The burden of musculoskeletal pain and the role of topical non-steroidal anti-inflammatory drugs (NSAIDs) in its treatment. Ten underpinning statements from a global pain faculty

Virtual reality is effective in the management of chronic low back ache in adults: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Chronic low back ache (CLBA) is a common condition that is conventionally managed with physical therapy and analgesics. Recently, virtual reality-based interventions have been tried out in the management of CLBA. Their effectiveness, however has not been established. This meta-analysis aims to find out if the application of VR will lead to better pain relief, as compared to conventional techniques in adults with CLBA.

METHODS

The literature search was carried out in three online databases for potential randomized controlled trials that compared VR-based interventions with conventional treatment in CLBA. Data on outcome parameters were recorded. Meta-analysis was carried out with the help of appropriate software.

RESULTS

Seven studies having data on 507 subjects were included in the meta-analysis. Their mean ages were 48.4 years. There were 252 subjects in the VR group and 255 in the control group. VR-based interventions were found to have a statistically significant improvement in the pain intensity compared with conventional techniques (p - 0.005).

CONCLUSION

VR-based interventions are effective in the management of CLBA in the short term. Further research with longer follow-up is required to evaluate if these improvements are persistent in the long term.

Patients' experience and utilization patterns of diclofenac gel in Germany: a real-world study with a prospective longitudinal survey and a retrospective analysis of pharmacy data

OBJECTIVE

Describe and characterize treatment patterns, satisfaction, improvement in pain and functional impairment (health-related quality of life [HRQoL]) in users of over the counter (OTC) Voltaren gel diclofenac (VGD) 2.32% and 1.16% in a real-world setting.

METHODS

This observational real-world German study had prospective and retrospective components. The prospective data were collected from electronic surveys completed by adults who purchased VGD to treat their musculoskeletal pain at baseline and 4 and 12 weeks after baseline. Retrospective data were from a 12-month (March 2019 to February 2020) abstraction from dispensing software platforms used in select German pharmacies.

RESULTS

Surveys from 467 participants (mean age 60.8 years) were analyzed. Average pain severity at baseline was 6.0 on an 11-point Numeric Rating Scale (0 = no pain, 10 = worst possible pain), improving by 0.8 and 1.2 points at Weeks 4 and 12, respectively. Performance of functional activities (daily/physical/social activities and errands/chores) improved and the proportion of participants with at least moderate interference decreased at both follow-up timepoints. Retrospective analyses indicated that majority of patients receiving VGD (n = 95,085) were ≥65 years old (67.9%), had one dispensed tube (70.8%) and did not switch to another topical treatment (including other NSAIDs) (77.3%), and were co-prescribed at least one cardiovascular medication (74.3%).

CONCLUSIONS

This study provides the first real-world insights into OTC VGD use in Germany. The participants using VGD reported a decrease in pain severity and an improvement of HRQoL while under treatment, as well as resulting satisfaction with treatment. Patients infrequently switched to alternate topical therapies/NSAIDs.

Treatment Satisfaction, Efficacy, and Tolerability of Low-Dose Diclofenac Epolamine Soft Capsules in Acute, Mild, or Moderate Musculoskeletal Pain: A Prospective Open-Label, Single-Arm Interventional Study

INTRODUCTION

The use of oral nonsteroidal anti-inflammatory drugs (NSAIDs) for acute musculoskeletal pain should be at the lowest effective dosage and for the shortest duration to minimize potential adverse effects. This study evaluated treatment satisfaction, effectiveness, and tolerability of a low-dose diclofenac epolamine 12.5-mg soft capsule formulation (DHEP 12.5-mg capsules) using patient-reported outcome measures in a real-life setting over a short period (3 days) in subjects with mild-to-moderate acute musculoskeletal pain.

METHODS

A prospective, open-label, phase IV clinical study in adult outpatients at hospital clinic departments/general practitioner's clinics at eight sites in Italy. The primary efficacy variable was the degree of satisfaction with treatment at 72 ± 7 h after initiation of treatment, assessed using the Overall Satisfaction Question of the Pain Treatment Satisfaction Scale (PTSS) and described by classic descriptive statistics. Secondary objectives were to evaluate the analgesic effect after the first administration and over time; the time to and satisfaction with the onset of pain relief, amount of and duration of pain relief; pain intensity differences over time; and safety and tolerability. The investigator's satisfaction with the treatment was also assessed. Subjects initially took 1-2 capsules of the study treatment and then one or two soft capsules every 4-6 h according to their needs. Not more than six soft capsules were to be taken in any 24-h period.

RESULTS

A total of 182 subjects (mean age, 56.2 years; 54.4% female) took ≥ 1 dose of DHEP capsule and were included in the full analysis set. The most common musculoskeletal conditions were arthralgia (39.0%) and low back pain (23.1%). All subjects completed the study, and 165/182 (90.7%, 95% CI 0.86, 0.95) were satisfied or very satisfied with the treatment at 72 ± 7 h after the first dose (primary efficacy variable). Similar percentages were recorded for treatment satisfaction concerning other efficacy parameters. The onset of the analgesic effect was rapid, with complete pain relief reached after a mean of 49.45 min. Investigators rated their overall treatment satisfaction as 92.9%. Treatment was well tolerated.

CONCLUSIONS

The low-dose (12.5 or 25 mg) oral diclofenac epolamine soft capsules formulation exerted rapid, effective, and safe analgesic activity in patients with mild-to-moderate musculoskeletal pain, with subjects' overall satisfaction with treatment more than 90%.

TRIAL REGISTRATION

EudraCT Number: 2018-004886-15 (Study 18I-Fsg08). Registered 04/09/2018.

Conjugation with Tris Decreases the Risk of Ketoprofen-Induced Mucosal Damage and Reduces Inflammation-Associated Methane Production in a Rat Model of Colitis

We have designed a new compound from the non-steroidal anti-inflammatory drug (NSAID) ketoprofen (Ket) and 2-amino-2-(hydroxymethyl)-1,3-propanediol (Tris) precursors, with the aim to reduce the gastrointestinal (GI) side effects of NSAID therapies. We investigated mucosal reactions in a standard rat model of colitis together with methane generation as a possible indicator of pro-inflammatory activation under this condition (approval number: V./148/2013). Whole-body methane production (photoacoustic spectroscopy) and serosal microcirculation (intravital videomicroscopy) were measured, and mucosal damage was assessed (conventional histology; in vivo laser-scanning endomicroscopy). Inflammatory markers were measured from tissue and blood samples. Colitis induced an inflammatory response, morphological colonic damage and increased methane output. Ket treatment lowered inflammatory activation and colonic mucosal injury, but macroscopic gastric bleeding and increased methane output were present. Ket-Tris reduced inflammatory activation, methane emission and colonic mucosal damage, without inducing gastric injury. Conjugation with Tris reduces the GI side effects of Ket and still decreases the inflammatory response in experimental colitis. Methane output correlates with the mucosal inflammatory response and non-invasively demonstrates the effects of anti-inflammatory treatments.

Spanish version of the pain beliefs questionnaire: Translation, cross-cultural adaptation, validation, and psychometric properties in a working population

BACKGROUND

Chronic musculoskeletal pain is a major health problem and a common cause of disability in the workplace. Beliefs related to musculoskeletal pain may influence its onset and perpetuation. Consequently, tools designed to identify potentially harmful beliefs are needed. However, the Pain Beliefs Questionnaire (PBQ) is not available for individuals speaking European-Spanish.

OBJECTIVES

To translate and culturally adapt the original English version of the PBQ into European-Spanish and evaluate its psychometric properties among Spanish workers with and without chronic musculoskeletal pain.

DESIGN

Study on measurement properties.

METHODS

A translation and cultural adaptation process was based on a forward-backward translation process. One hundred fifty-one active workers were included. Participants completed the PBQ (composed of the organic and psychological subscales), the Pain Catastrophizing Scale (PCS), and the Hospital Anxiety and Depression Scale (HADS). Finally, thirty participants completed the PBQ again two weeks later for test-retest reliability.

RESULTS

The PBQ showed adequate internal consistency (Cronbach's alpha: 0.72-0.73), good item response stability (weighted Kappa: 0.65-0.90), and reliability (Intraclass Correlation Coefficient: 0.72-0.80). A positive correlation was found between the PCS and the organic subscale (r = 0.403). However, no significant correlations were found between the HADS and the PBQ subscales. Workers with chronic musculoskeletal pain showed greater scores in the organic subscale and lower scores in the psychological subscale than workers without pain.

CONCLUSION

The Spanish version of the PBQ was linguistically accurate and acceptable for use by workers with and without musculoskeletal pain.

Comparison of the effects of ketoprofen and ketoprofen lysine salt on the Wistar rats' nervous system, kidneys and liver after ethyl alcohol intoxication

Side effects of Ketoprofen and ketoprofen lysine salt (KLS) may be inter alia from the central nervous system, kidneys and liver. After binge drinking people often use ketoprofen, which increases the risk for the occurrence of side effects. The aim of the study was to compere effects of ketoprofen and KLS on the nervous system, kidneys and liver after ethyl alcohol intoxication. There were 6 groups of 6 male rats which received: ethanol; 0.9%NaCl; 0.9%NaCl and ketoprofen; ethanol and ketoprofen; 0.9%NaCl and KLS; ethanol and KLS. On day 2, the motor coordination test on a rotary rod and memory and motor activity test in the Y-maze were performed. Hot plate test was performed on day 6. After euthanasia brains, livers and kidneys were taken to histopathological tests. Motor coordination was significant worse in group 5 vs 1,3, p 0.05. Spontaneous motor activity of group 6 was significant better than that of groups 1,5. Pain tolerance of group 6 was significant worse than that of groups 1,4,5. Liver and kidney mass were significantly lower in group 6 vs group 3,5 and vs group 1,3, respectively. The histopathologic examination of the brains and kidneys revealed normal picture in all groups, without signs of inflammation. In the histopathologic examination of the livers in one animal in group 3 some of the specimens showed perivascular inflammation. After alcohol ketoprofen is a better painkiller than KLS. Spontaneous motor activity is better after KLS after alcohol. Both drugs have a similar effect on the kidneys and liver.

Isolation of Murine Articular Chondrocytes for Single-Cell RNA or Bulk RNA Sequencing Analysis

Single-cell RNA sequencing (scRNA-seq) is highly dependent on cellular composition of a tissue of interest. For soft tissues, isolation of individual cells from the extracellular matrix (ECM) while retaining viability and minimizing degradation within subpopulations is well established. In contrast, articular cartilage is comprised of sparsely positioned chondrocytes embedded within a dense ECM high in glycosaminoglycans, proteoglycans, and many fibrous proteins such as collagens, elastin, fibronectin, and laminins. This densely packed ECM makes it difficult to isolate viable chondrocytes for further single-cell analysis. This protocol highlights a successful technique optimized for isolating chondrocytes from the articulated joints of rodent animal models using a series of enzymatic digestions and chondrocyte enrichment using a double negative selection process through florescence-activated cell sorting (FACS).

Phytochemical Characterization, Antioxidant and Anti-Inflammatory Effects of Cleome arabica L. Fruits Extract against Formalin Induced Chronic Inflammation in Female Wistar Rat: Biochemical, Histological, and In Silico Studies

In recent decades, the use of herbs and plants has been of great interest, as they have been the sources of natural products, commonly named as bioactive compounds. In specific, the natural compounds from the Capparaceae family which has been proved to have antioxidant, anti-inflammatory, antimicrobial and anti-carcinogenic activities, by several studies. Cleome arabica L. (CA) specie is the most used medicinal plants in Tunisia and elsewhere in North African countries for treatment of various diseases including diabetes, rheumatism, inflammation, cancer, and digestive disorders. The current work was undertaken to estimate the total phenolic, flavonoid and condensed tannin contents, to identify and quantify the polyphenolic compounds, and to evaluate the antioxidant and the anti-inflammatory proprieties of CA fruits extract against formalin induced chronic inflammation in Female Wistar rats. In fact, the antioxidant activity was tested by Diphenyl-1-Picrylhydrazyl free radical scavenging (DPPH), Ferric reducing antioxidant power (FRAP) and Nitric Oxide radical (NO·). Anti-inflammatory effect of fruits extract was examined using formalin (2%) induced paw edema in rats. Molecular docking tools were used to investigate the interaction of some compounds from CA fruits extract with the cyclooxygenase-2 (COX-2) target protein. Our results showed that, the total phenolic, flavonoid and tannins contents, which were assessed by the Folin-Ciocalteu, Quercetin, and Catechin methods, respectively, were 230.22 mg gallic acid equivalent/g dry weight (mg GAE/g DW), 55.08 mg quercetin equivalent/g dry weight (QE/g DW) and 15.17 mg catechin equivalents/g dry weight (CatE/g DW), respectively. HPLC analysis revealed the presence of five polyphenolic compounds whose catechin was found to be the most abundant compounds. The antioxidant activity of extract was quantified by DPPH, FRAP and NO· tests and IC₅₀ reached the values of 3.346 mg/mL, 2.306 and 0.023 mg/mL, respectively. Cleome fruits ameliorated the histological integrity of the skin and alleviated the disruptions in hematological parameters (WBC, LYM, RBC, and HGB), inflammatory cytokines (IL-1β, IL-6, TNF-α), C-reactive protein, and some oxidative stress markers (TBARS (-49%) and AOPP (-42%) levels, SOD (+33%) and GPx (+75%) activities, and GSH (+49%) content) induced by formalin injection. Moreover, the in-silico investigation had shown that CA fruits extract compounds have a stronger interaction with COX-2 active site, more than the reference drug "indomethacin" (two H-bonds). Our research gives pharmacological backing to the healthcare utilization of Cleome plant in the treatment of inflammatory diseases and oxidative harm.

Risk-based stratified primary care for common musculoskeletal pain presentations: qualitative findings from the STarT MSK cluster randomised controlled trial

BACKGROUND

The STarT MSK cluster randomised controlled trial (RCT) investigated the clinical- and cost-effectiveness of risk-based stratified primary care versus usual care for patients with back, neck, shoulder, knee or multi-site pain. Trial quantitative results showed risk-based stratified care was not superior to usual care for patients' clinical outcomes, but the intervention led to some changes in GP clinical decision-making. This paper reports a linked qualitative study exploring how risk-based stratified care was perceived and used in the trial, from the perspectives of clinicians and patients.

METHODS

Semi-structured interviews were conducted with 27 patients, and focus groups and interviews with 20 clinicians (GPs and physiotherapists) in the intervention arm of the trial. Data were analysed thematically and findings explored using Normalisation Process Theory (NPT) and the COM-B model.

MAIN FINDINGS

Risk-based stratified care (subgrouping and matching treatments) was found to have 'coherence' (i.e. made sense) to several clinicians and patients, in that it was well-integrated in practice, and supported clinical decision-making. However, for some GPs stratified care was less 'meaningful', as the risk-stratification tool did not fit with usual ways of consulting and added to already time-pressured consultations. GPs reported giving more patients written information/advice due to easier access to electronic information leaflets through the trial template and were motivated to refer patients to physiotherapy as they believed the trial resulted in faster physiotherapy access (although this was not the case). Patients and clinicians reported that risk-based stratified care influenced conversations in the consultation, prompting greater attention to psychosocial factors, and facilitating negotiation of treatment options. Physiotherapists saw benefits in receiving information about patients' risk subgroup on referral forms.

CONCLUSION

These findings provide context for interpreting some of the trial outcomes, particularly in relation to changes in clinical decision-making when risk-based stratified care was used. Findings also indicate potential reasons for lack of GP engagement with risk-based stratified care. Positive outcomes were identified that were not captured in the quantitative data, specifically that risk-based stratified care positively influenced some GP-patient conversations and facilitated negotiation of treatment options.

TRIAL REGISTRATION

ISRCTN15366334 (26/04/2016).

Patient and clinician perspectives of online-delivered exercise programmes for chronic musculoskeletal conditions: protocol for a systematic review

Background: Despite the growing economic and social impact of chronic musculoskeletal (MSK) conditions, there has been low uptake of clinical guidelines for management, owing partly to the negative perceptions of patients and clinicians of their appropriateness and accessibility. Online-delivered exercise programmes (ODEPs) offer an alternative that can reduce costs and offer convenience for those with mobility limitations. As such, investigating participants’ perceptions of such programmes provides insight into the complexity and interplay of factors associated with uptake and optimization of implementation strategies. Objectives: This study aims to systematically review of the literature of patients’ and clinicians’ perceptions of ODEPs for chronic MSK conditions. Methods: To ensure the likelihood of identifying all relevant published articles, the following databases will be searched from inception to end of the project: CINAHL Complete, MEDLINE, SportDiscus, AMED, APA PsycArticles, APA PsycInfo, Scopus, and Cochrane Library. Included articles will qualitatively and/or quantitatively report the perceptions of participants of ODEPs for chronic MSK conditions. ODEPs are defined as either (a) synchronous, users can exchange information simultaneously, or (b) asynchronous, with at least one synchronous feature, or (c) neither, where the authors investigate a user’s past experiences and/or likelihood of participating in such a programme. Article screening and quality assessment using the Critical Appraisal Skills Programme (CASP) checklists will be performed by two independent reviewers. All findings from included articles will be extracted and coded using a thematic synthesis approach. Discussion: It is important to offer diverse resources to address the growing public health burden of chronic MSK conditions. This study will explore patients and clinicians’ perceptions of ODEPs including needs, appropriateness and acceptability. Our findings could be used by policy makers, clinicians, and researchers to generate new models of care that could influence the uptake and long-term sustainability of ODEPs for chronic MSK conditions. PROSPERO registration: CRD42021273773.

Chronic Pain in Musculoskeletal Diseases: Do You Know Your Enemy?

Musculoskeletal pain is a condition that characterises several diseases and represents a constantly growing issue with enormous socio-economic burdens, highlighting the importance of developing treatment algorithms appropriate to the patient’s needs and effective management strategies. Indeed, the algic condition must be assessed and treated independently of the underlying pathological process since it has an extremely negative impact on the emotional and psychic aspects of the individual, leading to isolation and depression. A full understanding of the pathophysiological mechanisms involved in nociceptive stimulation and central sensitization is an important step in improving approaches to musculoskeletal pain. In this context, the bidirectional relationship between immune cells and neurons involved in nociception could represent a key point in the understanding of these mechanisms. Therefore, we provide an updated overview of the magnitude of the musculoskeletal pain problem, in terms of prevalence and costs, and summarise the role of the most important molecular players involved in the development and maintenance of pain. Finally, based on the pathophysiological mechanisms, we propose a model, called the “musculoskeletal pain cycle”, which could be a useful tool to counteract resignation to the algic condition and provide a starting point for developing a treatment algorithm for the patient with musculoskeletal pain.

Virtual Reality Assisted Non-Pharmacological Treatments in Chronic Pain Management: A Systematic Review and Quantitative Meta-Analysis

Virtual reality (VR) is a developing technology that has recently attracted the attention of healthcare practitioners. Recently, VR systems have been used to treat pain symptoms. The present study aims to evaluate the VR effectiveness on chronic pain management. A systematic literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords were used to discover the potentially eligible studies. The primary focus of the present investigation was to evaluate the possible effect of VR-assisted treatments on chronic pain, especially in the commonly occurring low back and neck pain. Nine studies reporting randomized controlled trials were included in the present study. VR-mediated interventions demonstrated significant improvement for pain symptoms in patients experiencing chronic pain. In addition, VR-mediated therapy decreased pain intensity and disability in the case of chronic neck pain compared to control conditions. However, the VR interventions showed a statistically non-significant improvement in chronic low back pain when experimental groups were compared with controls. VR therapy positive effect on chronic pain did not differ from the one reported for other types of interventions for pain management, as physical exercise and laser therapy. Taken together, these findings showed that currently available lines of evidence on the effect of VR-mediated therapy in chronic pain management, despite pointing towards possible therapeutical benefits of the VR-based intervention, are overall inconclusive and that more research on VR-assisted therapy for chronic pain is needed.

Lipidomic Profiling Identifies Serum Lipids Associated with Persistent Multisite Musculoskeletal Pain

Lipid mediators have been suggested to have a role in pain sensitivity and response; however, longitudinal data on lipid metabolites and persistent multisite musculoskeletal pain (MSMP) are lacking. This study was to identify lipid metabolic markers for persistent MSMP. Lipidomic profiling of 807 lipid species was performed on serum samples of 536 participants from a cohort study. MSMP was measured by a questionnaire and defined as painful sites ≥4. Persistent MSMP was defined as having MSMP at every visit. Logistic regression was used with adjustment for potential confounders. The Benjamini–Hochberg method was used to control for multiple testing. A total of 530 samples with 807 lipid metabolites passed quality control. Mean age at baseline was 61.54 ± 6.57 years and 50% were females. In total, 112 (21%) of the participants had persistent MSMP. Persistent MSMP was significantly associated with lower levels of monohexosylceramide (HexCer)(d18:1/22:0 and d18:1/24:0), acylcarnitine (AC)(26:0) and lysophosphatidylcholine (LPC)(18:1 [sn1], 18:2 [sn1], 18:2 [sn2], and 15-MHDA[sn1] [104_sn1]) after controlling for multiple testing. After adjustment for age, sex, body mass index, comorbidities, and physical activity, HexCer(d18:1/22:0 and d18:1/24:0) and LPC(15-MHDA [sn1] [104_sn1]) were significantly associated with persistent MSMP [Odds Ratio (OR) ranging from 0.25–0.36]. Two lipid classes—HexCer and LPC—were negatively associated with persistent MSMP after adjustment for covariates (OR = 0.22 and 0.27, respectively). This study identified three novel lipid signatures of persistent MSMP, suggesting that lipid metabolism is involved in the pathogenesis of persistent pain.

Gastrointestinal and cardiovascular adverse events associated with NSAIDs

INTRODUCTION

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most prescribed pharmacological groups, especially in elderly patients.

AREAS COVERED

The main GI and CV adverse events associated with NSAID use are reviewed. Risk factors and prophylactic strategies are also covered.

EXPERT OPINION

COX-2 selective agents are safer to the GI tract but have a worst CV profile. On the contrary, naproxen seems safer for CV system, but it is one of the NSAIDs with higher GI toxicity. Co-therapy with aspirin reduces the GI benefits of COX-2 selective agents, whereas ibuprofen and naproxen may neglect the antiplatelet effect of aspirin. NSAIDs increase the risk of both upper and lower GI complications. Co-therapy with PPI reduces the risk of upper but not lower GI complications, and seems to induce dysbiosis in the small bowel, which may be implicated in the damage induced by NSAIDs. Celecoxib, a COX-2 selective agent, seems safer for both the upper and the lower GI tract. Prescription of type and dose of NSAIDs must be individualized based on the stratification of the CV and GI risk of patients.