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

Investigating the hypoalgesic effects of spinal manipulative therapy using hidden pain conditioning and positive expectation in patients with chronic low back pain: protocol for a randomised controlled trial

INTRODUCTION

Placebo effects are responses capable of modulating pain and influencing treatment response. Two mechanisms are commonly related to placebo effects: expectations and conditioning. However, the research in this field is focused on laboratory studies with healthy participants. This study aims to identify whether a conditioning procedure with positive induced expectations about spinal manipulative therapy (SMT) will result in greater hypoalgesic effects in adults with chronic low back pain (CLBP) in a clinical trial design.

METHODS AND ANALYSIS

This trial will enrol 264 patients with non-specific CLBP, aged 18-60 years. Patients will undergo a calibration test to determine the thermal pain threshold for the hidden pain conditioning procedure. Afterward, they will be randomised to one of the three groups: hidden pain conditioning with positive induced expectations-group one (G1); positive expectations-group two (G2) and neutral expectations-group three (G3). Patients will receive instructions to manipulate the expectations. The pretreatment heat pain test will be performed before the SMT and after the intervention patients will undergo again the heat pain intensity test. However, only patients in G1 will receive hidden pain conditioning to reinforce the association between SMT and pain intensity reduction. All patients will undergo five sessions of SMT. The outcomes will be assessed immediately after the last session and at the 6 weeks and 3-month follow-ups. All statistical analyses will be conducted following intention-to-treat principles, and the treatment effects will be determined with linear mixed models.

ETHICS AND DISSEMINATION

The Federal University of São Carlos approved this research (Process n° 52359521.1.0000.5504). All participants will give written informed consent. Dissemination of the results will include publications in peer-reviewed journals and presentations at conferences. If positive expectations and classical conditioning improve outcomes, it may support the administration of such intervention.

TRIAL REGISTRATION NUMBER

NCT05202704.

Is discectomy effective for treating low back pain in patients with lumbar disc herniation and Modic changes? A systematic review and meta-analysis of cohort studies

BACKGROUND CONTEXT

Previous low-quality evidence has suggested preoperative Modic changes (MC) showed a trend toward less improvement in low back pain in patients with lumbar disc herniation (LDH) undergoing discectomy. However, a recent meta-analysis concluded that the presence of preoperative MC did not significantly impact clinical outcomes following lumbar discectomy.

PURPOSE

To compare low back pain and functional outcomes of patients after discectomy for LDH with preoperative MC.

STUDY DESIGN

Systematic review and meta-analysis of cohort studies.

METHODS

This comprehensive systematic review and meta-analysis used English-language articles identified through searches using Pubmed, Web of Science, Embase, and Cochrane library until August 2022. The included studies identified publications that concentrated on the patients suffering from LDH with different preoperative MCs treated by discectomy. The Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were the two main metrics to evaluate outcomes.

RESULTS

A series of 2,299 LDH patients with a definitive type of MC were included in four retrospective and five prospective studies. Overall, there is moderate to high quality evidence suggesting no significant difference between normal and MC groups for pain outcomes as well as normal and Modic type 2 groups in terms of pain or functional outcomes at one or two-year follow up. There are less functional outcomes in LDH patients with preoperative MC compared with no MC at 2-year follow up and showed no significant difference at 1-year follow-up. However, above all results may due to heterogeneity. Subgroup analysis revealed that only Modic type 1 showed statistically lower functional scores (mean difference in ODI scores range from 0 to 100) compared with Modic type 2 or compared with no MC at 2-year follow-up and showed no significant difference at 1-year follow-up (MC1 vs. MC0, p=.24, MD= -2.70; 95% CI, -7.15 to 1.76 for 1-year;p<.00001, MD= -7.92; 95% CI, -11.19 to -4.66 for 2 years. MC1 vs. MC2, p=.58, MD= -1.29; 95% CI, -5.83 to 3.25 for 1-year;p<.0001, MD= -6.77; 95% CI, -9.94 to -3.61 for 2 years).

CONCLUSIONS

These data suggest LDH patients with or without preoperative MCs show a similar improvement of low back pain at 1 and 2-year follow-up and functional scores after discectomy at one-year follow-up. LDH patients with preoperative Modic type 1 are associated with worse functional status after discectomy at 2-year follow-up. However, high-quality randomized controlled trials and prospective cohort studies which focus on analyzing the risk and confounding factors are lacking.

The one-year clinical course of back-related disability and the prognostic value of comorbidity among older adults with back pain in primary care

ABSTRACT

Back pain and comorbidity are common in older adults. Comorbidity is a promising prognostic factor for the clinical course of back-related disability, but confirmatory studies assessing its prognostic value are needed. Thus, the aims of this study were to describe the clinical course of back-related disability during 1-year follow-up in patients aged ≥55 years visiting primary care (general practitioner, physiotherapist, or chiropractor) with a new episode of back pain and assess the prognostic value of comorbidity on back-related disability during 1-year follow-up. A prospective cohort study was conducted, including 452 patients. The outcome measure was Roland-Morris Disability Questionnaire (RMDQ, range 0-24) measured at baseline and at 3-, 6-, and 12-month follow-up. The Self-Administered Comorbidity Questionnaire was used to assess comorbidity count (CC, range 0-15) and comorbidity burden (CB, range 0-45). The RMDQ scores improved from median (interquartile range) 9 (4-13) at baseline to 4 (1-9), 4 (0-9), and 3 (0-9) at 3, 6, and 12 months, respectively. Using linear mixed-effects models, we found that CC and CB were independently associated with RMDQ scores. A 1-point increase in CC was associated with an increase in RMDQ score of 0.76 points (95% confidence interval [0.48-1.04]) over the follow-up year, adjusted for known prognostic factors. A 1-point increase in CB was associated with an increased RMDQ score of 0.47 points (95% confidence interval [0.33-0.61]). In conclusion, the clinical course of back-related disability for older adults presenting in primary care was favorable, and increased comorbidity was an independent prognostic factor for increased disability levels.

Health-Related Quality of Life of Patients With Adolescent Idiopathic Scoliosis at Least 40 Years After Surgery

STUDY DESIGN

Retrospective study.

OBJECTIVE

The aim was to clarify the health-related quality of life (QOL) of patients who had adolescent idiopathic scoliosis (AIS) at a minimum of 40 years after surgery.

SUMMARY OF BACKGROUND DATA

The postoperative health-related QOL of middle-aged patients with AIS has been reported to be good, but that of middle-aged and older patients with AIS has yet to be completely explored.

MATERIALS AND METHODS

We included 179 patients with AIS who underwent spinal fusion(s) between 1968 and 1982. We conducted three surveys in 2009, 2014, and 2022. Patients self-administered both the Scoliosis Research Society-22 and the Roland-Morris Disability questionnaires three times (in 2009, 2014, and 2022) and the Oswestry Disability Index (ODI) questionnaire was self-administered in 2014 and 2022. We considered patients who responded to all three surveys in 2009, 2014, and 2022.

RESULTS

For the Scoliosis Research Society-22 questionnaires, no significant differences were detected among the three time points (2009, 2014, and 2022) for total scores, function domain, pain domain, self-image domain, mental domain, or satisfaction domain. The results of the Roland-Morris Disability Questionnaire were also not significantly different among the surveys over time. The ODI questionnaires revealed a significant worsening of the 2022 results compared with the 2014 results. Eight patients (29.6%) who had an ODI deterioration of 10% or more had numerically fewer mobile lumbar disks than those with <10% deterioration of the ODI, although the difference did not reach statistical significance.

CONCLUSION

Among patients with AIS who underwent spinal fusion(s) between 1968 and 1982, we found health-related QOL to be maintained over the last 13 years. Relatively good QOL was appreciated in this population of patients who are now middle-aged and older.

Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: systematic review and network meta-analysis

OBJECTIVE

To evaluate the comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, PubMed, Embase, CINAHL, CENTRAL, ClinicalTrials.gov, clinicialtrialsregister.eu, and World Health Organization's International Clinical Trials Registry Platform from database inception to 20 February 2022.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised controlled trials of analgesic medicines (eg, non-steroidal anti-inflammatory drugs, paracetamol, opioids, anti-convulsant drugs, skeletal muscle relaxants, or corticosteroids) compared with another analgesic medicine, placebo, or no treatment. Adults (≥18 years) who reported acute non-specific low back pain (for less than six weeks).

DATA EXTRACTION AND SYNTHESIS

Primary outcomes were low back pain intensity (0-100 scale) at end of treatment and safety (number of participants who reported any adverse event during treatment). Secondary outcomes were low back specific function, serious adverse events, and discontinuation from treatment. Two reviewers independently identified studies, extracted data, and assessed risk of bias. A random effects network meta-analysis was done and confidence was evaluated by the Confidence in Network Meta-Analysis method.

RESULTS

98 randomised controlled trials (15 134 participants, 49% women) included 69 different medicines or combinations. Low or very low confidence was noted in evidence for reduced pain intensity after treatment with tolperisone (mean difference -26.1 (95% confidence intervals -34.0 to -18.2)), aceclofenac plus tizanidine (-26.1 (-38.5 to -13.6)), pregabalin (-24.7 (-34.6 to -14.7)), and 14 other medicines compared with placebo. Low or very low confidence was noted for no difference between the effects of several of these medicines. Increased adverse events had moderate to very low confidence with tramadol (risk ratio 2.6 (95% confidence interval 1.5 to 4.5)), paracetamol plus sustained release tramadol (2.4 (1.5 to 3.8)), baclofen (2.3 (1.5 to 3.4)), and paracetamol plus tramadol (2.1 (1.3 to 3.4)) compared with placebo. These medicines could increase the risk of adverse events compared with other medicines with moderate to low confidence. Moderate to low confidence was also noted for secondary outcomes and secondary analysis of medicine classes.

CONCLUSIONS

The comparative effectiveness and safety of analgesic medicines for acute non-specific low back pain are uncertain. Until higher quality randomised controlled trials of head-to-head comparisons are published, clinicians and patients are recommended to take a cautious approach to manage acute non-specific low back pain with analgesic medicines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019145257.

Self-administered stretching exercises are as effective as motor control exercises for people with chronic non-specific low back pain: a randomised trial

QUESTION

In people with chronic non-specific low back pain, what is the effect of self-administered stretching exercises relative to motor control exercises on pain intensity, disability, fear avoidance, global perceived effect and flexibility?

DESIGN

Randomised trial with concealed allocation, intention-to-treat analysis and blinding of assessors.

PARTICIPANTS

One hundred people with chronic non-specific low back pain.

INTERVENTIONS

The self-stretching exercise group performed 6 stretches in 40-minute sessions. The motor control exercise group performed trunk stabilising exercises in 40-minute sessions. Both groups performed weekly supervised sessions for 8 weeks with one or more home sessions/week.

OUTCOME MEASURES

The primary outcomes were pain intensity (0 to 10 scale) and disability (Oswestry Disability Index). The secondary outcomes were the Fear Avoidance Beliefs Questionnaire, global perceived effect, and the fingertip-to-floor test. Measures were taken at baseline and at 8, 13 and 26 weeks.

RESULTS

On the 0 to 10 scale, the between-group difference in pain intensity was negligible, with a mean difference of roughly 0 (95% CI -1 to 1) at each time point. Similarly, the between-group difference on the 100-point disability scale was negligible: MD -1 (95% CI -3 to 1) at week 8, MD 1 (95% CI -1 to 3) at week 13 and MD 0 (95% CI -1 to 2) at week 26. The two interventions also had similar effects on the secondary outcomes.

CONCLUSION

In people with chronic non-specific low back pain, self-stretching exercises had very similar effects to motor control exercises on pain intensity, disability, fear avoidance, global perceived effect and flexibility up to 18 weeks beyond the end of an 8-week program. Given the established effectiveness of motor control exercises, either intervention could be recommended to people with chronic low back pain. The choice of intervention might be directed by patient preference.

REGISTRATION

NCT03128801.

Cost consequence analysis of waiting for lumbar disc herniation surgery

The economic repercussions of waiting for lumbar disc surgery have not been well studied. The primary goal of this study was to perform a cost-consequence analysis of patients receiving early vs late surgery for symptomatic disc herniation from a societal perspective. Secondarily, we compared patient factors and patient-reported outcomes. This is a retrospective analysis of prospectively collected data from the CSORN registry. A cost-consequence analysis was performed where direct and indirect costs were compared, and different outcomes were listed separately. Comparisons were made on an observational cohort of patients receiving surgery less than 60 days after consent (short wait) or 60 days or more after consent (long wait). This study included 493 patients with surgery between January 2015 and October 2021 with 272 patients (55.2%) in the short wait group and 221 patients (44.8%) classified as long wait. There was no difference in proportions of patients who returned to work at 3 and 12-months. Time from surgery to return to work was similar between both groups (34.0 vs 34.9 days, p = 0.804). Time from consent to return to work was longer in the longer wait group corresponding to an additional $11,753.10 mean indirect cost per patient. The short wait group showed increased healthcare usage at 3 months with more emergency department visits (52.6% vs 25.0%, p < 0.032), more physiotherapy (84.6% vs 72.0%, p < 0.001) and more MRI (65.2% vs 41.4%, p < 0.043). This corresponded to an additional direct cost of $518.21 per patient. Secondarily, the short wait group had higher baseline NRS leg, ODI, and lower EQ5D and PCS. The long wait group had more patients with symptoms over 2 years duration (57.6% vs 34.1%, p < 0.001). A higher proportion of patients reached MCID in terms of NRS leg pain at 3-month follow up in the short wait group (84.0% vs 75.9%, p < 0.040). This cost-consequence analysis of an observational cohort showed decreased costs associated with early surgery of $11,234.89 per patient when compared to late surgery for lumbar disc herniation. The early surgery group had more severe symptoms with higher healthcare utilization. This is counterbalanced by the additional productivity loss in the long wait group, which likely have a more chronic disease. From a societal economic perspective, early surgery seems beneficial and should be promoted.

Engagement and Utilization of a Complete Remote Digital Care Program for Musculoskeletal Pain Management in Urban and Rural Areas Across the United States: Longitudinal Cohort Study

BACKGROUND

Musculoskeletal (MSK) conditions are the number one cause of disability worldwide. Digital care programs (DCPs) for MSK pain management have arisen as alternative care delivery models to circumvent challenges in accessibility of conventional therapy. Despite the potential of DCPs to reduce inequities in accessing care, the outcomes of such interventions in rural and urban populations have yet to be studied.

OBJECTIVE

The aim of this study was to assess the impact of urban or rural residency on engagement and clinical outcomes after a multimodal DCP for MSK pain.

METHODS

This study consists of an ad hoc analysis of a decentralized single-arm investigation into engagement and clinical-related outcomes after a multimodal DCP in patients with MSK conditions. Patients were coded according to their zip codes to a specific rural-urban commuting area code and grouped into rural and urban cohorts. Changes in their engagement and clinical outcomes from baseline to program end were assessed. Latent growth curve analysis was performed to estimate change trajectories adjusting for the following covariates: age, gender, BMI, employment status, and pain acuity. Outcomes included engagement, self-reported pain, and the results of the Generalized Anxiety Disorder 7-item, Patient Health Questionnaire 9-item, and Work Productivity and Activity Impairment scales. A minimum clinically important difference (MCID) of 30% was considered for pain.

RESULTS

Patients with urban and rural residency across the United States participated in the program (n=9992). A 73.8% (7378/9992) completion rate was observed. Both groups reported high satisfaction scores and similar engagement with exercise sessions, with rural residents showing higher engagement with educational content (P<.001) and higher program completion rates (P=.02). All groups showed a significant improvement in all clinical outcomes, including pain, mental health, and work productivity, without statistically significant intergroup differences. The percentage of patients meeting the MCID was similar in both groups (urban: 67.1%, rural: 68.3%; P=.30).

CONCLUSIONS

This study advocates for the utility of a DCP in improving access to MSK care in urban and rural areas alike, showcasing its potential to promote health equity. High engagement, satisfaction, and completion rates were noted in both groups, as well as significant improvements in clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946.

Serum lipid biomarkers and inflammatory cytokines associated with onset and clinical status of patients with early knee osteoarthritis

Introduction

Osteoarthritis (OA) is a common joint condition and one of the greatest causes of disability worldwide. The role of serum lipid and inflammatory biomarkers in the origin and development of the disease is not clear, although it could have important implications for diagnosis and treatment. The primary aim of this study was to evaluate differences of serum lipid and inflammatory biomarkers with knee EOA in comparison with matched controls, in order to determine the role of these factors in the origin of EOA.

Methods

For this proposal, a cross-sectional study with a non-randomized sample was performed. 48 subjects with early osteoarthritis (EOA) and 48 matched controls were selected and serum lipid levels (total cholesterol, LDL, HDL) and inflammatory biomarkers C-reactive protein (CRP), uric acid (UA) were analyzed. In addition, clinical (pain, disability) and functional (gait speed, sit-to-stand) variables were measured to establish their relationship to serum lipid levels and inflammatory biomarkers.

Results

Patients with EOA showed higher levels of total cholesterol LDL, UA, and CRP. Higher levels of total cholesterol, LDL and CRP were correlated with higher levels of pain intensity and higher disability (p &lt; 0.05). In addition, UA and CRP were inversely correlated with gait speed and sit-to-stand tests (r = −0.038 to −0.5, p &lt; 0.05).

Conclusion

These results highlight the relevance of metabolic and proinflammatory aspects in the early stages of knee OA and could be key to developing early diagnoses to prevent the onset and development of the disease.

Factors associated with incomplete clinical improvement in patients undergoing transforaminal endoscopic lumbar discectomy for lumbar disc herniation

PURPOSES

To analyze the clinical and radiographic risk factors that might predict incomplete clinical improvement after transforaminal endoscopic lumbar discectomy (TELD).

METHODS

A retrospective analysis was conducted from 194 consecutive patients who underwent TELD due to lumbar disc herniation (LDH). Patients with incomplete clinical improvement were defined from patient-reported outcomes of poor improvement in pain or disability after surgery and patient dissatisfaction. Clinical and radiographic characteristics were evaluated to identify predicting factors of poor outcomes.

RESULTS

Of 194 patients who underwent TELD procedures, 32 patients (16.5%) had incomplete clinical improvement and 12 patients (6.1%) required revision surgery. The mean ages were 46.4 years and most of the patients suffered from predominant leg pain (48.9%). The most common surgical level was L4-5 (63.9%). Overall, the Oswestry Disability Index (44.3-15), visual analog scores of back pain (4.9-1.8) and leg pain (7.3-1.6) were significantly improved after surgery. Multivariate logistic regression analysis demonstrated that high body mass index, history of previous surgery, preoperative disability, weakness, and disc degeneration were related to incomplete clinical improvement. There were 15 recurrent LDH (7.7%) with a total of 12 revision surgeries (6.2%).

CONCLUSIONS

We identified independent risk factors associated with incomplete clinical improvement following TELD, including overweight, significant preoperative disability or weakness and history of previous surgery. Advanced age, disc degeneration, vacuum phenomenon, and spondylolisthesis were also possible risk factors. Recognizing these risk factors would help decide whether patients are good candidates for TELD, and optimize the surgical planning preoperatively to achieve good surgical results.

The effectiveness of hip interventions in patients with low-back pain: A systematic review and meta-analysis

BACKGROUND

Low-back pain (LBP) may be directly or indirectly related to impairments from the hip joint.

OBJECTIVE

To evaluate the effectiveness of hip interventions on pain and disability in patients with LBP in the short-, medium-, and long-term.

METHODS

PubMed, Cochrane Library, PEDro, Web of Science, and SCOPUS databases were searched in November 2022. Randomized controlled trials involving hip-targeted interventions compared to specific low back interventions in patients with LBP were selected. The outcomes were pain intensity and disability. The quality of the studies was assessed with the risk of bias tool. GRADE was used to rate the certainty of evidence. Meta-analyses were conducted using random effects models.

RESULTS

A total of 2581 studies were screened. Eight were included in the meta-analysis involving 508 patients with LBP. The results provided very low certainty that both hip strengthening and hip stretching improved pain (MD = -0.66; 95% CI -0.86, -0.48; I2:0%) (MD = -0.55; 95% CI -1.02, -0.08) and disability (SMD = -0.81; 95% CI -1.53, -0.10; I2: 80%) (SMD = -1.03; 95% CI -1.82, -0.25) in the short-term, respectively. No benefits were found in the medium- or long-term. The risk of bias, heterogeneity, and imprecision of the results downgraded the level of evidence.

CONCLUSIONS

Very low certainty evidence suggest a positive effect of hip strengthening in isolation or combined with specific low back exercise and hip stretching combined with specific low back exercise for decreasing pain intensity and disability in the short-term, in patients with LBP.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022303173.

The best structure of the Tampa Scale for Kinesiophobia for patients with chronic low back pain has two domains and nine items

PURPOSE

To identify the best internal structure of the Tampa Scale for Kinesiophobia in chronic low back pain patients.

DESIGN

Questionnaire validation study was designed for this study.

SETTING

This study was conducted in physical therapy facility.

SUBJECTS

Respondents reporting chronic low back pain (≥3 points on the 11-point Numerical Pain Rating Scale).

MAIN MEASURES

We included participants of both sexes, with a self-report of low back pain ≥3 months and with pain intensity ≥3 on the 11-point Numerical Pain Rating Scale; participants also answered the Roland-Morris Disability Questionnaire and the Pain-Related Catastrophizing Thoughts Scale for low back pain disability and catastrophizing, respectively. The dimensionality and number of items of the Tampa Scale for Kinesiophobia were evaluated using the confirmatory factor analysis. Criterion validity was assessed using Spearman's correlation coefficient using the original version of the 17-item Tampa Scale for Kinesiophobia as the gold standard.

RESULTS

A total of 122 participants were included, with mean values of low back pain duration ≥48 months, pain intensity >5 and disability >8. Tampa Scale for Kinesiophobia structure with two domains and nine items was the most suitable, with adequate values in all fit indices (Chi-square/degree of freedom <3, Comparative Fit Index and Tucker-Lewis Index >0.90, and root mean square error of approximation <0.08) and lower Akaike information criterion and Bayesian information criterion values. We observed a high correlation between the 17-item Tampa Scale for Kinesiophobia and the activity avoidance domain (rho = 0.850, P < 0.001) and somatic focus domain (rho = 0.792, P < 0.001) of the nine-item Tampa Scale for Kinesiophobia.

CONCLUSION

Tampa Scale for Kinesiophobia structure with two domains (activity avoidance and somatic focus) and nine items is the most suitable for patients with chronic low back pain.

Postmarketing Follow-Up of a Digital Home Exercise Program for Back, Hip, and Knee Pain: Retrospective Observational Study With a Time-Series and Matched-Pair Analysis

BACKGROUND

Musculoskeletal conditions are the main drivers of global disease burden and cause significant direct and indirect health care costs. Digital health applications improve the availability of and access to adequate care. The German health care system established a pathway for the approval of "Digitale Gesundheitsanwendungen" (DiGAs; Digital Health Applications) as collectively funded medical services through the "Digitale-Versorgung-Gesetz" (Digital Health Care Act) in 2019.

OBJECTIVE

This article presents real-world prescription data collected through the smartphone-based home exercise program "Vivira," a fully approved DiGA, regarding its effect on self-reported pain intensity and physical inability in patients with unspecific and degenerative pain in the back, hip, and knee.

METHODS

This study included 3629 patients (71.8% [2607/3629] female; mean age 47 years, SD 14.2 years). The primary outcome was the self-reported pain score, which was assessed with a verbal numerical rating scale. The secondary outcomes were self-reported function scores. To analyze the primary outcome, we used a 2-sided Skillings-Mack test. For function scores, a time analysis was not feasible; therefore, we calculated matched pairs using the Wilcoxon signed-rank test.

RESULTS

Our results showed significant reductions in self-reported pain intensity after 2, 4, 8, and 12 weeks in the Skillings-Mack test (T₃₆₂₈=5308; P<.001). The changes were within the range of a clinically relevant improvement. Function scores showed a generally positive yet more variable response across the pain areas (back, hip, and knee).

CONCLUSIONS

This study presents postmarketing observational data from one of the first DiGAs for unspecific and degenerative musculoskeletal pain. We noted significant improvements in self-reported pain intensity throughout the observation period of 12 weeks, which reached clinical relevance. Additionally, we identified a complex response pattern of the function scores assessed. Lastly, we highlighted the challenges of relevant attrition at follow-up and the potential opportunities for evaluating digital health applications. Although our findings do not have confirmatory power, they illustrate the potential benefits of digital health applications to improve the availability of and access to medical care.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00024051; https://drks.de/search/en/trial/DRKS00024051.

Effectiveness of patient education plus motor control exercise versus patient education alone versus motor control exercise alone for rural community-dwelling adults with chronic low back pain: a randomised clinical trial

BACKGROUND

Chronic low back pain (CLBP) is a common health problem in rural Nigeria but access to rehabilitation is limited. Current clinical guidelines unanimously recommend patient education (PE) including instruction on self-management, and exercises as frontline interventions for CLBP. However, the specific content of these interventions and how they are best delivered remain to be well-described, particularly for low-resource communities. This study determined the effectiveness of PE plus motor control exercise (MCE) compared with either therapy alone among rural community-dwelling adults with CLBP.

METHODS

A single-blind, three-arm parallel-group, randomised clinical trial including 120 adult rural dwellers (mean [SD] age, 46.0 [14.7] years) with CLBP assigned to PE plus MCE group (n = 40), PE group (n = 40), and MCE group (n = 40) was conducted. The PE was administered once weekly and the MCE twice weekly. Each group also received stretching and aerobic exercises twice weekly. All interventions were administered for 8 weeks. Blinded assessments for pain intensity and disability level as primary outcomes, and quality of life, global perceived recovery, fear-avoidance beliefs, pain catastrophising, back pain consequences belief and pain medication use as secondary outcomes were conducted at baseline, 8-week (immediately after intervention) and 20-week follow-ups.

RESULTS

All the groups showed significant improvements in all the primary and secondary outcomes evaluated over time. Compared with PE alone, the PE plus MCE showed a significantly greater reduction in pain intensity by an additional -1.15 (95% confidence interval [CI], -2.04 to -0.25) points at the 8-week follow-up and -1.25 (95% CI, -2.14 to -0.35) points at the 20-week follow-up. For disability level, both PE plus MCE and MCE alone showed a significantly greater improvement compared with PE alone by an additional -5.04% (95% CI, -9.57 to -0.52) and 5.68% (95% CI, 1.15 to 10.2) points, respectively, at the 8-week follow-up, and -5.96% (95% CI, -9.84 to -2.07) and 6.57% (95% CI, 2.69 to 10.4) points, respectively, at the 20-week follow-up. For the secondary outcomes, at the 8-week follow-up, PE plus MCE showed a significantly greater reduction in fear-avoidance beliefs about physical activity compared with either therapy alone, and a significantly greater reduction in pain medication use compared with PE alone. However, compared with PE plus MCE, PE alone showed a significantly greater reduction in pain catastrophising at all follow-up time points, and a significantly greater improvement in back pain consequences belief at the 20-week follow-up. Additionally, PE alone compared with MCE alone showed a significantly greater improvement in back pain consequences belief at all follow-up time points. No significant between-group difference was found for other secondary outcomes.

CONCLUSIONS

Among rural community-dwelling adults with CLBP, PE plus MCE led to greater short-term improvements in pain and disability compared with PE alone, although all intervention strategies were associated with improvements in these outcomes. This trial provides additional support for combining PE with MCE, as recommended in current clinical guidelines, to promote self-management and reduce the burden of CLBP in low-resource rural communities.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03393104), Registered on 08/01/2018.

Low Back Pain in Cycling. Are There Differences between Road and Mountain Biking?

Low back pain (LBP) is known to affect cyclists. This study aimed to describe perceived lumbar dysfunction and compare the pain sensation in recreational cyclists who practice road and mountain biking. Forty males were randomly assigned to carry out a 3-h road cycling (RC) and mountain biking (MTB) time trial (TT) at submaximal intensity. LBP and pain pressure threshold (PPT) were measured before and after the TT. A significant increment at the LBP was found after RC TT (p < 0.001; d = 2.61), similar to MTB TT (p < 0.001; d = 2.65). However, PPT decreased after completing the RC TT (p < 0.001; d = 1.73) and after MTB TT (p = 0.024; d = 0.77). There were no differences in the LBP evolution between both interventions (p > 0.01). Low back pain perception increases with cycling in recreational cyclists. Nevertheless, this increase appears to be more related to the traits of the cyclist than the modality practiced.

Establishing Responsiveness and Minimal Clinically Important Difference of Quebec Back Pain Disability Scale (Hindi Version) in Chronic Low Back Pain Patients Undergoing Multimodal Physical Therapy

Increasing emphasis is placed on physical functional measures to examine treatments for chronic low back pain (CLBP). The Quebec Back Pain Disability Scale (Hindi version) (QBPDS-H) has never been evaluated for responsiveness. The objectives of this study were to (1) examine the internal and external responsiveness of the Quebec Back Pain Disability Scale (Hindi version) (QBPDS-H) and (2) find out the minimal clinically important difference (MCID) and minimal detectable change (MDC) in the functional ability of patients with chronic low back pain (CLBP) undergoing multimodal physical therapy treatment. In this prospective cohort study, QBPDS-H responses were recorded at the baseline and after eight weeks from 156 CLBP patients undergoing multimodal physiotherapy treatment. To differentiate between the clinically unimproved (n = 65, age: 44.16 ± 11.8 years) and clinically improved (n = 91, age: 43.28 ± 10.7 years) scores of patients from the initial assessment to the last follow-up, the Hindi version of the Patient's Global Impression of Change (H-PGIC) scale was utilized. Internal responsiveness was large (E.S. (pooled S.D.) (n = 91): 0.98 (95% CI = 1.14-0.85) and Standardized Response Mean (S.R.M.) (n = 91): 2.57 (95% CI = 3.05-2.17)). In addition, the correlation coefficient and receiver operative characteristics (R.O.C.) curve were used to assess the QBPDS-H external responsiveness. MCID and MDC were detected by the R.O.C. curve and standard error of measurements (S.E.M.), respectively. The H-PGIC scale showed moderate responsiveness (ρ = 0.514 and area under the curve (A.U.C.) = 0.658; 95% CI, 0.596-0.874), while the MDC achieved 13.68 points, and the MCID was found have 6 points (A.U.C. = 0.82; 95% CI: 0.74-0.88, sensitivity = 90%, specificity = 61%). This study shows that QBPDS-H has moderate levels of responsiveness in CLBP patients receiving multimodal physical therapy treatment, so it can be used to measure the changes in disability scores. MCID and MDC changes were also reported with QBPDS-H.

Proportion of clinical holistic responders in patients with persistent spinal pain syndrome type II treated by subthreshold spinal cord stimulation compared to best medical treatment: a study protocol for a multicentric randomised controlled trial (TRADITION)

BACKGROUND

Integrating information on bodily functions, pain intensity and quality of life into one composite measure of a holistic responder has recently been proposed as a useful method to evaluate treatment efficacy of spinal cord stimulation (SCS) in patients with therapy-refractory persistent spinal pain syndrome type II (PSPS-T2). Previous studies already demonstrated the efficacy of standard SCS over best medical treatment (BMT) and the superiority of new subthreshold (i.e. paresthesia free) SCS paradigms compared to standard SCS. Nevertheless, the efficacy of subthreshold SCS compared to BMT has not yet been investigated in patients with PSPS-T2, neither with unidimensional outcomes nor with a composite measure. The current objective is to examine whether subthreshold SCS, compared to BMT, provided to patients with PSPS-T2 results in a different proportion of clinical holistic responders (as composite measure) at 6 months.

METHODS

A two-arm multicentre randomised controlled trial will be conducted whereby 114 patients will be randomised (1:1) to (a) BMT or (b) paresthesia-free SCS. After a follow-up period of 6 months (primary time endpoint), patients receive the opportunity to cross over towards the other treatment group. The primary outcome is the proportion of clinical holistic responders at 6 months (i.e. a composite measure of pain intensity, medication, disability, health-related quality of life and patient satisfaction). The secondary outcomes are work status, self-management, anxiety, depression and healthcare expenditure.

DISCUSSION

Within the TRADITION project, we propose to shift the focus from a unidimensional outcome measure towards a composite measure as primary outcome measure to evaluate the efficacy of currently used subthreshold SCS paradigms. The lack of methodologically rigorous trials exploring the clinical efficacy and socio-economic consequences of subthreshold SCS paradigms is pressing, especially in light of the growing burden of PSPS-T2 on the society.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05169047. Registered on December 23, 2021.

The Effect of a New Payment System on Physiotherapeutic Management of Patients With Low Back Pain in Primary Care

OBJECTIVE

To evaluate differences regarding the number of treatment sessions, costs, and outcomes (including relapses) between a regular payment-per-session system and the recently introduced product payment system.

DESIGN

Prospective cohort study.

SETTING

Dutch physical therapy practices in primary care over a 2-year period.

PARTICIPANTS

16,103 patients with low back pain (LBP).

INTERVENTION

The new product payment system is compared with the regular payment-per-session system.

MAIN OUTCOME MEASURES

Pain, disability, recovery, number of physical therapy sessions, therapy duration, costs (per episode), and LBP relapse.

RESULTS

At baseline, we found greater pain and disability scores associated with an increased risk profile in both payment systems. With regard to the payment systems, we found greater costs (€283.8 vs €210.8) and a greater percentage of relapse (4.5% vs 2.8%) for the product payment system compared with the payment-per-session system. Comparing the 2 payment systems within each risk strata, we found no significant differences, except for a decrease in pain in the medium-risk stratum. Concerning the therapy characteristics, we found that in the payment-per-session group, the therapy took 6 days longer for low-risk patients (median 27 vs 21 days) and 7 days shorter for high-risk patients (median 42 vs 49 days) compared with the product payment group. Moreover, the mean number of sessions in the payment-per-session group was greater for low-risk patients (5.4 vs 4.8 sessions) and lower for high-risk patients (7.7 vs 8.1 sessions) compared with the payment-per-session group. Finally, the costs were significantly greater in all strata of the product payment group compared with the payment-per-session group.

CONCLUSIONS

The 2 payment systems are largely comparable regarding patient outcomes, therapy duration, and treatment sessions. Both the average cost per patient per LBP episode and the number of relapses in the product payment system are statistically significantly greater than in the payment-per-session system.

Management of lumbar spinal stenosis: a systematic review and meta-analysis of rehabilitation, surgical, injection, and medication interventions

BACKGROUND

Lumbar spinal stenosis (LSS) has a substantial impact on mobility, autonomy, and quality of life. Previous reviews have demonstrated inconsistent results and/or have not delineated between specific nonsurgical interventions.

OBJECTIVE

The purpose of this systematic review is to assess the effectiveness of interventions in the management of LSS.

METHODS

Eligible studies were randomized controlled trials (RCTs) or prospective studies, included patients with LSS, assessed the effectiveness of any interventions (rehabilitation, surgical, injection, medication), included at least two intervention groups, and included at least one measure of pain, disability, ambulation assessment, or LSS-specific symptoms. Eighty-five articles met inclusion criteria. Meta-analyses were conducted across outcomes. Effect sizes were calculated using Hedge's g and reported descriptively. Formal grading of evidence was conducted.

RESULTS

Meta-analysis comparing rehabilitation to no treatment/placebo demonstrated significant effects on pain favoring rehabilitation (mean difference, MD -1.63; 95% CI: -2.68, -0.57; I² = 71%; p = .002). All other comparisons to no treatment/placebo revealed nonsignificant findings. The level of evidence ranged from very low to high for rehabilitation and medication versus no treatment/placebo for pain, disability, ambulation ability, and LSS symptoms.

CONCLUSIONS

Although the findings of this review are inconclusive regarding superiority of interventions, this accentuates the value of multimodal patient-centered care in the management of patients with LSS.

Effect of Trunk-Focused Exercises on Pain, Disability, Quality of Life, and Trunk Physical Fitness in Low Back Pain and How Potential Effect Modifiers Modulate Their Effects: A Systematic Review With Meta-analyses

OBJECTIVE: To analyze the effect of trunkfocused exercise programs (TEPs) and moderator factors on chronic nonspecific low back pain (LBP). DESIGN: Systematic review with meta-analyses. LITERATURE SEARCH: We searched the PubMed, Scopus, Embase, SPORTDiscus, and CENTRAL databases from their inception to June 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials comparing TEPs to control or general exercises. DATA SYNTHESIS: We used random-effects models to calculate the standardized mean difference (SMD) plus confidence interval (CI) and heterogeneity (I²) for pain, disability, quality of life, and trunk performance. The impact of moderator factors was analyzed through meta-regression. RESULTS: Forty randomized controlled trials (n = 2391) were included. TEPs showed positive effects for all outcomes versus control (SMD 0.90-2.46; 95% CI, -0.04 to 4.96; I2 61%-98%). There were small effects in favor of TEPs versus general exercises for pain (SMD = 0.20; 95% CI, 0.03-0.37; I² = 13.4%) and disability (SMD = 0.20; 95% CI, 0.02-0.38; I² = 0%). Trunk and/or hip range-of-motion improvements were associated with greater reductions in pain (P<.01; β = 0.56; 95% CI, 0.25-0.87) and disability (P<.01; β = 0.66; 95% CI, 0.27-1.05). Low body mass was associated with higher pain reduction (P = .03; β = -0.17; 95% CI, -0.32 to -0.02). CONCLUSIONS: Trunk-focused exercise programs had positive effects on pain, disability, quality of life, and trunk performance compared to control groups, and on pain and disability compared to general exercises. Increasing trunk and/or hip range of motion was associated with greater pain and disability reduction, and lower body mass with higher pain reduction. J Orthop Sports Phys Ther 2023;53(2):64-93. Epub: 16 January 2023. doi:10.2519/jospt.2023.11091.

Transcranial direct current stimulation combined with peripheral stimulation in chronic pain: a systematic review and meta-analysis

INTRODUCTION

The combination of Transcranial Direct Current Stimulation (tDCS) with peripheral stimulation may optimize their effects and bring positive results in treatment of people with chronic pain.

AREAS COVERED

A systematic review with meta-analysis of randomized and non-randomized trials was performed to investigate the combination of tDCS with peripheral stimulation in adults with chronic pain. The primary outcome was pain intensity. Six studies were included in this review (sample of 228 participants), which investigated the combination of tDCS and transcutaneous electrical nerve stimulation, peripheral electrical stimulation, breathing-controlled electrical stimulation and intramuscular electrical stimulation. The conditions studied were knee osteoarthritis, spinal cord injury, chronic low back pain, and neurogenic pain of the arms. Pain intensity, measured by visual analog scale or numerical rating scale, was reduced in all included studies when at least one of the interventions was active, regardless they were combined or alone, with or without tDCS. However, meta-analysis showed superiority of tDCS used in combination with peripheral stimulation.

EXPERT OPINION

This systematic review and meta-analysis suggests positive effects of tDCS combined with peripheral stimulation in chronic pain conditions. However, the evidence of the primary outcome was classified as low quality due to the limited number of studies.

Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment

BACKGROUND

Chronic low back pain (cLBP) is a common and highly disabling problem world-wide. Although many treatment options exist, it is unclear how to best sequence the multitude of care options to provide the greatest benefit to patients.

METHODS

The Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial uses a pragmatic, randomized, stepped design. Enrollment targets 2529 participants from 20 Veterans Affairs (VA) medical centers. Participants with chronic low back pain will first be randomized to one of three options: 1) an internet-based self-management program (Pain EASE); 2) a tailored physical therapy program (Enhanced PT); or 3) continued care with active monitoring (CCAM), a form of usual care. Participants not achieving a 30% or 2-point reduction on the study's primary outcome (Brief Pain Inventory Pain Interference (BPI-PI) subscale), 3 months after beginning treatment may undergo re-randomization in a second step to cognitive behavioral therapy for chronic pain, spinal manipulation therapy, or yoga. Secondary outcomes include pain intensity, back pain-related disability, depression, and others. Participants will be assessed every three months until 12 months after initiating their final trial therapy. Companion economic and implementation analyses are also planned.

RESULTS

The SCEPTER trial is currently recruiting and enrolling participants.

CONCLUSIONS

Trial results will inform treatment decisions for the stepped management of chronic low back pain - a common and disabling condition. Additional analyses will help tailor treatment selection to individual patient characteristics, promote efficient resource use, and identify implementation barriers of interventions.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT04142177.

American Society of Regional Anesthesia and Pain Medicine 2021 John J. Bonica Award Lecture

I am as deeply inspired and humbled to receive this prestigious award, as I am profoundly indebted to the Bonica Award selection committee and the American Society of Regional Anesthesia and Pain Medicine Board of Directors for recognizing my contributions to the development, teaching, and practice of pain medicine in the tradition of Dr John J Bonica. I would also like to recognize my parents, Aura and Tito for providing me with the support and the environment to fulfill my professional goals. Moreover, the support that I have gotten from my team at the hospital, and the Chair of my Department, Dr Mark Lema needs to be underscored.

Digital physical therapy practice and payment during the COVID-19 pandemic: A case series

BACKGROUND

Insurance regulation and reimbursement are barriers to physical therapy-delivered digital practice.

OBJECTIVE

The present case series describes the clinical reasoning, outcomes, and practical use of digital tools to improve pain and movement of patients seen for musculoskeletal pain during the COVID-19 pandemic.

CASE DESCRIPTION

Three patients, 2 with low back pain and 1 with cervicogenic headache, were treated at a private outpatient clinic. Collaborative reasoning was used to determine appropriate use of digital tools. Because of the pandemic, one patient used telephone visits to complete treatment (25% of total visits), one used telehealth visits only during stay-at-home orders (33% of total visits), and one was evaluated and treated entirely using telehealth (100% of total visits). All visits were billed and paid for by the patient or insurance at the same rate as an in-person visit.

OUTCOMES

All 3 patients met self-reported goals for physical therapy, met or surpassed their risk-adjusted predicted functional status score, and expressed high satisfaction with treatment.

CONCLUSION

Individualized prescription and execution of digital physical therapy practice allowed patients with musculoskeletal pain to have effective physical therapy care during the COVID-19 pandemic. Removal of regulatory and payment barriers were necessary for the provision of care.

Effectiveness of a Primary Care Multidisciplinary Treatment for Patients with Chronic Pain Compared with Treatment as Usual

To manage chronic pain, multidisciplinary interventions have been increasingly deployed, mostly in secondary or tertiary care settings. Evidence on the effectiveness of multidisciplinary intervention within primary care is scarce. This study examined the effectiveness of a primary care multidisciplinary treatment for chronic pain compared with treatment as usual (TAU). The intervention consisted of pain neuroscience education and treatment by a GP, psychologist, and physiotherapist. Both groups filled out patient-reported outcome measures at baseline, 6 months, and 12 months. The results indicated there were no statistically significant differences for the primary outcomes of pain intensity, number of pain sites, and health-related quality of life (HR-QoL). There was a statistically significant difference in the secondary outcome perceived health change in favor of the intervention group. None of the other differences were statistically significant. A post-hoc analysis showed that there were statistically significant effects on patients' illness perceptions in favor of the intervention group. Based on the results, the findings do not support effectiveness of a low intensity outpatient multidisciplinary primary care treatment to treat chronic pain compared with TAU. However, as a result of several study limitations, it is considered unwarranted to conclude that multidisciplinary treatment in primary care is not valuable at all.

An Exploration of the Influence of Non-Biomechanical Factors on Lifting-Related LBP

Objective: The primary objective was to compare non-biomechanical factors between manual workers with and without a history of LBP related to lifting. A secondary objective was to investigate associations between the change in pain intensity during repeated lifting (termed pain ramp) and non-biomechanical factors tested in the LBP group. Methods: Manual workers currently in lifting occupations with and without a history of lifting-related LBP were recruited (21 LBP and 20 noLBP) and took part in a repeated (100) lift task. A series of non-biomechanical factors, including psychological, work-related, lifestyle, whole health and psychophysical factors, were collected. Psychophysical factors (pressure pain thresholds (PPTs) and fatigue) were also measured at different time points. Associations between pain ramp during lifting and non-biomechanical factors were investigated with linear regression. Results: The LBP group reported worse perceived sleep quality, more musculoskeletal pain sites other than LBP and greater symptoms related to gastrointestinal complaints and pseudo-neurology compared to the group with no history of LBP. The group with LBP were also slightly more worried about the lifting task and felt more fatigued at the end of the lifting task. The feeling of fatigue during lifting was positively associated with pain ramp in the LBP group. Anxiety and gastrointestinal complaints were weakly negatively associated with pain ramp during lifting. Conclusions: The group differences of poorer perceived sleep, greater non-specific health complaints, slightly more worry about the lifting task and more perceived fatigue in the LBP group highlight the complex and multi-factorial nature of LBP related to lifting. The feeling of fatigue was positively associated with pain ramp in the LBP group, suggesting a close relationship with pain and fatigue during lifting that requires further exploration.

Adherence and Effect of Home-Based Rehabilitation with Telemonitoring Support in Patients with Chronic Non-Specific Low Back Pain: A Pilot Study

Home-based exercises have been on the rise recently. This pilot study aimed to assess the adherence and effect of a home-based rehabilitation programme using telemonitoring in patients with chronic non-specific low back pain (CNLBP). Twenty-seven patients with CNLBP were enrolled in the study, each of whom underwent a neurological assessment, including patient-oriented measures and a functional assessment-a battery of tests that comprehensively evaluated trunk muscle function. The rehabilitation programme lasted 18 weeks and included daily home-based exercises. A mobile application or an exercise diary was used to monitor compliance. Adherence to the programme was excellent for both the diary and mobile application groups, with 82.3% in the diary group exercising at least once a day and 72.9% twice a day, and 94.8% in the mobile application group exercising at least once a day and 86.6% twice a day. Both patient-oriented and functional outcomes improved significantly; however, the relative changes of the parameters in these two groups did not correlate, which supports the idea that trunk muscle function does not directly relate to patient complaints and that CNLBP is a multifactorial issue. This model of rehabilitation programme should be used in clinical practice, as its adherence and effectiveness seem noticeable.

Innovative seated vertical lumbar traction allows simultaneous computer work while inducing spinal height changes similar to supine lying

BACKGROUND

Lumbar intervertebral disc height loss has been associated with spinal height change (SHC) and low back pain (LBP), including stenosis. Non-invasive methods to improve disc height loss require forms of lying down, which are unconducive to computer work.

OBJECTIVE

Intermittent vertical traction (VT) integrated with seated computer work may provide ergonomic alternatives for increasing SHC to promote LBP relief. The primary aim was to develop and introduce a safe VT prototype and dosage to induce and measure SHC. Prototype comfort and LBP ratings were exploratory secondary aims.

METHODS

Forty-one participants were stadiometry-measured for pre- and post-intervention SHC from seated VT at 35% body weight removed, supine lying (SL), and sitting at a computer (SIT) without VT. Pain ratings were recorded for those self-reporting LBP. VT prototype evaluations were compiled from a 3-question, 7-point Likert-style survey.

RESULTS

SHC increased by 3.9 ± 3.4 mm in VT, 1.7 ± 3.4 mm in SIT, and 4.3 ± 3.1 mm in SL (P< 0.000). Post hoc findings were significant between VT and SIT (P< 0.000), and SL and SIT (P< 0.000). VT and SL LBP ratings both decreased, but not SIT.

CONCLUSION

Intermittent seated VT is a promising alternative for postural relief during seated computer work, producing SHC similar to lying down without compromising workflow.

Intensity of physical therapy services: Association with work and health outcomes in injured workers with back pain in Washington State

BACKGROUND

Associations between the intensity of physical therapy (PT) treatments and health outcomes among individuals with back pain have been examined in the general population; however, few studies have explored these associations in injured workers. Our study objective was to examine whether intensity of PT treatments is positively associated with work and health outcomes in injured workers with back pain.

METHODS

We conducted a secondary analysis of prospective data collected from the Washington State Workers' Compensation (WC) Disability Risk Identification Study Cohort (D-RISC). D-RISC combined survey results with WC data from the Washington State Department of Labor and Industries. Workers with a State Fund WC claim for back injuries between June 2002 and April 2004 and who received PT services within the first year of injury were eligible. Intensity of PT treatment was measured as the type and amount of PT services within 28 days from the first PT visit. Outcome measures included work disability and self-reported measures for working for pay, pain intensity, and functional status at 1-year follow-up. We conducted linear and logistic regression models to test associations.

RESULTS

We identified 662 eligible workers. In adjusted models, although the intensity of PT treatment was not significantly associated with work disability at 1-year follow-up, it was associated with lower odds of working for pay, decreased pain intensity, and improved functional status.

CONCLUSIONS

Our findings suggest that there may be small benefits from receiving active PT, manual therapy, and frequent PT treatments within 28 days of initiating PT care.

Treatment effect modifiers for individuals with acute low back pain: secondary analysis of the TARGET trial

ABSTRACT

Treatment effect modifiers identify patient characteristics associated with treatment responses. The purpose of this secondary analysis was to identify potential treatment effect modifiers for disability from the TARGET trial that compared usual care (control) with usual care + psychologically informed physical therapy (PIPT). The sample consisted of a STarT Back tool identified high-risk patients with acute low back pain that completed Oswestry Disability Index (ODI) data at index visit and 6 months later (n = 1250). Candidate treatment effect modifiers were identified a priori and informed by the literature. Linear mixed models tested for treatment effect modification through tests of statistical interaction. All statistical interactions ( P ≤ 0.20) were stratified by modifier to inspect for specific effects ( P ≤ 0.05). Smoking was identified as a potential effect modifier (treatment * smoking interaction, P = 0.08). In participants who were smokers, the effect of PIPT was (ODI = 5.5; 95% CI: 0.6-10.4; P = 0.03) compared with usual care. In participants who were nonsmokers, the effect of PIPT was (ODI = 1.5; 95% CI: -1.4 to 4.4; P = 0.31) compared with usual care. Pain medication was also identified as a potential effect modifier (treatment × pain medication interaction, P = 0.10). In participants prescribed ≥3 pain medications, the effect of PIPT was (ODI = 7.1; 95% CI: -0.1 to 14.2; P = 0.05) compared with usual care. The PIPT effect for participants prescribed no pain medication was (ODI = 3.5; 95% CI: -0.4 to 7.4; P = 0.08) and for participants prescribed 1 to 2 pain medications was (ODI = 0.6; 95% CI: -2.5 to 3.7; P = 0.70) when compared with usual care. These findings may be used for generating hypotheses and planning future clinical trials investigating the effectiveness of tailored application of PIPT.

Sensitivity to movement-evoked pain, central sensitivity symptoms, and pro-nociceptive profiles in people with chronic shoulder pain: A parallel-group cross-sectional investigation

OBJECTIVE

To investigate whether sensitivity to movement-evoked pain (SMEP), central sensitivity symptom burden, and quantitative sensory testing (QST) outcomes differ between healthy controls and people with chronic shoulder pain.

METHODS

People with chronic shoulder pain (n = 39) and healthy controls (n = 26) completed validated questionnaires measuring demographic, pain characteristics, psychological factors, social support, sleep quality, central sensitivity inventory (CSI), and physical activity levels. A blinded assessor administered QST measuring pressure pain threshold, temporal summation, conditioned pain modulation, and cold hyperalgesia. All participants performed repeated lifting of weighted canisters and reported severity of pain over successive lifts of the weighted canisters. Between-group differences in the QST, SMEP and CSI scores were investigated. Demographic and psychosocial variables were adjusted in the analyses.

RESULTS

Dynamic mechanical allodynia, mechanical temporal summation, movement-evoked pain scores, SMEP index, and CSI scores were significantly (p ≤ 0.05) higher in the chronic shoulder pain group than in healthy controls. A significant proportion of people with chronic shoulder pain presented with pro-nociceptive profiles and experienced higher pain severity, interference, and disability.

CONCLUSIONS

People with chronic shoulder pain displayed symptoms and signs of central sensitization. Future research should investigate the predictive role of central sensitization on clinical outcomes in shoulder pain.

Yoga Plus Mantram Repetition to Reduce Chronic Pain in Veterans With Post-Traumatic Stress Disorder: A Feasibility Trial

Background

Veterans with post-traumatic stress disorder (PTSD) are more likely to report chronic pain than veterans without PTSD. Yoga has been shown to reduce both chronic pain and PTSD symptoms in clinical trials. The goal of our study was to assess the feasibility and acceptability of conducting a randomized controlled trial (RCT) that combined yoga and mantram repetition (Yoga + MR) into one program for military veterans with both chronic pain and PTSD.

Methods

In this feasibility RCT, 27 veterans were randomized to either Yoga + MR or a relaxation intervention. Due to the COVID-19 pandemic, in-person recruitment, assessments, and intervention attendance were re-evaluated. Although remote delivery of aspects of the study were utilized, interventions were delivered in-person. Feasibility benchmarks met included full recruitment in 12 months or less, 75%+ retention at initial follow-up assessment, 50%+ attendance rate, and 75%+ of participants satisfied with the interventions.

Results

The sample was racially and ethnically diverse, and 15% of participants were women. Participant recruitment lasted approximately 11 months. Out of 32 participants initially randomized, two participants asked to be dropped from the study and three did not meet PTSD symptom criteria. For the remaining 27 participants, retention rates were 85% at 12 weeks and 81% at 18 weeks. Participants attended 66% of in-person yoga and 55% of in-person relaxation sessions. Satisfaction was high, with 100% of yoga participants and 75%/88% of relaxation participants agreeing or strongly agreeing they were satisfied with the intervention/instructors. After 12 weeks (end of intervention), Yoga + MR participants reported reduced back-pain related disability (primary outcome), reduced alcohol use, reduced fatigue, and increased quality of life, while relaxation group participants reported reductions in pain severity, PTSD symptoms, and fatigue.

Conclusions

Amidst many research challenges during the pandemic, recruitment, retention, and efficacy results from this feasibility trial support advancement to a larger RCT to study Yoga + MR for chronic pain and PTSD.

Prediction of 2-year clinical outcome trajectories in patients undergoing anterior cervical discectomy and fusion for spondylotic radiculopathy

OBJECTIVE

Anterior cervical discectomy and fusion (ACDF) is often described as the gold standard surgical technique for cervical spondylotic radiculopathy. Although outcomes are considered favorable, there is little prognostic evidence to guide patient selection for ACDF. This study aimed to 1) describe the 24-month postoperative trajectories of arm pain, neck pain, and pain-related disability; and 2) identify perioperative prognostic factors that predict trajectories representing poor clinical outcomes.

METHODS

In this retrospective cohort study, patients with cervical spondylotic radiculopathy who underwent ACDF at 1 of 12 orthopedic or neurological surgery centers were recruited. Potential outcome predictors included demographic, health, clinical, and surgery-related prognostic factors. Surgical outcomes were classified by trajectories of arm pain intensity, neck pain intensity (numeric pain rating scales), and pain-related disability (Neck Disability Index) from before surgery to 24 months postsurgery. Trajectories of postoperative pain and disability were estimated with latent class growth analysis, and prognostic factors associated with poor outcome trajectory were identified with robust Poisson models.

RESULTS

The authors included data from 352 patients (mean age 50.9 [SD 9.5] years; 43.8% female). The models estimated that 15.5%-23.5% of patients followed a trajectory consistent with a poor clinical outcome. Lower physical and mental health-related quality of life, moderate to severe risk of depression, and longer surgical wait time and procedure time predicted poor postoperative trajectories for all outcomes. Receiving compensation and smoking additionally predicted a poor neck pain outcome. Regular exercise, physiotherapy, and spinal injections before surgery were associated with a lower risk of poor disability outcome. Patients who used daily opioids, those with worse general health, or those who reported predominant neck pain or a history of depression were at greater risk of poor disability outcome.

CONCLUSIONS

Patients who undergo ACDF for cervical spondylotic radiculopathy experience heterogeneous postoperative trajectories of pain and disability, with 15.5%-23.5% of patients experiencing poor outcomes. Demographic, health, clinical, and surgery-related prognostic factors can predict ACDF outcomes. This information may further assist surgeons with patient selection and with setting realistic expectations. Future studies are needed to replicate and validate these findings prior to confident clinical implementation.

Comparisons of oblique lumbar interbody fusion and transforaminal lumbar interbody fusion for degenerative spondylolisthesis: a prospective cohort study with a 2-year follow-up

Objective

This study aimed to compare the clinical outcomes between oblique (OLIF) and transforaminal lumbar interbody fusion (TLIF) for patients with degenerative spondylolisthesis during a 2-year follow-up.

Methods

Patients with symptomatic degenerative spondylolisthesis who underwent OLIF (OLIF group) or TLIF (TLIF group) were prospectively enrolled in the authors' hospital and followed up for 2 years. The primary outcomes were treatment effects [changes in visual analog score (VAS) and Oswestry disability index (ODI) from baseline] at 2 years after surgery; these were compared between two groups. Patient characteristics, radiographic parameters, fusion status, and complication rates were also compared.

Results

In total, 45 patients were eligible for the OLIF group and 47 patients for the TLIF group. The rates of follow-up were 89% and 87% at 2 years, respectively. The comparisons of primary outcomes demonstrated no different changes in VAS-leg (OLIF, 3.4 vs. TLIF, 2.7), VAS-back (OLIF, 2.5 vs. TLIF, 2.1), and ODI (OLIF, 26.8 vs. TLIF, 30). The fusion rates were 86.1% in the TLIF group and 92.5% in the OLIF group at 2 years (P = 0.365). The OLIF group had less estimated blood loss (median, 200 ml) than the TLIF group (median, 300 ml) (P < 0.001). Greater restoration of disc height was obtained by OLIF (mean, 4.6 mm) than the TLIF group (mean, 1.3 mm) in the early postoperative period (P < 0.001). The subsidence rate was lower in the OLIF group than that in the TLIF group (17.5% vs. 38.9%, P = 0.037). The rates of total problematic complications were not different between the two groups (OLIF, 14.6% vs. TLIF, 26.2%, P = 0.192).

Conclusion

OLIF did not show better clinical outcomes than TLIF for degenerative spondylolisthesis, except for lesser blood loss, greater disc height restoration, and lower subsidence rate.

Residents of Mountainous Areas Have a Higher Low Back Pain Prevalence Than Flat Areas of Chongqing, China: A Cross-Sectional Study

Background and Purpose

Epidemiological studies on low back pain in residents living in mountainous areas are scarce. The study was aimed at investigating the prevalence and associated factors of low back pain in Chongqing, relatively impoverished mountainous areas of China.

Materials and Methods

This was a cross-sectional study conducted at selected community or village health service centers in Chongqing over a 2-month period (May 2021 to June 2021), which included adults of Chongqing aged >18 years with or without low back pain (N=1820) chosen by stratified, cluster-sampling. Associated factors of low back pain including sociodemographic characteristics, lifestyle, and occupational features were collected, along with medical history, Oswestry Disability Questionnaire (ODI), and Numerical Rating Scale (NRS) of patients with low back pain, and carried out for at least 20 minutes per respondent. Univariate and multivariate logistic regression models were utilized for statistical analysis.

Results

Overall, 30.5% of 1704 respondents presented with low back pain, with 26.3% living in flat areas and 35.6% in mountainous areas. The associated factors of low back pain were mountainous area residence (OR 1.4, 95% CI 1.1-1.8), advanced age (OR 1.8, 95% CI 1.3-2.5 for those aged 45-59 years, OR 2.3, 95% CI 1.6-3.4 for those aged 60-74 years, and OR 2.1, 95% CI 1.2-3.6 for those aged ≥75 years), married or remarried (OR 1.9, 95% CI 1.1-3.2), divorced or widowed (OR 2.7, 95% CI 14-5.4), moderate labor intensity (OR 1.4, 95% CI 1.1-1.8), frequent stoop (OR 1.6, 95% CI 1.1-2.4), and depressed mood (OR 1.6, 95% CI 1.2-2.1). Residents in the mountainous areas had a higher score on Oswestry Disability Questionnaire (8.3 [SD 6.3] vs 6.2 [SD 4.3]) than those in flat areas.

Conclusion

Mountainous areas in Chongqing had higher prevalence of low back pain as 35.6%, compared with 26.3% in flat areas, with more severe dysfunction in low back pain patients. Multifactorial analysis found that the factors associated with low back pain in Chongqing residents included mountain residence, labor intensity, stoop, psychological factors and frequency of exercise.

Three-Year Durability of Restorative Neurostimulation Effectiveness in Patients With Chronic Low Back Pain and Multifidus Muscle Dysfunction

BACKGROUND

Restorative neurostimulation is a rehabilitative treatment for patients with refractory chronic low back pain (CLBP) associated with dysfunction of the lumbar multifidus muscle resulting in impaired neuromuscular control. The ReActiv8-B randomized, sham-controlled trial provided evidence of the effectiveness and safety of an implanted, restorative neurostimulator. The two-year analysis previously published in this journal demonstrated accrual of clinical benefits and long-term durability.

OBJECTIVE

Evaluation of three-year effectiveness and safety in patients with refractory, disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery.

MATERIALS AND METHODS

Prospective, observational follow-up of the 204 implanted trial participants. Low back pain visual analog scale (VAS), Oswestry Disability Index (ODI), EuroQol quality of life survey, and opioid intake were assessed at baseline, six months, and one, two, and three years after activation. The mixed-effects model repeated measures approach was used to provide implicit imputations of missing data for continuous outcomes and multiple imputation for proportion estimates.

RESULTS

Data were collected from 133 participants, and 16 patients missed their three-year follow-up because of coronavirus disease restrictions but remain available for future follow-up. A total of 62% of participants had a ≥ 70% VAS reduction, and 67% reported CLBP resolution (VAS ≤ 2.5cm); 63% had a reduction in ODI of ≥ 20 points; 83% had improvements of ≥ 50% in VAS and/or ≥ 20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 71% (36/51) participants on opioids at baseline had voluntarily discontinued (49%) or reduced (22%) opioid intake. The attenuation of effectiveness in the imputed (N = 204) analyses was relatively small and did not affect the statistical significance and clinical relevance of these results. The safety profile remains favorable, and no lead migrations have been observed to date.

CONCLUSION

At three years, 83% of participants experienced clinically substantial improvements in pain, disability, or both. The results confirm the long-term effectiveness, durability, and safety of restorative neurostimulation in patients with disabling CLBP associated with multifidus muscle dysfunction.

CLINICAL TRIAL REGISTRATION

The Clinicaltrials.gov registration number for the study is NCT02577354.

Long-Term Outcomes of Restorative Neurostimulation in Patients With Refractory Chronic Low Back Pain Secondary to Multifidus Dysfunction: Two-Year Results of the ReActiv8-B Pivotal Trial

BACKGROUND

Impaired neuromuscular control and degeneration of the multifidus muscle have been linked to the development of refractory chronic low back pain (CLBP). An implantable restorative-neurostimulator system can override the underlying multifidus inhibition by eliciting episodic, isolated contractions. The ReActiv8-B randomized, active-sham-controlled trial provided effectiveness and safety evidence for this system, and all participants received therapeutic stimulation from four months onward.

OBJECTIVE

This study aimed to evaluate the two-year effectiveness of this restorative neurostimulator in patients with disabling CLBP secondary to multifidus muscle dysfunction and no indications for spine surgery.

MATERIALS AND METHODS

Open-label follow-up of 204 participants implanted with a restorative neurostimulation system (ReActiv8, Mainstay Medical, Dublin, Ireland) was performed. Pain intensity (visual analog scale [VAS]), disability (Oswestry disability index [ODI]), quality-of-life (EQ-5D-5L), and opioid intake were assessed at baseline, six months, one year, and two years after activation.

RESULTS

At two years (n = 156), the proportion of participants with ≥50% CLBP relief was 71%, and 65% reported CLBP resolution (VAS ≤ 2.5 cm); 61% had a reduction in ODI of ≥20 points, 76% had improvements of ≥50% in VAS and/or ≥20 points in ODI, and 56% had these substantial improvements in both VAS and ODI. A total of 87% of participants had continued device use during the second year for a median of 43% of the maximum duration, and 60% (34 of 57) had voluntarily discontinued (39%) or reduced (21%) opioid intake.

CONCLUSIONS

At two years, 76% of participants experienced substantial, clinically meaningful improvements in pain, disability, or both. These results provide evidence of long-term effectiveness and durability of restorative neurostimulation in patients with disabling CLBP, secondary to multifidus muscle dysfunction.

CLINICAL TRIAL REGISTRATION

The study is registered on clinicaltrials.gov with identifier NCT02577354.

A prospective, randomized trial of the effect of buprenorphine continuation versus dose reduction on pain control and post-operative opioid use

INTRODUCTION

An increasing number of individuals are taking buprenorphine for management of opioid use disorder (OUD). Pain control can be challenging when these patients develop acute pain requiring supplemental analgesia. Buprenorphine's pharmacokinetic profile can render supplemental opioid-based analgesia ineffective. There is limited guidance on the optimal management of buprenorphine when acute pain is anticipated. Although there is growing acceptance that the risk of OUD relapse with buprenorphine discontinuation overshadows the risks of increased opioid utilization and difficult pain control with buprenorphine continuation, perioperative courses comparing buprenorphine dose reduction and full dose buprenorphine continuation have yet to be investigated. Here, we describe the protocol for our randomized controlled, prospective trial investigating the effect of buprenorphine continuation compared to buprenorphine dose reduction on pain control, post-operative opioid use, and OUD symptom management in patients on buprenorphine scheduled for elective surgery.

METHODS AND ANALYSIS

This is a single institution, randomized trial that aims to enroll 80 adults using 12 mg buprenorphine or greater for treatment of OUD, scheduled for elective surgery. Participants will be randomly assigned to receive 8mg of buprenorphine on the day of surgery onwards until postsurgical pain subsides or to have their buprenorphine formulation continued at full dose perioperatively. Primary outcome will be a clinically significant difference in pain scores 24 hours following surgery. Secondary outcomes will be opioid consumption at 24, 48, and 72 hours postoperatively, opioid dispensing up to 30 days following surgery, changes in mood and withdrawal symptoms, opioid cravings, relapse of opioid misuse, and continued use of buprenorphine treatment postoperatively.

Patient reported outcomes after navigated minimally invasive hybrid lumbar interbody fusion (nMIS-HLIF) using cortical bone trajectory screws

Prospective observational study. To evaluate patient-reported outcomes after navigation-guided minimally invasive hybrid lumbar interbody fusion (nMIS-HLIF) for decompression and fusion in degenerative spondylolisthesis (Meyerding grade I-II). Posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbody fusion (TLIF) are well-known standard procedures for lumbar spinal fusion. nMIS-HLIF is a navigation-guided combined percutaneous and open procedure that combines the advantages of PLIF and TLIF procedures for the preparation of a single-port endoscopic approach. 33 patients underwent nMIS-HLIF. Core outcome measure index (COMI), oswestry disability index (ODI), numeric rating scale (NRS) back, NRS leg, and short form health-36 (SF-36) were collected preoperatively and at follow-up of 6 weeks, 3 months, 6 months, and 1 year. The impact of body mass index (BMI) was also analyzed. Computed tomography reconstruction was used to assess realignment and verify fused facet joints and vertebral bodies at the 1-year follow-up. 28 (85%) completed the 1-year follow-up. The median BMI was 27.6 kg/m2, age 69 yrs. The mean reduction in listhesis was 8.4% (P < .01). BMI was negatively correlated with listhesis reduction (P = .032). The improvements in the NRS back, NRS leg, ODI, and COMI scores were significant at all times (P < .001-P < .01). The SF-36 parameters of bodily pain, physical functioning, physical component summary, role functioning/physical functioning, and social functioning improved (P < .003). The complication rate was 15.2% (n = 5), with durotomy (n = 3) being the most frequent. To reduce the complication rate and allow transitioning to a fully endoscopic approach, expandable devices have been developed. The outcomes of nMIS-HLIF are comparable to the current standard open and minimally invasive techniques. A high BMI hinders this reduction. The nMIS-HLIF procedure is appropriate for learning minimally invasive dorsal lumbar stabilization. The presented modifications will enable single-port endoscopic lumbar stabilization in the future.

Full-Endoscopic Lumbar Foraminotomy for Foraminal Stenosis in Spondylolisthesis: Two-Year Follow-Up Results

Full-endoscopic lumbar foraminotomy (FELF) under local anesthesia has been developed as a minimally invasive alternative for lumbar foraminal stenosis. Some authors have described this technique for treating various lumbar spondylolisthesis. However, few studies have reported the outcomes of FELF for foraminal stenosis in patients with stable spondylolisthesis. This study aimed to demonstrate the specific technique and clinical outcomes of FELF for foraminal stenosis in patients with spondylolisthesis. Twenty-three consecutive patients with foraminal stenosis and stable spondylolisthesis were treated with FELF. Among them, 21 patients were followed up for 2 years. Full-endoscopic foraminal decompression via the transforaminal approach was performed by a senior surgeon. Clinical outcomes were evaluated using the visual analog pain score (VAS), Oswestry Disability Index (ODI), and modified MacNab criteria. The VAS and ODI scores significantly improved at the two-year follow-up. The global effects were excellent in six patients (28.6%), good in 13 (61.9%), and fair in two (9.5%). Therefore, all patients showed clinical improvement, with a success (excellent/good) rate of 90.5%. No significant surgical complications or signs of further instability were observed. FELF can be used for foraminal stenosis in patients with stable spondylolisthesis. A specialized surgical technique is required for foraminal decompression of spondylolisthesis.

Is Electrical Stimulation Effective in Preventing or Treating Delayed-onset Muscle Soreness (DOMS) in Athletes and Untrained Adults? A Systematic Review With Meta-Analysis

The effectiveness of electrical stimulation (ES) in preventing or treating delayed-onset muscle soreness (DOMS) and its effects on muscle recovery is unclear. The systematic review investigated the benefits or harms of ES on DOMS and muscle recovery. Databases (PubMed, Medline, CENTRAL, EMBASE, CINAHL, PsycINFO, PEDro, LILACS, SPORTDiscus) were searched up to March, 31st 2021 for randomized controlled trials (RCTs) of athletes or untrained adults with DOMS treated with ES and compared to placebo/sham (simulation or without ES), or control (no intervention). Data were pooled in a meta-analysis. Risk of bias (Cochrane Collaboration tool) and quality of evidence (GRADE) were analyzed. Fourteen trials (n=435) were included in this review and 12 trials (n=389) were pooled in a meta-analysis. Evidence of very low to low quality indicates that ES does not prevent or treat DOMS as well as ES does not help to promote muscle recovery immediately, 24, 48, 72, 96 hours after the intervention. Only one study monitored adverse events. There are no recommendations that support the use of ES in DOMS and muscle recovery. PERSPECTIVES: No recommendations support the use of electrical stimulation in delayed-onset muscle soreness and muscle recovery in athletes and untrained adults. This means that electrical stimulation is not fruitful for this population according those protocols used. Therefore, unlikely that further randomized controlled trials with the same approach will yield promising results.

The validity of the cervical rotation lateral flexion test in predicting benefit after manipulation treatment to the first and second rib

STUDY DESIGN

Prospective cohort study.

BACKGROUND

The cervical rotation lateral flexion (CRLF) test is frequently used in clinical practice to determine whether a thrust manipulation targeting the first rib should be performed.

OBJECTIVES

To evaluate the predictive validity of the CRLF test and manual examination in determining whether patients with neck pain are likely to benefit from manipulative treatment to the first and second rib.

METHODS

A physical examination incorporating the CRLF test was performed on 50 participants with neck pain followed by manipulation treatment to the first and second ribs. Clinical improvement was assessed immediately and one week after treatment. Participants who experienced at least a 30% improvement in their Neck Disability Index (NDI) score were considered "improved." Predictive validity was assessed by calculating sensitivity, specificity, and negative and positive likelihood ratios.

RESULTS

Neither the CRLF test nor manual examination were predictive of clinical improvement after manipulative treatment to the first and second rib. However, being male, of older age, and exhibiting T1 and/or T2 restricted end-feel were associated with improved neck related-disability at one-week follow-up.

CONCLUSION

The CRLF test does not appear to be helpful in determining whether patients with neck pain are likely to benefit from manipulative treatment to the first and second rib. Other factors from the history and clinical examination may be more helpful when selecting manipulative treatment including age and gender and possibly the presence of T1/T2 restricted end-feel.

Transforaminal Endoscopic Decompression for Foraminal Stenosis: Single-Arm Meta-Analysis and Systematic Review

OBJECTIVE

The objective of the study was to conduct a single-arm meta-analysis and comprehensive systematic review to identify the efficacy and safety of transforaminal endoscopic surgery for the treatment of lumbar foraminal stenosis (LFS).

METHODS

The meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. The PubMed, Web of Science, and Embase databases were searched from inception to February 20, 2022. Primary research results were visual analog scale scores, Oswestry Disability Index scores, MacNab criterion scores, and reported adverse events. Subgroup analyses were performed on the primary outcome to evaluate the potential effects of several clinical factors that affected the results.

RESULTS

Of the 2020 studies identified, 9 met the inclusion criteria, and 316 participants were eligible for meta-analysis. The meta-analysis results found that transforaminal endoscopic surgery for the treatment of LFS was associated with a significant improvement in postoperative 12-month clinical indicators: 8 studies reported improvements in visual analog scale scores: -5.38, Oswestry Disability Index scores: -40.44, and MacNab criterion scores: odds ratio = 0.86; 8 studies reported 11.53% adverse events occurred in a total of 295 patients, and the most commonly reported event was transient postoperative dysesthesia, which occurred in 26 patients in a total of 6 studies with 240 patients (10.83%).

CONCLUSIONS

Transforaminal endoscopic surgery positively affects postoperative LFS patients' clinical indicators; however, high-level literature with randomized controlled trials is needed to confirm this technique's applicability in LFS.

The effect of exercise engagement on low back disability at 12-months is mediated by pain and catastrophizing in a community sample of people with chronic low back pain

Despite being a first-line treatment recommendation, there is uncertainly for how exercise helps people with chronic low back pain. We designed this study to examine how exercise might help people with chronic low back pain by following a large community sample for 1-year. Qualitative questionnaires and self-report measures were collected every 3-months for 1-year in 400 people with chronic low back pain. People were not provided any specific treatment advice as part of this study but were allowed to engage with any normal physical activity, treatment, or medication as part of their normal life. Exercise engagement was defined from inspection of participant qualitative responses, according to minimum acceptable levels of exercise that elicit symptom reduction. Multiple mediation analysis was performed to examine the effect of exercise engagement on disability through the proposed mediators (pain, fear, catastrophizing, depression, anxiety, self-efficacy). The significant effect of exercise engagement on reductions in disability at 6- and 12-months was explained through pain and catastrophizing. People with chronic low back pain who reported worsening of symptoms over the year had similar reporting of exercise throughout the 12-months to people who had improvements in disability. Exercise can reduce disability through the effect on pain and catastrophizing, but how this effect occurs (i.e., an active or passive component of exercise) is unclear.

Effectiveness of muscle energy technique in patients with nonspecific low back pain: a systematic review with meta-analysis

INTRODUCTION

Low back pain (LBP) is a major cause of physical disability in the world. The origin of this condition can be due to differents causes, with a specific cause or of unknown mechanical origin,being characterized as unspecific. In this case a physical therapy treatment approach with manual therapy is relevant, which includes the muscle energy technique (MET) classified as a common conservative treatment for pathologies of the spine, mainly in LBP and disability. This study assessed the effectiveness of the muscle energy technique on nonspecific low back pain.

EVIDENCE ACQUISITION

Patients with acute, subacute or chronic non-specific low back pain. The primary outcomes were pain and disability. This study was designed by a systematic review and meta-analysis, registered in PROSPERO (CRD42020219295). For the report and methodological definitions of this study, the recommendations of the PRISMA protocol and the Cochrane collaboration, were followed, respectively.

EVIDENCE SYNTHESIS

The search yielded 164 citations, which 19 were eligible randomised trials were included in the review (N.=609 patients with low back pain). The methodological quality of the studies averaged 4.2 points, with an interval of 2 to 7 points. Three RCTs showed satisfactory methodological quality (PEDro Score ≥6). For patients with chronic LBP, a significant result on pain (but with a small and clinically unimportant effect) in favor of MET versus other (MD=-0.51 [95% CI,-0.93 to -0.09] P=0.02, N.=376, studies=11, I2=80%). In patients with subacute LBP, MET enabled a significant and moderate effect to reduce pain intensity when compared to the control group (MD=-1.32 [95% CI,-2.57 to -0.06] P=0.04, N.=120, studies=3, I²=88%). No significant effects were observed for the disability.

CONCLUSIONS

MET is not considered an efficient treatment to improve the incapacity of the lumbar spine, but it may be beneficial in reducing the intensity of LBP, although showing a small clinical effect in chronic LBP and a moderate effect in subacute LBP.

Efficacy and Safety of Add-on Mirogabalin to NSAIDs in Lumbar Spinal Stenosis with Peripheral Neuropathic Pain: A Randomized, Open-Label Study

INTRODUCTION

In Japan, conservative therapy for patients with lumbar spinal stenosis (LSS) includes non-steroidal anti-inflammatory drugs (NSAIDs), prostaglandin E1, tramadol, physical/exercise therapy, and nerve blocks. Mirogabalin, a selective oral α2δ ligand, is approved for treating peripheral neuropathic pain, though data regarding visual analog scores (VAS) for pain in patients with LSS are limited. We investigated the efficacy and safety of mirogabalin as an add-on treatment in patients with LSS taking NSAIDs compared with patients taking NSAIDs only.

METHODS

This multicenter, randomized, open-label study (MiroTAS) was conducted at 32 centers in Japan between June 2020 and October 2021. Patients were randomly assigned to mirogabalin and NSAIDs or NSAIDs alone in a 1:1 ratio. NSAIDs were administered according to their Japanese package inserts; mirogabalin was administered based on renal function [creatinine clearance (CrCL) ≥ 60 mL/min, 5 mg twice daily (BID) in Weeks 1-2, 10 mg BID in Weeks 3-4, and 15 or 10 mg BID after Week 5; CrCL 30 to < 60 mL/min, 2.5 mg BID Weeks 1-2, 5 mg BID Weeks 3-4, and 7.5 or 5 mg BID after Week 5]. The primary endpoint was the change in VAS score for leg pain from baseline to Week 12. Secondary endpoints were quality of life, evaluated using the EuroQol five-dimensional descriptive system (EQ-5D-5L) (at baseline and Week 12) and Patient Global Impression of Change (PGIC) (at Week 12), and safety. Change in VAS score at Week 12 was calculated using a linear mixed model for repeated measures. The safety endpoints were treatment-emergent adverse events (TEAEs) and adverse drug reactions.

RESULTS

In total, 220 patients who met the eligibility criteria were enrolled. In the mirogabalin and NSAIDs and NSAIDs groups, mean ages (67.8 vs. 70.9 years), proportions of female patients (54.5% vs. 49.0%), mean body weights (63.9 vs. 62.0 kg), mean CrCL values (81.5 vs. 70.7 mL/min), proportions of patients with CrCL 30 to < 60 mL/min (27.3% vs. 33.7%), mean VAS scores (63.8 vs. 62.8 mm), and proportions of patients with VAS score ≥ 60 (53.6% vs. 52.9%) at enrollment were similar. The median durations of LSS were 9.0 and 11.0 months and the spine pain DETECT questionnaire (SPDQ) scores were 6.8 and 7.8, respectively. The least square (LS) mean change in VAS score from baseline to Week 12 was - 24.1 mm in the mirogabalin and NSAIDs group and - 14.2 mm in the NSAIDs group (both P < 0.0001 vs. baseline). The difference in LS mean was - 9.9 [95% confidence interval (CI), - 18.0, - 1.8] (P = 0.0174). The improvement in EQ-5D-5L score at Week 12 was significantly greater in the mirogabalin and NSAIDs group versus the NSAIDs group [mean difference, 0.0529 (95% CI, 0.0036, 0.1022), P = 0.0357]. At Week 12, the proportions of patients with PGIC scores ≤ 3 and ≤ 2 were higher in the mirogabalin and NSAIDs group vs. the NSAIDs group (76.2% vs. 50.0%, P = 0.0006, and 47.6% vs. 32.4%, P = 0.0523). In the mirogabalin and NSAIDs group, the incidences of TEAEs and adverse drug reactions were 60.9% and 57.3%, respectively, and the most common TEAEs were somnolence (30.0%) and dizziness (25.5%).

CONCLUSIONS

The addition of mirogabalin to NSAIDs improved VAS, EQ-5D-5L, and PGIC. The main TEAEs were somnolence and dizziness. The addition of mirogabalin to NSAIDs improved peripheral neuropathic pain associated with LSS and raised no new safety concerns.

TRIAL REGISTRATION

Japan Registry of Clinical Trials (jRCTs021200007).

Service evaluation of telehealth in a physiotherapy musculoskeletal setting: Patient outcomes and results from risk stratification

INTRODUCTION

Due to COVID-19 the ability to see all patients face-to-face (FTF) was removed. Services implemented telehealth to cater for patients requiring musculoskeletal care. A service evaluation was undertaken to assess the effectiveness of a mixed telehealth/FTF approach and identify if stratifying patients could help tailor intervention.

METHODS

Retrospective analysis of data collected from patients who were assessed by Musculoskeletal Physiotherapists in one Scottish health board was undertaken. Patients were divided into low, medium and high risk sub-groups through the Keele STarT MSK tool. Outcome measures for pain and musculoskeletal health were taken at baseline/discharge along with satisfaction/preference. Descriptive and Inferential statistical analysis was conducted to establish whether changes in the outcome measures within and between risk sub-groups were statistically significant.

RESULTS

Pain level difference from baseline to discharge demonstrated clinically and statistically significant improvements across all risk groups (N = 89). Musculoskeletal health demonstrated clinically significant improvements across all risk groups and statistically significant improvements in the medium/high risk groups but not the low risk. Patients with knee osteoarthritis and low back pain in the medium risk group had fewest appointments while patients with chronic shoulder pain had the most. The majority of patients were satisfied with all mediums but preferred FTF or an option between telehealth/FTF in the future.

CONCLUSION

Telehealth is a promising model of care when utilised in combination with FTF for patients with musculoskeletal conditions. Through stratification, identifying specific conditions and shared decision making it may be possible to treat certain patient groups via telehealth.

Long-Term Clinical Outcomes of a Remote Digital Musculoskeletal Program: An Ad Hoc Analysis from a Longitudinal Study with a Non-Participant Comparison Group

Digital solutions have emerged as an alternative to conventional physiotherapy, particularly for chronic musculoskeletal pain (CMP) management; however, its long-term effects remain largely unexplored. This study focuses on patients reporting CMP, assessing 1-year clinical outcomes after a multimodal digital care program (DCP) versus non-participants, who enrolled in the program but never engaged in a single exercise session or partook of the educational content made available to them. In this longitudinal study ad-hoc analysis, pain and functionality outcomes at 1-year reassessment were studied, focusing on the odds of reaching minimal clinically important difference (MCID) and, overall average reduction in both outcomes. Healthcare utilization was additionally studied within the same period. From 867 individuals allocated to the study, 460 completed the 1-year reassessment (intervention group: 310; comparison group: 150). The intervention group presented sustained and greater pain reduction until 1-year reassessment than the comparison group, reflecting greater odds ratio of achieving the MCID both in pain and functionality (1.90 95% CI: 1.27-2.86, p = 0.002 and 2.02 95% CI: 1.31-3.12, p = 0.001, respectively). A lower healthcare utilization during the 1-year follow-up was observed in the intervention group than in the comparison group. This study suggests that a digital CMP program may have a lasting impact on improved pain and functionality in patients with CMP.

Effect of different weekly frequencies of Chen-style Tai Chi in elders with chronic non-specific low back pain: study protocol for a randomised controlled trial

BACKGROUND

Tai Chi (TC), as one of mild to moderate exercise therapies specifically recommended by clinical practice guideline from the American College of Physician, is a viable option for chronic non-specific low back pain (CNLBP) treatment. Nevertheless, limited studies focused on the effect of different weekly frequencies of TC in elders with CNLBP. This superiority study aims to compare the differences of TC with different weekly frequencies in elders with CNLBP on the premise of proving its effectiveness, and identifying whether mindfulness mediates the effect of TC on treatment outcomes.

METHODS

In total, 284 senior citizens with CNLBP will be recruited in this single-centre, randomised, single-blinded (outcome assessors, data managers and the statistician), parallel controlled trial. Participants will be randomly divided into either one of three TC groups (1, 3, or 5 sessions/week, on the basis of weekly health educational lectures) or weekly health educational lectures, sustaining for 12 weeks, followed by 12 weeks of follow-up after the end of intervention. The primary outcome (the changes of LBP intensity at rest) will be measured at baseline before randomisation and immediately after the completion of weeks 4, 8 and 12 of the intervention, and the end of follow-up (week 24) using the visual analogue scale (VAS, 0-10 cm) to put a mark on the VAS scale to show how severities of their average low back pain have been over the past 24 h. Secondary outcomes, including Beck Depression Inventory-II, Pain Catastrophising Scale and Five Facet Mindfulness Questionnaire, Oswestry Disability Index and Short Form-36, will be measured at baseline and immediately after the completion of week 12 of the intervention and end of follow-up. The intention-to-treat and per-protocol principles will be used to analyse outcomes with a setting at α = 0.05 as statistical significance.

DISCUSSION

This comprehensive and detailed protocol will be the first trial to compare the effectiveness of different weekly frequencies of TC in elders with CNLBP. The outcomes may provide valuable data about the choice of the ideal number of sessions to further normalise the application of exercise for clinicians.

TRIAL REGISTRATION

Chinese clinical trial registry ChiCTR2200058190 . Registered on 1 April 2022.