Nonsteroidal anti-inflammatory drugs in the treatment of low back pain

A magnetic resonance conditional robot for lumbar spinal injection: Development and preliminary validation

PURPOSE

This work presents the design and preliminary validation of a Magnetic Resonance (MR) conditional robot for lumbar injection for the treatment of lower back pain.

METHODS

This is a 4-degree-of-freedom (DOF) robot that is 200 × 230 × 130 mm3 in volume and has a mass of 0.8 kg. Its lightweight and compact features allow it to be directly affixed to patient's back, establishing a rigid connection, thus reducing positional errors caused by patient movements during treatment.

RESULTS

To validate the positioning accuracy of the needle by the robot, an electromagnetic (EM) tracking system and a needle with an EM sensor embedded in the tip were used for the free space evaluation with position accuracy of 0.88 ± 0.46 mm and phantom mock insertions using the Loop-X CBCT scanner with target position accuracy of 3.62 ± 0.92 mm.

CONCLUSION

Preliminary experiments demonstrated that the proposed robot showed improvements and benefits in its rotation range, flexible needle adjustment, and sensor protection compared with previous and existing systems, offering broader clinical applications.

Various Doses of Tanezumab in the Management of Chronic Low Back Pain (CLBP): A Pooled Analysis of 4,514 Patients

Chronic low back pain (CLBP) is a persistent and debilitating condition characterized by pain and discomfort in the lower back region that lasts more than 12 weeks. This review aims to determine the efficacy and safety of various doses of tanezumab for managing CLBP. The present meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Intervention standards. We searched multiple databases, including PubMed, Cochrane Library, Excerpta Medica Database (EMBASE), Scopus, and Web of Science, to identify randomized controlled trials comparing tanezumab to placebo or different dosage regimens for CLBP in adult patients. The primary outcome was the mean change in low back pain intensity (LBPI) score baseline to the end of treatment. Secondary outcomes included adverse events and the degree of disability or impairment. A total of six studies were included in the meta-analysis. Analysis of the data showed that tanezumab 5 mg significantly reduced LBPI compared to placebo at all time points (mean deviation (MD) ranging from -0.31 to -0.5). Similarly, tanezumab 10 mg showed a significant reduction in LBPI compared to placebo at all time points (MD ranging from -0.48 to -0.84). However, tanezumab 5 mg showed significantly less reduction of LBPI compared to 10 mg at two, four, eight, and 12 weeks (MD ranging from 0.19 to 0.32). These findings suggest that tanezumab is an effective treatment for CLBP, with 5 mg and 10 mg doses providing clinically meaningful reductions in LBPI.

A randomized controlled trial evaluating the short-term efficacy of a single-administration intramuscular injection with the fixed combination of thiocolchicoside-diclofenac versus diclofenac monotherapy in patients with acute moderate-to-severe low back pain

BACKGROUND

Non-specific acute low back pain (LBP) is a common health problem that may be accompanied by muscle spasm and decreased mobility. The combination of non-steroidal anti-inflammatory drugs and muscle relaxants represents an advantageous therapeutic option, however, available data on their combined use are conflicting. This prospective, randomized, single-blind, two-parallel-group trial assessed the efficacy of a single intramuscular (IM) injection of the fixed-dose combination (FDC) diclofenac (75 mg)-thiocolchicoside (4 mg/4 ml) product (test treatment) compared to diclofenac (75 mg/3 ml) alone (reference treatment) for the symptomatic relief of acute LBP. Tolerability and safety were also assessed as secondary variables.

METHODS

One hundred thirty-four patients were enrolled (safety population) and randomly allocated to the combination or single-agent regimen. Pain intensity and muscle spasm, assessed respectively by the patient-reported visual analogue scale and investigator-performed finger-to-floor distance test, were determined prior to the injection as well as 1 and 3 h post-injection in 123 patients (per-protocol population). The patients were blinded to treatment. Safety was assessed up to 24 h post-injection.

RESULTS

The test treatment was superior in both alleviating the pain intensity and reducing the finger-to-floor distance at both 1 (p < 0.01 and p = 0.023 respectively) and 3 h post-injection (p < 0.01). A higher percentage of patients experienced > 30% reduction in pain intensity at 1 and 3 h with the test treatment (p = 0.037 and p < 0.01 respectively). The corresponding VAS (SD) scores for the test treatment group were at baseline, 1 and 3 h post-injection 72.03 (± 11.72), 45.37 (± 16.28) and 31.56 (± 15.08) respectively and for the reference treatment group 65.20 (± 12.16), 48.98 (± 18.76) and 44.52 (± 17.33) respectively. No adverse effects were reported with the combination treatment, whereas two patients treated with diclofenac reported dizziness.

CONCLUSIONS

The FDC treatment is an effective and well-tolerated option for the symptomatic treatment of LBP. Clinical and patient-reported assessments confirmed that a single IM injection of FDC diclofenac-thiocolchicoside was more effective than diclofenac alone in conferring rapid and sustained improvement in mobility and pain intensity.

TRIAL REGISTRATION

EudraCT No: 2017-004530-29 Available at https://eudract.ema.europa.eu/ Registered 04 Dec 2017.

Results of ELBRUS clinical non-interventional study

Objective: non-interventional study ELBRUS (Etoricoxib in the Treatment of Back Pain) was conducted to investigate the efficacy and safety of daily administration of Rixia® (Etoricoxib) 60 mg per day in patients with chronic non-specific low back pain (CNSLBP).

Patients and methods. The study included 50 patients (31 women and 19 men, mean age 54.3±16.8 years) with CNSLBP. Educational conversation, cognitive therapy, regular therapeutic exercises, identification and treatment of comorbidities were conducted. Patients received etoricoxib 60 mg once daily. Pain intensity was assessed on a 10-point numerical rating scale (NRS), pain-related disability was assessed on the Oswestry Scale (ODS), and emotional state was assessed on the Hospital Anxiety and Depression Scale (HADS).

Results and discussion. The causes of CNSLBP were: in 5 (10%) patients – sacroiliac joint involvement, in 14 (28%) – lower lumbar facet joints involvement, in 3 (6%) – myofascial pain, the remaining 28 (56%) patients had a combination of several reasons. As a result of complex treatment, the intensity of pain at rest decreased on average from 4.0±2.5 to 1.4±1.3 points, while moving – from 6.6±1.9 to 2.8±1.8 points, at night – from 2.7±2 to 0.7±0.9 points according to the NRS, disability – from 39±18.9 to 19.9±14.6% according to the ODS, the severity of anxiety – from 6.5±3.9 to 3.3±2.4 points and depression from 5.0±3.7 to 3.1±2.9 points according to HADS (p<0.001). The duration of treatment was 14.14±3.6 days on average. No adverse events were observed during treatment with etoricoxib. Conclusion. The efficacy and safety of etoricoxib in the complex therapy of patients with CNSLBP was noted. Keywords: chronic nonspecific low back pain, non-steroidal anti-inflammatory drugs, etoricoxib, Rixia®>˂0.001). The duration of treatment was 14.14±3.6 days on average. No adverse events were observed during treatment with etoricoxib.

Conclusion. The efficacy and safety of etoricoxib in the complex therapy of patients with CNSLBP was noted. 

Rational Pharmacotherapy in Case of Exacerbation of the Primary Low Back Pain

Low back pain (LBP) is one of the most common causes of orthopedic disability in people under 45 years of age. Primary LBP accounts for more than 90 % of all cases. The main objectives of treatment are to slow the progression of the degenerative process, reduce the intensity of inflammation and pain, increase functional activity and quality of life of patients. The solution of the set tasks is impossible without effective complex influence on numerous links of pathogenesis of degenerative-dystrophic and inflammatory process and ensuring safety at treatment. The objective: to evaluate the clinical effectiveness of complex conservative treatment of primary LBP with the use of the drug Alsokam (meloxicam) in patients with uncomplicated forms of degenerative-dystrophic lesions of the spine in the period of exacerbation. Materials and methods. A non-randomized, prospective comparative clinical study in two parallel groups involved 30 patients with exacerbation of LBP on the background of uncomplicated forms of degenerative-dystrophic lesions of the spine (osteochondrosis, spondyloarthritis). The mean age of patients was 40±7,2 years. There were 12 (40 %) female patients and 18 (60 %) male patients. The main group consisted of 15 patients who were prescribed the drug Alsokam (meloxicam) at a dose of 15 mg 1 time per day intramuscularly for 7 days. The control group consisted of 15 patients who received diclofenac sodium at a traditional daily dose of 75 mg intramuscularly once daily for 7 days during the same treatment period. In both groups, tolperisone 150 mg 3 times a day and B vitamins were also used for 10 15 days. Outcome evaluation parameters included: Visual analog pain scale (VAS), Huskisson; assessment of the patient’s functional status on the Roland-Morris scale (RDQ-24); accounting for side effects and adverse events in the observation groups. Results. In both groups, a significant decrease in the intensity of the pain syndrome was observed in the assessment of pain by VAS, but no statistically significant difference was observed between the observation groups (p=0,312). The analysis of the results of the evaluation of RDQ-24 also showed an increase in functional capacity in both groups, but without a significant difference between the groups of clinical observation (p=0,302). Analysis of the number of undesirable side effects in the observation groups showed a significantly lower frequency in patients of the main group with a high statistical probability (p<0,01). Conclusions. The results of a clinical study showed the effectiveness of meloxicam (Alsokam) in the complex conservative treatment of patients with primary LBP in the period of exacerbation, which correlates with the effect of diclofenac sodium in the average daily dose. The nature and frequency of adverse reactions in the main and comparator groups showed that meloxicam in Alsocam has a significantly higher safety profile compared to diclofenac sodium, and its use in complex treatment regimens for patients with primary LBP syndrome reduces the risk of NSAIDs gastropathies.

Investigating the Effect of Melissa Officinalis on After-Pains: A Randomized Single-Blind Clinical Trial

Introduction: Regarding high prevalence of postpartum pain and side-effects of pharmaceutical analgesics on maternal and neonatal health, the present study aimed to explore the effect of Melissa officinalis on after-pain among mothers hospitalized in Asgariyeh Hospital, Isfahan, 2016.

Methods: In this single-blind clinical trial, 110 women with moderate to severe after-pain were divided into two M.officinalis and mefenamic acid groups by random allocation. Samples in the first group received 250mg of mefenamic acid and the second group received 395mg of M.officinalis oral capsules every 6hours for 24hours following childbirth. The primary outcome (After-pain) was assessed using a numeric 10-point scale before intervention, 1,2 and 3hours after the first intervention and every 6hours to 24hours after delivery for each of second, third and fourth interventions. Data were analyzed, using SPSS by independent t-test, Mann-Whitney and chi-square test.

Results: The demographic and obstetric variables and after-pain severity before the intervention in both groups were homogenous. Pain intensity wasn’t significantly different between the two groups during first and second hours after the first intervention, but there was a significant difference in the third hour, The severity of pain was significantly different between the two groups in different assessments including: an hour after the second, third and fourth intervention (P<0.05). A significant difference was found between mefenamic acid and M.officinalis in pain relief.

Conclusion: M.officinalis can reduce the severity of after-pain, because it eliminates the need for pharmaceutical analgesics and works much better than mefenamic acid.

[Diagnosis and treatment of acute low back pain]

Low back pain (LBP) is frequent cause for visit to the doctor and common cause of disability. Modern experts' recommendations for diagnostics and treatment of acute LBP are presented. Common mistakes, difficulties in diagnostics and treatment of acute LBP are discussed. Diagnosis of non - specific acute LBP is based on clinical examination and exclusion of specific causes of back pain. Instrumental studies are not needed in most cases of acute LBP. Key steps in the treatment of patients with acute non - specific LBP are to inform of patients about good prognosis of pain, to recommend daily activity and avoidance of bed rest, to prescribe nonsteroidal anti - inflammatory drug for pain reducing. Effectiveness of vitamins B in acute LBP is discussed.

Controlled and tuneable drug release from electrospun fibers and a non-invasive approach for cytotoxicity testing

Electrospinning is an attractive method to generate drug releasing systems. In this work, we encapsulated the cell death-inducing drug Diclofenac (DCF) in an electrospun poly-L-lactide (PLA) scaffold. The scaffold offers a system for a sustained and controlled delivery of the cytotoxic DCF over time making it clinically favourable by achieving a prolonged therapeutic effect. We exposed human dermal fibroblasts (HDFs) to the drug-eluting scaffold and employed multiphoton microscopy and fluorescence lifetime imaging microscopy. These methods were suitable for non-invasive and marker-independent assessment of the cytotoxic effects. Released DCF induced changes in cell morphology and glycolytic activity. Furthermore, we showed that drug release can be influenced by adding dimethyl sulfoxide as a co-solvent for electrospinning. Interestingly, without affecting the drug diffusion mechanism, the resulting PLA scaffolds showed altered fibre morphology and enhanced initial DCF burst release. The here described model could represent an interesting way to control the diffusion of encapsulated bio-active molecules and test them using a marker-independent, non-invasive approach.

Treatment of patients with acute and subacute dorsalgia

Objective: to investigate the efficiency of treatment for acute and subacute dorsalgia, by providing information to patients and by using nonsteroidal anti-inflammatory drugs (NSAIDs) without conducting physical therapy, reflexotherapy, and manual therapy. Patients and methods. A total of 140 patients (87 women and 53 men; mean age 50.7±17.6 years) with acute and subacute back pain were followed up. Out of them 127 (91%) patients were found to have nonspecific (musculoskeletal) pain; 13 (9%) had discogenic radiculopathy. All the patients were informed of the benign nature of the disease, the high probability of its rapid resolution, the feasibility of abandoning prolonged bedrest, and the lack of need for physical therapy, reflexotherapy, massage, and manual therapy. To reduce pain, the patients received meloxicam 15 mg/day orally or intramuscularly or first 15 mg/day intramuscularly and then orally. The investigators assessed pain intensity with the numerical rating scale and functional activity restrictions with the Roland-Morris disability (RMD) questionnaire. Results. After treatment, the visual analogue scale pain intensity scores decreased from an average of 6.4 to 1.0; the RMD scores dropped from 6.8 to 1.4 (p<0.001). The duration of treatment averaged 11.0±4.4 days. Comparison of different meloxicam dosage regimens showed no significant differences; a positive result was noted in all cases. No adverse events were observed during treatment. Conclusion. The investigation has shown the high efficiency of management in patients with acute and subacute dorsalgia, by providing information to patients (an education conversation), by using meloxicam, and by applying a personalized approach (treatment for concomitant diseases and conditions). Refusing physiotherapy, massage, acupuncture, and manual therapy substantially reduces the cost of treatment in patients with acute dorsalgia.

Unexpectedly decreased plasma cytokines in patients with chronic back pain

Introduction

Chronic back pain is one of the most important socioeconomic problems that affects the global population. Elevated levels of inflammatory mediators, such as cytokines, have been correlated with pain, but their role in chronic back pain remains unclear. The effectiveness of anti-inflammatory drugs seems to be limited for chronic back pain. The authors wanted to investigate the levels of inflammatory mediators in long-term medically treated patients with persistent chronic back pain.

Methods

Cytokine plasma levels of patients with chronic back pain (n=23), compared to pain-free healthy controls (n=30), were investigated by immunoassay. Patients with chronic back pain were exposed to long-term conservative medical therapy with physiotherapy and anti-inflammatories, also combined with antidepressants and/or muscle-relaxants.

Results

The patients with chronic back pain expressed lower levels of the chemokines MCP1, CCL5, and CXCL6 compared to pain-free healthy controls. Significantly lower concentrations of the anti-inflammatory cytokines, interleukin (IL)-4 and granulocyte-colony stimulating factor were also found. Interestingly, levels of proinflammatory cytokines (IL-2, IL-6, IL-1β, tumor necrosis factor alpha), IL-10, granulocyte-macrophage colony-stimulating factor, and stromal cell-derived factor 1 alpha showed no significant differences between both groups.

Conclusion

This decrease of inflammatory mediators in medically treated patients with chronic back pain is of unclear origin and might be either a long-term side effect of medical therapy or related to chronic pain. Further longitudinal research is necessary to elucidate the underlying cause of these findings.

Effects of intracutaneous injections of sterile water in patients with acute low back pain: a randomized, controlled, clinical trial

Intracutaneous sterile water injection (ISWI) is used for relief of low back pain during labor, acute attacks of urolithiasis, chronic neck and shoulder pain following whiplash injuries, and chronic myofascial pain syndrome. We conducted a randomized, double-blinded, placebo-controlled trial to evaluate the effect of ISWI for relief of acute low back pain (aLBP). A total of 68 patients (41 females and 27 males) between 18 and 55 years old experiencing aLBP with moderate to severe pain (scores ≥5 on an 11-point visual analogue scale [VAS]) were recruited and randomly assigned to receive either ISWIs (n=34) or intracutaneous isotonic saline injections (placebo treatment; n=34). The primary outcome was improvement in pain intensity using the VAS at 10, 45, and 90 min and 1 day after treatment. The secondary outcome was functional improvement, which was assessed using the Patient-Specific Functional Scale (PSFS) 1 day after treatment. The mean VAS score was significantly lower in the ISWI group than in the control group at 10, 45, and 90 min, and 1 day after injection (P<0.05, t-test). The mean increment in PSFS score of the ISWI group was 2.9±2.2 1 day after treatment, while that in the control group was 0.9±2.2. Our study showed that ISWI was effective for relieving pain and improving function in aLBP patients at short-term follow-up. ISWI might be an alternative treatment for aLBP patients, especially in areas where medications are not available, as well as in specific patients (e.g., those who are pregnant or have asthma), who are unable to receive medications or other forms of analgesia because of side effects.

Chromatographic finger print analysis of anti-inflammatory active extract fractions of aerial parts of Tribulus terrestris by HPTLC technique

OBJECTIVE

To develop HPTLC fingerprint profile of anti-inflammatory active extract fractions of Tribulus terrestris (family Zygophyllaceae).

METHODS

The anti-inflammatory activity was tested for the methanol and its fractions (chloroform, ethyl acetate, n-butanol and aqueous) and chloroform extract of Tribulus terrestris (aerial parts) by injecting different groups of rats (6 each) with carrageenan in hind paw and measuring the edema volume before and 1, 2 and 3 h after carrageenan injection. Control group received saline i.p. The extracts treatment was injected i.p. in doses of 200 mg/kg 1 h before carrageenan administration. Indomethacin (30 mg/kg) was used as standard. HPTLC studies were carried out using CAMAG HPTLC system equipped with Linomat IV applicator, TLC scanner 3, Reprostar 3, CAMAG ADC 2 and WIN CATS-4 software for the active fractions of chloroform fraction of methanol extract.

RESULTS

The methanol extract showed good antiedematous effect with percentage of inhibition more than 72%, indicating its ability to inhibit the inflammatory mediators. The methanol extract was re-dissolved in 100 mL of distilled water and fractionated with chloroform, ethyl acetate and n-butanol. The four fractions (chloroform, ethyl acetate, n-butanol and aqueous) were subjected to anti-inflammatory activity. Chloroform fraction showed good anti-inflammatory activity at dose of 200 mg/kg. Chloroform fraction was then subjected to normal phase silica gel column chromatography and eluted with petroleum ether-chloroform, chloroform-ethyl acetate mixtures of increasing polarity which produced 15 fractions (F1-F15). Only fractions F1, F2, F4, F5, F7, F9, F11 and F14 were found to be active, hence these were analyzed with HPTLC to develop their finger print profile. These fractions showed different spots with different Rf values.

CONCLUSIONS

The different chloroform fractions F1, F2, F4, F5, F7, F9, F11 and F14 revealed 4, 7, 7, 8, 9, 7, 7 and 6 major spots, respectively. The results obtained in this experiment strongly support and validate the traditional uses of this Sudanese medicinal plant.