PEER simplified decision aid: chronic back pain treatment options in primary care

Mechanisms of chiropractic spinal manipulative therapy for patients with chronic primary low back pain: protocol for a mechanistic randomised placebo-controlled trial

INTRODUCTION

Chronic low back pain (CLBP) is a highly prevalent and disabling condition. Identifying subgroups of patients afflicted with CLBP is a current research priority, for which a classification system based on pain mechanisms was proposed. Spinal manipulative therapy (SMT) is recommended for the management of CLBP. Yet, little data are available regarding its mechanisms of action, making it difficult to match this intervention to the patients who may benefit the most. It was suggested that SMT may influence mechanisms associated with central sensitisation. Therefore, classifying patients with CLBP according to central sensitisation mechanisms may help predict their response to SMT.

METHODS AND ANALYSIS

This protocol describes a randomised placebo-controlled trial aiming to examine which variables linked to central sensitisation may help predict the clinical response to SMT in a cohort of patients with CLBP. One hundred patients with chronic primary low back pain will be randomised to receive 12 sessions of SMT or placebo SMT over a 4-week period. Pain intensity and disability will be assessed as primary outcomes after completing the 4-week treatment (primary endpoint), and at 4-week and 12-week follow-ups. Baseline values of two pain questionnaires, lumbar pressure pain thresholds, concentrations of an inflammatory cytokine and expectations of pain relief will be entered as predictors of the response to SMT in a multiple regression model. Changes in these variables after treatment will be used in a second multiple regression model. The reference values of these predictors will be measured from 50 age and sex-matched healthy controls to allow interpretation of values in patients. Mixed analyses of variance will also be conducted to compare the primary outcomes and the predictors between groups (SMT vs placebo) over time (baseline vs post-treatment).

ETHICS AND DISSEMINATION

Ethical approval was granted by the Fundación Jiménez Díaz Clinical Research Ethics Committee.

TRIAL REGISTRATION NUMBER

NCT05162924.

Chronic Low Back Pain Forced Me to Search for and Find Pain Solutions: An Autobiographical Case Report

Lifelong, pregnancy-induced low back pain forced me to search for solutions to the problem of pain. Currently, low back pain is often diagnosed as “nonspecific” and, as a result, a multitude of tests and poorly effective, at times side effect-laden or habit-forming treatments are recommended. My quest for relief took me to first diagnose my pain as coming from the sacroiliac joints, then to prolotherapy, the first treatment which brought me prolonged relief. I then learned how to perform prolotherapy. In 2009, when I undertook a randomized controlled study of dextrose prolotherapy for rotator cuff tendinopathy, I restricted my practice to treating pain.

As low back pain was a large part of my practice, I sought new ways to examine the sacroiliac joints. I conducted a consecutive patient data collection which suggested that over three-quarters of those with low back pain suffer from displaced sacroiliac joints. In a further randomized controlled study, I found that the two-minute corrective exercise I derived from this test provided immediate relief to 90% of those using it.

With Dr. John Clark Lyftogt I discovered the safety and effectiveness of 5% dextrose perineural injections to provide immediate pain relief to any area supplied by a nerve I could reach with my needle. As I was treating many diabetics with peripheral neuropathy, I shifted my perineural injection material to 5% mannitol, which may be as effective, with less exposure to dextrose as a potential benefit for diabetics.

As most people dislike injections, a pharmacist and I developed a mannitol-containing topical cream for pain relief. We compared a base cream to the same cream with mannitol on lips pretreated with capsaicin cream which made them burn. By 10 minutes the probability the two creams were as effective in relieving the burn was less than 0.001 in favor of mannitol. When given to 235 patients with a total of 289 different painful conditions, we found that it provided 53% relief in an average of 16 minutes with a median of four hours duration.

Now retired, after 55 years of medical practice, I love to relieve the pain of friends and fellow hikers using exercise and cream. Searching for and finding solutions to chronic pain has enriched my life and that of many others.

Clinical Effectiveness and Efficacy of Chiropractic Spinal Manipulation for Spine Pain

Spine pain is a highly prevalent condition affecting over 11% of the world's population. It is the single leading cause of activity limitation and ranks fourth in years lost to disability globally, representing a significant personal, social, and economic burden. For the vast majority of patients with back and neck pain, a specific pathology cannot be identified as the cause for their pain, which is then labeled as non-specific. In a growing proportion of these cases, pain persists beyond 3 months and is referred to as chronic primary back or neck pain. To decrease the global burden of spine pain, current data suggest that a conservative approach may be preferable. One of the conservative management options available is spinal manipulative therapy (SMT), the main intervention used by chiropractors and other manual therapists. The aim of this narrative review is to highlight the most relevant and up-to-date evidence on the effectiveness (as it compares to other interventions in more pragmatic settings) and efficacy (as it compares to inactive controls under highly controlled conditions) of SMT for the management of neck pain and low back pain. Additionally, a perspective on the current recommendations on SMT for spine pain and the needs for future research will be provided. In summary, SMT may be as effective as other recommended therapies for the management of non-specific and chronic primary spine pain, including standard medical care or physical therapy. Currently, SMT is recommended in combination with exercise for neck pain as part of a multimodal approach. It may also be recommended as a frontline intervention for low back pain. Despite some remaining discrepancies, current clinical practice guidelines almost universally recommend the use of SMT for spine pain. Due to the low quality of evidence, the efficacy of SMT compared with a placebo or no treatment remains uncertain. Therefore, future research is needed to clarify the specific effects of SMT to further validate this intervention. In addition, factors that predict these effects remain to be determined to target patients who are more likely to obtain positive outcomes from SMT.