Managing acute back pain patients to avoid the transition to chronic pain

Virtual Reality for Subacute Pain After Orthopedic Traumatic Musculoskeletal Injuries: A Mixed Methods Pilot Study

OBJECTIVES

Acute orthopedic traumatic musculoskeletal injuries are prevalent, costly, and often lead to persistent pain and functional limitations. Psychological risk factors (eg, pain catastrophizing and anxiety) exacerbate these outcomes but are often overlooked in acute orthopedic care. Addressing gaps in current treatment approaches, this mixed-methods pilot study explored the use of a therapeutic virtual reality (VR; RelieVRx ), integrating principles of mindfulness and cognitive-behavioral therapy, for pain self-management at home following orthopedic injury.

METHODS

We enrolled 10 adults with acute orthopedic injuries and elevated pain catastrophizing or pain anxiety from Level 1 Trauma Clinics within the Mass General Brigham health care system. Participants completed daily RelieVRx sessions at home for 8 weeks, which included pain education, relaxation, mindfulness, games, and dynamic breathing biofeedback. Primary outcomes were a priori feasibility, appropriateness, acceptability, satisfaction, and safety. Secondary outcomes were pre-post measures of pain, physical function, sleep, depression, and hypothesized mechanisms (pain self-efficacy, mindfulness, and coping).

RESULTS

The VR and study procedures met or exceeded all benchmarks. We observed preliminary improvements in pain, physical functioning, sleep, depression, and mechanisms. Qualitative exit interviews confirmed high satisfaction with RelieVRx and yielded recommendations for promoting VR-based trials with orthopedic patients.

DISCUSSION

The results support a larger randomized clinical trial of RelieVRx versus a sham placebo control to replicate the findings and explore mechanisms. There is potential for self-guided VR to promote evidence-based pain management strategies and address the critical mental health care gap for patients following acute orthopedic injuries.

mHealth Apps for the Self-Management of Low Back Pain: Systematic Search in App Stores and Content Analysis

BACKGROUND

With the rapid development of mobile health (mHealth) technology, many health apps have been introduced to the commercial market for people with back pain conditions. However, little is known about their content, quality, approaches to care for low back pain (LBP), and associated risks of use.

OBJECTIVE

The aims of this research were to (1) identify apps for the self-management of LBP currently on the market and (2) assess their quality, intervention content, theoretical approaches, and risk-related approaches.

METHODS

The UK iTunes and Google Play stores were initially searched for apps related to the self-management of LBP in May 2022. A repeat search in June 2023 was conducted to ensure that any relevant new apps developed in the last year were incorporated into the review. A total of 3 keywords recommended by the Cochrane Back and Neck Group were used to search apps "low back pain," "back pain," and "lumbago." The quality of the apps was assessed by using the 5-point Mobile App Rating Scale (MARS).

RESULTS

A total of 69 apps (25 iOS and 44 Android) met the inclusion criteria. These LBP self-management apps mainly provide recommendations on muscle stretching (n=51, 73.9%), muscle strengthening (n=42, 60.9%), core stability exercises (n=32, 46.4%), yoga (n=19, 27.5%), and information about LBP mechanisms (n=17, 24.6%). Most interventions (n=14, 78%) are consistent with the recommendations in the National Institute for Health and Care Excellence (NICE) guidelines. The mean (SD) MARS overall score of included apps was 2.4 (0.44) out of a possible 5 points. The functionality dimension was associated with the highest score (3.0), whereas the engagement and information dimension resulted in the lowest score (2.1). Regarding theoretical and risk-related approaches, 18 (26.1%) of the 69 apps reported the rate of intervention progression, 11 (15.9%) reported safety checks, only 1 (1.4%) reported personalization of care, and none reported the theoretical care model or the age group targeted.

CONCLUSIONS

mHealth apps are potentially promising alternatives to help people manage their LBP; however, most of the LBP self-management apps were of poor quality and did not report the theoretical approaches to care and their associated risks. Although nearly all apps reviewed included a component of care listed in the NICE guidelines, the model of care delivery or embracement of care principles such as the application of a biopsychosocial model was unclear.

Interprofessional Active Learning for Chronic Pain: Transforming Student Learning From Recall to Application

Chronic pain (CP) affects over 50 million Americans daily and represents a unique challenge for healthcare professionals due to its complexity. Across all health professions, only a small percentage of the curriculum is devoted to treating patients with CP. Unfortunately, much of the content is delivered passively via lecture without giving students an opportunity to practice the communication skills to effectively treat patients in the clinic. An interprofessional team of health educators identified 5 essential messages that students frequently struggle to convey to patients with CP. Those messages were based on interprofessional and profession-specific competencies to treat patients with CP from the International Association for the Study of Pain. The 5 messages highlighted the importance of (1) therapeutic alliance, (2) consistent interdisciplinary language, (3) patient prognosis, (4) evidence for pain medicine, surgery, and imaging, and (5) early referral to the interprofessional team. For each message, the team summarized relevant research supporting the importance of each individual message that could serve as a foundation for didactic content. The team then developed active learning educational activities that educators could use to have students practice the skills tied to each message. Each learning activity was designed to be delivered in an interprofessional manner.

Multidisciplinary program based on early management of psychological factors reduces disability of patients with subacute low back pain: one-year results of a randomized controlled study

BACKGROUND

Multidisciplinary rehabilitation induces disability improvement, pain reduction and favors return-to-work in patients with subacute low back pain (LBP). Current research advises additional high-quality trials.

AIM

The aim of this study is to test the effect of a multidisciplinary rehabilitative program incorporating cognitive-behavioral interventions compared to general physiotherapy alone to treat subacute LBP, and to appraise its long-term extent.

DESIGN

Randomised parallel-group superiority-controlled trial.

SETTING

Outpatient rehabilitation hospital.

POPULATION

One hundred and fifty patients with subacute LBP.

METHODS

Patients were assigned randomly to a 10-week individual-based multimodal program of task-oriented exercises integrated with cognitive-behavioral therapy (experimental group, 75 patients) or individual-based general physiotherapy (control group, 75 patients). Before treatment, 10 weeks later (post-treatment), and 12 months after treatment, the staff administered the Oswestry Disability Index (ODI, primary outcome), a pain intensity numerical rating scale (NRS), the Tampa Scale for Kinesiophobia (TSK), the Pain Beliefs and Perception Inventory (PBAPI), the Hospital and Anxiety Depression Score (HADS) and the Coping Strategies Questionnaire-revised (CSQ-R). Linear mixed model analysis for repeated measures was carried out for each outcome measure.

RESULTS

Significant group (P<0.001), time (P=0.002), and time-by-group interaction (P<0.001) effects were found for ODI, with a between-group difference (standard error) after training of 11.5 (1.0) and at follow-up of 15.7 (0.9), in favor of the experimental group. A significant interaction effect (P<0.001) was found for all secondary outcome measures, with significantly greater improvements in the experimental group, after rehabilitation and at follow-up.

CONCLUSIONS

The multidisciplinary intervention was superior to general physiotherapy in reducing disability, pain, psychological factors and coping strategies of patients with subacute LBP. The effects were reinforced after one year.

CLINICAL REHABILITATION IMPACT

Treatment of subacute LBP requires cognitive modifications closely linked to physical performances in order to achieve mental adjustments and guarantee cognitive-behavioral and motor lasting changes.

Reliability and construct validity of the modified Finnish version of the 9-item patient health questionnaire and its associations within the biopsychosocial framework among female health-care workers with sub-acute or recurrent low back pain

BACKGROUND

Health-care workers have an increased risk for chronic low back pain (LBP) leading to reduced workability. Depression, a highly prevalent, costly and disabling condition, is commonly seen in patients with sub-acute LBP. This study investigated the psychometric properties and construct-validity of a modified 9-item Patient Health Questionnaire (PHQ-9-mFIN) in female health-care workers with sub-acute LBP.

METHODS

Reliability (internal consistency, test-retest repeatability) was assessed using standard methods. Construct validity of the PHQ-9-mFIN was assessed as level of depressive symptoms (PHQ-9-mFIN: 0-4 none, 5-9 mild, ≥10 at least moderate) against the RAND 36 Health Survey, a valid measure of health-related quality of life (HRQoL). Additionally, the strength of the association between the levels of PHQ-9-mFIN and selected biopsychosocial factors was determined.

RESULTS

The internal consistency of the PHQ-9-mFIN was high (Cronbach's α = 0.82) and the test-retest repeatability scores (n = 64) were moderate: Pearson's correlation was 0.73 and Intraclass Correlation Coefficient (ICC) 0.73 (95% CI: 0.58 to 0.82). Construct validity (Spearman correlation) against the Physical and Mental component items and their summary scales of the RAND 36 were much higher for the Mental (range, - 0.40 to - 0.67 and - 0.64) than for the Physical (range, - 0.08 to - 0.43 and - 0.22). There was a clear stepwise association (p < 0.001) between the levels of depressive symptoms and General health (physical component, range, 59.1 to 78.8). The associations with all items of the Mental components were strong and graded (p < 0.001). All participants had low scores for Bodily pain, regardless of the level of depressive symptoms. There was a strong association (p ≤ 0.003) between the levels of PHQ-9-mFIN and multisite pain, lumbar exertion and recovery after workdays, neuromuscular fitness in modified push-ups, workability, and fear of pain related to work.

CONCLUSIONS

The PHQ-9-mFIN showed adequate reliability and excellent construct validity among female health-care workers with recurrent LBP and physically strenuous work.

TRIAL REGISTRATION

NCT01465698 .

Fluoroscopic Epidural Steroid Injection: Pain Relief in Discogenic Sciatica Versus Lumbar Spinal Stenosis. A Study on Middle Eastern Patients

OBJECTIVE

To compare the effect of epidural steroid injections (ESI) in patients with discogenic sciatica (Sci) versus patients with lumbar canal stenosis (LSS), not controlled by conservative treatment.

MATERIALS AND METHODS

In our study, 80 patients with Sci and 66 with LSS were included. A single ESI (10 mg dexamethasone in 3 cc 0.25% bupivacaine) was applied under fluoroscopic control: one level above the highest stenotic level, in the posterior epidural space, via interlaminar approach in LSS and at the prolapse level, in the anterior epidural space, via transforaminal route in Sci. Pain intensity was assessed by VAS at baseline and on days 1, 15 and 30 after intervention.

RESULTS

The procedure was successful in 78 Sci and 63 LSS patients. Patients with Sci responded significantly better. At one month, pain reduction over 50% was achieved in 63% (52.3-73.7% at p = 0.95) of Sci but only in 35% (23.2-46.8%) of LSS (p = 0.03). Return to pre-intervention level happened in 47% (34.7-59.3%) of LSS versus 14% (6.3-21.7%) of Sci patients (p = 0.01). In 5 patients the procedure failed, without resulting morbidity.

CONCLUSION

ESI are more effective in patients with Sci than in single level LSS. In multiple level LSS, results are disappointing.

Efficacy and safety of thread embedding acupuncture for chronic low back pain: a randomized controlled pilot trial

Background

We investigated the efficacy and safety of thread-embedding acupuncture (TEA) for chronic low back pain (LBP) in a randomized controlled pilot trial with the aim of laying the foundation for a large-scale randomized controlled trial on this topic.

Methods

Forty participants were recruited for this two-arm, assessor-blinded randomized controlled pilot trial. The participants were randomly allocated to a TEA group (experimental group) or an acupuncture group (control group). The TEA group received TEA once every 2 weeks for 8 weeks (four sessions in total), while the acupuncture group received acupuncture twice per week for 8 weeks (16 sessions in total). The primary outcome was the visual analog scale (VAS) score for pain and the secondary outcomes were short-form McGill Pain Questionnaire (SF-MPQ) and Oswestry Disability Index (ODI) scores. Assessments were performed at screening and at 2, 4, 6, 8, and 10 weeks after treatment initiation (the 10-week assessment was conducted at 2 weeks after treatment cessation).

Results

Of the 40 participants, 36 completed the study and four dropped out. Both the TEA group and the acupuncture group showed significant improvements in VAS, SF-MPQ, and ODI scores in a time-dependent manner. Furthermore, with regard to ODI, a significant interaction between group and time was observed, with the two groups exhibiting a different pattern of change at 8 weeks according to contrast analysis with Bonferroni’s correction. No serious adverse event occurred, and hematological and biochemical test findings were within normal limits.

Conclusion

This pilot study has provided basic data for a larger clinical trial to demonstrate the efficacy and safety of TEA for chronic LBP.

Trial registration

Clinical Research Information Service of the Korea National Institute of Health, ID: KCT0001819. Registered on 15 February 2016.

Multidisciplinary biopsychosocial rehabilitation for subacute low back pain

BACKGROUND

Low back pain (LBP) is associated with enormous personal and societal burdens, especially when it reaches the chronic stage of the disorder (pain for a duration of more than three months). Indeed, individuals who reach the chronic stage tend to show a more persistent course, and they account for the majority of social and economic costs. As a result, there is increasing emphasis on the importance of intervening at the early stages of LBP.According to the biopsychosocial model, LBP is a condition best understood with reference to an interaction of physical, psychological, and social influences. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds.This review is an update of a Cochrane Review on MBR for subacute LBP, which was published in 2003. It is part of a series of reviews on MBR for musculoskeletal pain published by the Cochrane Back and Neck Group and the Cochrane Musculoskeletal Group.

OBJECTIVES

To examine the effectiveness of MBR for subacute LBP (pain for a duration of six to 12 weeks) among adults, with a focus on pain, back-specific disability, and work status.

SEARCH METHODS

We searched for relevant trials in any language by a computer-aided search of CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and two trials registers. Our search is current to 13 July 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of adults with subacute LBP. We included studies that investigated a MBR program compared to any type of control intervention. We defined MBR as an intervention that included a physical component (e.g. pharmacological, physical therapy) in combination with either a psychological, social, or occupational component (or any combination of these). We also required involvement of healthcare professionals from at least two different clinical backgrounds with appropriate training to deliver the component for which they were responsible.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. In particular, the data extraction and 'risk of bias' assessment were conducted by two people, independently. We used the Cochrane tool to assess risk of bias and the GRADE approach to assess the overall quality of the evidence for each outcome.

MAIN RESULTS

We included a total of nine RCTs (981 participants) in this review. Five studies were conducted in Europe and four in North America. Sample sizes ranged from 33 to 351. The mean age across trials ranged between 32.0 and 43.7 years.All included studies were judged as having high risk of performance bias and high risk of detection bias due to lack of blinding, and four of the nine studies suffered from at least one additional source of possible bias.In MBR compared to usual care for subacute LBP, individuals receiving MBR had less pain (four studies with 336 participants; SMD -0.46, 95% CI -0.70 to -0.21, moderate-quality of evidence due to risk of bias) and less disability (three studies with 240 participants; SMD -0.44, 95% CI -0.87 to -0.01, low-quality of evidence due to risk of bias and inconsistency), as well as increased likelihood of return-to-work (three studies with 170 participants; OR 3.19, 95% CI 1.46 to 6.98, very low-quality of evidence due to serious risk of bias and imprecision) and fewer sick leave days (two studies with 210 participants; SMD -0.38 95% CI -0.66 to -0.10, low-quality of evidence due to risk of bias and imprecision) at 12-month follow-up. The effect sizes for pain and disability were low in terms of clinical meaningfulness, whereas effects for work-related outcomes were in the moderate range.However, when comparing MBR to other treatments (i.e. brief intervention with features from a light mobilization program and a graded activity program, functional restoration, brief clinical intervention including education and advice on exercise, and psychological counselling), we found no differences between the groups in terms of pain (two studies with 336 participants; SMD -0.14, 95% CI -0.36 to 0.07, low-quality evidence due to imprecision and risk of bias), functional disability (two studies with 345 participants; SMD -0.03, 95% CI -0.24 to 0.18, low-quality evidence due to imprecision and risk of bias), and time away from work (two studies with 158 participants; SMD -0.25 95% CI -0.98 to 0.47, very low-quality evidence due to serious imprecision, inconsistency and risk of bias). Return-to-work was not reported in any of the studies.Although we looked for adverse events in both comparisons, none of the included studies reported this outcome.

AUTHORS' CONCLUSIONS

On average, people with subacute LBP who receive MBR will do better than if they receive usual care, but it is not clear whether they do better than people who receive some other type of treatment. However, the available research provides mainly low to very low-quality evidence, thus additional high-quality trials are needed before we can describe the value of MBP for clinical practice.

Management of moderate to severe chronic low back pain with buprenorphine buccal film using novel bioerodible mucoadhesive technology

With a global prevalence of ~9%-12%, low back pain (LBP) is a serious public health issue, associated with high costs for treatment and lost productivity. Chronic LBP (cLBP) involves central sensitization, a neuropathic pain component, and may induce maladaptive coping strategies and depression. Treating cLBP is challenging, and current treatment options are not fully satisfactory. A new BioErodible MucoAdhesive (BEMA®) delivery system for buprenorphine has been developed to treat cLBP. The buccal buprenorphine (BBUP) film developed for this product (Belbuca™) allows for rapid delivery and titration over a greater range of doses than was previously available with transdermal buprenorphine systems. In clinical studies, BBUP was shown to effectively reduce pain associated with cLBP at 12 weeks with good tolerability. The most frequently reported side effects with the use of BBUP were nausea, constipation, and vomiting. There was no significant effect on the QT interval vs placebo. Chronic pain patients using other opioids can be successfully rotated to BBUP without risk of withdrawal symptoms or inadequate analgesia. The role of BBUP in managing cLBP remains to be determined, but it appears to be a promising new product in the analgesic arsenal in general.