolar affinity to the rat and human somatostatin receptor type 4 (SST4 receptor). Hence, our aim was to assess the efficacy of J-2156 for relief of chronic mechanical LBP in a rat model. Male Sprague Dawley rats were anaesthetised and their lumbar L4/L5 and L5/L6 intervertebral discs (IVDs) were punctured (0.5 mm outer diameter, 2 mm-deep) 10 times per disc. Sham-rats underwent similar surgery, but without disc puncture. For LBP-rats, noxious pressure hyperalgesia developed in the lumbar axial deep tissues from day 7 to day 21 post-surgery, which was maintained until study completion. Importantly, mechanical hyperalgesia did not develop in the lumbar axial deep tissues of sham-rats. In LBP-rats, single intraperitoneal (i.p.) injection of J-2156 (3, 10, 30 mg kg-1) alleviated primary and secondary hyperalgesia in the lumbar axial deep tissues at L4/L5 and L1, respectively. This was accompanied by a reduction in the otherwise augmented lumbar (L4-L6) dorsal root ganglia expression levels of the pro-nociceptive mediators: phosphorylated p38 (pp38) mitogen-activated protein kinase (MAPK) and phosphorylated p44/p42 MAPK and a reduction in pp38 MAPK in the lumbar enlargement of the spinal cord. The SST4 receptor is worthy of further investigation as a target for discovery of novel analgesics for the relief of chronic LBP.
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Affiliation(s)
- Thomas S W Park
- School of Biomedical Sciences, Faculty of Medicine, Level 3, Steele Building, St Lucia Campus, The University of Queensland, Brisbane, Australia
| | - Nemat Khan
- School of Biomedical Sciences, Faculty of Medicine, Level 3, Steele Building, St Lucia Campus, The University of Queensland, Brisbane, Australia
| | - Andy Kuo
- School of Biomedical Sciences, Faculty of Medicine, Level 3, Steele Building, St Lucia Campus, The University of Queensland, Brisbane, Australia
| | | | - Laura Corradini
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Maree T Smith
- School of Biomedical Sciences, Faculty of Medicine, Level 3, Steele Building, St Lucia Campus, The University of Queensland, Brisbane, Australia.
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Freynhagen R, Parada HA, Calderon-Ospina CA, Chen J, Rakhmawati Emril D, Fernández-Villacorta FJ, Franco H, Ho KY, Lara-Solares A, Li CCF, Mimenza Alvarado A, Nimmaanrat S, Dolma Santos M, Ciampi de Andrade D. Current understanding of the mixed pain concept: a brief narrative review. Curr Med Res Opin 2019; 35:1011-1018. [PMID: 30479161 DOI: 10.1080/03007995.2018.1552042] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Despite having been referenced in the literature for over a decade, the term "mixed pain" has never been formally defined. The strict binary classification of pain as being either purely neuropathic or nociceptive once left a good proportion of patients unclassified; even the recent adoption of "nociplastic pain" in the IASP Terminology leaves out patients who present clinically with a substantial overlap of nociceptive and neuropathic symptoms. For these patients, the term "mixed pain" is increasingly recognized and accepted by clinicians. Thus, an independent group of international multidisciplinary clinicians convened a series of informal discussions to consolidate knowledge and articulate all that is known (or, more accurately, thought to be known) and all that is not known about mixed pain. To inform the group's discussions, a Medline search for the Medical Subject Heading "mixed pain" was performed via PubMed. The search strategy encompassed clinical trial articles and reviews from January 1990 to the present. Clinically relevant articles were selected and reviewed. This paper summarizes the group's consensus on several key aspects of the mixed pain concept, to serve as a foundation for future attempts at generating a mechanistic and/or clinical definition of mixed pain. A definition would have important implications for the development of recommendations or guidelines for diagnosis and treatment of mixed pain.
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Affiliation(s)
- Rainer Freynhagen
- a Department of Anaesthesiology , Critical Care Medicine, Pain Therapy and Palliative Care, Benedictus Hospital Tutzing , Tutzing , Germany
- b Department of Anaesthesiology , Klinikum Rechts der Isar, Technische Universität München , Munich , Germany
| | | | - Carlos Alberto Calderon-Ospina
- d Pharmacology Unit, Department of Biomedical Sciences, School of Medicine and Health Sciences , Universidad del Rosario , Bogota , Colombia
- e Center For Research in Genetics and Genomics (CIGGUR), GENIUROS Research Group, School of Medicine and Health Sciences, Universidad del Rosario , Bogota , Colombia
| | - Juythel Chen
- f Pain Clinic , Hospital Santo Tomas , Panama City , Panama
| | - Dessy Rakhmawati Emril
- g Neurology Department , Medical Faculty of Syiah Kuala University/Dr Zainoel Abidin Hospital (RSUZA) , Banda Aceh , Indonesia
| | | | - Hector Franco
- i Clinica Neurologia y Neurofisiologica Integral , Guatemala City, Guatemala
| | - Kok-Yuen Ho
- j Pain Management Service , Raffles Hospital , Singapore
| | - Argelia Lara-Solares
- k Department of Pain and Palliative Care , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | | | - Alberto Mimenza Alvarado
- m Department of Geriatrics , Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán , Mexico City , Mexico
| | - Sasikaan Nimmaanrat
- n Department of Anesthesiology, Faculty of Medicine , Prince of Songkla University , Hat Yai , Thailand
| | - Maria Dolma Santos
- o Department of Anesthesiology , Asian Hospital and Medical Center , Muntinlupa City , Philippines
- p Department of Anesthesiology , The Medical City , Pasig City , Philippines
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Meisel HJ, Agarwal N, Hsieh PC, Skelly A, Park JB, Brodke D, Wang JC, Yoon ST, Buser Z. Cell Therapy for Treatment of Intervertebral Disc Degeneration: A Systematic Review. Global Spine J 2019; 9:39S-52S. [PMID: 31157145 PMCID: PMC6512192 DOI: 10.1177/2192568219829024] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVE To review, critically appraise, and synthesize evidence on use of cell therapy for intervertebral disc repair. METHODS A systematic search of PubMed/MEDLINE was conducted for literature published through October 31, 2018 and EMBASE and ClinicalTrials.gov databases through April 13, 2018 comparing allogenic or autologous cell therapy for intervertebral disc (IVD) repair in the lumbar or cervical spine. In the absence of comparative studies, case series of ≥10 patients were considered. RESULTS From 1039 potentially relevant citations, 8 studies across 10 publications on IVD cell therapies in the lumbar spine met the inclusion criteria. All studies were small and primarily case series. For allogenic cell sources, no difference in function or pain between mesenchymal cell treatment and sham were reported in 1 small randomized controlled trial; 1 small case series reported improved function and pain relative to baseline but it was unclear if the change was clinically significant. Similarly for autologous cell sources, limited data across case series suggest pain and function may be improved relative to baseline; whether the changes were clinically significant was not clear. Safety data was sparse and poorly reported. The need for subsequent surgery was reported in 3 case-series studies ranging from 6% to 80%. CONCLUSIONS The overall strength of evidence for efficacy and safety of cell therapy for lumbar IVD repair was very low primarily due to substantial risk of bias, small sample sizes and lack of a comparator intervention. Methodologically sound studies comparing cell therapies to other treatments are needed.
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Affiliation(s)
| | | | | | | | - Jong-Beom Park
- Uijongbu St. Mary’s Hospital, The Catholic University of Korea, Uijongbu, Republic of Korea
| | | | | | | | - Zorica Buser
- University of Southern California, Los Angeles, CA, USA
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The appropriate management of persisting pain after spine surgery: a European panel study with recommendations based on the RAND/UCLA method. 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 2018; 28:31-45. [PMID: 30078053 DOI: 10.1007/s00586-018-5711-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/29/2018] [Accepted: 07/25/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Management of patients with persisting pain after spine surgery (PPSS) shows significant variability, and there is limited evidence from clinical studies to support treatment choice in daily practice. This study aimed to develop patient-specific recommendations on the management of PPSS. METHODS Using the RAND/UCLA appropriateness method (RUAM), an international panel of 6 neurosurgeons, 6 pain specialists, and 6 orthopaedic surgeons assessed the appropriateness of 4 treatment options (conservative, minimally invasive, neurostimulation, and re-operation) for 210 clinical scenarios. These scenarios were unique combinations of patient characteristics considered relevant to treatment choice. Appropriateness had to be expressed on a 9-point scale (1 = extremely inappropriate, 9 = extremely appropriate). A treatment was considered appropriate if the median score was ≥ 7 in the absence of disagreement (≥ 1/3 of ratings in each of the opposite sections 1-3 and 7-9). RESULTS Appropriateness outcomes showed clear and specific patterns. In 48% of the scenarios, exclusively one of the 4 treatments was appropriate. Conservative treatment was usually considered appropriate for patients without clear anatomic abnormalities and for those with new pain differing from the original symptoms. Neurostimulation was considered appropriate in the case of (predominant) neuropathic leg pain in the absence of conditions that may require surgical intervention. Re-operation could be considered for patients with recurrent disc, spinal/foraminal stenosis, or spinal instability. CONCLUSIONS Using the RUAM, an international multidisciplinary panel established criteria for appropriate treatment choice in patients with PPSS. These may be helpful to educate physicians and to improve consistency and quality of care. These slides can be retrieved under Electronic Supplementary Material.
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Hong JT, Kim JH, Kim KS, Lee CS, Shin HC, Kim WK, Kim JH, Lee JK, Kim IS, Ha Y, Im SB, Kim SW, Han IH, Shin JJ, Rim B, Suk KS, Kim JH, Park YS, Chang BS, Jun DS, Kim YH, Lee JH, Min WK, Lee JS, Park SY, Oh IS, Hong JY, Seo BJ, Kim YJ, Lee J. Pharmacological target therapy of neuropathic pain and patient-reported outcomes in patients with chronic low back pain in Korea: Results from the NLBP Outcomes Research. Medicine (Baltimore) 2018; 97:e11919. [PMID: 30170385 PMCID: PMC6393114 DOI: 10.1097/md.0000000000011919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A number of studies have demonstrated an association of neuropathic pain and chronic low back pain (CLBP), but the outcome difference in each medical management is poorly understood. This study is aimed to investigate treatment patterns of neuropathic pain in CLBP patients and to explore patient-reported outcomes (PROs) including quality of life (QoL) and functional disability by treatment patterns.Data were extracted from the neuropathic low back pain (NLBP) outcomes research. It was a multicenter and cross-sectional study in which 1200 patients were enrolled at 27 general hospitals, from 2014 to 2015. Of total, 478 patients classified as neuropathic pain were used for this subgroup analysis. The patients were divided into 2 groups according to treatment patterns (with vs. without the targeted therapy [TT] of neuropathic pain). Demographic and clinical features were collected by chart reviews and PROs were measured by patient's survey. QoL was assessed by EuroQoL 5-dimension (EQ-5D) questionnaire. Functional disability was measured by the Quebec Back Pain Disability Scale (QBPDS). Multiple linear regression analyses were conducted to compare the PROs between TT group and non-targeted therapy (nTT) group.Among the NLBP patients (mean age 63years, female 62%), EQ-5D index, EuroQoL-Visual Analog Scale (EQ-VAS), and QBPDS Scores (mean ± standard deviation) were 0.40 ± 0.28, 54.98 ± 19.98, and 46.03 ± 21.24, respectively. Only 142 (29.7%) patients had pharmacological TT of neuropathic pain. Univariate analyses revealed no significant mean differences between TT group and nTT group in the EQ-5D index (0.41 ± 0.27 and 0.39 ± 0.28), EQ-VAS (56.43 ± 18.17 and 54.37 ± 20.69), and QBPDS (45.31 ± 21.32 and 46.31 ± 21.24). After adjustment with covariates, TT group had higher scores of EQ-5D index (β = 0.07; P < 0.01) and EQ-VAS (β = 4.59; P < 0.05) than the nTT group. The TT group's QBPDS score was lower than the nTT group, although its statistical significance still has not been reached (β = -4.13; P = 0.07).We found that considerable proportion of the NLBP patients remains untreated or undertreated. Although TT group had significantly better QoL than nTT group, only 29.7% of NLBP patients had pharmacological TT. Therefore, clinicians should consider using TT for better QoL of neuropathic pain patients.
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Affiliation(s)
- Jae Taek Hong
- Department of Neurosurgery, The catholic university of Korea, St. Vincent's hospital & Eunpyung St. Mary's Hospital, Suwon
| | - Jin-Hwan Kim
- Department of Orthopedic Surgery, Inje University Ilsan Paik Hospital, Gyeonggi-do
| | - Keun-Su Kim
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University Health System
| | - Chong-Suh Lee
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Hyun-Chul Shin
- Department of Neurosurgery, Kangbuk Samsung Hospital, Seoul
| | - Woo-Kyung Kim
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon
| | - Joo-Han Kim
- Department of Neurosurgery, Korea University Guro Hospital, Seoul
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Hospital, Kwangju
| | - In-Soo Kim
- Department of Neurosurgery, Keimyung University Dongsan Hospital, Daegu
| | - Yoon Ha
- Department of Neurosurgery, Severance Hospital, Yonsei University Health System, Seoul
| | - Soo-Bin Im
- Department of Neurosurgery, Soonchunhyang University Hospital Bucheon, Gyeonggi-do
| | - Sang Woo Kim
- Department of Neurosurgery, Yeungnam university Hospital, Daegu
| | - In-Ho Han
- Department of Neurosurgery, Pusan National University Hospital, Busan
| | - Jun-Jae Shin
- Department of Neurosurgery, Inje University Industry Academic Cooperation Foundation, Wonju, Korea
| | - ByeongCheol Rim
- Department of Neurosurgery, Sun Medical Center, Kerala, India
| | - Kyung-Soo Suk
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University Health System
| | - Jin-Hyok Kim
- Department of Orthopedic Surgery, Inje University Sanggye Paik Hospital, Seoul
| | - Ye-Soo Park
- Department of Orthopedic Surgery, Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul
| | - Deuk Soo Jun
- Department of Orthopedic Surgery, Gachon University Gil Medical Center, Incheon
| | - Young-Hoon Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital of the Catholic University of Korea
| | - Jung-Hee Lee
- Department of Orthopedic Surgery, Kyung Hee University Hospital, Seoul
| | - Woo-Kie Min
- Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu
| | - Jung Sub Lee
- Department of Orthopedic Surgery, Pusan National University Hospital, Busan
| | - Si-Young Park
- Department of Orthopedic Surgery, Korea University Anam Hospital, Seoul
| | - In-Soo Oh
- Department of Orthopedic Surgery, Incheon St. Mary's Hospital of the Catholic University of Korea, Incheon
| | - Jae-Young Hong
- Department of Orthopedic Surgery, Korea University Ansan Hospital, Gyeonggi-do
| | - Bo-Jeong Seo
- Outcomes Research/Real World Data, Corporate Affairs & Health and Value, Pfizer Pharmaceuticals Korea Ltd
| | - Young-Joo Kim
- Outcomes Research/Real World Data, Corporate Affairs & Health and Value, Pfizer Pharmaceuticals Korea Ltd
| | - Juneyoung Lee
- Department of Biostatistics, College of Medicine, Korea University, Seoul, Republic of Korea
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Hüllemann P, Keller T, Kabelitz M, Gierthmühlen J, Freynhagen R, Tölle T, Forstenpointner J, Baron R. Clinical Manifestation of Acute, Subacute, and Chronic Low Back Pain in Different Age Groups: Low Back Pain in 35,446 Patients. Pain Pract 2018; 18:1011-1023. [PMID: 29710429 DOI: 10.1111/papr.12704] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/26/2018] [Accepted: 03/31/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Low back pain (LBP) is a major healthcare problem causing tremendous economic costs. METHODS Clinical manifestation of LBP was characterized in 35,446 patients. We focused on the comparison of the acute, subacute, and chronic LBP stage with regard to patients' ages, based on epidemiologic and clinical questionnaires (eg, painDETECT Questionnaire, Pain Disability Index), pain intensity, pain descriptors, and functional impairment. RESULTS We found that neuropathic components were most frequent in chronic LBP patients at the ages of 51 to 60 years. Elderly LBP patients showed a decrease in neuropathic and an increase in nociceptive pain. The most frequently reported pain descriptors were "pressure pain" and "pain attacks" through all stages of LBP, whereas "burning" and "prickling" were most frequent in the chronic stage. Patients after back surgery presented neuropathic pain symptoms most frequently and had the highest amount of pain medication intake. CONCLUSIONS Burning and prickling were revealed as possible indicators for LBP chronicity. Combined with pain attacks and pressure pain, these 4 pain descriptors might be a promising adjunct to pain intensity in terms of outcome parameters for future LBP studies. The decrease of neuropathic pain syndromes in the elderly might be explained by degenerative processes. The presented work provides important insights on LBP management in the acute, subacute, and chronic stages.
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Affiliation(s)
- 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
| | - Rainer Freynhagen
- Centre of Anaesthesiology, Intensive Care Medicine, Pain Medicine and Palliative Care Medicine, Benidictus Hospital Tutzing and Department of Anaesthesiology, Technical University of Munich, Munich, Germany
| | - Thomas Tölle
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Julia Forstenpointner
- 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
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Huang WC, Lin MHC, Lee MH, Chen KT, Cheng CY, Lin CH, Yang WH, Wang TC, Yang JT. Percutaneous dorsal root ganglion block for treating lumbar compression fracture-related pain. Acta Neurochir (Wien) 2018; 160:1283-1289. [PMID: 29696504 DOI: 10.1007/s00701-018-3535-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/04/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The pain of acute compression fracture in the lumbar spine may be refractory to conservative treatment, and surgery is not an optimal choice for the elderly or infirm individuals. Moreover, even vertebroplasty can cause many side effects such as chemical leak, adjacent segment instability, and residual pain. Percutaneous dorsal root ganglion block (PDRGB) possibly is an alternative therapeutic option. In this study, we evaluated the efficacy of pain relief and the rate of adjacent level compression fracture in patients with acute compression fracture of the lumbar spine. METHODS We retrospectively reviewed 40 patients with lumbar compression fracture from 2013 to 2015. The patients were treated with navigation-assisted CT-guided PDRGB with steroid at the pathological level and at the adjacent level above and below. Therapeutic response was evaluated using the Numerical Rating Scale (NRS); and an optimal, acceptable, and unfavorable outcome were analyzed. RESULTS Among the 40 patients treated, initial pain relief on the first day was dramatic, and the average NRS did not change significantly up to the first-year follow-up. The highest percentage of a good outcome, at 90% (37.5% with an optimal outcome, 52.5% with an acceptable outcome), was reported at 1 week postoperatively. The percentage of optimal outcomes increased even at the 1-year follow-up. No adjacent compression fracture was found in the group treated with PDRGB alone at the 1-year follow-up. CONCLUSIONS PDRGB is a simple, safe, and minimally invasive procedure that showed immediate and prolonged improvement of pain in lumbar osteoporotic compression fracture patients who failed conservative treatment or had residual pain after vertebroplasty. However, continuous medication for osteoporosis was still required.
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Martin ML, Blum SI, Liedgens H, Bushnell DM, McCarrier KP, Hatley NV, Ramasamy A, Freynhagen R, Wallace M, Argoff C, Eerdekens M, Kok M, Patrick DL. Mixed-methods development of a new patient-reported outcome instrument for chronic low back pain: part 1-the Patient Assessment for Low Back Pain - Symptoms (PAL-S). Pain 2018; 159:1045-1055. [PMID: 29432327 PMCID: PMC5965933 DOI: 10.1097/j.pain.0000000000001187] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 01/24/2018] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
We describe the mixed-methods (qualitative and quantitative) development and preliminary validation of the Patient Assessment for Low Back Pain-Symptoms (PAL-S), a patient-reported outcome measure for use in chronic low back pain (cLBP) clinical trials. Qualitative methods (concept elicitation and cognitive interviews) were used to identify and refine symptom concepts and quantitative methods (classical test theory and Rasch measurement theory) were used to evaluate item- and scale-level performance of the measure using an iterative approach. Patients with cLBP participated in concept elicitation interviews (N = 43), cognitive interviews (N = 38), and interview-based assessment of paper-to-electronic mode equivalence (N = 8). A web-based sample of patients with self-reported cLBP participated in quantitative studies to evaluate preliminary (N = 598) and revised (n = 401) drafts and a physician-diagnosed cohort of patients with cLBP (N = 45) participated in preliminary validation of the measure. The PAL-S contained 14 items describing symptoms (overall pain, sharp, prickling, sensitive, tender, radiating, shocking, shooting, burning, squeezing, muscle spasms, throbbing, aching, and stiffness). Item-level performance, scale structure, and scoring seemed to be appropriate. One-week test-retest reproducibility was acceptable (intraclass correlation coefficient 0.81 [95% confidence interval, 0.61-0.91]). Convergent validity was demonstrated with total score and MOS-36 Bodily Pain (Pearson correlation -0.79), Neuropathic Pain Symptom Inventory (0.73), Roland-Morris Disability Questionnaire (0.67), and MOS-36 Physical Functioning (-0.65). Individual item scores and total score discriminated between numeric rating scale tertile groups and painDETECT categories. Respondent interpretation of paper and electronic administration modes was equivalent. The PAL-S has demonstrated content validity and is potentially useful to assess treatment benefit in cLBP clinical trials.
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Affiliation(s)
- Mona L. Martin
- Health Research Associates, Inc, Mountlake Terrace, WA, USA
| | - Steven I. Blum
- Health Economics and Outcomes Research, Forest Research Institute, Jersey City, NJ, USA. Mr. Blum is now with the GlaxoSmithKline, Collegeville, PA, USA. Ms. Ramasamy is now with the Novo Nordisk, Plainsboro, NJ, USA
| | | | | | | | - Noël V. Hatley
- Health Research Associates, Inc, Mountlake Terrace, WA, USA
| | - Abhilasha Ramasamy
- Health Economics and Outcomes Research, Forest Research Institute, Jersey City, NJ, USA. Mr. Blum is now with the GlaxoSmithKline, Collegeville, PA, USA. Ms. Ramasamy is now with the Novo Nordisk, Plainsboro, NJ, USA
| | - Rainer Freynhagen
- Zentrum für Anästhesiologie, Intensivmedizin, Schmerztherapie & Palliativmedizin, Benedictus Krankenhaus Tutzing and Technische Universität, München, Germany
| | - Mark Wallace
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Charles Argoff
- Department of Neurology, Albany Medical College, Albany, NY, USA
| | | | | | - Donald L. Patrick
- Department of Health Sciences, University of Washington, Seattle, WA, USA
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Eldabe SS, Taylor RS, Goossens S, Bouche B, Gültuna I, Green C, Tinsley J, Luyet PP, Buchser E. A Randomized Controlled Trial of Subcutaneous Nerve Stimulation for Back Pain Due to Failed Back Surgery Syndrome: The SubQStim Study. Neuromodulation 2018; 22:519-528. [PMID: 29704437 PMCID: PMC6767391 DOI: 10.1111/ner.12784] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 02/19/2018] [Accepted: 03/09/2018] [Indexed: 11/30/2022]
Abstract
Objectives To compare the effectiveness of peripheral nerve stimulation utilizing a subcutaneous lead implant technique—subcutaneous nerve stimulation (SQS) plus optimized medical management (SQS + OMM arm) vs. optimized medical management alone (OMM arm) in patients with back pain due to failed back surgery syndrome. Patients and Methods Patients were recruited from 21 centers, in Europe, Israel, and Australia. Eligible patients were randomized (1:1) to SQS + OMM or OMM arms. Those in the SQS arm were implanted with a neurostimulator and up to two subcutaneous percutaneous cylindrical leads in the area of pain. Patients were evaluated pre‐randomization and at one, three, six, and nine months post‐randomization. The primary endpoint was the proportion of subjects with a ≥50% reduction in back pain intensity (“responder”) from baseline to nine months. Secondary outcomes included proportion of responders with a ≥50% reduction in back pain intensity at six months and ≥30% reduction at nine months, and the mean change from baseline in back pain intensity at six and nine months between the two arms. Results Due to the slow rate of recruitment, the study was terminated early with 116 subjects randomized. A total of 33.9% (19/56, missing: n = 20 [36%]) of subjects in the SQS + OMM arm and 1.7% (1/60, missing: n = 24 [40%]) in the OMM arm were responders at Month 9 (p < 0.0001). Secondary objectives showed a significant difference in favor of SQS + OMM arm. Conclusion The results indicate that the addition of SQS to OMM is more effective than OMM alone in relieving low back pain at up to nine months.
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Affiliation(s)
- Sam S Eldabe
- Department of Pain and Anaesthesia, The James Cook Hospital, Middlesbrough, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | | | - Ismail Gültuna
- Albert Schweitzer Ziekenhuis, Sliedrecht, The Netherlands
| | - Colin Green
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
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Gierthmühlen J, Greinacher J, Höper J, Oberlojer V, Lankes M, Traulsen F, Hüllemann P, Borzikowsky C, Reimer M, Baron R. Sensory symptoms in low back pain-how do they matter? Curr Med Res Opin 2018; 34:657-667. [PMID: 28748733 DOI: 10.1080/03007995.2017.1360851] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Successful treatment of chronic low back pain (LBP) is difficult in clinical practice and hard to measure in trials. One reason might be the use of insufficient outcome parameters. The aim was to investigate the importance of typical clinical characteristics of chronic LBP on QoL and functionality. METHODS A total of 51 patients with chronic LBP (19 with, 32 without radiculopathy) were investigated with different questionnaires. RESULTS Burdening symptoms differed in frequency, intensity and impairment of QoL and functionality between patients with and without radiculopathy and between the area of pain within the same patient, i.e. between back and leg. Symptoms of nerve affection such as prickling pain and numbness were rated higher in the area of radiating pain than on the back in radiculopathy, and typical neuropathic pain symptoms such as burning pain, prickling, spontaneous pain, and feeling of deep pressure and pain at the beginning of movement were rated with a higher impairment of QoL and functionality in patients with compared to those without radiculopathy. Furthermore, intensity, impairment of QoL, and functionality were not necessarily reported in association with one another: some patients were highly impaired in QoL or functionality, despite a moderate-to-low pain intensity, whereas others suffered from severe pain, but were less impaired in QoL or functionality. CONCLUSION Results suggest the consideration of impairment of QoL and functionality in addition to symptom intensity for treatment evaluation of chronic LBP. This can help to improve overall well-being of the patients and enhance efficacy in clinical pain trials and patient-centered treatment.
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Affiliation(s)
- Janne Gierthmühlen
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
| | - Jessica Greinacher
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
| | - Johanna Höper
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
| | - Violetta Oberlojer
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
| | | | | | - Philipp Hüllemann
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
| | - Christoph Borzikowsky
- c Institute of Medical Informatics and Statistics , Universitätsklinikum Schleswig-Holstein, Campus Kiel , Germany
| | - Maren Reimer
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
| | - Ralf Baron
- a Division of Neurological Pain Research and Therapy, Department of Neurology , Universitätsklinikum Schleswig-Holstein , Kiel , Germany
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Hasvik E, Haugen A, Gjerstad J, Grøvle L. Assessing neuropathic pain in patients with low back-related leg pain: Comparing the painDETECT Questionnaire with the 2016 NeuPSIG grading system. Eur J Pain 2018; 22:1160-1169. [DOI: 10.1002/ejp.1204] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2018] [Indexed: 11/08/2022]
Affiliation(s)
- E. Hasvik
- Department of Physical Medicine and Rehabilitation; Østfold Hospital Trust; Grålum Norway
- National Institute of Occupational Health; Oslo Norway
| | - A.J. Haugen
- Department of Rheumatology; Østfold Hospital Trust; Grålum Norway
| | - J. Gjerstad
- National Institute of Occupational Health; Oslo Norway
- Department of Biosciences; University of Oslo; Norway
| | - L. Grøvle
- Department of Rheumatology; Østfold Hospital Trust; Grålum Norway
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Deckers K, De Smedt K, Mitchell B, Vivian D, Russo M, Georgius P, Green M, Vieceli J, Eldabe S, Gulve A, van Buyten JP, Smet I, Mehta V, Ramaswamy S, Baranidharan G, Sullivan R, Gassin R, Rathmell J, Gilligan C. New Therapy for Refractory Chronic Mechanical Low Back Pain-Restorative Neurostimulation to Activate the Lumbar Multifidus: One Year Results of a Prospective Multicenter Clinical Trial. Neuromodulation 2017; 21:48-55. [PMID: 29244235 PMCID: PMC5814827 DOI: 10.1111/ner.12741] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Revised: 10/06/2017] [Accepted: 11/02/2017] [Indexed: 12/28/2022]
Abstract
Objectives The purpose of the international multicenter prospective single arm clinical trial was to evaluate restorative neurostimulation eliciting episodic contraction of the lumbar multifidus for treatment of chronic mechanical low back pain (CMLBP) in patients who have failed conventional therapy and are not candidates for surgery or spinal cord stimulation (SCS). Materials and Methods Fifty‐three subjects were implanted with a neurostimulator (ReActiv8, Mainstay Medical Limited, Dublin, Ireland). Leads were positioned bilaterally with electrodes close to the medial branch of the L2 dorsal ramus nerve. The primary outcome measure was low back pain evaluated on a 10‐Point Numerical Rating Scale (NRS). Responders were defined as subjects with an improvement of at least the Minimal Clinically Important Difference (MCID) of ≥2‐point in low back pain NRS without a clinically meaningful increase in LBP medications at 90 days. Secondary outcome measures included Oswestry Disability Index (ODI) and Quality of Life (QoL; EQ‐5D). Results For 53 subjects with an average duration of CLBP of 14 years and average NRS of 7 and for whom no other therapies had provided satisfactory pain relief, the responder rate was 58%. The percentage of subjects at 90 days, six months, and one year with ≥MCID improvement in single day NRS was 63%, 61%, and 57%, respectively. Percentage of subjects with ≥MCID improvement in ODI was 52%, 57%, and 60% while those with ≥MCID improvement in EQ‐5D was 88%, 82%, and 81%. There were no unanticipated adverse events (AEs) or serious AEs related to the device, procedure, or therapy. The initial surgical approach led to a risk of lead fracture, which was mitigated by a modification to the surgical approach. Conclusions Electrical stimulation to elicit episodic lumbar multifidus contraction is a new treatment option for CMLBP. Results demonstrate clinically important, statistically significant, and lasting improvement in pain, disability, and QoL.
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Affiliation(s)
| | | | - Bruce Mitchell
- Monash Clinical Research Pty Ltd, Clayton, VIC, Australia
| | - David Vivian
- Monash Clinical Research Pty Ltd, Clayton, VIC, Australia
| | - Marc Russo
- Hunter Pain Clinic, Broadmeadow, NSW, Australia
| | - Peter Georgius
- Sunshine Coast Clinical Research, Noosa Heads, QLD, Australia
| | - Matthew Green
- Pain Medicine of South Australia, Welland, SA, Australia
| | - John Vieceli
- Pain Medicine of South Australia, Welland, SA, Australia
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Ashish Gulve
- The James Cook University Hospital, Middlesbrough, UK
| | | | - Iris Smet
- Algemeen Ziekenhuis Nikolaas, Sint-Niklaas, Belgium
| | | | | | | | | | | | - James Rathmell
- Brigham and Women's Healthcare, Harvard Medical School, Boston, MA, USA
| | - Chris Gilligan
- Brigham and Women's Healthcare, Harvard Medical School, Boston, MA, USA
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Russo M, Deckers K, Eldabe S, Kiesel K, Gilligan C, Vieceli J, Crosby P. Muscle Control and Non-specific Chronic Low Back Pain. Neuromodulation 2017; 21:1-9. [PMID: 29230905 PMCID: PMC5814909 DOI: 10.1111/ner.12738] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 10/14/2017] [Indexed: 12/15/2022]
Abstract
Objectives Chronic low back pain (CLBP) is the most prevalent of the painful musculoskeletal conditions. CLBP is a heterogeneous condition with many causes and diagnoses, but there are few established therapies with strong evidence of effectiveness (or cost effectiveness). CLBP for which it is not possible to identify any specific cause is often referred to as non‐specific chronic LBP (NSCLBP). One type of NSCLBP is continuing and recurrent primarily nociceptive CLBP due to vertebral joint overload subsequent to functional instability of the lumbar spine. This condition may occur due to disruption of the motor control system to the key stabilizing muscles in the lumbar spine, particularly the lumbar multifidus muscle (MF). Methods This review presents the evidence for MF involvement in CLBP, mechanisms of action of disruption of control of the MF, and options for restoring control of the MF as a treatment for NSCLBP. Results Imaging assessment of motor control dysfunction of the MF in individual patients is fraught with difficulty. MRI or ultrasound imaging techniques, while reliable, have limited diagnostic or predictive utility. For some patients, restoration of motor control to the MF with specific exercises can be effective, but population results are not persuasive since most patients are unable to voluntarily contract the MF and may be inhibited from doing so due to arthrogenic muscle inhibition. Conclusions Targeting MF control with restorative neurostimulation promises a new treatment option.
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Affiliation(s)
- Marc Russo
- Hunter Pain Clinic, Broadmeadow, NSW, Australia
| | | | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Kyle Kiesel
- University of Evansville, Evansville, IN, USA
| | | | - John Vieceli
- Physioscope Pain Medicine of SA, South Australia, Australia
| | - Peter Crosby
- Mainstay Medical International plc, Dublin, Ireland
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Nakawaki M, Fukushima K, Inoue G, Moriya M, Uchiyama K, Takahira N, Takaso M. Use of the painDETECT questionnaire to differentiate the nature of hip pain associated with a labrum tear. ASIA-PACIFIC JOURNAL OF SPORT MEDICINE ARTHROSCOPY REHABILITATION AND TECHNOLOGY 2017; 11:1-5. [PMID: 29552502 PMCID: PMC5850904 DOI: 10.1016/j.asmart.2017.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/04/2017] [Accepted: 10/18/2017] [Indexed: 11/25/2022]
Abstract
The nature of pain associated with a labrum tear of the hip joint can vary widely among patients and does not always correlate with findings from diagnostic imaging. Identifying the components of the pain (nociceptive, neuropathic, or mixed pattern) is important to direct treatment. This report aimed to describe the use of the painDETECT questionnaire as a screening tool in order to classify the nature of the pain in three patients who presented with pain that was atypical for a labrum tear. The painDETECT questionnaire was an effective tool to identify appropriate pain management strategies in each case.
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Affiliation(s)
- Mitsufumi Nakawaki
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
| | - Kensuke Fukushima
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
| | - Gen Inoue
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
| | - Mitsutoshi Moriya
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
| | - Katsufumi Uchiyama
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
| | - Naonobu Takahira
- Department of Rehabilitation, Kitasato University School of Allied Health Sciences, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
| | - Masashi Takaso
- Department of Orthopaedic Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252-0374, Japan
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Tzschentke TM, Linz K, Frosch S, Christoph T. Antihyperalgesic, Antiallodynic, and Antinociceptive Effects of Cebranopadol, a Novel Potent Nociceptin/Orphanin FQ and Opioid Receptor Agonist, after Peripheral and Central Administration in Rodent Models of Neuropathic Pain. Pain Pract 2017; 17:1032-1041. [PMID: 28112482 DOI: 10.1111/papr.12558] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/23/2016] [Accepted: 12/10/2016] [Indexed: 12/14/2022]
Abstract
Cebranopadol is a novel and highly potent analgesic acting via nociceptin/orphanin FQ peptide (NOP) and opioid receptors. Since NOP and opioid receptors are expressed in the central nervous system as well as in the periphery, this study addressed the question of where cebranopadol exerts its effects in animal models of chronic neuropathic pain. Mechanical hypersensitivity in streptozotocin (STZ)-treated diabetic rats, cold allodynia in the chronic constriction injury (CCI) model in rats, and heat hyperalgesia and nociception in STZ-treated diabetic and control mice was determined after intraplantar (i.pl.), intracerebroventricular (i.c.v.), or intrathecal (i.th.) administration. In STZ-treated rats, cebranopadol (i.pl.) reduced mechanical hypersensitivity in the ipsilateral paw, but had no effect at the contralateral paw. In CCI rats, cebranopadol (i.pl.) showed antiallodynic activity at the ipsilateral paw. After administration to the contralateral paw, cebranopadol also showed ipsilateral antiallodynic activity, but with reduced potency and delayed onset. In diabetic mice, cebranopadol i.th. and i.c.v. decreased heat hyperalgesia with full efficacy and similar potency for both routes. Cebranopadol also produced significant antinociception in nondiabetic controls. Thus, cebranopadol exerts potent and efficacious antihyperalgesic, antiallodynic, and antinociceptive effects after local/peripheral, spinal, and supraspinal administration. The contralateral effects after i.pl. administration were likely due to systemic redistribution. After central administration of cebranopadol, antihyperalgesic efficacy is reached at doses that are not yet antinociceptive. This study shows that cebranopadol is effective after peripheral as well as central administration in nociceptive and chronic neuropathic pain. Thus, it may be well-suited for the treatment of chronic pain conditions with a neuropathic component.
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Affiliation(s)
| | - Klaus Linz
- Preclinical Drug Development, Grünenthal GmbH, Aachen, Germany
| | - Stefanie Frosch
- Preclinical Drug Development, Grünenthal GmbH, Aachen, Germany
| | - Thomas Christoph
- Pharmacology and Biomarker Development, Grünenthal GmbH, Germany
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Abstract
BACKGROUND AND OBJECTIVES Neck pain exerts a steep personal and socioeconomic toll, ranking as the fourth leading cause of disability. The principal determinant in treatment decisions is whether pain is neuropathic or nonneuropathic, as this affects treatment at all levels. Yet, no study has sought to classify neck pain in this manner. METHODS One hundred participants referred to an urban, academic military treatment facility with a primary diagnosis of neck pain were enrolled and followed up for 6 months. Pain was classified as neuropathic, possible neuropathic, or nonneuropathic using painDETECT and as neuropathic, mixed, or nociceptive by s-LANSS (self-completed Leeds Assessment of Neuropathic Symptoms and Signs pain scale) and physician designation. Based on previous studies, the intermediate possible neuropathic pain category was considered to be a mixed condition. The final classification was based on a metric combining all 3 systems, slightly weighted toward physician's judgment, which is considered the reference standard. RESULTS Fifty percent of participants were classified as having possible neuropathic pain, 43% as having nonneuropathic pain, and 7% with primarily neuropathic pain. Concordance was high between the various classification schemes, ranging from a low of 62% between painDETECT and physician designation for possible neuropathic pain, to 83% concordance between s-LANSS and the 2 other systems for neuropathic pain. Individuals with neuropathic pain reported higher levels of baseline disability, were more likely to have a coexisting psychiatric illness, and underwent surgery more frequently than other pain categories, but were also more likely to report greater reductions in disability after 6 months. CONCLUSIONS Although pure neuropathic pain comprised a small percentage of our cohort, 50% of our population consisted of mixed pain conditions containing a possible neuropathic component. There was significant overlap between the various classification schemes.
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Muralidharan A, Park TSW, Mackie JT, Gimenez LGS, Kuo A, Nicholson JR, Corradini L, Smith MT. Establishment and Characterization of a Novel Rat Model of Mechanical Low Back Pain Using Behavioral, Pharmacologic and Histologic Methods. Front Pharmacol 2017; 8:493. [PMID: 28798688 PMCID: PMC5529395 DOI: 10.3389/fphar.2017.00493] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/10/2017] [Indexed: 11/22/2022] Open
Abstract
Chronic low back pain (LBP), the leading cause of disability globally, is notoriously difficult to treat. Most rodent models of LBP mimic lumbar radicular pain rather than mechanical LBP. Here, we describe establishment of a new rat model of mechanical LBP that is devoid of a neuropathic component. Groups of adult male Sprague Dawley rats were anesthetized and their lumbar L4/L5 and L5/L6 intervertebral disks (IVDs) were punctured (0.5 mm outer diameter, 2mm-deep) 5 (LPB-5X), or 10 (LBP-10X) times per disk. Sham-rats underwent similar surgery, but without disk puncture. Baseline noxious pressure hyperalgesia of lumbar axial deep tissues, mechanical allodynia in the hindpaws and gait were assessed prior to surgery and once-weekly until study completion on day 49. The model was also characterized using pharmacologic and histologic methods. Good animal health was maintained for ≥ 49 days post-surgery. For LBP- but not sham-rats, there was temporal development of noxious pressure hyperalgesia in lumbar axial deep tissues at days 14–49 post-surgery. Importantly, there were no between-group differences in von Frey paw withdrawal thresholds or gait parameters until study completion. On day 49, significant histologic changes were observed in the L4/L5 and L5/L6 IVDs for LBP-10X rats, but not sham-rats. In LBP-10X rats, single bolus doses of morphine produced dose-dependent relief of primary and secondary mechanical hyperalgesia in lumbar axial deep tissues at L4/L5 and L1, respectively. In conclusion, our new rat model has considerable potential for providing novel insight on the pathobiology of mechanical LBP and for analgesic efficacy assessment of novel compounds.
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Affiliation(s)
- Arjun Muralidharan
- Centre for Integrated Preclinical Drug Development, The University of Queensland, BrisbaneQLD, Australia
| | - Thomas S W Park
- Centre for Integrated Preclinical Drug Development, The University of Queensland, BrisbaneQLD, Australia
| | - John T Mackie
- School of Veterinary Science, The University of Queensland, GattonQLD, Australia
| | - Luiz G S Gimenez
- Centre for Integrated Preclinical Drug Development, The University of Queensland, BrisbaneQLD, Australia
| | - Andy Kuo
- Centre for Integrated Preclinical Drug Development, The University of Queensland, BrisbaneQLD, Australia
| | | | | | - Maree T Smith
- Centre for Integrated Preclinical Drug Development, The University of Queensland, BrisbaneQLD, Australia.,School of Pharmacy, The University of Queensland, BrisbaneQLD, Australia
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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.
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Spahr N, Hodkinson D, Jolly K, Williams S, Howard M, Thacker M. Distinguishing between nociceptive and neuropathic components in chronic low back pain using behavioural evaluation and sensory examination. Musculoskelet Sci Pract 2017; 27. [PMID: 28637600 PMCID: PMC5329124 DOI: 10.1016/j.msksp.2016.12.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Diagnosis of chronic low back pain (CLBP) is traditionally predicated on identifying underlying pathological or anatomical causes, with treatment outcomes modest at best. Alternately, it is suggested that identification of underlying pain mechanisms with treatments targeted towards specific pain phenotypes may yield more success. Differentiation between nociceptive and neuropathic components of CLBP is problematic; evidence suggests that clinicians fail to identify a significant neuropathic component in many CLBP patients. The painDETECT questionnaire (PDQ) was specifically developed to identify occult but significant neuropathic components in individuals thought to have predominantly nociceptive pain. METHODS Using the PDQ, we classified 50 CLBP patients into two distinct groups; those with predominantly nociceptive pain (Group 1) and those with a significant neuropathic component (Group 2). We characterised these two distinct CLBP sub-groups using a) questionnaire-based behavioural evaluation measuring pain-related function and quality of life, pain intensity and psychological well-being and b) sensory examination, using two-point and tactile threshold discrimination. OBJECTIVE We sought to determine if differences in the pain phenotype of each CLBP sub-group would be reflected in sensory and behavioural group profiles. RESULTS We report that Group 1 and Group 2 sub-groups demonstrate unique clinical profiles with significant differences in sensory tactile discrimination thresholds and in a wide range of behavioural domains measuring pain intensity, disability and psychological well-being. CONCLUSION We have demonstrated distinct clinical profiles for CLBP patient sub-groups classified by PDQ. Our results give diagnostic confidence in using the PDQ to characterise two distinct pain phenotypes in a heterogeneous CLBP population.
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Affiliation(s)
- N Spahr
- Dept. of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Dept. of Physiotherapy, Guy's & St Thomas' NHS Foundation Trust, London, UK.
| | - D Hodkinson
- Dept. of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - K Jolly
- Dept. of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - S Williams
- Dept. of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - M Howard
- Dept. of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - M Thacker
- Dept. of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; Dept. of Physiotherapy, Guy's & St Thomas' NHS Foundation Trust, London, UK; Centre of Human & Aerospace Physiological Sciences, King's College London, UK
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Vardeh D, Mannion RJ, Woolf CJ. Toward a Mechanism-Based Approach to Pain Diagnosis. THE JOURNAL OF PAIN 2016; 17:T50-69. [PMID: 27586831 PMCID: PMC5012312 DOI: 10.1016/j.jpain.2016.03.001] [Citation(s) in RCA: 193] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/22/2016] [Accepted: 03/08/2016] [Indexed: 12/13/2022]
Abstract
UNLABELLED The past few decades have witnessed a huge leap forward in our understanding of the mechanistic underpinnings of pain, in normal states where it helps protect from injury, and also in pathological states where pain evolves from a symptom reflecting tissue injury to become the disease itself. However, despite these scientific advances, chronic pain remains extremely challenging to manage clinically. Although the number of potential treatment targets has grown substantially and a strong case has been made for a mechanism-based and individualized approach to pain therapy, arguably clinicians are not much more advanced now than 20 years ago, in their capacity to either diagnose or effectively treat their patients. The gulf between pain research and pain management is as wide as ever. We are still currently unable to apply an evidence-based approach to chronic pain management that reflects mechanistic understanding, and instead, clinical practice remains an empirical and often unsatisfactory journey for patients, whose individual response to treatment cannot be predicted. In this article we take a common and difficult to treat pain condition, chronic low back pain, and use its presentation in clinical practice as a framework to highlight what is known about pathophysiological pain mechanisms and how we could potentially detect these to drive rational treatment choice. We discuss how present methods of assessment and management still fall well short, however, of any mechanism-based or precision medicine approach. Nevertheless, substantial improvements in chronic pain management could be possible if a more strategic and coordinated approach were to evolve, one designed to identify the specific mechanisms driving the presenting pain phenotype. We present an analysis of such an approach, highlighting the major problems in identifying mechanisms in patients, and develop a framework for a pain diagnostic ladder that may prove useful in the future, consisting of successive identification of 3 steps: pain state, pain mechanism, and molecular target. Such an approach could serve as the foundation for a new era of individualized/precision pain medicine. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION)-American Pain Society (APS) Pain Taxonomy (AAPT) includes pain mechanisms as 1 of the 5 dimensions that need to be considered when making a diagnostic classification. The diagnostic ladder proposed in this article is consistent with and an extension of the AAPT. PERSPECTIVE We discuss how identifying the specific mechanisms that operate in the nervous system to produce chronic pain in individual patients could provide the basis for a targeted and rational precision medicine approach to controlling pain, using chronic low back pain as our example.
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Affiliation(s)
- Daniel Vardeh
- Division of Pain Neurology, Department of Neurology and Anesthesia, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Richard J Mannion
- Department of Academic Neurosurgery, Cambridge University Hospitals NHS Trust, Cambridge, United Kingdom
| | - Clifford J Woolf
- FM Kirby Neurobiology Center, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.
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Reimer M, Hüllemann P, Hukauf M, Keller T, Binder A, Gierthmühlen J, Baron R. Prediction of response to tapentadol in chronic low back pain. Eur J Pain 2016; 21:322-333. [PMID: 27510567 PMCID: PMC5248647 DOI: 10.1002/ejp.926] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2016] [Indexed: 11/12/2022]
Abstract
BACKGROUND Many chronic low back pain (cLBP) patients do not satisfactorily respond to treatment. The knowledge of responders and non-responders before initiating treatment would improve decision making and reduce health care costs. The aims of this exploratory prediction study in cLBP patients treated with tapentadol were to identify predictors of treatment outcome based on baseline characteristics, to evaluate quality-of-life and functionality as alternative outcome parameters and to develop nomograms to calculate the individual probability of response. METHODS In a retrospective analysis of an open-label phase 3b trial, 46 baseline characteristics were included into statistical prediction modelling. One hundred and twenty-one patients were followed up during the titration and treatment period and 67 patients were analysed who discontinued the trial. RESULTS Demographic data were not relevant for response prediction. Nine baseline co-variables were robust: painDETECT score, intensity of burning and painful attacks, SF36 Health Survey score (MCS, PCS), EuroQol-5, Hospital Anxiety/Depression Scale. Gender had a minor influence. Alternative outcomes (quality-of-life, functionality) were more important for response prediction than conventional pain intensity measures. Neuropathic symptoms (high painDETECT score) had a positive predictive validity. Painful attacks and classical yellow flags (depression, anxiety) negatively influenced the treatment response. High depression scores, female gender and low burning predicted discontinuation during titration. CONCLUSION In this exploratory study, predictive baseline characteristics have been identified that can be used to calculate the individual probability of tapentadol response in cLBP. The small sample size in relation to the number of initial variables is a limitation of this approach. SIGNIFICANCE Predictors for treatment response of tapentadol were identified in patients with chronic low back pain based on clinical pre-treatment characteristics that can guide personalized treatment. Quality-of-life and functionality were the most relevant outcomes for response prediction.
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Affiliation(s)
- M Reimer
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - P Hüllemann
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - M Hukauf
- StatConsult GmbH, Magdeburg, Germany
| | - T Keller
- StatConsult GmbH, Magdeburg, Germany
| | - A Binder
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - J Gierthmühlen
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - R Baron
- Division of Neurological Pain Research and Therapy, Department of Neurology, University Hospital Schleswig-Holstein, Kiel, Germany
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Hüllemann P, Keller T, Kabelitz M, Freynhagen R, Tölle T, Baron R. Pain Drawings Improve Subgrouping of Low Back Pain Patients. Pain Pract 2016; 17:293-304. [PMID: 27334429 DOI: 10.1111/papr.12470] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/12/2016] [Accepted: 04/08/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Subgrouping of low back pain (LBP) patients may be improved when pain drawings are combined with the painDETECT (PD-Q) questionnaire. We hypothesized that (1) different LBP subgroups determined by their pain radiation show different clinical patterns and (2) the occurrence of neuropathic symptoms depends on pain radiation. METHODS A total of 19,263 acute (< 6 weeks' duration), subacute (6 to 12 weeks), and chronic (> 3 months) LBP patients were allocated prospectively into 4 groups based on the location of pain drawings on a manikin and compared regarding neuropathic pain components, functionality, depression, pain intensity, and surgical interventions. All items were investigated at baseline and follow-up visits. Group I was composed of patients with axial LBP without radiating pain; group II, LBP with radiation into the thigh; group III, LBP with radiation into the shank; and group IV, LBP with radiation into the feet. Side-dependent pain radiation was assessed additionally. RESULTS Depression, functionality, and pain intensity showed no clinically relevant differences, whereas PD-Q scores and the probability to rate positive for neuropathic pain increased with more distally radiating pain. Surgery and medication intake were most frequent in group IV. Follow-up analyses showed that only axial LBP became more neuropathic, whereas pain intensity decreased over time. CONCLUSIONS Radicular patterns of pain drawings in LBP patients indicate severe pain conditions with the most neuropathic components, while axial LBP has the fewest. For the categorization of LBP, pain drawings help explain the underlying mechanism of pain, which might further improve mechanism-based treatment when used in clinical routines and research.
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Affiliation(s)
- Philipp Hüllemann
- Sektion Neurologische Schmerzforschung und -therapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
| | | | | | - Rainer Freynhagen
- Zentrum für Anästhesiologie, Intensivmedizin, Schmerztherapie & Palliativmedizin, Benedictus Krankenhaus, Tutzing, Germany.,Technische Universität München, Klinik für Anästhesiologie, Munich, Germany
| | - Thomas Tölle
- Technische Universität München, Klinik für Neurologie, Munich, Germany
| | - Ralf Baron
- Sektion Neurologische Schmerzforschung und -therapie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany
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