Economic Burden of Back and Neck Pain: Effect of a Neuropathic Component

Physical and psychological predictors for persistent and recurrent non-specific neck pain: a protocol for a systematic review and meta-analysis

INTRODUCTION

Both physical adaptations (e.g., altered neck kinematics and muscle coordination) and psychological features are common in people presenting with neck pain (NP). Additionally, both physical and psychological features may be relevant for the development of persistent or recurrent NP. Although a number of original studies have reported this, currently there is no available systematic review reporting physical and psychological predictors for the recurrence of non-specific NP.

METHODS AND ANALYSIS

The report of this systematic review protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols. Studies will be searched from PubMed, MEDLINE, EMBASE, CINAHL Plus, PsycINFO and grey literature. Title, abstract and full-text screening, data extraction and risk of bias assessment will be conducted by two independent reviewers. Studies investigating the prediction of persistent or recurrent NP from physical or psychological predictors will be included. Physical predictors will be commonly reported objective measures including neck kinematics, measures of muscle activity and sensory function. Psychological predictors will include variables such as kinesiophobia, self-efficacy, pain coping strategies and quality of life. The main outcomes of interest are the Neck Disability Index, presence of pain recurrence, as well as pain intensity and frequency during a persistent or recurrent NP episode. Observational cohort studies will be included, and studies on both single-factor and multifactor predictions or associations will be investigated. Risk of bias will be assessed using the Quality in Prognosis Studies (QUIPS) tool. The certainty of evidence will be rated using Grading of Recommendations Assessment, Development and Evaluation (GRADE). A random-effect meta-analysis will be conducted if methodological and clinical homogeneity is deemed satisfactory.

ETHICS AND DISSEMINATION

Ethical approval will not be required for this review as there is no primary data collection involving humans. The findings will be published in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42024596844.

Are combined conservative interventions effective in reducing pain, disability and/or global rating of pain in people with sciatica with known neuropathic pain mechanisms?

PURPOSE

National Clinical Guidelines recommend an integrated combination of conservative management strategies for sciatica. However, the efficacy of such combinations have not been established. The purpose of this systemic review with meta-analysis was to determine the efficacy of combined conservative (non-pharmacological) compared to single interventions for people with sciatica with a confirmed neuropathic mechanism.

METHODS

The systematic review was registered on PROSPERO CRD42023464011. The databases included were the Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL (EBSCO), Embase, PubMed, Scopus, APA PsycINFO, and grey literature sources from inception until January 2024. Inclusion criteria were randomized controlled trials that assessed the effectiveness of combined non-pharmacological interventions in comparison to a control intervention among individuals with sciatica of a neuropathic origin identified using diagnostic or clinical tests. Primary outcomes were back pain, leg pain, and disability. The secondary outcome was global rating of change. Study selection, data extraction and risk of bias assessment (using Cochrane ROB2) were assessed by two reviewers. Meta-analysis was performed with a random effects model with inverse variance weighting used for the metanalysis using SPSS v 29.

RESULTS

3,370 articles were identified, of which 6 were included. Risk of bias was high in one study and had some concerns in the remaining 5 studies for each outcome measure. There was evidence of efficacy for combined interventions for back pain in the short-and long-term (SMD - 0.56 (95% CI -0.91, -0.22, p = 0.01, I2 = 0.2; SMD - 0.44 (95% CI -0.79, -0.1, p = 0.03, I2 = 0.00), and for disability in the short term (SMD - 0.48 (95% CI -0.92, -0.04, p = 0.04, I2 = 0.72). There was no evidence of efficacy for leg pain at any time point (( short term SMD - 0.45 (95% CI -0.91, 0.02, p = 0.06, I2 = 0.65), medium term (SMD - 0.29 (95% CI -1.12, 0.54, p = 0.35, I2 = 0.82), long term (SMD - 0.40 (95% CI -1.23, 0.44, p = 0.18, I2 = 0.57).Certainty of evidence ranged from very low to moderate.

CONCLUSION

There are few studies that have combined conservative (non-pharmacological) interventions for the management of sciatica with a neuropathic component pain mechanism, as recommended by National Clinical Guidelines. This review indicates that combining conservative (no-pharmacological) management strategies appeared more effective than single interventions for the outcomes of low back pain in the short and long term, and for disability in the short term, but not for leg pain at any time point. The overall low certainty of evidence, suggests that future studies with more robust methodologies are needed.

Neck Pain, Mental Status, and Associated Factors Among Hospital Secretaries: A Cross-Sectional Study From Turkey

Introduction

Neck disorders occur in the presence of various risk factors. Determining the cause-effect relationship is highly important in treating existing health problems. Our study aimed to determine the relationship between neck pain and mental status and the factors affecting them in hospital secretaries.

Materials and Methods

The study was cross-sectional. A total of 427 people who had been working as hospital secretaries at Gazi University Medical Faculty Hospital for at least one year were included in the study. Sociodemographic characteristics, working conditions, psychopathology levels, and the presence of neck pain were questioned. The study was conducted with 354 (82.9%) people.

Results

34.3% of the hospital secretaries had neck pain, and 26.3% required psychiatric evaluation. There was a statistically significant (p<0.001) difference in neck pain according to gender, adjustability of the chair, accessibility of the tools, and the need for psychiatric evaluation. Data was collected during November 2022. Those who did neck exercises during the study period had lower mean scores on the General Health Questionnaire-12 than those who did not, and the difference was statistically significant (p<0.001). According to the General Health Questionnaire-12 scores and the Bournemouth Neck Pain Questionnaire Scale, there is a significant (p<0.001), positive, and moderate (r=0.481) correlation between the frequency of mental problems and neck pain disability levels.

Conclusion

The relationship between the need for psychiatric status evaluation and neck pain is striking. A significant proportion of hospital secretaries complain of neck pain, work in non-ergonomic conditions, and need psychiatric evaluation. The study's results underline the necessity of targeted workplace interventions and wellness procedures, highlighting the need to implement ergonomic improvements, promote regular exercise regimes, and provide psychosocial support services to improve the general well-being of hospital secretaries and develop a better working environment.

Relationship between neck kinematics and neck dissability index. An approach based on functional regression

Numerous studies use numerical variables of neck movement to predict the level of severity of a pathology. However, the correlation between these numerical variables and disability levels is low, less than 0.4 in the best cases, even less in subjects with nonspecific neck pain. This work aims to use Functional Data Analysis (FDA), in particular scalar-on-function regression, to predict the Neck Disability Index (NDI) of subjects with nonspecific neck pain using the complete movement as predictors. Several functional regression models have been implemented, doubling the multiple correlation coefficient obtained when only scalar predictors are used. The best predictive model considers the angular velocity curves as a predictor, obtaining a multiple correlation coefficient of 0.64. In addition, functional models facilitate the interpretation of the relationship between the kinematic curves and the NDI since they allow identifying which parts of the curves most influence the differences in the predicted variable. In this case, the movement's braking phases contribute to a greater or lesser NDI. So, it is concluded that functional regression models have greater predictive capacity than usual ones by considering practically all the information in the curve while allowing a physical interpretation of the results.

Association between socioeconomic status and treatment in patients with low back or neck pain: a population-based cross-sectional study in South Korea

INTRODUCTION

Socioeconomic status affects the treatment of patients with low back pain and/or neck pain. We examined the relationship between socioeconomic status (occupation and household income level) and treatments such as chronic opioid use and interventional procedures among these patients.

METHODS

Data from the National Health Insurance Service database in South Korea were used in this population-based cross-sectional study. Approximately 2.5% of adult patients diagnosed with low back pain and/or neck pain between 2010 and 2019 were selected using a stratified random sampling technique and included in the analysis.

RESULTS

We analyzed the data of 5,861,007 patients with low back pain and/or neck pain in total. Among them, 4.9% were chronic opioid users and 17.7% underwent interventional procedures. Healthcare workers and unemployed individuals had 18% lower and 6% higher likelihood of chronic opioid use compared with office workers, respectively. Those with a very low household income had 18% higher likelihood of chronic opioid use than those with a poor household income. Other workers and unemployed individuals had 4% and 8% higher likelihood of undergoing interventional procedures than office workers, respectively. Healthcare workers had 5% lower likelihood of undergoing interventional procedures than office workers. Patients with middle, high, and very poor household incomes had a higher likelihood of undergoing interventional procedures, while those in the very high household income group had a lower likelihood of undergoing interventional procedures than those with poor household incomes.

CONCLUSIONS

Socioeconomic status factors are associated with treatment in patients with low back pain and/or neck pain.

Adaptation and Limitations of painDETECT Questionnaire Score Approach Before and After Posterior Cervical Decompression Surgery

BACKGROUND

The painDETECT questionnaire (PDQ) is one of the available screening tools for neuropathic pain (NeP), with a cut-off score of 13. This study aimed to investigate changes in PDQ scores in patients undergoing posterior cervical decompression surgery for degenerative cervical myelopathy (DCM).

METHODS

Patients with DCM undergoing cervical laminoplasty or laminectomy with posterior fusion were recruited. They were asked to complete a booklet questionnaire including PDQ and Numerical Rating Scales (NRS) for pain at baseline and one year after surgery. Patients with a preoperative PDQ score ≥13 were further investigated.

RESULTS

A total of 131 patients (mean age = 70.1 years; 77 male and 54 female) were analyzed. After posterior cervical decompression surgery for DCM, mean PDQ scores decreased from 8.93 to 7.28 (P = 0.008) in all patients. Of the 35 patients (27%) with preoperative PDQ scores ≥13, mean PDQ changed from 18.83 to 12.09 (P < 0.001). Comparing the NeP improved group (17 patients with postoperative PDQ scores ≤12) with the NeP residual group (18 patients with postoperative PDQ scores ≥13), the NeP improved group showed less preoperative neck pain (2.8 vs. 4.4, P = 0.043) compared to the NeP residual group. There was no difference in the postoperative satisfaction rate between the two groups.

CONCLUSIONS

Approximately 30% of patients exhibited preoperative PDQ scores ≥13, and about half of these patients demonstrated improvements to below to the cut-off value for NeP after posterior cervical decompression surgery. The PDQ score change was relatively associated with preoperative neck pain.

Recommendations for terminology and the identification of neuropathic pain in people with spine-related leg pain. Outcomes from the NeuPSIG working group

ABSTRACT

Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.

Impact assessment of e-trainings in occupational safety and health: a literature review

BACKGROUND

Implementing workplace preventive interventions reduces occupational accidents and injuries, as well as the negative consequences of those accidents and injuries. Online occupational safety and health training is one of the most effective preventive interventions. This study aims to present current knowledge on e-training interventions, make recommendations on the flexibility, accessibility, and cost-effectiveness of online training, and identify research gaps and obstacles.

METHOD

All studies that addressed occupational safety and health e-training interventions designed to address worker injuries, accidents, and diseases were chosen from PubMed and Scopus until 2021. Two independent reviewers conducted the screening process for titles, abstracts, and full texts, and disagreements on the inclusion or exclusion of an article were resolved by consensus and, if necessary, by a third reviewer. The included articles were analyzed and synthesized using the constant comparative analysis method.

RESULT

The search identified 7,497 articles and 7,325 unique records. Following the title, abstract, and full-text screening, 25 studies met the review criteria. Of the 25 studies, 23 were conducted in developed and two in developing countries. The interventions were carried out on either the mobile platform, the website platform, or both. The study designs and the number of outcomes of the interventions varied significantly (multi-outcomes vs. single-outcome). Obesity, hypertension, neck/shoulder pain, office ergonomics issues, sedentary behaviors, heart disease, physical inactivity, dairy farm injuries, nutrition, respiratory problems, and diabetes were all addressed in the articles.

CONCLUSION

According to the findings of this literature study, e-trainings can significantly improve occupational safety and health. E-training is adaptable, affordable, and can increase workers' knowledge and abilities, resulting in fewer workplace injuries and accidents. Furthermore, e-training platforms can assist businesses in tracking employee development and ensuring that training needs are completed. Overall, this analysis reveals that e-training has enormous promise in the field of occupational safety and health for both businesses and employees.

The Choice of Spinal Cord Stimulation vs Targeted Drug Delivery in the Management of Chronic Pain: Validation of an Outcomes Predictive Formula

OBJECTIVE

In 2020, Mekhail et al published a formula that predicted the likelihood of a successful outcome for those who undergo spinal cord stimulation (SCS) for long-term pain management, based on retrospectively collected clinical and demographic data from one major medical center. The aim of this study is to validate such a predictive formula, prospectively, in a cohort of patients from multiple medical practices that are more representative of real-life clinical practice.

MATERIALS AND METHODS

For the study, 939 patients who underwent successful SCS or targeted drug delivery (TDD) trials at multiple independent medical centers in the USA were enrolled into the Medtronic product surveillance registry data base before they underwent SCS or TDD device implantation, from 2018 to 2020. The registry data were collected prospectively but not specifically for this study. The data examined included demographic information, pain diagnosis, pain scores (visual analog scale [VAS]), Oswestry Disability Index scores, and quality-of-life scores at baseline and six months after implant. Because our goal is to validate the previously published predictive formula, in addition to the outcomes data previously mentioned, we collected the variables necessary for such a task: sex, age, depression, the presence of neuropathic pain, spine-related pain diagnosis, and persistent spinal pain syndrome "post laminectomy syndrome." Spine-related pain diagnosis included subjects with chronic spine pain who never had back surgery and whose pain was not radicular nor neuropathic.

RESULTS

Of 619 patients with SCS, 138 (22%) achieved ≥ 50% reductions of the baseline VAS at six months. The logistic model predicts SCS success with an area under the receiver operating characteristic curve (AUC) of 80% in the current validation data set. Of 320 patients with TDD, 147 (46%) achieved ≥ 50% reduction of the baseline VAS at six months. The logistic model predicts TDD success with an AUC of 78% in the current validation data set.

CONCLUSION

The study provides real life validation of the previously published predictive formula(4).

Factors predicting the transition from acute to persistent pain in people with 'sciatica': the FORECAST longitudinal prognostic factor cohort study protocol

INTRODUCTION

Sciatica is a common condition and is associated with higher levels of pain, disability, poorer quality of life, and increased use of health resources compared with low back pain alone. Although many patients recover, a third develop persistent sciatica symptoms. It remains unclear, why some patients develop persistent sciatica as none of the traditionally considered clinical parameters (eg, symptom severity, routine MRI) are consistent prognostic factors.The FORECAST study (factors predicting the transition from acute to persistent pain in people with 'sciatica') will take a different approach by exploring mechanism-based subgroups in patients with sciatica and investigate whether a mechanism-based approach can identify factors that predict pain persistence in patients with sciatica.

METHODS AND ANALYSIS

We will perform a prospective longitudinal cohort study including 180 people with acute/subacute sciatica. N=168 healthy participants will provide normative data. A detailed set of variables will be assessed within 3 months after sciatica onset. This will include self-reported sensory and psychosocial profiles, quantitative sensory testing, blood inflammatory markers and advanced neuroimaging. We will determine outcome with the Sciatica Bothersomeness Index and a Numerical Pain Rating Scale for leg pain severity at 3 and 12 months.We will use principal component analysis followed by clustering methods to identify subgroups. Univariate associations and machine learning methods optimised for high dimensional small data sets will be used to identify the most powerful predictors and model selection/accuracy.The results will provide crucial information about the pathophysiological drivers of sciatica symptoms and may identify prognostic factors of pain persistence.

ETHICS AND DISSEMINATION

The FORECAST study has received ethical approval (South Central Oxford C, 18/SC/0263). The dissemination strategy will be guided by our patient and public engagement activities and will include peer-reviewed publications, conference presentations, social media and podcasts.

TRIAL REGISTRATION NUMBER

ISRCTN18170726; Pre-results.

The Effectiveness of Neuromobilization in Patients With Cervical Radiculopathy: A Systematic Review With Meta-Analysis

CONTEXT

Neuromobilization exercises (NE) could be a useful therapeutic tool to induce analgesia and increase function and range of motion (ROM) in patients with musculoskeletal pathologies with neuropathic components; however, the effectiveness of this intervention in patients with cervical radiculopathy (CR) is unknown.

OBJECTIVE

To determine the effectiveness of NE in CR on pain, function, and ROM.

DESIGN

Systematic review and meta-analysis.

EVIDENCE ACQUISITION

An electronic search was performed in the MEDLINE, Scopus, PEDro, and EBSCO databases from inception until June 2022. The authors included randomized clinical trials that evaluated the effectiveness of NE against control groups or other interventions that aimed to treat patients with CR.

EVIDENCE SYNTHESIS

Seven clinical trials met the eligibility criteria, and for the quantitative synthesis, 5 studies were included. For the studies that compared NE with a control group, the standardized mean difference for pain was -1.33/10 (95% confidence interval [CI], -1.80 to -0.86; P < .01; I2 = 0%), for function with the Neck Disability Index was -1.21/50 (95% CI, -1.67 to -0.75; P < .01; I2 = 0%), and for neck flexion and extensions was 0.66 (95% CI, 0.23 to 1.10; P < .01; I2 = 0%) and 0.47 (95% CI, 0.04 to 0.90; P < .01; I2 = 0%), respectively, with evidence of clinical effectiveness. These findings were based on moderate-quality evidence according to the Grading of Recommendation, Assessment, Development, and Evaluation rating. In studies that compared NE with other interventions, the meta-analysis failed to demonstrate the statistical or clinical superiority of NE.

CONCLUSIONS

Moderate quality of evidence suggests that NE may be superior to no treatment for pain, function, and ROM in patients with CR. In contrast, NE are not superior to other interventions in the same outcomes, based on low- to very low-quality evidence. More high-quality research is needed to assess the consistency of these results.

Responsiveness of the German version of the Neck Disability Index in chronic neck pain patients: a prospective cohort study with a seven-week follow-up

Background

The need for an efficient and feasible strategy to deal with neck pain has a high priority for many countries. Validated assessment tools like the Neck Disability Index (NDI) to evaluate the functional status of a neck pain patient are urgently needed to treat and to follow-up patients purposefully. A German version (NDI-G) was shown to be valid and reliable, but has so far not been tested for responsiveness. The aim of this study was to evaluate the NDI-G`s responsiveness.

Methods

This was a prospective cohort study with a seven-week follow-up. Fifty chronic neck pain patients filled out NDI-G twice. Additionally, the Patients’ Global Impression of Change score (PGIC) was assessed at follow-up. Wilcoxon and Spearman tests were used to assess direction and strength of the association between the change in NDI-G and PGIC. The receiver operating characteristics method and the area under the curve (AUC) were calculated to assess sensitivity and specificity of the NDI-G change over time.

Results

The Wilcoxon test showed statistically significant differences for NDI-G at baseline and follow-up in the total sample, the “clinically improved” and “clinically not improved” subgroups as indicated in the PGIC. Spearman test resulted in a moderate correlation between the NDI-G and the PGIC (rS = -0.53, p = 0.01) at follow-up. AUC showed an acceptable discrimination [AUC = 0.78 (95% confidence interval 0.64 – 0.91)] of the NDI-G, with a cutoff score of 1.5, between clinically improved and clinically not improved patients, based on the PGIC.

Conclusions

The NDI-G is responsive to change in chronic neck pain. Together with the results of a previous study on its validity and reliability, the NDI-G can be recommended for research and clinical settings in patients with neck pain in German speaking countries.

Trial registration

NCT02676141. February 8, 2016.

Classification criteria for cervical radiculopathy: An international e-Delphi study

BACKGROUND

Establishing a set of uniform classification criteria (CC) for cervical radiculopathy (CR) is required to aid future recruitment of homogenous populations to clinical trials.

OBJECTIVES

To establish expert informed consensus on CC for CR.

DESIGN

A pre-defined four round e-Delphi study in accordance with the guidance on Conducting and Reporting Delphi Studies.

METHODS

Individuals with a background in physiotherapy who had authored two or more peer-reviewed publications on CR were invited to participate. The initial round asked opinions on CC for CR. Content analysis was performed on round one output and a list of discrete items were generated forming the round two survey. In rounds two to four, participants were asked to rate the level of importance of each item on a six-point Likert scale. Data were analysed descriptively using median, interquartile range and percentage agreement. Items reaching pre-defined consensus criteria were carried forward to the next round. Items remaining after the fourth round constituted expert consensus on CC for CR.

RESULTS

Twelve participants participated with one drop out. The final round identified one inclusion CC and 12 exclusion CC. The inclusion CC that remained achieved 82% agreement and was a cluster criterion consisting of radicular pain with arm pain worse than neck pain; paraesthesia or numbness and/or weakness and/or altered reflex; MRI confirmed nerve root compression compatible with clinical findings.

CONCLUSIONS

The CC identified can be used to inform eligibility criteria for future CR trials although caution should be practiced as consensus on measurement tools requires further investigation.

Predictors of neck disability among undergraduate students: A cross-sectional study

BACKGROUND: Many cross-sectional studies have examined the predictors of neck pain among adolescents and working-age populations, but there are limited studies included undergraduate students. OBJECTIVE: To investigate the predictors of neck disability among undergraduate students. METHODS: A cross-sectional study using a self-administered online survey. Students completed the survey that included socio-demographic factors, academic-related factors, health and lifestyle factors, and standardized questionnaires including Neck Disability Index (NDI), 12-Item Short-Form Health Survey (SF-12), Depression Anxiety Stress Scales (DASS-21), and Pittsburgh Sleep Quality Index (PSQI). Students who reported an NDI score higher than 15 were considered as having a neck disability. A multivariable logistic regression model was used to identify the significant predictors of neck disability. RESULTS: Of all students (n = 1292), 20.8% reported neck disability. Among all possible predictors, students’ major satisfaction (OR 1.46 [95% CI 1.06–2.01]; p = 0.019), DASS-21 anxiety score (OR 1.06 [95% CI 1.03–1.09]; p < 0.001), SF-12 total score (OR 0.89 [95% CI 0.86–92]; p < 0.001), and PSQI score (OR 1.21 [95% CI 1.15–1.28]; p < 0.001) were the only significant predictors of neck disability. CONCLUSIONS: Increased levels of academic stressors and anxiety, and decreased levels of quality of life and sleep quality are associated with increased neck disability among undergraduate students.

Cross-Sectional Evaluation of the Economic Burden on Patients Seeking Surgical Treatment for Chronic Nerve Injuries

INTRODUCTION

Little emphasis has been paid toward characterizing the socioeconomic burdens experienced by patients seeking treatment for chronic nerve injuries. The aim of this study was to characterize the direct and indirect costs faced by patients with chronic nerve injuries and their attendant health care utilization.

MATERIALS AND METHODS

A cross-sectional survey was distributed to all patients (N = 767) from a single nerve surgeon's practice treated for chronic nerve injuries in the ambulatory setting between 2014 and 2020. Data collected included demographics, etiology, comorbidities, duration and severity of symptoms, history of prior medical and interventional treatments, work or school time lost due to injury or treatment, money spent on treatment, and health care utilization.

RESULTS

Of the 767 patients, 209 (27.2%) completed the survey. Average age was 48.8 (SD = 19.1) years, 68.9% female and 31.1% male. Patients with chronic nerve injury reported significant direct costs, indirect costs, and health care utilization associated with their nerve injury symptoms. Direct costs consisted of out-of-pocket spending (68.4% had spent >$1000 per year), physician specialists visits (71.3% had seen at least 4 specialists), and prior interventional procedures intended to address symptoms. Indirect costs included lost time from work or school (24.6% had missed more than 12 months). Health care utilization, represented by annual emergency room visits and hospitalizations related to nerve symptoms, was increased relative to the general population. Detailed statistics are presented in the manuscript.

CONCLUSIONS

Chronic nerve injuries may be associated with a notable socioeconomic burden to the patient, including missed work or school, frequent physician visits and procedures, hospital visits, and out-of-pocket costs. Interdisciplinary algorithms recognizing a role for surgical evaluation in patients with chronic neuropathic pain due to underlying nerve injuries would facilitate future research into whether timely surgical intervention may reduce this economic burden.

Hypnosis As A Therapy for Chronic Lower Back Pain

PURPOSE OF REVIEW

Chronic lower back pain is a crippling condition for the individual and a significant burden on society. It is notoriously challenging to manage despite access to invasive interventions. Understanding hypnosis as a powerful therapeutic adjunct to this condition allows holistic treatment of patients in distress.

RECENT FINDINGS

In addition to classic etiologies of chronic lower back pain, hypnosis has proven to be beneficial in chronic back pain caused by pregnancy, diabetic and HIV neuropathy. Combination of hypnosis with other mind-body techniques such as olfactory stimulation, music therapy and patient education offers further promise to this treatment modality. Our review provides a run-through of the fundamental mechanisms of hypnosis in moderating chronic back pain, its quantifiable benefits, its novel areas of use and its potentials in the future based on the most recent and relevant peer-reviewed literature in order to guide clinicians to better deploy this valuable resource.

First neurological symptoms in degenerative cervical myelopathy: does it predict the outcome?

PURPOSE

Degenerative cervical myelopathy (DCM) is the most common non-traumatic cause of spinal cord dysfunction. Prediction of the neurological outcome after surgery is important. The aim of this study was to analyze the relationship between first symptoms of DCM and the neurological outcome after surgery.

METHODS

A retrospective analysis over a period of 10 years was performed. First symptoms such as cervicobrachial neuralgia, sensory and motor deficits and gait disturbances were evaluated regarding the postoperative neurological outcome. The modified Japanese Orthopedic Association Score (mJOA Score) was used to evaluate neurological outcome.

RESULTS

In total, 411 patients (263 males, 64%) with a median age of 62.6 ± 12.1 years were included. Cervicobrachial neuralgia was described in 40.2%, gait disturbance in 31.6%, sensory deficits in 19% and motor deficits in 9.2% as first symptom. Patients with cervicobrachial neuralgia were significantly younger (median age of 58 years, p = 0.0005) than patients with gait disturbances (median age of 68 years, p = 0.0005). Patients with gait disturbances and motor deficits as first symptom showed significantly lower mJOA Scores than other patients (p = 0.0005). Additionally, motor deficits and gait disturbance were negative predictors for postoperative outcome according to the mJOA Score.

CONCLUSION

Motor deficits and gait disturbances as the first symptom of DCM are negative predictors for postoperative neurological outcome. Nevertheless, patients with motor deficits and gait disturbance significantly profit from the surgical treatment despite poor preoperative mJOA Score.

Reliability and validity of the Istanbul Low Back Pain Disability Index in lumbosacral radiculopathy

BACKGROUND

Lumbosacral radiculopathy is associated with a broad range of complaints; therefore, specific disability measurements should be validated for this condition.

OBJECTIVES

The aim of this study was to investigate the validity and reliability of the Istanbul Low Back Pain Disability Index (ILBPDI) in lumbosacral radiculopathy.

METHODS

Patients diagnosed with radiculopathy caused by a disc herniation were included. Disability and quality of life were evaluated with the Oswestry Disability Index (ODI) and Short Form-36 (SF-36), respectively. The severity of low back pain and leg pain were evaluated using a Numeric Rating Scale (NRS). The reliability of the ILBPDI was assessed using the Cronbach's alpha coefficient. The relation of ILBPDI with SF-36, ODI, NRS-back and NRS-leg scores were analyzed for convergent validity. The relation of the ILBPDI with age, body mass index (BMI), and disease duration was analyzed for divergent validity. Factor analysis was used to establish the internal construct validity.

RESULTS

One hundred patients (55% female) were included in this study. The Cronbach's alpha coefficient was 0.92. The ILBPDI was found to be correlated with the ODI (rho: 0.619, p< 0.005) and NRS-leg score (rho: 0.597, p< 0.005), but not with NRS-back score (rho: 0.164, p> 0.05). The ILBPDI was significantly correlated with physical functioning (rho: -0.638, p< 0.005), bodily pain (rho: -0.488, p< 0.005), general health (rho: -0.264, p= 0.008) and social function (rho: -0.372, p< 0.005) subscales of SF-36 (convergent validity). The ILBPDI was not correlated with age, BMI, or disease duration (divergent validity). Factor analysis showed that the scale had three-factors which were correlated to bending forward, standing, and sitting activities.

CONCLUSION

The ILBPDI is a valid and reliable instrument in patients with lumbosacral radiculopathy.

Myocardin‑related transcription factor A nuclear translocation contributes to mechanical overload‑induced nucleus pulposus fibrosis in rats with intervertebral disc degeneration

Previous studies have reported that the Ras homolog family member A (RhoA)/myocardin‑related transcription factor A (MRTF‑A) nuclear translocation axis positively regulates fibrogenesis induced by mechanical forces in various organ systems. The aim of the present study was to determine whether this signaling pathway was involved in the pathogenesis of nucleus pulposus (NP) fibrosis induced by mechanical overload during the progression of intervertebral disc degeneration (IVDD) and to confirm the alleviating effect of an MRTF‑A inhibitor in the treatment of IVDD. NP cells (NPCs) were cultured on substrates of different stiffness (2.9 and 41.7 KPa), which mimicked normal and overloaded microenvironments, and were treated with an inhibitor of MRTF‑A nuclear import, CCG‑1423. In addition, bipedal rats were established by clipping the forelimbs of rats at 1 month and gradually elevating the feeding trough, and in order to establish a long‑term overload‑induced model of IVDD, and their intervertebral discs were injected with CCG‑1423 in situ. Cell viability was determined by Cell Counting Kit‑8 assay, and protein expression was determined by western blotting, immunofluorescence and immunohistochemical staining. The results demonstrated that the viability of NPCs was not affected by the application of force or the inhibitor. In NPCs cultured on stiff matrices, MRTF‑A was mostly localized in the nucleus, and the expression levels of fibrotic proteins, including type I collagen, connective tissue growth factor and α‑smooth muscle cell actin, were upregulated compared with those in NPCs cultured on soft matrices. The levels of these proteins were reduced by CCG‑1423 treatment. In rats, 6 months of upright posture activated MRTF‑A nuclear‑cytoplasmic trafficking and fibrogenesis in the NP and induced IVDD; these effects were alleviated by CCG‑1423 treatment. In conclusion, the results of the present study demonstrated that the RhoA/MRTF‑A translocation pathway may promote mechanical overload‑induced fibrogenic activity in NP tissue and partially elucidated the molecular mechanisms underlying the occurrence of IVDD.

Does the presence of neuropathic pain affect the outcomes of the interlaminar epidural steroid injection for cervical disc herniation?: A prospective clinical study

Epidural steroid injections (ESI) are commonly performed for the treatment of chronic cervical disc herniation (CDH). Although they are considered to be effective for both nociceptive and neuropathic types of pain, there is a lack of data regarding the impact of neuropathic pain (NP) and nociceptive pain components on treatment outcomes. The aim of this study is to compare the effectiveness of interlaminar epidural steroid injection (ILESI) between patients with predominantly NP and nociceptive pain due to CDH.Sixty five participants were initially included in the study and assessed by numeric rating scale (NRS), neck pain and disability scale (NPDS), short form-12 (SF-12), and self-reported Leeds assessment of neuropathic symptoms and signs (S-LANSS) pain scale at baseline and 1 month, 3 months, 6 months after ILESI.All patients were evaluated at 1st month and 3rd month follow-up periods while 54 of patients achieved to complete 6th month follow-up. There were significant improvements in all outcome measures for all time periods when compared with the pre-intervention scores. At baseline 24 (36.9%) of patients had predominantly NP in accordance with S-LANSS pain scale. The ratio of NP predominant patients reduced to 7.6% at 1st month, 12.3% at 3rd month, and 12.9% at 6th month with a significant difference for each follow-up period when compared with the baseline. Although all NRS and NPDS scores at baseline were significantly higher in patients with NP, improvement was significant at all follow-up periods in both groups. Minimal clinically important change in NRS was observed in >75% of patients at 1st, 3rd, and 6th month in both groups.The results of this study showed that NP is present in one-third of the patients suffering from neck and radiating arm pain due to CDH and cervical ILESI is an effective treatment approach for both neuropathic and nociceptive components of pain.Clinical Trials Registration Number: NCT04235478.

Chronic opioid use is associated with early biologic discontinuation in inflammatory bowel disease

BACKGROUND

Chronic opioid use is associated with poorer clinical outcomes in inflammatory bowel disease.

AIMS

To investigate an association between chronic opioid use and persistence with biologic agents in management of inflammatory bowel disease.

METHODS

A total of 16 624 patients diagnosed with inflammatory bowel disease and receiving a first-time biologic prescription from 2011 to 2016 were identified retrospectively from the Truven MarketScan Database. A cohort of 1768 patients were identified as chronic opioid users utilising outpatient prescription claims. Utilisation patterns of biologic therapies were assessed from inpatient administration and outpatient claims data, including persistence calculations. Information on healthcare utilisation and common comorbidities was also collected. A Cox regression model was constructed to assess the hazard of chronic opioid use on early discontinuation of biologic therapy controlling for disease severity.

RESULTS

A mean 1.5 different biologic agents were utilised by inflammatory bowel disease patients with chronic opioid use (vs 1.37 in the comparator group; P < 0.0001). A lower proportion of the chronic opioid use cohort persisted on biologic therapies to the end of the study period (16.2% vs 33.5% P < 0.0001). Inflammatory bowel disease patients with chronic opioid use utilised more healthcare resources and had a higher rate of comorbidities than the reference cohort. Patients with chronic opioid use were 23% more likely (hazard ratio 1.23; 95% CI [1.16-1.31]) to be non-persistent with biologic therapy while accounting for relevant markers of disease acuity.

CONCLUSIONS

Chronic opioid use is associated with increased hazard of biologic discontinuation in inflammatory bowel disease. Symptoms of opioid withdrawal may mimic IBD flares thereby leading providers to inappropriately switch biologic therapies and compromise disease control.

Ultrasound Investigation of Dorsal Neck Muscle Deformation During a Neck Rotation Exercise

OBJECTIVES

Neck-specific exercise can reduce neck pain and increase function, but information on how different neck muscle layers are activated during neck exercises is scarce. The aim of this study was to investigate deformation and deformation rate in 5 dorsal neck muscles and the correlation among these muscles during a loaded dynamic exercise used in clinical practice.

METHODS

Deformation and deformation rate were investigated in 5 dorsal right-sided neck muscles in 20 individuals without neck pain using ultrasonography and speckle-tracking analyses. Repeated-measures analysis of variance was used to measure differences between the muscles, and correlations between neck muscles were analyzed with Kendall's tau.

RESULTS

Deformation in left (contralateral) rotation showed significant differences among the muscles (P = .01), with higher deformation of the semispinalis capitis muscle compared with the trapezius muscle (P = .02). There were no significant differences among the 5 neck muscles in right (unilateral) rotation (P = .46). There were significant differences in deformation rate among muscles in both right and left rotation (P < .01). The trapezius muscles have the lowest deformation rate in right rotation (P < .01). In left rotation, the trapezius and multifidus muscles showed lower deformation rates compared with most of the other muscles (P < .03). Almost all muscles were correlated in both deformation and deformation rate.

CONCLUSION

The quadruped standing loaded dynamic neck exercise seemed to activate all the investigated neck muscles, with a tendency for more activation of the semispinalis capitis.

Cervical traction combined with neural mobilization for patients with cervical radiculopathy: A randomized controlled trial

BACKGROUND

Although both neural mobilization (NM) and cervical traction (CT) are widely used interventions in cervical radiculopathy (CR), there is limited clinical data to support their use.

OBJECTIVE

To evaluate the effects of CT, with or without the addition of NM, on pain, function, and disability in patients with CR.

DESIGN

A randomized, double-blinded, placebo-controlled clinical trial.

METHODS

66 patients with CR were randomly allocated to: a group (n = 22) received CT combined with NM (CT + NM), a group (n = 22) received CT combined with sham NM (CT + shamNM) and a wait-list control (WLC) group (n = 22). The Neck Disability Index (NDI), the Patient-Specific Functional Scale, the Numeric Pain Rating Scale (NPRS), grip strength and cervical spine mobility were used as outcome measures. A two-way analysis of variance was used to evaluate differences between the three groups at baseline and at 4-week follow-up.

RESULTS

Statistically and clinically significant between-group differences at 4-week follow-up were found between CT + NM and WLC groups in favor of CT + NM group in NDI scores (d = 1.30), NRPS (d = 1.94), and active cervical rotation towards the opposite arm (d = 1.18) and between CT + NM and CT + shamNM groups in favor of CT + NM group in NRPS (d = 1.21). No significant differences were observed between CT + shamNM and WLC groups in all outcome measures. Clinically significant within-group improvements were found only for the CT + NM group.

CONCLUSION

At 4-week follow-up, CT in combination with NM resulted in improved outcomes in pain, function and disability in patients with CR.

Acupuncture for chronic neck pain with sensitive points: study protocol for a multicentre randomised controlled trial

INTRODUCTION

Chronic neck pain is a challenging condition to treat in clinical practice and has a considerable impact on quality of life and disability. According to the theory of traditional Chinese medicine, acupoints and tender points may become sensitised when the body is in a diseased state. Stimulation of such sensitive points may lead to disease improvement and improved clinical efficacy. This study aims to evaluate the efficacy and safety of needling at sensitive acupoints in providing pain relief, improvement of cervical vertebral function and quality of life in patients with chronic neck pain.

METHODS AND ANALYSIS

This multicentre, randomised controlled, explanatory and parallel clinical trial will include 716 patients with chronic neck pain. Study participants will be randomly assigned in a 1:1:1:1 ratio to four treatment groups: the highly sensitive acupoints group, low/non-sensitive acupoints group, sham acupuncture group and waiting-list control group. The primary outcome will be the change in the visual analogue scale score for neck pain from baseline to 4 weeks. Secondary outcomes will be the Northwick Park Neck Pain Questionnaire and McGill pain questionnaire, 12-item Short-Form health survey, Neck Disability Index, changes in the pressure pain threshold, range of cervical motion, Self-Rating Anxiety Scale, Self-Rating Depression Scale and adverse events before treatment, post-treatment, and at 4, 8, 12, 16 and 20 weeks post-treatment. The intention-to-treat approach will be used in the statistical analysis. Group comparisons will be undertaken using χ2 tests for categorical characteristics, and analysis of variance for continuous variables to analyse whether acupuncture in the highly sensitive acupoints group achieves better treatment outcomes than in each of the other three groups.

ETHICS AND DISSEMINATION

Ethical approval of this study has been granted by the local Institutional Review Board (ID: 2017 KL-038). The outcomes of the trial will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ChiCTR1800016371; Pre-results.

Osteopathic care for spinal complaints: A systematic literature review

The aim of the current study was to evaluate the literature examining the impact of osteopathic care for spinal complaints. The bibliographic databases Medline (Pubmed), Web of Science, Embase, and PEDro were searched. In addition, a number of grey literature sources were searched. Only randomized controlled trials conducted in high-income Western countries were considered. Two authors independently screened the titles and abstracts. Primary outcomes included ‘pain’ and ‘functional status’, while secondary outcomes included ‘medication use’ and ‘health status’. It was examined if differences existed related to the treatment protocol and geography (European vs. US studies). Study quality was assessed using the risk of bias tool of the Cochrane Back Review Group. Nineteen studies were included and qualitatively synthesized. Nine studies were from the US, followed by Germany with seven studies. The majority of studies (n = 13) focused on low back pain. In general, mixed findings related to the impact of osteopathic care on primary and secondary outcomes were observed. For the primary outcomes, a clear distinction between US and European studies was found, in favor of the latter ones. Studies were characterized by substantial methodological differences in sample sizes, number of treatments, control groups, and follow-up. In conclusion, there is some evidence suggesting that osteopathic care may be effective for people suffering from spinal complaints. Further studies with larger study samples and assessment of long-term impact are required to further increase the evidence-based knowledge of the potential of osteopathic care for individuals suffering from spinal complaints.

Prevalence and Cost Analysis of Chronic Pain After Hernia Repair: A Potential Alternative Approach With Neurostimulation

OBJECTIVES

Chronic pain (CP) affects a significant number of patients following hernia repair, ranging from 11 to 54% in the literature. The aim of this study was to assess the prevalence, overall costs, and health care utilization associated with CP after hernia repair.

MATERIALS AND METHODS

A retrospective longitudinal study was performed using the Truven MarketScan® data base to identify patients who develop chronic neuropathic posthernia repair pain from 2001 to 2012. Patients were grouped into CP and No Chronic Pain (No CP) cohorts. Patients were excluded if they 1) were under 18 years of age; 2) had a previous pain diagnosis; 3) had CP diagnosed <90 days after the index hernia repair; 4) had less than one year of follow-up; or 5) had less than one-year baseline record before hernia repair. Patients were grouped into the CP cohort if their CP diagnosis was made within the two years following index hernia repair. Total, outpatient, and pain prescription costs were collected in the period of five years prehernia to nine years posthernia repair. A longitudinal multivariate analysis was used to model the effects of chronic neuropathic posthernia repair pain on total inpatient/outpatient and pain prescription costs.

RESULTS

We identified 76,173 patients who underwent hernia repair and met inclusion criteria (CP: n = 14,919, No CP: n = 61,254). There was a trend for increased total inpatient/outpatient and pain prescription costs one-year posthernia repair, when compared to baseline costs for both cohorts. In both cohorts, total inpatient/outpatient costs remained elevated from baseline through nine years posthernia repair, with the CP cohort experiencing significantly higher cumulative median costs (CP: $51,334, No CP: $37,388). The CP diagnosis year was associated with a 1.75-fold increase (p < 0.001) in total inpatient/outpatient costs and a 2.26-fold increase (p < 0.001) in pain prescription costs versus all other years. In the longitudinal analysis, the CP cohort had a 1.14-fold increase (p < 0.001) in total inpatient/outpatient costs and 2.00-fold increase (p < 0.001) in pain prescription costs.

CONCLUSIONS

Our study demonstrates the prevalence of CP after hernia surgery to be nearly 20%, with significantly increased costs and healthcare resource utilization. While current treatment paradigms are effective for many, there remains a large number of patients that could benefit from an overall approach that includes nonopioid treatments, such as potentially incorporating neurostimulation, for CP that presents posthernia repair.

Return to work following surgery for lumbar radiculopathy: a systematic review

BACKGROUND CONTEXT

Informing patients about postoperative return to work (RTW) expectations is of utmost importance because of the influence of realistic expectations on RTW outcomes.

PURPOSE

We aimed to give an overview of the duration of sick leave and RTW rates after surgery for lumbar radiculopathy and to list predictors of and factors related to RTW.

STUDY DESIGN

A systematic review was carried out.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, EMBASE, and SCOPUS. Full-text articles on RTW following surgery for lumbar radiculopathy were included through double-blind screening. Risk of bias was assessed using a modified version of the Downs and Black checklist.

RESULTS

Sixty-three full-text articles (total sample size: 7,100 patients) were included. Risk of bias was scored low to high. Mean duration of sick leave ranged from 0.8 to 20 weeks. Within 0.1-240 months post surgery, 3%-100% of patients resumed work. Most important predictors for work resumption were preoperative work status, presence of comorbidities, age, sex and duration of preoperative symptoms. Duration of sick leave can be predicted by the preoperative level of pain or disability and presence of symptoms of depression, occupational mental stress, and lateral disc prolapse. Furthermore, less invasive surgical techniques were found to result in better RTW outcomes compared with more invasive techniques.

CONCLUSIONS

Diverse results were found for RTW rates and duration of sick leave. Preoperative work status, presence of comorbidities, and several demographic factors were retrieved as predictors of RTW and duration of sick leave.

Genetic studies of human neuropathic pain conditions: a review

Numerous studies have shown associations between genetic variants and neuropathic pain disorders. Rare monogenic disorders are caused by mutations of substantial effect size in a single gene, whereas common disorders are likely to have a contribution from multiple genetic variants of mild effect size, representing different biological pathways. In this review, we survey the reported genetic contributors to neuropathic pain and submit them for validation in a 150,000-participant sample of the U.K. Biobank cohort. Successfully replicated association with a neuropathic pain construct for 2 variants in IL10 underscores the importance of neuroimmune interactions, whereas genome-wide significant association with low back pain (P = 1.3e-8) and false discovery rate 5% significant associations with hip, knee, and neck pain for variant rs7734804 upstream of the MAT2B gene provide evidence of shared contributing mechanisms to overlapping pain conditions at the molecular genetic level.

Intrarater and Inter-rater Reliability of Active Cervical Range of Motion in Patients With Nonspecific Neck Pain Measured With Technological and Common Use Devices: A Systematic Review With Meta-regression

OBJECTIVES

The purpose of this systematic review was to compare intrarater and inter-rater reliability of active cervical range of motion (ACROM) measures obtained with technological devices to those assessed with low-cost devices in patients with nonspecific neck pain. As a secondary outcome, we investigated if ACROM reliability is influenced by the plane of the assessed movement.

METHODS

Medline, Scopus, Embase, the Cochrane Library, CINHAL, PEDro, and gray literature were searched until August 2016. Inclusion criteria were reliability design, population of adults with nonspecific neck pain, examiners of any level of experience, measures repeated at least twice, and statistical indexes on reliability. A device was considered inexpensive if it cost less than €500. The risk of bias of included studies was assessed by Quality Appraisal of Reliability Studies.

RESULTS

The search yielded 35 151 records. Nine studies met all eligibility criteria. Their Quality Appraisal of Reliability Studies mean score was 3.7 of 11. No significant effect of the type of device (inexpensive vs expensive) on intraclass correlation coefficient (ICC) was identified for intrarater (ICC = 0.93 vs 0.91; P > .99) and inter-rater reliability (ICC = 0.80 vs 0.87; P > .99). The plane of movement did not affect inter-rater reliability (P = .11). Significant influences were identified with intrarater reliability (P = .0001) of inexpensive devices, where intrarater reliability decreased (P = .01) in side bending, compared with flexion-extension.

CONCLUSIONS

The use of expensive devices to measure ACROM in adults with nonspecific neck pain does not seem to improve the reliability of the assessment. Side bending had a lower level of intrarater reliability.

The diagnostic accuracy and test-retest reliability of the Dutch PainDETECT and the DN4 screening tools for neuropathic pain in patients with suspected cervical or lumbar radiculopathy

BACKGROUND

It is important to identify neuropathic pain early to guide treatment decisions and prevent chronicity. There is lack of evidence whether the Dutch painDETECT questionnaire and Douleure Neuropathique en 4 questions (DN4) can adequately assess neuropathic pain.

METHODS

Patients suspected of cervical or lumbar radiculopathy were eligible for inclusion. The Dutch painDETECT and DN4 were considered as the index tests and were compared to the reference test consisting of the consensus expert diagnosis by using the grading system for neuropathic pain. The index tests and neuropathic pain diagnosis were blindly performed. Diagnostic accuracy was determined by calculating sensitivity, specificity, predictive values and likely hood ratios. Test-retest reliability for the index tests was assessed using Intraclass Correlation Coefficients (ICC).

RESULTS

A total of 180 patients were included, of which 110 for the reliability analysis. Fifty-nine patients (33%) had neuropathic pain according to the reference test. Both the painDETECT and DN4 had moderate sensitivity of respectively 75% (95% CI: 61.6-85.0) and 76% (95% CI: 63.4-86.4) and poor specificity of respectively 51% (95% CI: 42.0-60.4) and 42% (95% CI: 33.2-51.5). Combining negative test results for both screening tools increased the sensitivity up to 83% (95% CI: 71.0-91.6). The ICC for the painDETECT was 0.91 (95% CI: 0.86-0.94) and for the DN4 0.86 (95% CI: 0.80-0.91).

CONCLUSIONS

The use of the Dutch painDETECT and the DN4 in patients with suspected radiculopathy should not be recommended yet. A combination of both screening tools seems most suitable to rule out neuropathic pain in patients suspected of radiculopathy.

LEVEL OF EVIDENCE

Diagnosis, Level 1B.

Predictors of Chronic Opioid Use in Newly Diagnosed Crohn's Disease

BACKGROUND AND AIMS

Patients with Crohn's disease (CD) are often prescribed opioids chronically to manage pain associated with their disease. However, little evidence exists to support this practice. Here, we examine newly diagnosed patients with CD with and without chronic opioid use (COU) and sought to identify predictors and consequences of COU.

METHODS

A nationally representative administrative health care claims that data set identified newly diagnosed patients with CD. Their data were examined during the periods 6 months before and 2 years after diagnosis. Multivariable logistic regression was used to assess predictors of COU at diagnosis.

RESULTS

The final study cohort consisted of 47,164 patients with CD. Of them, 3.8% were identified with new COU. Chronic opioid users were more likely women, older, and likely who had more surgeries, endoscopies, admissions, and medication usage compared with other patients. Features detected before CD diagnosis that correlated with COU after diagnosis included previous opioid use (odds ratio [OR] = 6.6), chronic pain (OR = 1.36), arthritis (OR = 1.95), and mental disorders (OR = 1.58). Interestingly, emergency department visits before CD Dx increased the risk of COU (OR = 1.11), whereas endoscopy reduced COU risk (OR = 0.88).

CONCLUSIONS

This study presents a nationally representative assessment of COU in newly diagnosed patients with CD. The results may be used to determine the impact of COU in this population and to alert clinicians to those patients with CD at high risk of COU. Chronic opioids are consistently associated with indicators of more severe disease; however, additional research is needed to determine whether COU drives disease severity or vice versa.

Feasibility of a Smartphone-Based Exercise Program for Office Workers With Neck Pain: An Individualized Approach Using a Self-Classification Algorithm

OBJECTIVE

To explore the feasibility of a newly developed smartphone-based exercise program with an embedded self-classification algorithm for office workers with neck pain, by examining its effect on the pain intensity, functional disability, quality of life, fear avoidance, and cervical range of motion (ROM).

DESIGN

Single-group, repeated-measures design.

SETTING

The laboratory and participants' home and work environments.

PARTICIPANTS

Offices workers with neck pain (N=23; mean age ± SD, 28.13±2.97y; 13 men).

INTERVENTION

Participants were classified as having 1 of 4 types of neck pain through a self-classification algorithm implemented as a smartphone application, and conducted corresponding exercise programs for 10 to 12min/d, 3d/wk, for 8 weeks.

MAIN OUTCOME MEASURES

The visual analog scale (VAS), Neck Disability Index (NDI), Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), Fear-Avoidance Beliefs Questionnaire (FABQ), and cervical ROM were measured at baseline and postintervention.

RESULTS

The VAS (P<.001) and NDI score (P<.001) indicated significant improvements in pain intensity and functional disability. Quality of life showed significant improvements in the physical functioning (P=.007), bodily pain (P=.018), general health (P=.022), vitality (P=.046), and physical component scores (P=.002) of the SF-36. The FABQ, cervical ROM, and mental component score of the SF-36 showed no significant improvements.

CONCLUSIONS

The smartphone-based exercise program with an embedded self-classification algorithm improves the pain intensity and perceived physical health of office workers with neck pain, although not enough to affect their mental and emotional states.

Epidural steroid injections: an updated review on recent trends in safety and complications

SUMMARY 

Epidural steroid injections (ESIs), which can provide significant but temporary pain relief in well-selected patients, are the most commonly performed procedure in pain management. The anatomy of the epidural space provides a framework for understanding risks associated with ESIs, a topic relevant to both patients and physicians in interventional pain, surgery and primary care. Safety considerations of epidural steroids include drug preparation and myriad physiological effects stemming from steroid exposure. Although major complications associated with ESI occur rarely, potentially catastrophic events resulting from infectious, hematologic and neurologic morbidity may lead to permanent injury. The safety profile of ESIs may improve with development and dissemination of sound injection technique, safer compounds manufactured in a sterile manner and deficient of thromboembolic potential and the application of existing technology.

Effectiveness of app-based relaxation for patients with chronic low back pain (Relaxback) and chronic neck pain (Relaxneck): study protocol for two randomized pragmatic trials

BACKGROUND

Chronic low back pain (LBP) and neck pain (NP) are highly prevalent conditions resulting in high economic costs. Treatment guidelines recommend relaxation techniques, such as progressive muscle relaxation, as adjuvant therapies. Self-care interventions could have the potential to reduce costs in the health care system, but their effectiveness, especially in a usual care setting, is unclear. The aim of these two pragmatic randomized studies is to evaluate whether an additional app-delivered relaxation is more effective in the reduction of chronic LBP or NP than usual care alone.

METHODS/DESIGN

Each pragmatic randomized two-armed study aims to include a total of 220 patients aged 18 to 65 years with chronic (>12 weeks) LBP or NP and an average pain intensity of ≥ 4 on a numeric rating scale (NRS) in the 7 days before recruitment. The participants will be randomized into an intervention and a usual care group. The intervention group will be instructed to practice one of these 3 relaxation techniques on at least 5 days/week for 15 minutes/day over a period of 6 months starting on the day of randomization: autogenic training, mindfulness meditation, or guided imagery. Instructions and exercises will be provided using a smartphone app, baseline information will be collected using paper and pencil. Follow-up information (daily, weekly, and after 3 and 6 months) will be collected using electronic diaries and questionnaires included in the app. The primary outcome measure will be the mean LBP or NP intensity during the first 3 months of intervention based on daily pain intensity measurements on a NRS (0 = no pain, 10 = worst possible pain). The secondary outcome parameters will include the mean pain intensity during the first 6 months after randomization based on daily measurements, the mean pain intensity measured weekly as the average pain intensity of the previous 7 days over 3 and 6 months, pain acceptance, 'LBP- and NP-related' stress, sick leave days, pain medication intake, adherence, suspected adverse reaction, and serious adverse events.

DISCUSSION

The designed studies reflect a usual self-care setting and will provide evidence on a pragmatic self-care intervention that is easy to combine with care provided by medical professionals.

TRIAL REGISTRATION

ClinicalTrials.gov identifier Relaxback NCT02019498, Relaxneck NCT02019134 registered on 18 December 2013.

Training and certification of doctors of chiropractic in delivering manual cervical traction forces: Results of a longitudinal observational study

Objective : Doctors of chiropractic (DCs) use manual cervical distraction to treat patients with neck pain. Previous research demonstrates variability in traction forces generated by different DCs. This article reports on a training protocol and monthly certification process using bioengineering technology to standardize cervical traction force delivery among clinicians. Methods : This longitudinal observational study evaluated a training and certification process for DCs who provided force-based manual cervical distraction during a randomized clinical trial. The DCs completed a 7-week initial training that included instructional lectures, observation, and guided practice by a clinical expert, followed by 3 hours of weekly practice sessions delivering the technique to asymptomatic volunteers who served as simulated patients. An instrument-modified table and computer software provided the DCs with real-time audible and visual feedback on the traction forces they generated and graphical displays of the magnitude of traction forces as a function of time immediately after the delivery of the treatment. The DCs completed monthly certifications on traction force delivery throughout the trial. Descriptive accounts of certification attempts are provided. Results : Two DCs achieved certification in traction force delivery over 10 consecutive months. No certification required more than 3 attempts at C5 and occiput contacts for 3 force ranges (0-20 N, 21-50 N, and 51-100 N). Conclusions : This study demonstrates the feasibility of a training protocol and certification process using bioengineering technology for training DCs to deliver manual cervical distraction within specified traction force ranges over a 10-month period.