Interpreting change scores for pain and functional status in low back pain: towards international consensus regarding minimal important change

Physiotherapists as first-contact practitioners for patients with low back pain in French primary care: a pragmatic cluster randomised controlled trial

BACKGROUND

A new model of care enables French physiotherapists (PT) working in collaboration with family physicians (FP) to expand their usual scope of practice for patients with acute low back pain (LBP). The aim of our study is to evaluate the impact of this new first-contact physiotherapy (FCP) advanced practice model compared to usual FP care.

METHODS

A multicentre pragmatic non-inferiority cluster randomised controlled trial (RCT) has been conducted in six multidisciplinary primary healthcare centres in France. Patients from 20 to 55 years old with acute LBP consulted either the PT or the FP. PT independently assessed and managed patients including medication prescription. The primary outcome measure was disability at six weeks (Roland Morris Disability Questionnaire, range 0-24). Secondary outcomes include pain, risk disability prognosis, satisfaction with care, healthcare resources use and wait times. Data were collected at baseline, six and twelve weeks. Outcomes across arms were compared using mixed models regression analysis. Except for non-inferiority analysis of the primary outcome measure, other analyses were performed with a two-sided significance level of 0.05.

RESULTS

Sixty patients were recruited (PT: 32, FP: 28). The adjusted mean difference between groups for disability at 6 weeks was 0.39 in favour of the FP group (95%CI: -2.03; 2.81, p = 0.753). Considering a 5 points minimal clinically important difference, the FCP-led model of care was not inferior to usual FP care for the primary outcome. There was no statistically significant difference between groups in disability at 3 months and pain at 6 weeks and 3 months. PTs prescribed significantly less medications than FPs (p < 0.001). No statistically significant difference was found for other healthcare resource use outcomes, patients' satisfaction and wait times.

CONCLUSION

This is the first RCT to evaluate the impact of a FCP advanced practice model of care including medical delegated acts in a primary care setting. Our results suggest that the FCP-led model of care is not inferior to usual FP care regarding disability at 6 weeks. The FCP model could result in possible benefits in terms of healthcare resources use. Further adequate powered studies with larger sample size are needed to draw stronger conclusions.

TRIAL REGISTRATION

The study has been registered in ClinicalTrials.gov (NCT05200533) on the 20th of January 2022.

Functional outcomes and healthcare utilization trends in postsurgical and nonsurgical patients following high-frequency (10 kHz) spinal cord stimulation therapy

Introduction

Chronic low back pain (CLBP) is the leading cause of disability in the United States and is associated with a steadily increasing burden of healthcare expenditures. Given this trend, it is essential to evaluate interventions aimed at reducing disability and optimizing healthcare utilization (HCU) in affected populations. This study investigates the impact of prior spinal surgery on functional outcomes and HCU patterns following high-frequency (10 kHz) spinal cord stimulation (SCS) therapy.

Methods

This retrospective observational study included 160 subjects who underwent implantation of a 10 kHz SCS device. Participants were divided into surgical and non-surgical cohorts for comparative analysis. Pain relief was assessed using the Numeric Rating Scale (NRS), while disability levels were evaluated using the Oswestry Disability Index (ODI). HCU was examined through the frequency of emergency department (ED) visits, outpatient visits for interventional pain procedures, and opioid consumption measured in morphine milliequivalents (MME).

Results

No statistically significant differences were observed between the surgical and non-surgical groups regarding pain relief and disability outcomes. Additionally, ED visits and outpatient visits for interventional pain procedures did not show significant differences between the two cohorts.

Discussion

This study represents the first comparative analysis of pain, disability, and HCU trends between surgical and non-surgical populations following 10 kHz SCS therapy. The results suggest that prior spinal surgery may not substantially affect the efficacy of 10 kHz SCS therapy in terms of pain relief, disability reduction, or HCU patterns.

Acupuncture combined with Chinese herbal medicine for discogenic low back pain: protocol for a multicentre, randomised controlled trial

INTRODUCTION

Discogenic low back pain is a common form of chronic low back pain. In traditional Chinese medicine, combinations of acupuncture and herbal medicine are frequently used to manage this condition. However, evidence for the efficacy of a combined approach remains scarce. To address this gap, we designed a multicentre, randomised controlled trial to compare the effects of the combined use of acupuncture and Chinese herbal medicine, and their separate applications along with non-steroidal anti-inflammatory drugs, in treating discogenic low back pain.

METHODS AND ANALYSIS

This is a multicentre, prospective, randomised, four-arm, parallel-controlled trial involving patients with discogenic low back pain. Patients will be randomly divided into four groups (acupuncture combined with herbal medicine, acupuncture, herbal medicine and positive drug control) at a 1:1:1:1 ratio. All patients will undergo a 4-week treatment regimen consisting of acupuncture (active or sham acupuncture) and oral medication (herbal medicine or placebo granules and celecoxib or placebo capsules), as well as a 3-month follow-up assessment. The primary outcome measure will be pain intensity, measured using the Visual Analogue Scale after a 4-week treatment period. Secondary outcome measures will include the lumbar pressure pain threshold, pain-related disability measured using the Oswestry Disability Index, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, 36-Item Short-Form Health Survey and incidence of adverse events. Assuming an SD of 1.8, minimal clinically important difference of 1.5 and a 10% dropout rate, at least 97 participants per group are needed, totalling 388 participants.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of Dongzhimen Hospital Affiliated with Beijing University of Chinese Medicine (approval number: 2024DZMEC-083-03) and the other seven participating subcentres. All participants will provide written informed consent. This trial will be conducted in accordance with the principles outlined in the Declaration of Helsinki and its amendments. This work will be disseminated through the publication of peer-reviewed manuscripts.

TRIAL REGISTRATION NUMBER

ChiCTR2400082428.

Spinal Cord Stimulation vs Medical Management for Chronic Back and Leg Pain: A Systematic Review and Network Meta-Analysis

Importance

Chronic back and lower extremity pain is one of the leading causes of disability worldwide. Spinal cord stimulation (SCS) aims to improve symptoms and quality of life.

Objective

To evaluate the efficacy of SCS therapies compared with conventional medical management (CMM).

Data Sources

MEDLINE, Embase, and Cochrane Library were systematically searched from inception to September 2, 2022.

Study Selection

Selected studies were randomized clinical trials comparing SCS therapies with sham (placebo) and/or CMM or standard treatments for adults with chronic back or leg pain who had not previously used SCS.

Data Extraction and Synthesis

Evidence synthesis estimated odds ratios (ORs) and mean differences (MDs) and their associated credible intervals (CrI) through bayesian network meta-analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline for network meta-analyses was followed.

Main Outcomes and Measures

The primary outcomes were pain-related end points, including pain intensity (measured by visual analog scale) and proportion of patients achieving at least 50% pain relief (responder rate) in the back or leg. Quality of life (measured by EQ-5D index score) and functional disability (measured by the Oswestry Disability Index score) were also considered.

Results

A total of 13 studies of 1561 patients were included in the network meta-analysis comparing conventional and novel SCS therapies with CMM across the 6 outcomes of interest at the 6-month follow-up. Both conventional and novel SCS therapies were associated with superior efficacy compared with CMM in responder rates in back (conventional SCS: OR, 3.00; 95% CrI, 1.49 to 6.72; novel SCS: OR, 8.76; 95% CrI, 3.84 to 22.31), pain intensity in back (conventional SCS: MD, -1.17; 95% CrI, -1.64 to -0.70; novel SCS: MD, -2.34; 95% CrI, -2.96 to -1.73), pain intensity in leg (conventional SCS: MD, -2.89; 95% CrI, -4.03 to -1.81; novel SCS: MD, -4.01; 95% CrI, -5.31 to -2.75), and EQ-5D index score (conventional SCS: MD, 0.15; 95% CrI, 0.09 to 0.21; novel SCS: MD, 0.17; 95% CrI, 0.13 to 0.21). For functional disability, conventional SCS was superior to CMM (MD, -7.10; 95% CrI, -10.91 to -3.36). No statistically significant differences were observed for other comparisons.

Conclusions and Relevance

This systematic review and network meta-analysis found that SCS therapies for treatment of chronic pain in back and/or lower extremities were associated with greater improvements in pain compared with CMM. These findings highlight the potential of SCS therapies as an effective and valuable option in chronic pain management.

Effects of pain neuroscience education combined with neuromuscular exercises on pain, functional disability and psychological factors in chronic low back pain: A study protocol for a single-blind randomized controlled trial

OBJECTIVE

Chronic low back pain (CLBP) is a prevalent health condition worldwide. Several therapeutic interventions aim to improve CLBP. Pain Neuroscience Education (PNE) helps patients better understand their pain from biological and physiological perspectives, which clinicians use to reduce pain and disability in patients with chronic musculoskeletal conditions. Neuromuscular exercises (NMS) are also treatments adopted in CLBP. This study will investigate whether PNE combined with an NMS program improves pain, functional and psychological outcomes more than NMS alone in patients with CLBP.

METHODS

In this single-blind randomized controlled trial, 60 patients (male and female; age range, 30-60 years) diagnosed with CLBP will be randomly assigned to one of the following groups: (1) PNE plus NMS (n = 30; 24 sessions of PNE plus NMS in a total of 8 weeks, 3 each week), and (2) NMS alone (n = 30; 24 sessions of NMS sessions in a total of 8 weeks, 3 each week). Outcome assessors will be blinded to the group allocation. The primary outcome will be pain. Secondary outcomes will be disability, fear-avoidance beliefs about work and physical activity, self-efficacy, exercise anxiety, and kinesiophobia. Outcomes will be assessed at baseline, after 8 weeks of intervention, and 6 months post-intervention.

DISCUSSION

The findings of this RCT will help shed light on new treatment strategies to address the biopsychosocial dimensions of CLBP. The study protocol will be conducted in a clinical setting, offering the opportunity for future implementation in healthcare systems. Moreover, it will help clarify whether a combined treatment (PNE with NMS) is more effective than NMS alone for improving pain, functional and psychological outcomes in CLBP.

TRIAL REGISTRATION

Study registration: The study was prospectively registered in the Iranian Registry of Clinical Trials-IRCT20190427043384N2 (https://www.irct.ir/trial/69146). Registered on March 17, 2023.

Which Scale to Assess Pain Self-efficacy Shows Better Measurement Properties in Chronic Low Back Pain? A Head-To-Head Comparison Study

OBJECTIVE

To compare the quality of the measurement properties of Pain Self-Efficacy Questionnaire (PSEQ)-10, PSEQ-4, PSEQ-2, Chronic Pain Self-Efficacy Scale (CPSS) long-form, and CPSS short-form (CPSS-SF) in patients with chronic low back pain (CLBP).

DESIGN

Cross-sectional and longitudinal studies (measurement properties).

SETTING

Outpatient rehabilitation.

PARTICIPANTS

Participants (N=245) with nonspecific CLBP (18-60y, 63% women) were enrolled in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Pain self-efficacy questionnaires were administered on 3 occasions: baseline assessment, 1 week after the first assessment (reliability), and after an 8-week exercise program (responsiveness). The intraclass correlation coefficient (ICC) and Cronbach α were used to assess reliability and internal consistency, respectively. Pearson correlation and confirmatory factor analyses were used to assess construct validity. The area under the curve and hypothesis testing were used to assess responsiveness.

RESULTS

No difference was observed for all the questionnaires regarding internal consistency (Cronbach α>.7), criterion validity (r>.88), and reliability (ICC>.7). The scales confirmed >75% of the hypotheses for the construct validity, except for CPSS-SF. PSEQ-2 did not meet the criterion for structural validity. PSEQ-10 met all the criteria for good measurement properties according to Consensus-Based Standards for the Selection of Health Measurement Instruments.

CONCLUSIONS

It was not possible to calculate structural validity for PSEQ-2, CPSS-SF did not meet the criterion for suitable hypothesis testing for construct validity, and all the questionnaires did not show suitable measurement error, except for the PSEQ-10. Hence, the PSEQ-10 was the unique scale that met all the criteria for good measurement properties for assessing pain self-efficacy in CLBP.

Efficacy of naproxen in patients with sciatica: multicenter, randomized, double-blind, placebo-controlled trial

ABSTRACT

This trial assessed the efficacy of naproxen in patients with sciatica in outpatient clinics across 4 Norwegian hospitals. A total of 123 adults with radiating pain below the knee (≥4 on a 0-10 numeric rating scale) and signs consistent with nerve root involvement were included. Participants were randomized to receive either naproxen 500 mg or a placebo twice daily for 10 days. The primary outcome, daily leg pain intensity measured on a 0 to 10 numeric rating scale throughout the treatment period, revealed a statistically significant difference in favor of naproxen, with an adjusted mean difference of -0.5 (95% CI -0.8 to -0.1, P = 0.015). In the naproxen group, the treatment effect was significantly related to time, and over the whole 10-day period, the average adjusted difference was -0.6 (95% CI -0.8 to -0.5). Mean numbers needed to treat for 30% and 50% improvement were 9.9 (95% CI 4.7-15.0) and 20.7 (8.7-32.7), respectively. The adjusted mean difference for back pain was -0.4 (95% CI -0.8 to 0.0), and for Roland Morris Disability Questionnaire for Sciatica, it was -1.5 (95% CI -3.0 to 0.0). No differences were found for sciatica bothersomeness or consumption of rescue medication or opioids. Participants in the naproxen group exhibited an adjusted odds ratio of 4.7 (95% CI 1.3-16.2) for improvement by 1 level on the global perceived change scale. In conclusion, naproxen treatment showed small, likely clinically unimportant benefits compared with placebo in patients with moderate-to-severe sciatica.

Effectiveness of Pilates compared with home-based exercises in individuals with chronic non-specific low back pain: Randomised controlled trial

OBJECTIVE

To investigate the effectiveness of a Pilates exercise program compared with home-based exercises in individuals with chronic non-specific low back pain.

DESIGN

A randomised controlled trial with a six-month follow-up.

SETTING

Rehabilitation clinic.

PARTICIPANTS

One hundred and forty-five individuals (18-50 years of age) with low back pain for ≥ 12 consecutive weeks were enrolled and randomly allocated to either Pilates (n = 72) or home-based exercise groups (n = 73).

INTERVENTIONS

Method Pilates (Mat Pilates exercises using accessories) versus home-based exercise (postural exercises, muscle stretching and strengthening, and spine stabilisation/mobilisation), twice a week, for 6 weeks.

MAIN MEASURES

Assessments were performed at baseline, post-intervention, and six months follow-up. Outcomes were pain intensity, disability, and health-related quality of life.

RESULTS

At post-intervention, the Pilates group had significantly lower pain intensity (mean difference = -1.14; 95% CI -2.05; -0.23), less disability (mean difference = -6.7; 95% CI -11.3; -2.0), and higher health-related quality of life (mean difference = 0.102; 95% CI 0.054; 0151) compared to the home-based exercise group. At follow-up, the Pilates group had a significantly higher health-related quality of life (mean difference = 0.055; 95% CI 0.003; 0.106) compared with the home-based exercise group but there were no significant differences in pain and disability. A significant overall effect of Pilates compared to home-based exercise was found for disability (mean difference = -4.4; 95% CI -7.6; -1.1), and health-related quality of life (mean difference = 0.049; 95% CI 0.022; 0.076), but not for pain.

CONCLUSION

Although Pilates was significantly superior to home exercise for pain and disability, the differences were not considered clinically relevant. However, Pilates did provide significant and clinically relevant differences in utility.

The effects of in-person-supervised, tele-supervised, and unsupervised stabilization exercises on pain, functionality, and kinesiophobia in patients with chronic low back pain: a randomized, single-blind trial

BACKGROUND

The efficacy of various supervision methods for stabilization exercises in patients with chronic low back pain (CLBP) remains uncertain.

OBJECTIVE

To evaluate the impact of supervised and unsupervised stabilization exercises in patients with CLBP.

METHODS

Sixty-six participants were assigned to the in-person-supervised, tele-supervised, or unsupervised groups. All participants received a 20-30-minute exercise program three times a week for 4 weeks. We assessed functionality (Oswestry Disability Index), pain intensity (Numeric Rating Scale), and kinesiophobia (Tampa Scale of Kinesiophobia) before and after the 4 weeks. The outcomes were analyzed using effect size, minimum clinically important difference (MCID), minimal detectable change (MDC), Wilcoxon test, and post hoc analyses.

RESULTS

While the unsupervised group improved in all measures (p < .05) both the tele-supervised (p = .001) and in-person-supervised (p < .001) groups achieved superior functionality exceeding MDC. The in-person-supervised group demonstrated greater functionality (p < .001) than the tele-supervised group, exceeding MCID. Pain intensity decreased in the tele-supervised (p = .011) and in-person-supervised groups (p < .001) compared to the unsupervised group, exceeding MCID and MDC. No significant difference was found in post-treatment NRS score changes between the supervised groups (p = .071). The in-person-supervised group displayed a greater reduction in kinesiophobia than the tele-supervised (p < .001) and unsupervised groups (p < .001) but not exceeding MCID or MDC. Effect sizes were large within and between groups except for a small effect size between the tele-supervised and unsupervised groups in kinesiophobia.

CONCLUSION

While tele-supervised stabilization exercises alleviate pain and enhance functionality, in-person-supervised exercises may be more effective in improving functionality and reducing kinesiophobia in patients with CLBP.

Hyperalgesia in Patients With a History of Opioid Use Disorder: A Systematic Review and Meta-Analysis

Importance

Short-term and long-term opioid treatment have been associated with increased pain sensitivity (ie, opioid-induced hyperalgesia). Treatment of opioid use disorder (OUD) mainly involves maintenance with methadone and buprenorphine, and observations of heightened cold pain sensitivity among patients are often considered evidence of opioid-induced hyperalgesia.

Objective

To critically examine the evidence that hyperalgesia in patients with OUD is related to opioid use.

Data Sources

Web of Science, PubMed, and Embase between March 1, 2023, and April 12, 2024, were searched.

Study Selection

Studies assessing cold pressor test (CPT) pain responses during treatment seeking, pharmacological treatment, or abstinence in patients with OUD history were included.

Data Extraction and Synthesis

Multilevel random-effects models with robust variance estimation were used for all analyses. Study quality was rated with the JBI checklist. Funnel plots and Egger regression tests were used to assess reporting bias.

Main Outcomes and Measures

Main outcomes were pain threshold, tolerance, and intensity in patients and healthy controls, and unstandardized, standardized (Hedges g), and percentage differences (%Δ) in these measures between patients and controls. The association between pain sensitivity and opioid tolerance, withdrawal, and abstinence indices was tested with meta-regression.

Results

Thirty-nine studies (1385 patients, 741 controls) met the inclusion criteria. Most studies reported CPT data on patients undergoing opioid agonist treatment. These patients had a mean 2- to 3-seconds lower pain threshold (95% CI, -4 to -1; t test P = .01; %Δ, -22%; g = -0.5) and 29-seconds lower pain tolerance (95% CI, -39 to -18; t test P < .001; %Δ, -52%; g = -0.9) than controls. Egger tests suggested that these differences may be overestimated. There were some concerns of bias due to inadequate sample matching and participant dropout. Meta-regressions yielded no clear support for hyperalgesia being opioid related.

Conclusion and Relevance

Patients receiving opioid agonist treatment for OUD are hypersensitive to cold pain. It remains unclear whether hyperalgesia develops prior to, independent of, or as a result of long-term opioid treatment. Regardless, future studies should investigate the impact of hyperalgesia on patients' well-being and treatment outcomes.

Tuina versus physiotherapy or a combination of both for the management of chronic nonspecific low back pain: A randomized controlled trial

OBJECTIVE

To rigorously evaluate the short-term and long-term effectiveness of Tuina (TN), alone and in combination with physiotherapy (PT), for Chronic nonspecific low back pain (CNLBP) through a comprehensive, high-quality clinical trial.

METHODS

This randomized, single-blind trial was conducted from September 2020 to July 2023, involving 204 CNLBP patients from the First Affiliated Hospital of Jinan University. Participants underwent a baseline assessment, 6 treatment sessions over 8 weeks, a post-treatment evaluation in the 9th week, and a 20-week follow-up. Participants were randomly assigned to TN, PT, or a combination of TN and PT (TP) groups. Each treatment involved 6 sessions with a minimum 7-day interval, each lasting 30 minutes. Primary outcome was the change in Visual Analog Scale (VAS) for pain. Secondary outcomes included the Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), Range of Motion (ROM) of the spine, Traditional Chinese Medicine Syndrome Scale (TCMSS), and adverse events (AE).

RESULTS

Among the 204 participants, 67.16 % were female, and 88.73 % completed the 20-week follow-up. All groups showed significant reductions in VAS scores post-treatment and at follow-up. Secondary outcomes improved significantly, with notable decreases in ODI and TCMSS scores. Pairwise comparisons within groups indicated statistical significance, particularly in ODI scores, with clinical relevance. No significant differences were found between the groups. ROM and SF-36 showed statistical but not clinical significance. Only one AE (0.49 %) was reported, with no severe incidents.

CONCLUSION

All treatment groups, including TN, TP, and PT, demonstrated significant reductions in VAS scores for CNLBP patients, with effects lasting up to 20 weeks. While TN and TP showed substantial improvements in secondary outcomes, particularly in ODI scores, no significant differences were found between the groups. These findings suggest that all treatments can be effective for managing CNLBP, supporting clinical practitioners in selecting appropriate interventions for patients, especially for those unable to engage in active exercises, utilizing passive movements like TN to enhance health outcomes.

Responsiveness of the Oswestry Disability Index and Zurich Claudication Questionnaire in patients with lumbar spinal stenosis: evaluation of surgically treated patients from the NORDSTEN study

PURPOSE

To evaluate the responsiveness of the original low back pain specific Oswestry Disability Index (ODI) and the spinal stenosis specific Zürich Claudication Questionnaire (ZCQ), and to investigate cut-off values for clinical "success" for ODI and ZCQ in surgically treated patients with lumbar spinal stenosis (LSS).

METHODS

We included 601 LSS patients (218 with, 383 without degenerative spondylolisthesis) from the NORDSTEN trials. Outcome measures included ODI and ZCQ (symptom severity and physical function scales) with three alternative response parameters: scores at follow-up, absolute and relative changes from baseline to two-year follow-up. Effect size and standardised response mean evaluated internal responsiveness. External responsiveness was assessed by the Spearman rank correlation between patient-reported global perceived effect scale (GPE) and ODI and ZCQ, and receiver operating characteristics (ROC). We evaluated which cut-off values could maximise the percentage of correctly classified patients according to the GPE-anchor "completely recovered" / "much improved" for each parameter.

RESULTS

Internal and external responsiveness were high for all three indices with effect sizes, standardized response means, ROC and corresponding area under the curve > 0.8. Correlations with GPE responses were moderate (> 0.50) for absolute change and strong (> 0.67) for relative change and follow-up scores. The 30% ODI relative change cut-off correctly classified 81% of patients to "success", within a range of accurate cut-offs according to the GPE-anchor.

CONCLUSION

ODI and ZCQ demonstrate comparable responsiveness in evaluating outcomes for surgically treated LSS patients. The 30% ODI threshold was consistent with treatment "success" in NORDSTEN trials.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT02007083 10/12/2013, NCT02051374 31/01/2014 and NCT03562936 20/06/2018.

Spinal cord stimulation combined with exercise in patients diagnosed with persistent spinal pain syndrome. Study protocol for a randomized control trial

INTRODUCTION

Administration of spinal cord stimulation to individuals with PSPS-T1/2 may induce supraspinal descending activation. Similarly, exercise is recognized as a fundamental aspect of spinal pain management. Studies have demonstrated its impact on neurophysiological factors, including the release of spinal and supraspinal beta-endorphins, which activate μ-opioid receptors. Therefore, the purpose of this study will be to examine the effect of SCS in combination with lumbo-pelvic stability core training on perceived low back pain, quality of life and disability in PSPS-T2 patients.

METHODS/MATERIALS

A double-blind randomized clinical trial (RCT) has been designed. All participants will be randomized from a pre-set sequence. The intervention design has been elaborated from the CONSORT guidelines. This study has been registered at Clinicaltrial.gov (NCT06272539). Sample size was calculated using G Power® Sample size software (University of Düsseldorf). The calculation was based on a moderate effect size of 0.7 (partial η2 = 0.70, α = .05, power = 0.95), resulting in a total of 40 patients. Assuming a 30% dropout rate, 52 participants will be recruited in total. Two sessions per week will be scheduled for 8 weeks with a total of 16 sessions. Each work session will have a duration of 60 minutes. The exercise will be adapted according to the phases based on the results already published, limiting in each phase the degrees of flexion and extension of the spine to avoid the risk of electrode migration. Primary outcomes will be functionality, satisfaction, strength, psychosocial variables, quality of life and pain perception.

Mind your pain: A single-arm feasibility study to assess a smartphone-based interoceptive attention training for patients with chronic low back pain

OBJECTIVE

People commonly cope with chronic low back pain (cLBP) by ignoring and distraction. Can mindful interoceptive exposure to the pain sensation itself and its phenomenological components be an alternative approach?

METHODS

Single-arm feasibility study in patients with cLBP using a 2-minute attention exercise guided by a smartphone app several times per day over 8 weeks. We assessed feasibility, pre/post pain, function, and psychological parameters using mixed methods: standard questionnaires, ecological momentary assessment, and exit interviews that included micro-phenomenology technique and subsequent reflexive thematic qualitative analysis.

RESULTS

We enrolled 31 participants, mostly female, mean age 48, the majority had pain for >5 years; 29 completed. Mean pain intensity [0-10] improved from 4.8 ±1.7 to 3.1 ±1.9 (p < .0001); mean PEG scores (intensity and interference with daily life; range 0-30) improved from 13.7 ±6.2 to 8.4 ±6.6 (p < .0001); pain impact (9 items incl physical function) 22.3 ±8.7 to 19.7 ±8.1 (p = .0010). Twenty-one of 29 improved PEG score ≥30%. There were significant improvements in PCS Rumination and MAIA Not-Worrying. Participants became aware of their usual habit of avoidance and the challenge of and resistance to focusing on pain. They were surprised how pain sensations varied over time, and that pain intensity and the threat value of pain could diminish by focusing on it. They described a variety of 3D pain shapes (e.g., football, pool ball, rod, nail, brick, stars) with a range of colors, transparency, temperature, and density that for some changed with mindful attention. Most struggled to find appropriate words for sensory awareness and attention regulation and found that the threat value of their pain diminished.

CONCLUSIONS

Mindful interoceptive exposure to the sensations of their cLBP using a 2-minute attention exercise with a phone app-rather than ignoring and distracting from it-may be a beneficial intervention for cLBP.

TRIAL REGISTRATION

ClinicalTrials.gov #NCT06186193.

Internet-Delivered Psychological Pain Management: A Prospective Cohort Study Examining Routine Care Delivery by a Specialist Regional Multidisciplinary Pain Service

Several clinical trials have demonstrated the effectiveness of internet-delivered psychological-based pain management programs (PMPs). However, to date, no large studies have reported the outcomes of PMPs when delivered by specialist multidisciplinary pain services in routine care. The present study reports (n = 653) the outcomes of an internet-delivered PMP provided as routine care by a specialist Australian regional pain service over a 6-year period. High levels of treatment commencement (85%) and completion (72%) were observed, with more than 80% of patients reporting they were satisfied with the intervention. Clinical improvements were observed from pretreatment to post-treatment (% change, 95% confidence intervals (CI)) in pain-related disability (8.8%; 4.5, 12.8), depression (28.4%; 23.0, 33.4), anxiety (21.9%; 14.6, 28.5), and pain intensity (7%; 3.5, 10.5), which were maintained to 3-month follow-up. At 3-month follow-up, 27% (23, 31), 46% (41, 51), 44% (39, 49), and 22% (19, 26) reported clinically meaningful (defined as ≥ 30%) improvements in pain-related disability, depression, anxiety, and pain intensity, respectively. These results were obtained with relatively little therapist time per patient (M = 30.0, (standard deviation) SD = 18.8) to deliver the intervention. The current findings highlight the potential of internet-delivered PMPs as part of the services provided by specialist pain services, particularly those servicing large geographical regions and for patients unable to travel to clinics for face-to-face care. PERSPECTIVE: This study reports the outcomes of the routine delivery of an internet-delivered psychological PMP by a specialist pain service. The findings highlight the potential of this model of care when provided by specialist pain services, particularly for patients not unable to attend and not requiring intensive face-to-face care.

Efficacy of Biphasic Calcium Phosphate Ceramic With a Needle-Shaped Surface Topography Versus Autograft in Instrumented Posterolateral Spinal Fusion

STUDY DESIGN

A multicenter randomized controlled noninferiority trial with intrapatient comparisons.

OBJECTIVE

The aim of this study was to determine noninferiority of a slowly resorbable biphasic calcium phosphate with submicron microporosity (BCP<μm, MagnetOs Granules) as an alternative for autograft in instrumented posterolateral fusion (PLF).

SUMMARY OF BACKGROUND DATA

Successful spinal fusion with a solid bone bridge between the vertebrae is traditionally achieved by grafting with autologous iliac bone. However, the disadvantages of autografts and unsatisfactory fusion rates have prompted the exploration of alternatives, including ceramics. Nevertheless, clinical evidence for the standalone use of these materials is limited.

METHODS

Adults indicated for instrumented PLF (1 to 6 levels) were enrolled at 5 participating centers. After bilateral instrumentation and fusion-bed preparation, the randomized allocation side (left or right) was disclosed. Per segment 10 cc of BCP<μm granules (1 to 2 mm) were placed in the posterolateral gutter on one side and 10 cc autograft on the contralateral side. Fusion was systematically scored on 1-year follow-up CT scans. The study was powered to detect >15% inferiority with binomial paired comparisons of the fusion performance score per treatment side.

RESULTS

Of the 100 patients (57 ± 12.9 y, 62% female), 91 subjects and 128 segments were analyzed. The overall posterolateral fusion rate per segment (left and/or right) was 83%. For the BCP<μm side only the fusion rate was 79% versus 47% for the autograft side (difference of 32 percentage points, 95% CI, 23-41). Analysis of the primary outcome confirmed the noninferiority of BCP<μm with an absolute difference in paired proportions of 39.6% (95% CI, 26.8-51.2; p < 0.001).

CONCLUSION

This clinical trial demonstrates noninferiority and indicates superiority of MagnetOs Granules as a standalone ceramic when compared to autograft for posterolateral spinal fusion. These results challange the belief that autologous bone is the most optimal graft material.

Effects of photobiomodulation therapy associated with motor control exercise for chronic non-specific low back pain: protocol for a randomised placebo-controlled trial

Photobiomodulation therapy (PBMT), as an adjunct therapy to exercise, can reduce pain in musculoskeletal disorders. In addition, PBMT associated with exercise decreases fatigue, accelerates muscle recovery and enhances performance and gain through different training protocols. Although it has not been investigated, the association of PBMT and exercise therapy could be an alternative to improve the positive effects of exercise in patients with non-specific low back pain (LBP). Therefore, we aim to evaluate the effects of PBMT associated with motor control exercise (MCE) versus placebo associated with MCE in patients with chronic non-specific LBP. This is a prospectively registered, two-arm, randomised, placebo-controlled, triple-blind trial. A total of 148 patients with chronic non-specific LBP will be randomised to either active PBMT associated with MCE or placebo PBMT associated with MCE. Treatment sessions will be provided twice a week for 6 weeks. The primary outcomes will be pain intensity and general disability measured at the end of the treatment. The secondary outcomes will be pain intensity and general disability measured 1 month after the end of the treatment, 3, 6 and 12 months after randomisation, in addition to levels of prostaglandin E2 measured at the end of the treatment. Medication intake, cointerventions and adverse events will be measured at all time points. This study was approved by the Research Ethics Committee of Irmandade de Santa Casa de Misericórdia de Porto Alegre. The results will be disseminated through scientific publications and presentations at scientific meetings. Trial registration number: NCT05487118.

A novel opioid/pramipexole combination treatment for the management of acute pain: a pilot study

Purpose

Despite their dangerous side effects, opioid drugs remain a standard of care for moderate to severe pain with few alternatives. Strategies to maintain the analgesic effects of opioids while minimizing the associated risks are needed. Pre-clinical studies have shown using a dopamine 3 receptor (D3R) agonist as an adjuvant to morphine provides superior analgesia against painful stimuli compared to morphine alone. Our objective was to test if adjunct treatment with a D3R agonist can lead to a reduction in opioid use while maintaining effective analgesia.

Patients and methods

This study was set up as a double-blinded, placebo-controlled randomized trial. Enrollment included acute renal colic patients presenting to the emergency department, from which patients were randomized to either the "control" or "study arm". The control group received standard treatment of care (morphine, 0.1 mg/kg; i.v.) and an oral placebo pill. The experimental group received half-dosed morphine and oral pramipexole pill (0.25 mg). Pain measurements including a numerical pain scale and visual analog scale were collected from enrollees at baseline and every subsequent 15 min.

Results

A total of 19 patients completed the study, 10 in the experimental arm and 9 in the control arm. During the study period, effective analgesia (50% decrease from baseline) was achieved in 80% of patients in the experimental arm vs. 33.3% in the control arm.

Conclusion

Our pilot clinical trial demonstrated that D3R recruitment can serve as an effective adjuvant to low-dose morphine for control of renal colic pain and potentially other acute pain conditions.

Clinical Trial Registration

ClinicalTrials.gov, identifier, (NCT04160520).

Comparison of diclofenac with tramadol, tizanidine or placebo in the treatment of acute low back pain and sciatica: multi-center randomized controlled trial

BACKGROUND

Low back pain (LBP) is a leading cause of disability worldwide and has posed numerous health and socioeconomic challenges. This study compared whether nonsteroidal anti-inflammatory drugs (NSAIDs) in combination with tramadol, tizanidine or placebo would be the best treatment regime to improve the Roland Morris Disability Questionnaire (RMDQ) scores at 1 week.

METHODS

This was a multi-center, double-blind, randomized, and placebo-controlled trial including adult patients with acute LBP and sciatica in three emergency departments in Hong Kong. Patients were randomized to the receive tramadol 50 mg, tizanidine 2 mg, or placebo every 6 hours for 2 weeks in a 1:1:1 ratio. The RMDQ and other secondary outcomes were measured at baseline, Day 2, 7, 14, 21, and 28. Data were analyzed on an intention to treat basis. Crude and adjusted mean differences in the changes of RMDQ and NRS scores from baseline to Day 7 between tizanidine/tramadol and placebo were determined with 95% confidence intervals.

RESULTS

Two hundred and ninety-one patients were analyzed with the mean age of 47.4 years and 57.7% were male. The primary outcome of mean difference in RMDQs on Day 7 (compared with baseline) was non-significant for tizanidine compared with placebo (adjusted mean difference - 0.56, 95% CI -2.48 to 1.37) and tramadol compared with placebo (adjusted mean difference - 0.85, 95% CI -2.80 to 1.10). Only 23.7% were fully compliant to the treatment allocated. Complier Average Causal Effect analysis also showed no difference in the primary outcome for the tizanidine and tramadol versus placebo.

CONCLUSION

Among patients with acute LBP and sciatica presenting to the ED, adding tramadol or tizanidine to diclofenac did not improve functional recovery.

Expectations in patients undergoing spine surgery are high and unmet

BACKGROUND CONTEXT

Defining success in spine surgery lacks a standardized approach, and all existing concepts are based on registrations after surgery.

PURPOSE

To examine patients' expectations before spine surgery assessed by a modified Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS). The authors asked: how do the expectations align with actual outcomes and can a patient's individual expectations be used as a success criterion in itself?

STUDY DESIGN /SETTING

Prospective single-center study.

PATIENT SAMPLE

Patients scheduled for spine surgery at Akershus University Hospital (AHUS) were included in the study. They underwent 1 of 3 procedures: decompression for spinal stenosis, disc removal for lumbar disc herniation, or spinal fusion for degenerative disc disease.

OUTCOME MEASURES

Modified and standard version of ODI and NRS (back and leg pain).

METHODS

Preoperatively, the patients were given a modified ODI and NRS questionnaire in which they were asked to register the minimum acceptable functional impairment and pain they anticipated to have postsurgery. The patients' expectations were compared with 3-and 12-month follow-up data from the Norwegian Registry for Spine Surgery (NORspine) with ODI, NRS and Global Perceived Effect (GPE) scale. We used simple descriptive statistics.

RESULTS

A total of 93 patients completed the pre-op questionnaire. Of these, 65 responded to the 3-month follow-up and 53 at 12-month follow-up. The mean (95%CI) ODI before surgery was 38.3 (34.2-42.3), the mean (95% CI) preoperative NRS back pain was 6.34 (5.81-6.88), and leg pain was 6.67 (6.08-7.26). The patients expected a mean (95% CI) ODI of 10.5 (7.5-13.5), mean (95%CI) NRS back pain of 2.5 (2.1-3.0), and NRS leg pain of 1.8 (1.5-2.2). The actual clinical outcome after 12 months were a mean (95% CI) ODI of 21.7 (17.0-26.5), NRS back pain of 3.4 (2.8-4.1), and leg pain of 2.8 (2.0-3.5). Only 12 (30.8%) patients achieved their expected ODI, while 26 (65.0%) classified themselves as significantly better according to GPE.

CONCLUSIONS

Patients seem to have high expectations before spine surgery, and the expectations may exceed the clinical outcome. Only 30.8% had their ODI expectations met, but perceived benefit was higher. High expectations may be due to inadequate preoperative information and/or the unsuitability of ODI for capturing expectations.

Redefining Oswestry Disability Index success criteria to assess the effect of consecutive surgeries on lumbar spinal stenosis

BACKGROUND

Register studies have shown that chances of success after surgery for lumbar spinal stenosis (LSS) decrease with increasing numbers of previous operations. However, these studies presumed that success criteria remain constant with each consecutive spinal surgery.

PURPOSE

We aimed to redefine success criteria specific for each consecutive surgery. Also, we assessed if fusion could be an effective procedure for LSS patients with previous decompression(s).

STUDY DESIGN

We retrospectively analyzed prospectively collected patient-reported outcome measures (PROMs) from surgically treated LSS patients enrolled in The NORspine Register.

PATIENT SAMPLE

Patients operated for lumbar spinal stenosis.

OUTCOME MEASURES

PROMs: Oswestry Disability Index (ODI) percentage (%) change and Global Perceived Effect (GPE).

METHODS

We categorized the LSS cohort by number of previous spine surgeries (none to ≥3). ROC analyses gave the most accurate cut-offs for ODI% change that corresponded to success, anchored by GPE, i.e., "much improved" and "completely recovered". Areas under the ROC curves (AUCs) indicated how well ODI discriminated between success and nonsuccess for each consecutive surgery: good (0.8-0.89) and excellent (0.9-0.99). We then calculated proportions of successfully treated patients by number of consecutive surgeries. We also analyzed whether fusion succeeded in patients with previous lumbar decompression(s).

RESULTS

At 12 months, 8,919 (75%) responded; 6,961 (78%) had no previous LSS surgery, 1,338 (15%) had one, 417 (5%) had 2, and 203 (2%) had ≥3 previous surgeries. Preoperative ODI (95% CI) was 38.7 (38.2-39.1) for no previous surgery versus 49.4 (46.9-51.9) for patients with ≥3 previous surgeries. The postoperative ODIs (95% CI) were 21.9 (21.4-22.4) and 37.9 (34.9-40.8) for patients with no and ≥3 previous surgeries, respectively. For patients with no previous surgeries, ODI% change of 37.6% most accurately defined success (AUC [95% CI]=0.909 [0.903-0.916]), and 57.1% reported success. For patients with ≥3 previous surgeries, success was an ODI% change of 25.0% (AUC [95%CI]=0.930 [0.890-0.971]), and 46.3% reported success. Finally, 350 patients received fusion after previous decompression(s). ODI% change of 34.6% defined success (AUC [95% CI]=0.920 [0.890-0.949]). The proportion of successfully treated fusion patients was 47.7%, compared to 54.3% for the entire cohort.

CONCLUSIONS

We redefined ODI success criteria for patients with consecutive lumbar spinal stenosis surgeries. Our register study found the detrimental effect of consecutive surgeries on success rates to be less pessimistic than previously reported; fusion may be an effective option for LSS patients with previous decompression.

Treatment Expectations-You Get What You Expect-and Depression Plays a Role

Positive treatment expectations demonstrably shape treatment outcomes regarding pain and disability in patients with chronic low back pain. However, knowledge about positive and negative treatment expectations as putative predictors of interindividual variability in treatment outcomes is sparse, and the role of other psychological variables of interest, especially of depression as a known predictor of long-term disability, is lacking. We present results of the first prospective study considering expectations in concert with depression in a sample of 200 patients with chronic low back pain undergoing an inpatient interdisciplinary multimodal pain therapy. We analyzed the characteristics of pain and disability, treatment expectation, and depression assessed at the beginning (T0), at the end of (T1), and at 3-month follow-up (T2) of interdisciplinary multimodal pain therapy. Treatment expectations did emerge as a significant predictor of changes in pain intensity and disability, respectively, showing that positive expectations were associated with better treatment outcomes. Mediation analyses revealed a partially mediating effect of treatment expectations on the relation between depression and pain outcomes. PERSPECTIVE: These results expand knowledge regarding the role of treatment expectations in individual treatment outcome trajectories in chronic pain patients, paving the way for much-needed efforts toward optimizing patient expectations and personalized approaches in clinical settings.

Multicenter external validation of prediction models for clinical outcomes after spinal fusion for lumbar degenerative disease

BACKGROUND

Clinical prediction models (CPM), such as the SCOAP-CERTAIN tool, can be utilized to enhance decision-making for lumbar spinal fusion surgery by providing quantitative estimates of outcomes, aiding surgeons in assessing potential benefits and risks for each individual patient. External validation is crucial in CPM to assess generalizability beyond the initial dataset. This ensures performance in diverse populations, reliability and real-world applicability of the results. Therefore, we externally validated the tool for predictability of improvement in oswestry disability index (ODI), back and leg pain (BP, LP).

METHODS

Prospective and retrospective data from multicenter registry was obtained. As outcome measure minimum clinically important change was chosen for ODI with ≥ 15-point and ≥ 2-point reduction for numeric rating scales (NRS) for BP and LP 12 months after lumbar fusion for degenerative disease. We externally validate this tool by calculating discrimination and calibration metrics such as intercept, slope, Brier Score, expected/observed ratio, Hosmer-Lemeshow (HL), AUC, sensitivity and specificity.

RESULTS

We included 1115 patients, average age 60.8 ± 12.5 years. For 12-month ODI, area-under-the-curve (AUC) was 0.70, the calibration intercept and slope were 1.01 and 0.84, respectively. For NRS BP, AUC was 0.72, with calibration intercept of 0.97 and slope of 0.87. For NRS LP, AUC was 0.70, with calibration intercept of 0.04 and slope of 0.72. Sensitivity ranged from 0.63 to 0.96, while specificity ranged from 0.15 to 0.68. Lack of fit was found for all three models based on HL testing.

CONCLUSIONS

Utilizing data from a multinational registry, we externally validate the SCOAP-CERTAIN prediction tool. The model demonstrated fair discrimination and calibration of predicted probabilities, necessitating caution in applying it in clinical practice. We suggest that future CPMs focus on predicting longer-term prognosis for this patient population, emphasizing the significance of robust calibration and thorough reporting.

Does risk stratification with a matched treatment pathway improve clinical outcomes for adults with acute back pain? A systematic review and meta-analysis

BACKGROUND

Risk stratification is an approach which has been recommended across a number of international guidelines for the management of back pain.

OBJECTIVE

To assess whether the use of risk stratification with a matched treatment pathway improves clinical outcomes, when compared with usual care or other interventions, in adults with acute back pain.

METHODS

A comprehensive search was conducted of the databases Medline, Embase, PEDro, CINAHL and Cochrane Library in November 2022. Studies of adults with back pain of less than 3 months' duration and who had been stratified according to their level of risk of a poor functional outcome and provided with a treatment matched to their level of risk were included. Participants with specific and/or serious spinal pathologies were excluded.

RESULTS

Five trials involving 3519 participants were included. Meta-analysis found very-low certainty evidence that the use of a risk stratification approach with matched treatment may lead to a very small reduction in pain levels at 3-6 months compared with usual care (MD -0.62, 95 % CI -0.88, -0.36). These results did not achieve clinical significance. No difference was found for the use of risk stratification compared to usual care for disability (MD -1.52, 95 % CI -4.15, 1.11).

CONCLUSION

The use of risk stratification with matched treatment may be just as worthwhile as usual care for acute back pain, however the evidence is very uncertain. Further high quality research is required to confirm whether risk stratification is a useful approach for this population.

SYSTEMATIC REVIEW REGISTRATION NUMBER

CRD42022379987.

Emotion regulation skills-focused interventions for chronic pain: A systematic review and meta-analysis

OBJECTIVES

To investigate the effect of emotion regulation skills-focused (ERSF) interventions to reduce pain intensity and improve psychological outcomes for people with chronic pain and to narratively report on safety and intervention compliance.

METHODS

Six databases and four registries were searched for randomized controlled trials (RCTs) up to 29 April 2022. Risk of bias was evaluated using the Cochrane RoB 2.0 tool, and certainty of evidence was assessed according to the Grading, Assessment, Development and Evaluation (GRADE). Meta-analyses for eight studies (902 participants) assessed pain intensity (primary outcome), emotion regulation, affect, symptoms of depression and anxiety, and pain interference (secondary outcomes), at two time points when available, post-intervention (closest to intervention end) and follow-up (the first measurement after the post-intervention assessment).

RESULTS

Compared to TAU, pain intensity improved post-intervention (weighted mean difference [WMD] = -10.86; 95% confidence interval [CI] [-17.55, -2.56]) and at follow-up (WMD = -11.38; 95% CI [-13.55, -9.21]). Emotion regulation improved post-intervention (standard mean difference [SMD] = 0.57; 95% CI [0.14, 1.01]), and depressive symptoms improved at follow-up (SMD = -0.45; 95% CI [-0.66, -0.24]). Compared to active comparators, anxiety symptoms improved favouring the comparator post-intervention (SMD = 0.10; 95% CI [0.03, 0.18]), and compared to CBT, pain interference improved post-intervention (SMD = -0.37; 95% CI [-0.69, -0.04]). Certainty of evidence ranged from very low to moderate.

SIGNIFICANCE

The findings provide evidence that ERSF interventions reduce pain intensity for people with chronic pain compared to usual treatment. These interventions are at least as beneficial to reduce pain intensity as the current gold standard psychological intervention, CBT. However, the limited number of studies and certainty of evidence mean further high-quality RCTs are warranted. Additionally, further research is needed to identify whether ERSF interventions may be more beneficial for specific chronic pain conditions.

Pelvic floor muscle training for urinary symptoms, vaginal prolapse, sexual function, pelvic floor muscle strength, and quality of life after hysterectomy: a systematic review with meta-analyses

BACKGROUND

After hysterectomy, women could experience pelvic floor dysfunction and negative impact on quality of life, which could be improved by pelvic floor muscle training.

OBJECTIVE

To investigate effects of pelvic floor muscle training on urinary symptoms, vaginal prolapse, sexual function, pelvic floor muscle strength, and quality of life after hysterectomy.

METHODS

Systematic review with meta-analyses of randomized controlled trials. Trials with pelvic floor muscle training in women after hysterectomy were included. The outcomes measures were urinary symptoms, vaginal prolapse, sexual function, pelvic floor muscle strength, and quality of life. Quality of evidence was assessed by adopting the GRADE approach.

RESULTS

Six trials, involving 776 participants, were included. The mean PEDro score of trials was 5.5. Moderate-quality evidence suggested that pelvic floor muscle training improves sexual function by 5 points (95% CI: 4, 6) on the Female Sexual Function Index, compared with no intervention. It might affect strength (SMD 0.5; 95% CI: -0.4, 1.3), quality of life (SMD 0.5 points out of 108, 95% CI: -0.1, 0.9), urinary symptoms (RD -0.02; 95% CI: -0.06, 0.1); however, the estimates were too imprecise. In addition, it produces no or negligible effects on vaginal prolapse (RD 0; 95% CI: -0.1, 0.1). Long-term effects remain uncertain.

CONCLUSION

This systematic review provides moderate-quality evidence that pelvic floor muscle training is effective for improving women's sexual function after hysterectomy, in comparison with no intervention. Benefits on urinary symptoms, pelvic floor muscle strength, quality of life, and vaginal prolapse remains unclear. Also, the effects beyond the intervention period remains uncertain.

Radiofrequency for chronic lumbosacral and cervical pain: Results of a consensus study using the RAND/UCLA appropriateness method

BACKGROUND

Despite the routine use of radiofrequency (RF) for the treatment of chronic pain in the lumbosacral and cervical region, there remains uncertainty on the most appropriate patient selection criteria. This study aimed to develop appropriateness criteria for RF in relation to relevant patient characteristics, considering RF ablation (RFA) for the treatment of chronic axial pain and pulsed RF (PRF) for the treatment of chronic radicular pain.

METHODS

The RAND/UCLA Appropriateness Method (RUAM) was used to explore the opinions of a multidisciplinary European panel on the appropriateness of RFA and PRF for a variety of clinical scenarios. Depending on the type of pain (axial or radicular), the expert panel rated the appropriateness of RFA and PRF for a total of 219 clinical scenarios.

RESULTS

For axial pain in the lumbosacral or cervical region, appropriateness of RFA was determined by the dominant pain trigger and location of tenderness on palpation with higher appropriateness scores if these variables were suggestive of the diagnosis of facet or sacroiliac joint pain. Although the opinions on the appropriateness of PRF for lumbosacral and cervical radicular pain were fairly dispersed, there was agreement that PRF is an appropriate option for well-selected patients with radicular pain due to herniated disc or foraminal stenosis, particularly in the absence of motor deficits. The panel outcomes were embedded in an educational e-health tool that also covers the psychosocial aspects of chronic pain, providing integrated recommendations on the appropriate use of (P)RF interventions for the treatment of chronic axial and radicular pain in the lumbosacral and cervical region.

CONCLUSIONS

A multidisciplinary European expert panel established patient-specific recommendations that may support the (pre)selection of patients with chronic axial and radicular pain in the lumbosacral and cervical region for either RFA or PRF (accessible via https://rftool.org). Future studies should validate these recommendations by determining their predictive value for the outcomes of (P)RF interventions.

Prediction of transforaminal epidural injection success in sciatica (POTEISS): a protocol for the development of a multivariable prediction model for outcome after transforaminal epidural steroid injection in patients with lumbar radicular pain due to disc herniation or stenosis

BACKGROUND

Transforaminal epidural injections (TEI) can alleviate symptoms and help to maintain physical functioning and quality of life in patients with lumbar radicular pain. We aim to develop a prediction model for patient outcome after TEI in patients suffering from unilateral lumbar radicular pain due to lumbar disc herniation (LDH) or single-level spinal stenosis (LSS). The secondary aim is to estimate short-term patient outcome differences between LDH and LSS patients, the association between psychological variables and patient outcome, the rate of additional injections, surgery and complications, and to explore the short-term cost-effectiveness of TEI.

METHODS

This study is designed as a multi-centre, observational, prospective cohort study in two large regional hospitals in the Netherlands. Patients diagnosed with unilateral lumbar radicular pain secondary to LDH or LSS and congruent with MRI findings, who are referred for TEI along usual care pathways, are eligible for study participation. A total of 388 patients with LDH or LSS will be included. A pre-defined set of demographic, clinical and radiological variables will be used as the predictors in the model. The primary outcome measure is the Numerical Rating Scale (NRS) for leg pain. Secondary outcome measures include back pain, physical functioning, perceived recovery, pain coping strategies, anxiety and depression and use of analgesics and physical therapy. Patients will be evaluated at baseline, 2 weeks and 6 weeks after treatment. NRS leg pain and Likert perceived recovery data will be used as the dependent variables in a generalized linear mixed model for prediction of TEI outcome, with internal validation of performance (explained variation) by bootstrap resampling. Cost-effectiveness for a period of 6 weeks prior to and after treatment will be performed with decision-analytic modelling.

DISCUSSION

Patients with severe lumbar radicular pain often request additional treatment when conservative care is insufficient. TEI can offer relief of symptoms. Currently, it is not possible to predict responsiveness to this treatment for individual patients. This study is designed to explore predictors that can differentiate between patients that will and will not have a positive outcome after TEI. This information may support treatment strategies for this patient group.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov database under registry number NCT04540068 on September 1, 2020.

Development, validation and use of custom software for the analysis of pain trajectories

In chronic musculoskeletal conditions, the prognosis tends to be more informative than the diagnosis for the future course of the disease. Many studies have identified clusters of patients who seemingly share similar pain trajectories. In a dataset of low back pain (LBP) patients, pain trajectories have been identified, and distinct trajectory types have been defined, making it possible to create pattern recognition software that can classify patients into respective pain trajectories reflecting their condition. It has been suggested that the classification of pain trajectories may create clinically meaningful subgroups of patients in an otherwise heterogeneous population of patients with LBP. A software tool was created that combined the ability to recognise the pain trajectory of patients with a system that could create subgroups of patients based on their characteristics. This tool is primarily meant for researchers to analyse trends in large heterogeneous datasets without large losses of data. Prospective analysis of pain trajectories is not directly helpful for clinicians. However, the tool might aid in the identification of patient characteristics which have predictive capabilities of the most likely trajectory a patient might experience in the future. This will help clinicians to tailor their advice and treatment for a specific patient.

Transforaminal Endoscopic Lumbar Foraminotomy for the Treatment of L5-S1 Isthmic Lumbar Spondylolisthesis with Foraminal Stenosis: A 1-Year Follow-Up

BACKGROUND

Isthmic lumbar spondylolisthesis (ILS) is a prevalent spinal pathology. Radicular pain in patients is often attributed to L5-S1 ILS combined with foraminal stenosis (FS), making such patients prime candidates for surgical intervention. We herein aimed to elucidate the surgical technique and clinical outcomes of transforaminal endoscopic lumbar foraminotomy (TELF) in the treatment of L5-S1 ILS with FS.

METHODS

From September 2021 to December 2022, 20 consecutive patients were diagnosed with L5-S1 ILS with FS and underwent TELF. All patients were followed up for at least 12 months. The clinical outcomes were evaluated using the visual analog scale (VAS), Oswestry Disability Index, and modified MacNab criteria.

RESULTS

The mean age of the patients was 62.4 ± 10.9 years. The mean preoperative VAS score for low back, VAS score of the leg, and Oswestry Disability Index score was 5.1 ± 1.7, 7.4 ± 0.7, and 58.0 ± 8.4, respectively. These scores significantly improved to 1.8 ± 0.7, 1.5 ± 0.6, and 15.3 ± 7.1 at 12 months postoperatively, respectively (P < 0.01). Evaluation based on the modified MacNab criteria revealed that 95.0% of patients achieved a good-to-excellent outcome. One patient underwent revision surgery.

CONCLUSIONS

TELF emerges as a potentially safe and effective surgical option for alleviating radicular pain in patients with L5-S1 stable ILS combined with FS. While our short-term clinical results are satisfactory, it is necessary to expand the sample size and extend the follow-up time to validate the effectiveness and long-term efficacy of TELF.

Cortical Mechanisms Underlying Effects of Repetitive Peripheral Magnetic Stimulation on Dynamic and Static Postural Control in Patients with Chronic Non-Specific Low Back Pain: A Double-Blind Randomized Clinical Trial

INTRODUCTION

Patients with chronic non-specific low back pain (CNLBP) often experience impaired postural control, contributing to pain recurrence. Although repetitive peripheral magnetic stimulation (rPMS) combined with core muscle training (CMT) could improve postural control, its neural mechanism remains unclear. This study aims to investigate the postural control-related cortical mechanism of the effect of rPMS on patients with CNLBP.

METHODS

This unicentric, prospective, randomized, double-blind, controlled trial was conducted in a public hospital from May to December 2023. A total of 40 patients (27 females and 13 males, mean age 29.38 ± 7.72) with CNLBP were randomly assigned to either the rPMS group (real rPMS with CMT) or the sham-rPMS group (sham-rPMS with CMT) for 12 sessions over 4 weeks. The rPMS was applied to the lumbar paravertebral multifidus muscle on the painful side. Pain and disability were quantified using the visual analog scale (VAS) and Oswestry dysfunction index (ODI) pre- and post-intervention. Furthermore, the sway area and velocity of the center of pressure (COP) were measured using a force platform. The cortical activities in 6 regions of interest during 4 tasks (standing with eyes open/closed on a stable/unstable plane) were recorded by functional near-infrared spectroscopy (fNIRS) pre- and post-intervention. The repeated measure ANOVA was applied for statistical analysis. Spearman's correlation was used to determine the relationships between variables.

RESULTS

After the intervention, the rPMS group showed decreased pain intensity (p = 0.001) and sway area (unstable eyes-closed task) (p = 0.046) compared to the sham-rPMS group. Additionally, the rPMS group exhibited increased activation in left primary motor cortex (M1) (p = 0.042) and reduced in left supplementary motor area (SMA) (p = 0.045), whereas the sham-rPMS group showed no significant changes. The increased activation of left M1 was negatively correlated to the reduction of pain intensity (r = - 0.537, p = 0.018) and sway area (r = - 0.500, p = 0.029) under the static balancing task. Furthermore, there was a positive correlation between sway velocity and VAS (r = 0.451, p = 0.046) post-rPMS intervention.

CONCLUSION

Repetitive peripheral magnetic stimulation combined with core muscle training demonstrated better analgesic effects and postural control improvements, compared to sham-stimulation. This may be attributed to the increased activation of the left primary motor cortex.

CLINICAL TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov (ChiCTR2300070943).

Effect of Acupuncture on Neurogenic Claudication Among Patients With Degenerative Lumbar Spinal Stenosis : A Randomized Clinical Trial

BACKGROUND

Acupuncture may improve degenerative lumbar spinal stenosis (DLSS), but evidence is insufficient.

OBJECTIVE

To investigate the effect of acupuncture for DLSS.

DESIGN

Multicenter randomized clinical trial. (ClinicalTrials.gov: NCT03784729).

SETTING

5 hospitals in China.

PARTICIPANTS

Patients with DLSS and predominantly neurogenic claudication pain symptoms.

INTERVENTION

18 sessions of acupuncture or sham acupuncture (SA) over 6 weeks, with 24-week follow-up after treatment.

MEASUREMENTS

The primary outcome was change from baseline in the modified Roland-Morris Disability Questionnaire ([RMDQ] score range, 0 to 24; minimal clinically important difference [MCID], 2 to 3). Secondary outcomes were the proportion of participants achieving minimal (30% reduction from baseline) and substantial (50% reduction from baseline) clinically meaningful improvement per the modified RMDQ.

RESULTS

A total of 196 participants (98 in each group) were enrolled. The mean modified RMDQ score was 12.6 (95% CI, 11.8 to 13.4) in the acupuncture group and 12.7 (CI, 12.0 to 13.3) in the SA group at baseline, and decreased to 8.1 (CI, 7.1 to 9.1) and 9.5 (CI, 8.6 to 10.4) at 6 weeks, with an adjusted difference in mean change of -1.3 (CI, -2.6 to -0.03; P = 0.044), indicating a 43.3% greater improvement compared with SA. The between-group difference in the proportion of participants achieving minimal and substantial clinically meaningful improvement was 16.0% (CI, 1.6% to 30.4%) and 12.6% (CI, -1.0% to 26.2%) at 6 weeks. Three cases of treatment-related adverse events were reported in the acupuncture group, and 3 were reported in the SA group. All events were mild and transient.

LIMITATION

The SA could produce physiologic effects.

CONCLUSION

Acupuncture may relieve pain-specific disability among patients with DLSS and predominantly neurogenic claudication pain symptoms, although the difference with SA did not reach MCID. The effects may last 24 weeks after 6-week treatment.

PRIMARY FUNDING SOURCE

2019 National Administration of Traditional Chinese Medicine "Project of building evidence-based practice capacity for TCM-Project BEBPC-TCM" (NO. 2019XZZX-ZJ).

Pain Education and Virtual Reality Improves Pain, Pain-related Fear of Movement, and Trunk Kinematics in Individuals With Persistent Low Back Pain

OBJECTIVES

To evaluate the effect of combining pain education and virtual reality (VR) exposure therapy using a cognitive-behavioral therapy-informed approach (virtual reality-based cognitive behavioral therapy [VR-CBT]) on pain intensity, fear of movement, and trunk movement in individuals with persistent low back pain.

MATERIALS AND METHODS

Thirty-seven participants were recruited in a single cohort repeated measures study, attending 3 sessions 1 week apart. The VR-CBT intervention included standardized pain education (session 1) and virtual reality-based exposure therapy (VRET; session 2) incorporating gameplay with mixed reality video capture and reflective feedback of performance. Outcome measures (pain intensity, pain-related fear of movement (Tampa Scale of Kinesiophobia), and trunk kinematics during functional movements (maximum amplitude and peak velocity) were collected at baseline (session 1) and 1 week after education (session 2) and VRET (session 3). One-way repeated measures analysis of variances evaluated change in outcomes from baseline to completion. Post hoc contrasts evaluated effect sizes for the education and VR components of VR-CBT.

RESULTS

Thirty-four participants completed all sessions. Significant ( P < 0.001) reductions were observed in mean (SD) pain (baseline 5.9 [1.5]; completion 4.3 [2.1]) and fear of movement (baseline 42.6 [6.4]; completion 34.3 [7.4]). Large effect sizes (Cohen d ) were observed for education (pain intensity: 0.85; fear of movement: 1.28), whereas the addition of VRET demonstrated very small insignificant effect sizes (pain intensity: 0.10; fear of movement: 0.18). Peak trunk velocity, but not amplitude, increased significantly ( P < 0.05) across trunk movement tasks.

CONCLUSION

A VR-CBT intervention improved pain, pain-related fear of movement, and trunk kinematics. Further research should explore increased VR-CBT dosage and mechanisms underlying improvement.

Implementing a pragmatic clinical trial to tailor opioids for chronic pain on behalf of the IGNITE ADOPT PGx investigators

Chronic pain is a prevalent condition with enormous economic burden. Opioids such as tramadol, codeine, and hydrocodone are commonly used to treat chronic pain; these drugs are activated to more potent opioid receptor agonists by the hepatic CYP2D6 enzyme. Results from clinical studies and mechanistic understandings suggest that CYP2D6-guided therapy will improve pain control and reduce adverse drug events. However, CYP2D6 is rarely used in clinical practice due in part to the demand for additional clinical trial evidence. Thus, we designed the ADOPT-PGx (A Depression and Opioid Pragmatic Trial in Pharmacogenetics) chronic pain study, a multicenter, pragmatic, randomized controlled clinical trial, to assess the effect of CYP2D6 testing on pain management. The study enrolled 1048 participants who are taking or being considered for treatment with CYP2D6-impacted opioids for their chronic pain. Participants were randomized to receive immediate or delayed (by 6 months) genotyping of CYP2D6 with clinical decision support (CDS). CDS encouraged the providers to follow the CYP2D6-guided trial recommendations. The primary study outcome is the 3-month absolute change in the composite pain intensity score assessed using Patient-Reported Outcomes Measurement Information System (PROMIS) measures. Follow-up will be completed in July 2024. Herein, we describe the design of this trial along with challenges encountered during enrollment.

Reduction of Chronic Primary Low Back Pain by Spinal Manipulative Therapy is Accompanied by Decreases in Segmental Mechanical Hyperalgesia and Pain Catastrophizing: A Randomized Placebo-controlled Dual-blind Mixed Experimental Trial

Chronic primary low back pain (CPLBP) refers to low back pain that persists over 3 months, that cannot be explained by another chronic condition, and that is associated with emotional distress and disability. Previous studies have shown that spinal manipulative therapy (SMT) is effective in relieving CPLBP, but the underlying mechanisms remain elusive. This randomized placebo-controlled dual-blind mixed experimental trial (NCT05162924) aimed to investigate the efficacy of SMT to improve CPLBP and its underlying mechanisms. Ninety-eight individuals with CPLBP and 49 controls were recruited. Individuals with CPLBP received SMT (n = 49) or a control intervention (n = 49), 12 times over 4 weeks. The primary outcomes were CPLBP intensity (0-100 on a numerical rating scale) and disability (Oswestry Disability Index). Secondary outcomes included pressure pain thresholds in 4 body regions, pain catastrophizing, Central Sensitization Inventory, depressive symptoms, and anxiety scores. Individuals with CPLBP showed widespread mechanical hyperalgesia (P < .001) and higher scores for all questionnaires (P < .001). SMT reduced pain intensity compared with the control intervention (mean difference: -11.7 [95% confidence interval, -11.0 to -12.5], P = .01), but not disability (P = .5). Similar mild to moderate adverse events were reported in both groups. Mechanical hyperalgesia at the manipulated segment was reduced after SMT compared with the control intervention (P < .05). Pain catastrophizing was reduced after SMT compared with the control intervention (P < .05), but this effect was not significant after accounting for changes in clinical pain. Although the reduction of segmental mechanical hyperalgesia likely contributes to the clinical benefits of SMT, the role of pain catastrophizing remains to be clarified. PERSPECTIVE: This randomized controlled trial found that 12 sessions of SMT yield greater relief of CPLBP than a control intervention. These clinical effects were independent of expectations, and accompanied by an attenuation of hyperalgesia in the targeted segment and a modulation of pain catastrophizing.

Responsiveness and minimal important change of specific and generic patient-reported outcome measures for back patients: the Norwegian Neck and Back Register

PURPOSE

To evaluate responsiveness and minimal important change (MIC) of Oswestry Disability Index (ODI), pain during activity on a numeric rating scale (NRSa) and health related quality of life (EQ-5D) based on data from the Norwegian neck and back registry (NNRR).

METHODS

A total of 1617 patients who responded to NNRR follow-up after both 6 and 12 months were included in this study. Responsiveness was calculated using standardized response mean and area under the receiver operating characteristic (ROC) curve. We calculated MIC with both an anchor-based and distribution-based method.

RESULTS

The condition specific ODI had best responsiveness, the more generic NRSa and EQ-5D had lower responsiveness. We found that the MIC for ODI varied from 3.0 to 9.5, from 0.4 to 2.5 for NRSa while the EQ5D varied from 0.05 to 0.12 depending on the method for calculation.

CONCLUSION

In a register based back pain population, the condition specific ODI was more responsive to change than the more generic tools NRSa and EQ5D. The variations in responsiveness and MIC estimates also indicate that they should be regarded as indicative, rather than fixed estimates.

Implementation of back to living well, a community-based program for the tertiary prevention of low back pain: a study protocol

BACKGROUND

The current literature supports the effectiveness of exercise, education, and self-management interventions for the long-term management of persistent low back pain. However, there is significant uncertainty about the implementation of interventions related to barriers, facilitators, and patient's preferences. This study will evaluate the Back to Living Well program implementation from a participant and organizational perspective. More specifically we address the following objectives: 1) identify program barriers and facilitators from participants' perspectives, 2) identify factors related to program, personal and contextual factors that contribute to negative and positive outcomes, and outcome trajectories, 3) identify factors influencing participants' selection of an in-person or e-health program, and 4) evaluate program specific barriers and facilitators from the organization and care delivery perspectives.

METHODS

This study will utilize a mixed-method convergent design including a longitudinal cohort strand and a longitudinal qualitative interview strand. The RE-AIM framework will be used to assess program implementation. Participants (n = 90, 1:1: in person or virtual) who choose to register in the program as well as staff (n = 10 to 15) involved in the delivery of the program will be invited to participate. Participants will participate in a 12-week physical activity, education, and self-management program. Implementation outcomes will be measured at 3-, 6-, 12-months, and six months after the end of the follow-ups. Interview scripts and directed content analysis will be constructed based on the Theoretical Domains Framework and the Neuromatrix Model of Pain, Theoretical Domains Framework. Staff interviews will be constructed and analyzed using the Consolidated Framework for Implementation Research. Participants will also complete pain, disability, quality of life and psychological questionnaires, wear an activity tracker at all time points, and complete weekly pain and activity limitation questions using a mobile application.

DISCUSSION

The study results will provide evidence to inform potential future implementation of the program. An effective, appropriately targeted, and well implemented exercise program for the long-term management (i.e., tertiary prevention) of LBP could minimize the burden of the condition on patients, the health care system and society.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05929846. This (Registration Date: July 3 2023) study has been approved by the Hamilton Integrated Research Ethics Board Project ID#15,354.

Effectiveness and cost-effectiveness of radiofrequency denervation versus placebo for chronic and moderate to severe low back pain: study protocol for the RADICAL randomised controlled trial

INTRODUCTION

Low back pain (LBP) is the leading global cause of disability. Patients with moderate to severe LBP who respond positively to a diagnostic medial nerve branch block can be offered radiofrequency denervation (RFD). However, high-quality evidence on the effectiveness of RFD is lacking.

METHODS AND ANALYSIS

RADICAL (RADIofrequenCy denervAtion for Low back pain) is a double-blind, parallel-group, superiority randomised controlled trial. A total of 250 adults listed for RFD will be recruited from approximately 20 National Health Service (NHS) pain and spinal clinics. Recruitment processes will be optimised through qualitative research during a 12-month internal pilot phase. Participants will be randomised in theatre using a 1:1 allocation ratio to RFD or placebo. RFD technique will follow best practice guidelines developed for the trial. Placebo RFD will follow the same protocol, but the electrode tip temperature will not be raised. Participants who do not experience a clinically meaningful improvement in pain 3 months after randomisation will be offered the alternative intervention to the one provided at the outset without disclosing the original allocation. The primary clinical outcome will be pain severity, measured using a pain Numeric Rating Scale, at 3 months after randomisation. Secondary outcomes will be assessed up to 2 years after randomisation and include disability, health-related quality of life, psychological distress, time to pain recovery, satisfaction, adverse events, work outcomes and healthcare utilisation. The primary statistical analyses will be by intention to treat and will follow a prespecified analysis plan. The primary economic evaluation will take an NHS and social services perspective and estimate the discounted cost per quality-adjusted life-year and incremental net benefit of RFD over the 2-year follow-up period.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the London-Fulham Research Ethics Committee (21/LO/0471). Results will be disseminated in open-access publications and plain language summaries.

TRIAL REGISTRATION NUMBER

ISRCTN16473239.

Measurement Properties of Two Questionnaires Assessing Fear-Avoidance in Patients With Chronic Low Back Pain

The Fear-Avoidance Components Scale (FACS) and the Fear of Daily Activities Questionnaire (FDAQ) assess fear-avoidance model components. However, the questionnaires are not available in Brazilian Portuguese. This study aimed to translate the original English FACS and FDAQ into Brazilian (Br) Portuguese and assess their measurement properties in patients with Chronic Low Back Pain (CLBP). One hundred thirty volunteers with CLBP participated in this study. Structural validity, internal consistency, test-retest reliability, and hypothesis testing for construct validity were analyzed. Results indicated a 2-factor solution for the FACS-Br, while the FDAQ-Br had a one-factor solution. Internal consistency showed acceptable Cronbach's alpha (alpha >.8). Suitable reliability was found for the FDAQ-Br (Intraclass Correlation Coefficient [ICC] = .98). For both FACS-Br factors, suitable reliability was found as well (ICC = .95 and .94). Hypothesis testing for construct validity confirmed more than 75% of the hypotheses proposed a priori for the FACS maladaptive pain/movement-related beliefs domain and the FDAQ-Br. In conclusion, the FACS-Br and FDAQ-Br demonstrated acceptable reliability, internal consistency, and structural validity measurement properties and their correlation (r < .50) suggests that the tools are not interchangeable measures.

Prediction of Back Disability Using Clinical, Functional, and Biomechanical Variables in Adults with Chronic Nonspecific Low Back Pain

Background: Researchers are focusing on understanding the etiology and predisposing factors of chronic nonspecific low back pain (CNSLBP), a costly prevalent and disabling disorder. Related clinical, functional, and biomechanical variables are often studied, but in isolation. We aimed to identify key factors for managing CNSLBP by examining the relationship between back disability and related clinical, functional, and biomechanical variables and developed prediction models to estimate disability using various variables. Methods: We performed a cross-sectional correlational study on 100 recruited patients with CNSLBP. Clinical variables of pain intensity (visual analog score), back extensor endurance (Sorenson test), functional variables of the back performance scale, 6 min walk test, and the biomechanical variable C7-S1 sagittal vertical axis were analyzed to predict disability (Oswestry disability index). Results: All variables independently, as well as in multi-correlation, were significantly correlated to disability (p < 0.05). The bivariate regression models were significant between back disability and pain intensity (Y = 11.24 + 2.189x), Sorensen results (Y = 105.48 - 0.911x), the back performance scale (Y = 6.65 + 2.486x), 6 min walk test (Y = 49.20 - 0.060x), and sagittal vertical axis (Y = 0.72 + 4.23x). The multi-regression model showed significant contributions from pain (p = 0.001) and Sorensen results (p = 0.028) in predicting back disability, whereas no significant effect was found for other variables. Conclusions: A multidisciplinary approach is essential not only for the management of but also for the assessment of chronic nonspecific low back pain, including its clinical, functional, and biomechanical characteristics. However, special emphasis should be placed on clinical characteristics, including the intensity of pain and back extensor endurance.

Evaluating the efficacy of wearable biofeedback on the outcomes of exercise interventions in people with chronic non-specific spinal pain: protocol for a systematic review and meta-analysis

INTRODUCTION

Wearable neuromuscular and biomechanical biofeedback technology has the potential to improve patient outcomes by facilitating exercise interventions. We will conduct a systematic review to examine whether the addition of wearable biofeedback to exercise interventions improves pain, disability and quality of life beyond exercise alone for adults with chronic non-specific spinal pain. Specific effects on clinical, physiological, psychological, exercise adherence and safety outcomes will also be examined.

METHODS AND ANALYSIS

A systematic search will be conducted from inception to February 2024. Full articles in the English language will be included. MEDLINE, PubMed, CINAHL, EMBASE, Web of Science, PsycINFO, AMED, SPORTDiscus, CENTRAL databases, clinical trial registries and ProQuest (PQDT) will be used to search for eligible studies. Grey literature and conference proceedings (2022-2024) will be searched for relevant reports. Randomised controlled trials using wearable neuromuscular or kinematic biofeedback devices as an adjunct to exercise interventions for the treatment of chronic spinal pain will be included in this systematic review. The comparators will be wearable biofeedback with exercise versus exercise alone, or wearable biofeedback with exercise versus placebo and exercise. Risk of bias will be assessed using Cochrane Back Review Group criteria and the quality of evidence using Grading of Recommendations Assessment, Development and Evaluation recommendations.

ETHICS AND DISSEMINATION

The systematic review will be based on published studies, and therefore, does not require ethical approval. The study results will be submitted for publication in an international, open-access, peer-reviewed journal and shared through conferences and public engagement.

PROSPERO REGISTRATION NUMBER

CRD42023481393.

Pain neuroscience education improves post-traumatic stress disorder, disability, and pain self-efficacy in veterans and service members with chronic low back pain: Preliminary results from a randomized controlled trial with 12-month follow-up

Post-traumatic stress disorder (PTSD) and chronic low back pain (CLBP) are frequently co-morbid. Some research suggests that PTSD and CLBP may share common neurobiological mechanisms related to stress. Traditional biomedical education may be ineffective for PTSD and CLBP, especially when co-morbid. The purpose of this study is to determine if pain neuroscience education (PNE) is more effective than traditional education in reducing PTSD, disability, pain, and maladaptive beliefs in patients with CLBP. Participants with CLBP and possible PTSD/PTSD-symptoms were recruited for this study. Participants were randomly allocated to a PNE group or a traditional education group. The intervention included 30 minutes of education followed by a standardized exercise program once a week for 4-weeks with a 4 and 8-week follow-up and healthcare utilization assessed at 12-months. Forty-eight participants consented for this research study with 39 allocated to treatment (PNE n = 18, traditional n = 21). PNE participants were more likely to achieve a clinically meaningful reduction in PTSD symptoms and disability at short-term follow-up. At 12-months, the PNE group utilized healthcare with 76% lower costs. In participants with CLBP, PNE may reduce hypervigilance toward pain and improve PTSD symptoms. Participants who received PNE were more confident body-tissues were safe to exercise. These beliefs about pain could contribute to a decrease in perceived disability and healthcare consumption for CLBP.

Effectiveness of Ultrasonography- and Fluoroscopy-Guided Caudal Epidural Injections in the Management of Chronic Lumbar Disc Disease: A Retrospective Comparative Study

INTRODUCTION

Lumbar disc disease is one of the common causes of lower back pain caused by a change in the structure of the normal disc. Most of the time, disc disease happens as a result of aging and the normal breakdown that occurs within the disc. Caudal epidural steroid injections are the popular treatment for patients with chronic low back pain that does not respond to conservative management.

METHOD

A retrospective survey was administered to 160 patients who had received caudal epidural injections for chronic low back pain in the past, but only 74 patients who completed the scheduled follow-ups were included in the study. They were divided into two groups based on the imaging modality used for guiding the caudal epidural steroid injections, either ultrasonography or fluoroscopy, and then assessed for improvement in pain on the Numeric Rating Scale (NRS), for functional improvement on the Oswestry Disability Index (ODI), and for satisfaction on the North American Spine Society Patient Satisfaction Scale (SSPSS).

RESULTS

Mean NRS pain scores improved significantly from baseline at 6.78 and 7.00 in the fluoroscopy and ultrasound groups, respectively, to 2.03 and 2.16 at 12 weeks post-procedure. The difference between the groups was not statistically significant (p > 0.05). The Oswestry Disability Index was completed at baseline and after 12 weeks of follow-up for both groups, and there was no significant difference between the two groups; the fluoroscopy group's mean Oswestry Disability Index scores were 52.4 at baseline and 35.6 at 12 weeks, whereas the scores for the ultrasound group were 50.3 at baseline and 37.9 at 12 weeks. Conversely, patient satisfaction as assessed using the SSPSS rose in both groups up to 12 weeks (p > 0.05).

CONCLUSION

The ultrasound- and fluoroscopy-guided caudal epidural steroid injections proved equally effective in easing the pain, disability, and satisfaction levels of patients with chronic lower back pain.

Effects of a mat Pilates-based exercise program for low back pain in helicopter pilots of the Brazilian Air Force: Randomized controlled trial

INTRODUCTION

Helicopter pilots may present chronic low back pain due to vibration exposure and asymmetric posture during flight.

OBJECTIVES

To analyze the effects of a Pilates-based exercise program on low back pain of helicopter pilots of the Brazilian Air Force.

METHODS

This is a randomized controlled trial with fifteen helicopter pilots of the Brazilian Air Force, who were assessed for pain intensity (Numerical Pain Rating Scale), disability associated with low back pain, and spine muscle endurance in three positions: trunk extension (Ito test) and left and right lateral bridge. Individuals were randomly distributed into the regular exercises group (REG) (n = 7), oriented to maintain their exercise routine, and Pilates group (PG) (n = 8), which performed an exercise program based on Pilates method twice a week for 12 weeks. Reassessments occurred after 6 and 12 weeks. Data were analyzed on SPSS 20.0 software using a significance level of 5%.

RESULTS

PG showed a significant reduction in low back pain after 12 weeks of training compared with REG (mean difference of 3.5 points, p < 0.0001). We also observed increased endurance of trunk extensors (p = 0.002) and right (p = 0.001) and left lateral muscles (p = 0.001) in the PG compared with REG. However, the indexes of disability did not change between groups.

CONCLUSION

Pain intensity was significantly reduced while spine muscle endurance increased in PG compared with REG after intervention; thus, Pilates-based exercises should be considered in physical conditioning programs for helicopter pilots.

Gait analysis of individuals with specific low back pain undergoing surgery: case series report with one and six-month follow-up

INTRODUCTION

In addition to pain, specific low back pain is frequently accompanied by restricted range of motion (ROM) during gait.

PURPOSE

To compare the behavior of kinematic and spatiotemporal gait parameters, pain, functional status, and self-efficacy, in patients with a diagnosis of herniated disk or lumbar stenosis undergoing surgery, in the pre- and postoperative periods of 1 and 6 months (PO6).

METHODS

Seven participants and 11 control subjects were assessed. A kinematics system comprising 10 optoelectronic cameras was used to assess gait. The Roland-Morris questionnaire, pain intensity, and self-efficacy, over three periods, were used.

RESULTS

The ROM of the pelvis, hip, and knee of the hernia group presented an increase after surgery and the stenosis group presented a reduction of values in the hip. During the stance phase, the pelvis and hip ROM of both groups remained smaller than the control group. There was improvement in pain in individuals with hernia and stenosis (effect size = 0.6 and 0.8, respectively) in the three analyzed moments; for functional status there was improvement in the first postoperative period (ES = 0.4) compared to the preoperative in those individuals with hernia; and those with stenosis had improvement at PO6 when compared to the time before the surgery (ES = 0.2).

CONCLUSION

Surgical intervention modifies the spatiotemporal parameters, the ROM of the pelvis, hip, and knee in the total gait cycle, primarily in the sagittal plane, and causes alterations, particularly in the hip joint, in these individuals during the support phase.

Five-Year Longitudinal Follow-Up of Restorative Neurostimulation Shows Durability of Effectiveness in Patients With Refractory Chronic Low Back Pain Associated With Multifidus Muscle Dysfunction

BACKGROUND

Adults with refractory, mechanical chronic low back pain associated with impaired neuromuscular control of the lumbar multifidus muscle have few treatment options that provide long-term clinical benefit. This study hypothesized that restorative neurostimulation, a rehabilitative treatment that activates the lumbar multifidus muscles to overcome underlying dysfunction, is safe and provides relevant and durable clinical benefit to patients with this specific etiology.

MATERIALS AND METHODS

In this prospective five-year longitudinal follow-up of the ReActiv8-B pivotal trial, participants (N = 204) had activity-limiting, moderate-to-severe, refractory, mechanical chronic low back pain, a positive prone instability test result indicating impaired multifidus muscle control, and no indications for spine surgery. Low back pain intensity (10-cm visual analog scale [VAS]), disability (Oswestry Disability Index), and quality of life (EuroQol's "EQ-5D-5L" index) were compared with baseline and following the intent-to-treat principle, with a supporting mixed-effects model for repeated measures that accounted for missing data.

RESULTS

At five years (n = 126), low back pain VAS had improved from 7.3 to 2.4 cm (-4.9; 95% CI, -5.3 to -4.5 cm; p < 0.0001), and 71.8% of participants had a reduction of ≥50%. The Oswestry Disability Index improved from 39.1 to 16.5 (-22.7; 95% CI, -25.4 to -20.8; p < 0.0001), and 61.1% of participants had reduction of ≥20 points. The EQ-5D-5L index improved from 0.585 to 0.807 (0.231; 95% CI, 0.195-0.267; p < 0.0001). Although the mixed-effects model attenuated completed-case results, conclusions and statistical significance were maintained. Of 52 subjects who were on opioids at baseline and had a five-year visit, 46% discontinued, and 23% decreased intake. The safety profile compared favorably with neurostimulator treatments for other types of back pain. No lead migrations were observed.

CONCLUSION

Over a five-year period, restorative neurostimulation provided clinically substantial and durable benefits with a favorable safety profile in patients with refractory chronic low back pain associated with multifidus muscle dysfunction.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT02577354; registration date: October 15, 2016; principal investigator: Christopher Gilligan, MD, Brigham and Women's Hospital, Boston, MA, USA. The study was conducted in Australia (Broadmeadow, New South Wales; Noosa Heads, Queensland; Welland, South Australia; Clayton, Victoria), Belgium (Sint-Niklaas; Wilrijk), The Netherlands (Rotterdam), UK (Leeds, London, Middlesbrough), and USA (La Jolla, CA; Santa Monica, CA; Aurora, CO; Carmel, IN; Indianapolis, IN; Kansas City, KS; Boston, MA; Royal Oak, MI; Durham, NC; Winston-Salem, NC; Cleveland, OH; Providence, RI; Spartanburg, SC; Spokane, WA; Charleston, WV).

Prognostic factors for long-term improvement in pain and disability among patients with persistent low back pain

BACKGROUND

Prognostic research in low back pain (LBP) is essential for understanding and managing the condition. This study aimed to, (1) describe the proportions with mild-moderate and severe pain and disability at baseline, 1-year and 4-year follow-up, and (2) investigate prognostic factors for improvement in pain and disability over 4 years in a cohort of secondary care LBP patients.

METHODS

This was a secondary analysis of a cohort of patients with LBP aged 18-40 years recruited from a non-surgical outpatient spine clinic between March 2011 and October 2013 (n = 1037). Questionnaires were collected at baseline, 1-year, and 4-year follow-up. Disability was assessed using the Roland Morris Disability Questionnaire (RMDQ 0-100) and pain intensity using the Numeric Rating Scale (NRS 0-10). 'Mild-moderate pain' was defined as NRS < 7 and 'severe pain' as NRS ≥ 7. Likewise, 'mild-moderate disability' was defined as RMDQ < 58.3, and 'severe disability' was RMDQ ≥ 58.3. In the prognostic analysis, improvement in pain and disability over 4 years was defined as meeting both criteria: decrease of ≥ 2 on the NRS and of ≥ 20.8 on the RMDQ. Sixteen candidate prognostic factors were assessed by multivariate logistic regression.

RESULTS

Among patients with information available at all three time points (n = 241), 54%/48% had persistent mild-moderate pain/disability, while only 7%/15% had persistent severe pain/disability. Of patients included in the multivariate prognostic analysis regarding improvement over 4 years (n = 498), 32% had improved in pain and disability after 4 years. Positive associations were found for pain intensity (OR 1.34 [95%CI: 1.17-1.54]), disability (OR 1.01 [1.00-1.02]), and regular employment or studying (OR 1.67 [1.06-2.64]), and negative associations for episode duration (OR 0.99 [0.99-1.00]) and risk of persistent pain (OR 0.58 [0.38-0.88]).

CONCLUSION

Patients with persistent LBP in secondary care had mostly mild-moderate pain and disability consistently at all three time points, with few having consistently severe symptoms over 4 years. Moreover, approximately half of the included patients improved in pain and disability. We found that pain intensity, disability, episode duration, regular employment or studying, and risk of persistent pain predicted a long-term improvement. However, the limited availability of complete follow-up data may affect generalisability.

The effect of EMS, IFC, and TENS on patient-reported outcome measures for chronic low back pain: a systematic review and meta-analysis

Introduction

Chronic low back pain (CLBP) is the leading cause of years lived with disability worldwide. Transcutaneous electrotherapies have been widely used to treat CLBP but, with the partial exception of transcutaneous electrical nerve stimulation (TENS), their effect on pain, disability, quality-of-life, and psychosocial outcomes have not been systematically reviewed. The purpose of this systematic review and meta-analysis was to clarify the overall effect of transcutaneous electrotherapies on patient-reported outcome measures (PROMs) in CLBP patients.

Methods

Four databases and two study registries were searched for studies that utilized transcutaneous electrotherapies as a primary intervention for CLBP, compared against active or passive controls. Two reviewers independently extracted study data and assessed risk of bias. Studies were grouped by intervention vs. comparison, and by time of follow-up. Meta-analyses were conducted where appropriate.

Results

A total of 89 full-text were assessed for eligibility; 14 studies were included, with 6 in the meta-analyses (all TENS or mixed TENS). Pain: meta-analyses revealed no significant difference for TENS vs. active control, TENS vs. passive control, or mixed TENS vs. active control at post-intervention, nor for mixed TENS vs. active control at 1-month post-intervention. Interferential current (IFC) was more effective than active control (2 studies), while electromyostimulation (EMS) was generally superior to passive, but not active, controls (6 studies).

Disability

Meta-analyses revealed no significant difference for TENS vs. active control at post-intervention, mixed TENS vs. active control at post-intervention, or mixed TENS vs. active control at 1-month post-intervention. IFC was more effective than active control (2 studies), while the EMS results were mixed (6 studies). We were unable to perform meta-analyses for quality-of-life or psychosocial outcomes.

Conclusion

There is moderate evidence that TENS is similar to all controls for improving pain and disability. There is limited evidence that IFC is superior to active controls for improving pain and disability. There is limited evidence that EMS is superior to passive but not active controls for improving pain, and similar to all controls for improving disability.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=452851, Identifier (CRD42023452851).

Effects of monopolar pulsed-capacitive dielectric radiofrequency diathermy in patients with chronic low back pain: a randomised clinical trial

Monopolar capacitive diathermy is a physiotherapy technique that uses high-frequency currents to generate heat in deep tissues. This heat can have several therapeutic effects, especially in the treatment of chronic low back pain (CLBP), however, until now there is little evidence of this type of diathermy. The purpose was to evaluate the efficacy of a pulsed monopolar dielectric radiofrequency diathermy (PRF)-capacitive type versus simulated treatment on symptomatology of patients with CLBP. A single-blind randomised controlled trial was conducted. Sixty patients with CLBP were randomly assigned to a PRF-capacitive or a simulated treatment group. All participants received 3 sessions per week for 3 weeks. Disability, pain intensity, movement phobia, lumbar anteflexion, quality of life, and sleep quality were assessed at baseline, after treatment, and at two months. The application of 9 sessions of PRF-capacitive showed significant improvements compared to simulated therapy during the entire follow-up for disability (F = 26.99, p < 0.001), pain intensity (F = 0.550, p < 0.001), the quality of life components of physical function (F = 0.780, p < 0.001), social function (F = 0.780, p < 0.001) and mental health (F = 0.858, p = 0.003) and for sleep duration (F = 0.863, p = 0.004).

Lumbar Decompression With and Without Fusion for Lumbar Stenosis With Spondylolisthesis: A Cost Utility Analysis

STUDY DESIGN

Markov model.

OBJECTIVE

To compare the cost-effectiveness of lumbar decompression alone (DA) with lumbar decompression with fusion (DF) for the management of adults undergoing surgery for lumbar stenosis with associated degenerative spondylolisthesis.

SUMMARY OF BACKGROUND DATA

Rates of lumbar fusion have increased for all indications in the United States over the last 20 years. Recent randomized controlled trial data, however, have suggested comparable functional outcomes and lower reoperation rates for lumbar decompression and fusion as compared with DA in the treatment of lumbar stenosis with degenerative spondylolisthesis.

MATERIALS AND METHODS

A multistate Markov model was constructed from the US payer perspective of a hypothetical cohort of patients with lumbar stenosis with associated spondylolisthesis requiring surgery. Data regarding clinical improvement, costs, and reoperation were generated from contemporary randomized trial evidence, meta-analyses of recent prospective studies, and large retrospective cohorts. Base case, one-way sensitivity analysis, and probabilistic sensitivity analyses were conducted, and the results were compared with a WTP threshold of $100,000 (in 2022 USD) over a two-year time horizon. A discount rate of 3% was utilized.

RESULTS

The incremental cost and utility of DF relative to DA were $12,778 and 0.00529 aggregated quality adjusted life years. The corresponding incremental cost-effectiveness ratio of $2,416,281 far exceeded the willingness to pay threshold of $100,000. In sensitivity analysis, the results varied the most with respect to rate of improvement after DA, rate of improvement after lumbar decompression and fusion, and odds ratio of reoperation between the two groups. Zero percent of one-way and probabilistic sensitivity analyses achieved cost-effectiveness at the willingness-to-pay threshold.

CONCLUSIONS

Within the context of contemporary surgical data, DF is not cost-effective compared with DA in the surgical management of lumbar stenosis with associated spondylolisthesis over a two-year time horizon.