Pharmacological and non-pharmacological treatment approaches to chronic lumbar back pain

Comparative efficacy of acupuncture, venesection, and physical therapy on chronic low back pain outcomes: a randomized clinical trial

Objective

Chronic low back pain (CLBP) imposes considerable financial and social burden with poor response to medical and surgical treatments. Alternatively, acupuncture and venesection(Fasd) are traditionally used to alleviate nociceptive and musculoskeletal pains. This study aimed to evaluate the effectiveness and the safety of acupuncture and venesection on CLBP and patient functionality.

Methods

The current study was a single-blinded, randomized clinical trial with balanced allocation, conducted in the Department of Physical Medicine & Rehabilitation Medicine, in 2022. One hundred five CLBP patients who had no back pain-attributable structural or major diseases were randomly allocated into three parallel arms and received either physical therapy (PTG), acupuncture (APG), or venesection (VSG). Pain severity and functional aspects were evaluated using the visual analogue scale (VAS) and Oswestry disability index (ODI) during the study. VAS and ODI scores were defined as the primary outcomes.

Results

Ninety-five patients were reviewed in the final analysis (PTG=33, APG=30, VSG=31). Demographic data showed equal group distribution. Statistical analysis showed all procedures had reduced VAS score immediately after the first session, after the last session, and after follow-up; however, APG and VSG values were significantly lower (P<0.05). Pain reduction results in follow-up period were more sustainable in APG and VSG as compared to PTG (P<0.01). ODI results revealed global improvement after the last session of the treatment in all groups, while APG had more significant results (P<0.05). During the follow-up period, ODI still tended to decrease in VSG, non-significantly increased in APG, and significantly increased in PTG. Only two patients reported fainting after receiving venesection.

Conclusion

Considering the pain and functional scores, both acupuncture and venesection can reproduce reliable results. Acupuncture and venesection both have sustained effects on pain and daily function of the patients even after treatment termination, while physical therapy had more relapse in pain and functional limitations.

Effectiveness of Back care education Programme among school children: a systematic review of randomized controlled trials

STUDY DESIGN

Systematic review of Randomised controlled trials.

OBJECTIVES

With the increasing incidence of back pain among children and its untold implications to their future, back education tailored in an effective way would be indicated. However literature appears unsettled. This study aims to review available literature to determine the effect of school-based back education in preventing and managing low back pain in school children.

METHODS

Randomized controlled trials carried out on elementary and secondary school children of ages 6 to 18 years and published in English language were included. Back education taught in hospitals or other settings were excluded. Primary outcome was back pain prevalence and secondary outcomes were constituted from the study characteristics of selected studies which includes: back behavior, knowledge, postural habits, physical activity, fear-avoidance beliefs, back pack carriage, pain intensity, skills and self efficacy. Databases searched were PEDro, HINARI, PubMed, Cochrane, and Google Scholar. Available stiudies from 2000 to March 2022 were retrieved. Quality of studies were assessed using the PEDro scale. Obtained studies were descriptively analyzed.

RESULTS

A total 8420 studies were retrieved and 8 studies (with 1239 participants) were included in this review. Four studies each assessed back knowledge and back behavior, and two assessed back pain prevalence. There were improvements in back knowledge and back behaviour, but effectiveness of back care education on back pain prevalence was not conclusive. Forms of education used involved the indirect method of conditioning the environment and the direct method which made use of theory, practical lessons and educational books and materials.

CONCLUSION

Back care education programmes in schools are effective in improving back care knowledge, behavior and reduction in low back pain frequency. Reduction in back pain prevalence is not conclusive. Back care education could be incorporated as part of schools' education programmes. Limitations include exclusion of non English language studies and inconsistent outcome measures.

FUNDING SOURCE

None.

REGISTRATION

This review protocol was registered under the International platform of Registered systematic review and meta-analysis protocol (INPLASY) with the registration number; INPLASY202310044 and DOI number; https://doi.org/10.37766/inplasy2023.1.0044.

What do we mean by 'self-management' for chronic low back pain? A narrative review

BACKGROUND

Chronic low back pain (CLBP) is a highly prevalent musculoskeletal condition affecting 60-80% of the general population within their lifetime. Given the large numbers of people affected, self-management approaches have been introduced as a way to manage this condition with endorsement by the national institute for health and care excellence. Interventions are often termed self-management without defining either content or goals. Our study sought to determine the content, characteristics, and evidence for self-management of CLBP.

METHODS

This narrative review was conducted using a systematic approach to search journal articles in English that focused on CLBP self-management. MEDLINE, EMBASE, CINAHL, and PsycINFO databases were used to identify publications with terms relating to back pain and self-management from January 2016 until January 2022.

RESULTS

In total, 15 studies were found suitable for inclusion in the review. Core components of self-management strategies include exercise, education, and psychological interventions, but there was a lack of consistency with respect to content. Intervention characteristics were either under-reported or varied. Furthermore, outcome measures used to assess these self-management programmes were diverse, mainly focusing on functional disability and pain intensity.

CONCLUSIONS

Inconsistencies in the content of self-management interventions, intervention characteristics, and outcome measures used for assessing self-management programmes were found across the literature. Current self-management approaches do not consider the complex biopsychosocial nature of CLBP. A consensus on the key components of self-management interventions, and how they should be evaluated, will pave the way for research to determine whether self-management can effectively manage CLBP.

Various Doses of Tanezumab in the Management of Chronic Low Back Pain (CLBP): A Pooled Analysis of 4,514 Patients

Chronic low back pain (CLBP) is a persistent and debilitating condition characterized by pain and discomfort in the lower back region that lasts more than 12 weeks. This review aims to determine the efficacy and safety of various doses of tanezumab for managing CLBP. The present meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Intervention standards. We searched multiple databases, including PubMed, Cochrane Library, Excerpta Medica Database (EMBASE), Scopus, and Web of Science, to identify randomized controlled trials comparing tanezumab to placebo or different dosage regimens for CLBP in adult patients. The primary outcome was the mean change in low back pain intensity (LBPI) score baseline to the end of treatment. Secondary outcomes included adverse events and the degree of disability or impairment. A total of six studies were included in the meta-analysis. Analysis of the data showed that tanezumab 5 mg significantly reduced LBPI compared to placebo at all time points (mean deviation (MD) ranging from -0.31 to -0.5). Similarly, tanezumab 10 mg showed a significant reduction in LBPI compared to placebo at all time points (MD ranging from -0.48 to -0.84). However, tanezumab 5 mg showed significantly less reduction of LBPI compared to 10 mg at two, four, eight, and 12 weeks (MD ranging from 0.19 to 0.32). These findings suggest that tanezumab is an effective treatment for CLBP, with 5 mg and 10 mg doses providing clinically meaningful reductions in LBPI.

Needling Point Location Used in Sham Acupuncture for Chronic Nonspecific Low Back Pain: A Systematic Review and Network Meta-Analysis

Importance

When sham acupuncture is set as a control in evaluating acupuncture, the sham needling technique is usually different from acupuncture. However, the sham procedure is conducted either at the same points that are used for the acupuncture group or at nonindicated points.

Objective

To assess whether the outcome of sham acupuncture varies according to the needling points in sham-controlled trials of acupuncture for chronic nonspecific low back pain (CLBP) as an example.

Data sources

Searches of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and the Allied and Complementary Medicine Database were conducted on February 12, 2023.

Study selection

Randomized clinical trials (RCTs) assessing the outcomes of acupuncture in sham acupuncture-controlled or waiting list-controlled trials on CLBP were included.

Data extraction and synthesis

Two researchers independently extracted data on study characteristics and outcomes and assessed quality. Sham acupuncture was classified according to whether it was conducted at the same acupuncture points used in the acupuncture group, referred to as sham acupuncture therapy (verum) (SATV) or at different points, referred to as sham acupuncture therapy (sham) (SATS). Clinical similarity, transitivity, and consistency tests were conducted, followed by a random-effects frequentist network meta-analysis (NMA).

Main outcomes and measures

The primary outcome was pain, and the secondary outcome was back-specific function. The first assessment after the end of treatment was chosen for analysis. Effect sizes are reported as standardized mean differences (SMD) with 95% CIs. The risk of bias was assessed using the Cochrane risk of bias tool, and the certainty of evidence for findings was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results

Ten RCTs involving 4379 participants were included. In comparison with SATS, acupuncture was significantly associated with improvements in both pain (SMD, -0.33; 95% CI, -0.52 to -0.15) and function outcomes (SMD, -0.13; 95% CI, -0.25 to -0.02); however, there were no differences between acupuncture and SATV. In comparison with SATS, SATV was significantly associated with better pain (SMD, -0.45; 95% CI, -0.88 to -0.03) and function outcomes (SMD, -0.30; 95% CI, -0.56 to -0.05). The risk of bias that could affect the interpretation of the results was usually low, and the certainty of evidence was moderate to low.

Conclusions and relevance

In this NMA, sham acupuncture needling at the same points as those in acupuncture was not a true placebo control for assessing the efficacy of acupuncture for CLBP and might underestimate the outcome of acupuncture in clinical settings.

Self-administered stretching exercises are as effective as motor control exercises for people with chronic non-specific low back pain: a randomised trial

QUESTION

In people with chronic non-specific low back pain, what is the effect of self-administered stretching exercises relative to motor control exercises on pain intensity, disability, fear avoidance, global perceived effect and flexibility?

DESIGN

Randomised trial with concealed allocation, intention-to-treat analysis and blinding of assessors.

PARTICIPANTS

One hundred people with chronic non-specific low back pain.

INTERVENTIONS

The self-stretching exercise group performed 6 stretches in 40-minute sessions. The motor control exercise group performed trunk stabilising exercises in 40-minute sessions. Both groups performed weekly supervised sessions for 8 weeks with one or more home sessions/week.

OUTCOME MEASURES

The primary outcomes were pain intensity (0 to 10 scale) and disability (Oswestry Disability Index). The secondary outcomes were the Fear Avoidance Beliefs Questionnaire, global perceived effect, and the fingertip-to-floor test. Measures were taken at baseline and at 8, 13 and 26 weeks.

RESULTS

On the 0 to 10 scale, the between-group difference in pain intensity was negligible, with a mean difference of roughly 0 (95% CI -1 to 1) at each time point. Similarly, the between-group difference on the 100-point disability scale was negligible: MD -1 (95% CI -3 to 1) at week 8, MD 1 (95% CI -1 to 3) at week 13 and MD 0 (95% CI -1 to 2) at week 26. The two interventions also had similar effects on the secondary outcomes.

CONCLUSION

In people with chronic non-specific low back pain, self-stretching exercises had very similar effects to motor control exercises on pain intensity, disability, fear avoidance, global perceived effect and flexibility up to 18 weeks beyond the end of an 8-week program. Given the established effectiveness of motor control exercises, either intervention could be recommended to people with chronic low back pain. The choice of intervention might be directed by patient preference.

REGISTRATION

NCT03128801.

Assessment of the Community Pharmacists' Knowledge and Attitudes Toward Pain and Pain Management in Saudi Arabia

Background

Pain is a global health issue that affects an individual's quality of life. Its alleviation and management will enhance patients' experience. Community pharmacists can help manage pain severity through their valuable roles in medical teams and by managing the consequences of pain.

Objective

This study aimed to evaluate community pharmacists' knowledge and attitudes toward pain and pain management in Saudi Arabia.

Methods

A cross-sectional study was performed to evaluate community pharmacists' knowledge and attitudes toward pain and pain management in Saudi Arabia. Pharmacists aged ≥ 21 years, with a degree in pharmacy were included in this study. Each respondent participated in an online survey covering cancer-oriented pain and assessment of pain; pharmacology; abuse of substances; and physical dependence. An independent t-test and One-way ANOVA, with least significant difference as a post-hoc test, were employed, in addition to the General Linear Regression Model using Main Effect as the model.

Results

This study revealed that the pain-related knowledge and attitude among community pharmacists in Saudi Arabia were inadequate. Age (p = 0.003), work experience (p = 0.036), nature of work (p = 0.001), and work location (p = 0.003) were determined as significant factors affecting their overall knowledge and attitude toward pain.

Conclusion

Overall, attempts to expand community pharmacists' knowledge and foster an appropriate attitude toward pain management among them in Saudi Arabia are highly recommended. Additional academic courses, studies, and tailored neuroscience courses will improve their awareness and knowledge of pain and pain management.

A multi-center, double-blind, randomized parallel-group Phase IV study comparing the efficacy and safety of thiocolchicoside ointment versus placebo in patients with chronic mechanical low back pain and an acute muscle spasm

Objectives

This study aims to evaluate the efficacy and safety of thiocolchicoside (TCC) ointment treatment compared to placebo in patients with chronic mechanical low back pain (LBP) accompanied by acute muscle spasms.

Patients and methods

A total of 292 adult patients (106 males, 186 females; mean age: 38.5±11.2 years; range, 18 to 64 years) were randomized to TCC group (n=147) and placebo group (n=145) in 12 centers between March 2020 and March 2021. Eight patients from each group were excluded from the analysis. The primary endpoint was pressure pain threshold (PPT) on Day 3, which was measured using a pressure algometer. Secondary endpoints were PPT on Day 7, patient, and physician Visual Analog Scales-pain (VAS-pain) on Days 3 and 7, and safety.

Results

The PPT values on Day 3 was not significantly different between the treatment groups (p=0.701). Similarly, TCC and placebo group had similar VAS-pain scores over trial period (p=0.577 or higher for comparisons). Significantly higher PPT values and lower VAS-pain scores on Days 3 and 7 were observed in both groups (p<0.001 for all). In patients with a PPT value of ≥3.87, TCC arm had higher PPT on Day 3 compared to placebo (p=0.029). Three patients (two in the TCC arm and one in the placebo arm) discontinued the trial due to an adverse event.

Conclusion

Topical TCC can be an appropriate option in a subset of patients with mild chronic LBP accompanied by muscle spasms. In a subset of patients with milder pain intensity, topical TCC may improve pain earlier. The results of this trial are compatible with the treatment approaches used in daily practice.

The Effect of Static Cupping Therapy in Non-specific Low Back Pain for Primary Dysmenorrhea

Dysmenorrhea is often referred to as painful menstruation with cramping sensations in the lower abdomen, resulting in discomfort. This pain commonly radiates to both the thighs and lumbosacral regions. A 23-year-old female presented with a complaint of severe abdominal pain during menses, accompanied by low back pain (LBP) that typically started at the onset of menstrual flow and lasted for the first 24-48 hours for which no analgesics were taken by the patient. The pain intensity was recorded on a numerical pain rating scale (NPRS) that showed 6 out of 10 for abdominal and low back pain during activity and 4 out of 10 at rest, on account of which a two-day supervised static cupping therapy protocol was devised for the patient. After treatment, the NPRS recorded a remarkable decrease in pain intensity to 2 out of 10 for abdominal and low back pain during activity, as well as at rest. As static cupping therapy is used to target deeper muscles in the lower back and abdomen; this case report aims to highlight the beneficial effects of static cupping on primary dysmenorrhea and related non-specific low back pain.

Potential Nociceptive Role of the Thoracolumbar Fascia: A Scope Review Involving In Vivo and Ex Vivo Studies

Nociceptive innervation of the thoracolumbar fascia (TLF) has been investigated over the past few decades; however, these studies have not been compiled or collectively appraised. The purpose of this scoping review was to assess current knowledge regarding nociceptive innervation of the TLF to better inform future mechanistic and clinical TLF research targeting lower back pain (LBP) treatment. PubMed, ScienceDirect, Cochrane, and Embase databases were searched in January 2021 using relevant descriptors encompassing fascia and pain. Eligible studies satisfied the following: (a) published in English; (b) preclinical and clinical (in vivo and ex vivo) studies; (c) original data; (d) included quantification of at least one TLF nociceptive component. Two-phase screening procedures were conducted by a pair of independent reviewers, after which data were extracted and summarized from eligible studies. The search resulted in 257 articles of which 10 met the inclusion criteria. Studies showed histological evidence of nociceptive nerve fibers terminating in lower back fascia, suggesting a TLF contribution to LBP. Noxious chemical injection or electrical stimulation into fascia resulted in longer pain duration and higher pain intensities than injections into subcutaneous tissue or muscle. Pre-clinical and clinical research provides histological and functional evidence of nociceptive innervation of TLF. Additional knowledge of fascial neurological components could impact LBP treatment.