Move to health-a holistic approach to the management of chronic low back pain: an intervention and implementation protocol developed for a pragmatic clinical trial

Exploring the differences in resting state functional magnetic resonance imaging brain activity in patients with chronic low back pain based on ALE meta-analysis

Chronic low back pain (cLBP) is a prevalent condition, yet neuroimaging findings across studies remain inconsistent. This inconsistency may stem from overreliance on a priori regions of interest (ROI) hypotheses in prior studies, which neglected the spatial distribution of true functional abnormalities in cLBP. To address methodological heterogeneity, this study conducted an activation likelihood estimation (ALE) meta-analysis, guided by high-quality neuroimaging meta-analysis guidelines, to identify reliable neural features across 17 eligible cLBP studies, providing more robust conclusions than individual neuroimaging studies. Significantly, the cLBP group exhibited enhanced activity in the bilateral medial frontal gyrus (MFG), right precentral gyrus, and right cingulate gyrus. Based on the data-driven and objective ROI, we further analyzed the functional interactions or connectivity between brain regions by including a cohort of 30 patients with chronic non-specific low back pain (CNLBP) and 30 age- and sex-matched healthy controls. The results revealed decrease functional connectivity in the cortico-limbic circuit in the CNLBP group, particularly between the left MFG and the right hippocampus. Furthermore, effective connectivity from the right to left MFG was significantly reduced in the CNLBP group. Multivariate regression analysis established significant associations between cortico-limbic circuit connectivity alterations and pain catastrophizing. These findings highlight the cortico-limbic circuit as a key biomarker for cLBP, suggesting its targeted modulation could inform novel therapeutic strategies. This study provides novel neurobiological insights into cLBP pathophysiology, while underscoring the necessity for replication in larger cohorts to validate clinically valuable. PERSPECTIVE: This study utilized ALE meta-analysis to investigate abnormal activation regions in cLBP patients, and further analysis revealed functional interactions or connectivity between brain regions. The results highlighted the cortico-limbic circuit as a key biomarker of cLBP, suggesting that modulating this circuit may provide insights into potential therapeutic strategies.

Knowledge of the genetics of human pain gained over the last decade from next-generation sequencing

Next-generation sequencing (NGS) technologies have revolutionized pain research by providing comprehensive insights into genetic variation across the genome. Recent studies have expanded the known spectrum of mutations in genes such as SCN9A and NTRK1, which are commonly mutated in hereditary sensory neuropathies. NGS has uncovered critical alternative splicing events and facilitated single-cell transcriptomics, revealing cellular heterogeneity within tissues. An NGS-based classifier predicted extremely high opioid requirements with 80 % accuracy, highlighting the importance of tailoring opioid therapy based on genetic profiles. Key genes such as GDF5, COL11A1, and TRPV1 have been linked to osteoarthritis risk and pain sensitivity, while HLA-DRB1, TNF, and P2X7 play critical roles in inflammation and pain modulation in rheumatoid arthritis. Innovative tools, such as an atlas of the somatosensory system in neuropathic pain, have been developed based on NGS data, focusing on the dorsal root and trigeminal ganglia. This approach allows the analysis of cellular changes during the development of chronic pain. In the study of rare variants, NGS outperforms single nucleotide variant candidate studies and classical genome-wide association approaches. The complex data generated by NGS enables integrated multi-omics approaches, allowing deeper exploration of the molecular and cellular basis of pain perception. In addition, the characterization of non-coding RNAs has opened new therapeutic avenues. NGS-based pain research faces challenges related to complex data analysis and interpretation of rare genetic variants with unknown biological functions. Nevertheless, NGS offers significant potential for improving personalized pain management and highlights the need for interdisciplinary collaboration to translate findings into clinical practice.

Mental and Physical Well-Being of Partners of People Living with Chronic Pain: A Narrative Review

This narrative review aims to explore the mental and physical well-being of partners of individuals living with chronic pain. Chronic pain not only affects those who suffer from it, but also significantly impacts the lives of their partners; however, the impacts on partners are not well recognised, despite extensive evidence indicating that their quality of life can be equally affected. This review synthesises current literature to identify the psychological and physical challenges faced by these partners, including increased stress, anxiety, depression, and the potential for developing chronic health conditions themselves. A search of Medline for "chronic pain" and "partner/spouse" from January 1990 to the present was performed, and relevant articles were selected for review. The main findings were that while partners often experience a range of negative physical and psychosocial impacts on their quality of life, dyadic coping strategies can mitigate these effects. This review underscores the importance of future research to develop targeted interventions that address the unique needs of this population, promoting better health outcomes and fostering resilience in the face of chronic pain.

Temporal Trends in the Epidemiology of Lower Back Pain in the United States

STUDY DESIGN

This was an observational study.

OBJECTIVE

This study aims to explore sociodemographic and regional geographic variations in lower back pain (LBP) incidence, prevalence, and burden in the United States (US from 2000 to 2019).

SUMMARY OF BACKGROUND DATA

LBP is a major contributor to lost wages and disability in the United States. As LBP is associated with increasing age and sedentary lifestyle, the incidence of LBP is expected to rise. Due to LBP's multifactorial causes, US epidemiological trends lack sufficient data.

MATERIALS AND METHODS

Descriptive epidemiological data including disability-adjusted life years (DALYs), incidence, and prevalence per 100,000 population from 2000 to 2019 were collected from the Global Burden of Disease database. State-level data regarding poverty, insurance and employment status were obtained from the US Government Census Bureau and US Department of Labor. Statistical significance was indicated by P <0.05.

RESULTS

From 2000 to 2019, the US demonstrated reductions in LBP incidence, prevalence, and DALYs. Regional analysis demonstrated the Midwest to have the greatest mean incidence, prevalence, and DALYs; with Midwestern females significantly more affected than females in other regions. Those aged 25 to 49 in the Midwest were impacted significantly more across all measures compared with age-matched populations in other regions. Nationally, there were no significant associations between unemployment and LBP. Poverty was inversely correlated with LBP incidence. Uninsured status was positively correlated with prevalence and DALYs.

CONCLUSION

Although there has been progress in reducing the impact of LBP in the United States, the Midwest region has greater rates for all measures compared with other US regions. Further, females and those aged 25 to 49 in the Midwest were more likely to be affected by LBP compared with counterparts in other regions. Future studies should identify specific factors contributing to elevated LBP rates in the Midwest in order to guide targeted interventions to reduce the incidence and burden of LBP there.

Utility of the PICOTS framework to assess clinical trial disruptions: monitoring the impact of COVID-19 in the Pain Management Collaboratory

OBJECTIVE

Despite careful design of clinical trials, unforeseen disruptions can arise. The PICOTS (Patient population, Intervention, Comparator, Outcomes, Timepoints, Setting) framework was used to assess disruptions in pain management research imposed by coronavirus disease 2019 (COVID-19) within the Pain Management Collaboratory.

METHODS

Rapid qualitative methods were employed to identify trial disruptions due to COVID-19 in 11 pragmatic clinical trials of nonpharmacological approaches for pain management. The PICOTS framework was applied by investigators of 4 Collaboratory trials selected to cover 4 types of trial designs (individually randomized, stepped-wedge, cluster, sequential multiple assignment randomized trial-SMART). Interviews with the lead investigators of these trials were completed, and findings were presented/discussed on video calls over a 6-month period (March-August 2021) from which themes/lessons learned were identified and consensus reached.

RESULTS

Investigators indicated that patient populations remained generally stable. A major COVID-19 trial disruption was moving from in-person to virtual care affecting delivery of interventions/comparators and outcome assessments. The resultant mixed-mode of care delivery created issues with intervention fidelity posing analytic challenges. COVID-19 also induced ongoing/intermittent delays and other barriers to accessing primary and specialty care at some facilities, creating research capacity issues affecting delivery of experimental interventions requiring sustained, reliable participation of clinical partners. Study designs most affected by COVID-19 were stepped-wedge (intervention/comparator changing over time), cluster (increased site variability inflating intracluster correlation), and SMART (second-stage randomizations disrupted); stratified individually-randomized trials were less vulnerable because of individual-level randomization.

CONCLUSIONS

PICOTS provides a framework for assessing the impact of trial disruptions in a structured manner. Given the COVID-19 experience, it is important for researchers to consider the potential impact of future trial disruptions during study planning.

Intervention Fidelity in Pain Pragmatic Trials for Nonpharmacologic Pain Management: Nuanced Considerations for Determining PRECIS-2 Flexibility in Delivery and Adherence

Nonpharmacological treatments are considered first-line pain management strategies, but they remain clinically underused. For years, pain-focused pragmatic clinical trials (PCTs) have generated evidence for the enhanced use of nonpharmacological interventions in routine clinical settings to help overcome implementation barriers. The Pragmatic Explanatory Continuum Indicator Summary (PRECIS-2) framework describes the degree of pragmatism across 9 key domains. Among these, "flexibility in delivery" and "flexibility in adherence," address a key goal of pragmatic research by tailoring approaches to settings in which people receive routine care. However, to maintain scientific and ethical rigor, PCTs must ensure that flexibility features do not compromise delivery of interventions as designed, such that the results are ethically and scientifically sound. Key principles of achieving this balance include clear definitions of intervention core components, intervention monitoring and documentation that is sufficient but not overly burdensome, provider training that meets the demands of delivering an intervention in real-world settings, and use of an ethical lens to recognize and avoid potential trial futility when necessary and appropriate. PERSPECTIVE: This article presents nuances to be considered when applying the PRECIS-2 framework to describe pragmatic clinical trials. Trials must ensure that patient-centered treatment flexibility does not compromise delivery of interventions as designed, such that measurement and analysis of treatment effects is reliable.

Different Dosage Regimens of Tanezumab for the Treatment of Chronic Low Back Pain: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

The aim of this study was to assess the efficacy of different dosage regimens of tanezumab among individuals living with chronic low back pain (CLBP).

METHODS

PubMed, Embase, The Cochrane Library, and other databases were searched from inception until August 2021. Randomized controlled trials investigating the efficacy and safety of tanezumab in individuals with CLBP were included. Data were extracted independently by 2 investigators and assessed the study quality by the Cochrane risk-of-bias tool. The measurements include low back pain intensity and Roland-Morris Disability Questionnaire. The incidence of adverse events and serious adverse events was set to assess the safety of tanezumab for CLBP.

RESULTS AND DISCUSSION

Three high-quality randomized controlled trials with 3414 patients were finally included in our analysis. Tanezumab, respectively, led to a notable decrease compared with placebo in low back pain intensity (mean difference, -0.62; 95% confidence interval [CI], -0.77 to -0.46; P < 0.01) and Roland-Morris Disability Questionnaire (mean difference, -0.64; 95% CI, -0.80 to -0.47; P = 0.01). In addition, no significant difference existed between tanezumab and placebo groups (risk ratio, 1.10; 95% CI, 0.81-1.49; P = 0.55) in the adverse events and (risk ratio, 1.06; 95% CI, 0.34-3.27; P = 0.93) serious adverse events.

CONCLUSIONS

Intravenous and subcutaneous tanezumab injections as treatment for improving CLBP have promising clinical application as its great improvement on all efficacy and its controllable safety issues. Furthermore, intravenous and subcutaneous tanezumab injections were proved to achieve excellent and long-term curative effect on CLBP through our subgroup analysis and comparison.

Multidimensional Effectiveness of Botulinum Toxin in Neuropathic Pain: A Systematic Review of Randomized Clinical Trials

Although botulinum toxin (BoNT) has been suggested as a treatment to counter neuropathic pain, no previous systematic reviews investigated the multidimensional effects of BoNT on pain relief and Health-Related Quality of Life (HR-QoL). The aim of this systematic review is to summarize the current evidence on the effectiveness of BoNT treatment for neuropathic pain, and to characterize its multidimensional effectiveness in order to guide physicians in clinical practice. Five databases were systematically searched up to 4 April 2022, to identify randomized controlled trials satisfying the following criteria: adults suffering from neuropathic pain, BoNT administration, any comparator, multidimensional assessment of pain as primary outcome, HR-QoL, physical function, anxiety and depression, and sleep quality as secondary outcomes. Twelve studies were included. The multidimensional pain scales used were short-form McGill Pain Questionnaire, Neuropathic pain scale, Neuropathic Pain Symptom Inventory, International SCI Pain Basic Data Set, West Haven-Yale Multidimensional Pain Inventory, Brief Pain Inventory, and Douleur Neuropathique 4. These scales highlighted the positive effects of BoNT administration. According to the Jadad scale, all the RCTs included were high-quality studies. BoNT administration might be effectively introduced in the comprehensive management of neuropathic pain. Further research should focus on optimal and cost-effective therapeutic protocols.

Misbeliefs about non-specific low back pain and attitudes towards treatment by primary care providers in Spain: a qualitative study

AIM

To identify misbeliefs about the origin and meaning of non-specific chronic low back pain and to examine attitudes towards treatment by primary health care providers.

DESIGN

Generic qualitative study.

METHODS

Ten semi-structured interviews were conducted between October and November 2016 with physicians and nurses from primary health care centres in Lleida. The interviews were transcribed and analysed using inductive thematic analysis via Atlas.ti-8 software.

RESULTS

Five themes were identified: i. beliefs about the origin and meaning of chronic low back pain, ii. psychosocial aspects of pain modulators, iii. Therapeutic exercise as a treatment for chronic low back pain, iv. biomedical attitudes of primary health care providers, and v. difficulties in the clinical approach to chronic low back pain.

CONCLUSION

Primary health care providers have a unifactorial view of chronic low back pain and base their approach on the biomedical model. Professionals attribute chronic low back pain to structural alterations in the lumbar spine while psychosocial factors are only recognized as pain modulators. For professionals, therapeutic exercise represents a possible solution to chronic low back pain; however, they still do not prescribe it and continue to educate on postural hygiene and recommend limiting physical and/or occupational activities, as opposed to clinical practice guidelines. These findings suggest that to improve the adherence of primary health care providers to the biopsychosocial model, it may be necessary first to modify their misbeliefs about non-specific chronic low back pain by increasing their knowledge on pain neurophysiology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02962817 . Date of registration: 11/11/2016.