Beyond Anatomy: Fat-Suppressed MR and Molecular Imaging of Spinal Pain Generators

Spine pain is highly prevalent and costly, but evaluation with clinical features and anatomic imaging remain limited. Fat-suppressed MR imaging and molecular imaging (MI) may help identify inflammatory, lesional, and malignant causes. Numerous MI agents are available, each with advantages and disadvantages. Herein, FDG PET, prostate-specific membrane antigen (PSMA), bone radiotracers, and others are highlighted. No specific pain MI agents have been identified, but mechanisms of key agents are shown in video format, and the mechanism of PSMA as a theranostic agent is displayed. A multidisciplinary approach is needed to master this topic.

Perceptions in orthopedic surgery on the use of cannabis in treating pain: a survey of patients with spine pain (POSIT Spine)

BACKGROUND

Back pain is the leading cause of disability worldwide. Despite guidelines discouraging opioids as first-line treatment, opioids remain the most prescribed drugs for back pain. There is renewed interest in exploring the potential medical applications of cannabis, and with the recent changes in national legislation there is a unique opportunity to investigate the analgesic properties of cannabis.

METHODS

This was a multi-center survey-based study examining patient perceptions regarding cannabis for spine pain. We included patients presenting with back or neck pain to one of three Orthopedic clinics in Ontario. Our primary outcome was perceived effect of cannabis on back pain, while secondary outcomes were perceptions regarding potential applications and barriers to cannabis use.

RESULTS

259 patients participated in this study, 35.3% (90/255) stating they used cannabis medically. Average pain severity was 6.5/10 ± 0.3 (95% CI 6.2-6.8). Nearly three-quarters were prescribed opioids (73.6%, 148/201), with oxycodone/oxycontin (45.9% 68/148) being the most common, and almost half of (49.3%, 73/148) had used an opioid in the last week. Patients estimated cannabis could treat 54.3% ± 4.0 (95% CI 50.3-58.3%) of their spine pain and replace 46.2% ± 6. 6 (95% CI 39.6-52.8%) of their current analgesics. Age (β = - 0.3, CI - 0.6-0.0), higher pain severity (β = 0.4, CI 0.1-0.6) and previous cannabis use (β = 14.7, CI 5.1-24.4) were associated with a higher perceived effect of cannabis. Patients thought cannabis would be beneficial to treat pain (129/146, 88.4%), and reduce (116/146, 79.5%) or eliminate opioids (102/146, 69.9%). Not considering using cannabis for medical purposes (65/150, 43.3%) was the number one reported barrier.

CONCLUSIONS

Patients estimated medical cannabis could treat more than half of their spine pain, with one in three patients already using medical cannabis. 79% of patients also believe cannabis could reduce opioid usage. This data will help support more research into cannabis for musculoskeletal pain.

The Lumbar Stenosis Prognostic Subgroups for Personalizing Care and Treatment (PROSPECTS) study: protocol for an inception cohort study

Background

Lumbar spinal stenosis (LSS) is a common degenerative condition that contributes to back and back-related leg pain in older adults. Most patients with symptomatic LSS initially receive non-operative care before surgical consultation. However, there is a scarcity of data regarding prognosis for patients seeking non-surgical care. The overall goal of this project is to develop and evaluate a clinically useful model to predict long-term physical function of patients initiating non-surgical care for symptomatic LSS.

Methods

This is a protocol for an inception cohort study of adults 50 years and older who are initiating non-surgical care for symptomatic LSS in a secondary care setting. We plan to recruit up to 625 patients at two study sites. We exclude patients with prior lumbar spine surgeries or those who are planning on lumbar spine surgery. We also exclude patients with serious medical conditions that have back pain as a symptom or limit walking. We are using weekly, automated data pulls from the electronic health records to identify potential participants. We then contact patients by email and telephone within 21 days of a new visit to determine eligibility, obtain consent, and enroll participants. We collect data using telephone interviews, web-based surveys, and queries of electronic health records. Participants are followed for 12 months, with surveys completed at baseline, 3, 6, and 12 months. The primary outcome measure is the 8-item PROMIS Physical Function (PF) Short Form. We will identify distinct phenotypes using PROMIS PF scores at baseline and 3, 6, and 12 months using group-based trajectory modeling. We will develop and evaluate the performance of a multivariable prognostic model to predict 12-month physical function using the least absolute shrinkage and selection operator and will compare performance to other machine learning methods. Internal validation will be conducted using k-folds cross-validation.

Discussion

This study will be one of the largest cohorts of individuals with symptomatic LSS initiating new episodes of non-surgical care. The successful completion of this project will produce a cross-validated prognostic model for LSS that can be used to tailor treatment approaches for patient care and clinical trials.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05598-x.

Fear-Avoidance Beliefs, Kinesiophobia, and Disability Risk Among Indians with Spine Pain

PURPOSE

To determine the burden of fear-avoidance beliefs (FAB), kinesiophobia, and risk of persistent disability among Indians with spine pain.

METHODS

Demographic and clinical data collected from 139 patients who attended a spine rehabilitation clinic for assessment and treatment of their spine pain were analyzed. Fear-avoidance beliefs, kinesiophobia, and risk of persistent disability were measured using the Fear-avoidance Beliefs Questionnaire (FABQ), Tampa Scale for Kinesiophobia (TSK), and the STarT Back Tool (SBT). A multivariate analysis was performed to determine the effect of pain, disability, age, gender, BMI, lifestyle, pain duration, and pain location on FAB, TSK, and SBT scores.

RESULTS

A majority of patients had medium to high-risk FAB-physical activities (FAB-P) (50.5%) and SBT (54%) scores. The percentage of patients with medium or high-risk FAB-P (p = 0.03), FAB-work (FAB-W) (p = 0.03), and SBT (p = 0.03) scores were significantly higher in patients with pain score > 7, and the percentage of patients with medium or high-risk with FAB-P (p < 0.0001), TSK (p = 0.0003), and SBT (p < 0.0001) scores were significantly higher in patients with severe, crippled or bed-ridden disability. Disability was the only significant predictor for FAB-W, FAB-P, and SBT scores.

CONCLUSION

The prevalence of fear-avoidance beliefs and risk of persistent disability was significant among Indians and should be taken into account while planning treatment for their spine pain.

Burden of spine pain among rural and tribal populations in Raigad District of Maharashtra State of India

BACKGROUND

Among non-communicable disorders, low back and neck pain are the most common causes of severe, long-term pain and disability affecting more than a billion people globally. Yet, the burden and impact of these conditions are not well understood, especially among rural and tribal people living in low- and middle-income countries.

OBJECTIVE

The aims of this study were to measure point prevalence of low back and neck pain among rural and tribal people in Raigad District of Maharashtra, India, and explore attitudes and beliefs of rural people towards spine pain and disability.

DESIGN

In a cross-sectional survey of six villages in the Raigad District of Maharashtra State of India from August to October 2016, low back and neck pain were measured using the Spine Pain Questionnaire.

RESULTS

We surveyed 2323 participants, which did not include children and adolescents. Among rural people (n = 2073), the point prevalence of low back and neck pain was 4.9% (95% CI 3.94-5.79) and 2.9% (95% CI 2.21-8.87), respectively. Among tribal people (n = 250), prevalence was 10.0% (95% CI 6.28-13.71) for low back pain and 3.6% (95% CI 1.29-5.90) for neck pain. Lifting heavy weights and bending trunk were the most limiting activities. During informal discussions, most villagers attributed spine pain to traditional lifestyle and age. Participants continued occupational work in the presence of pain. Lack of transport facilities and cost of treatment emerged as the two most common reasons for delay in seeking treatment at nearby healthcare centres. This information will inform the development of customized spine care programmes through community-engaged partnerships and self-empowerment of the local community.

Promoting the use of self-management in patients with spine pain managed by chiropractors and chiropractic interns: barriers and design of a theory-based knowledge translation intervention

Background

The literature supports the effectiveness of self-management support (SMS) to improve health outcomes of patients with chronic spine pain. However, patient engagement in SMS programs is suboptimal. The objectives of this study were to: 1) assess participation in self-care (i.e. activation) among patients with spine pain, 2) identify patients’ barriers and enablers to using SMS, and 3) map behaviour change techniques (BCTs) to key barriers to inform the design of a knowledge translation (KT) intervention aimed to increase the use of SMS.

Methods

In summer 2016, we invited 250 patients with spine pain seeking care at the Canadian Memorial Chiropractic College in Ontario, Canada to complete the Patient Activation Measure (PAM) survey to assess the level of participation in self-care. We subsequently conducted individual interviews, in summer 2017, based on the Theoretical Domains Framework (TDF) in a subset of patients to identify potential challenges to using SMS. The interview guide included 20 open-ended questions and accompanying probes. Findings were deductively analysed guided by the TDF. A panel of 7 experts mapped key barriers to BCTs, designed a KT intervention, and selected the modes of delivery.

Results

Two hundred and twenty-three patients completed the PAM. Approximately 24% of respondents were not actively involved in their care. Interview findings from 13 spine pain patients suggested that the potential barriers to using SMS corresponded to four TDF domains: Environmental Context and Resources; Emotion; Memory, Attention & Decision-Making; and Behavioural Regulation. The proposed theory-based KT intervention includes paper-based educational materials, webinars and videos, summarising and demonstrating the therapeutic recommendations including exercises and other lifestyle changes. In addition, the KT intervention includes Brief Action Planning, a SMS strategy based on motivational interviewing, along with a SMART plan and reminders.

Conclusions

Almost one quarter of study participants were not actively engaged in their spine care. Key barriers likely to influence uptake of SMS among patients were identified and used to inform the design of a theory-based KT intervention to increase their participation level. The proposed multi-component KT intervention may be an effective strategy to optimize the quality of spine pain care and improve patients’ health-outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12998-019-0267-6) contains supplementary material, which is available to authorized users.

Advanced Image-Guided Procedures for Painful Spine

In addition to basic image-guided injections, there are many advanced procedures to address the challenges of spine pain. Patients with debilitating symptoms are offered relief, a shorter recovery period, and fewer potential complications. Pain arises from numerous sites along the spine, presenting as spine pain or radiculopathy. This article is an overview of advanced techniques in this rapidly progressing field, including neuromodulation, radiofrequency thermocoagulation, discography, intradiscal thermocoagulation, and percutaneous image-guided lumbar decompression; and it highlights etiologic factors and their relationship to therapeutic technique and clinical evidence.

Promoting the use of self-management in novice chiropractors treating individuals with spine pain: the design of a theory-based knowledge translation intervention

Background

Clinical practice guidelines generally recommend clinicians use self-management support (SMS) when managing patients with spine pain. However, even within the educational setting, the implementation of SMS remains suboptimal. The objectives of this study were to 1) estimate the organizational readiness for change toward using SMS at the Canadian Memorial Chiropractic College (CMCC), Toronto, Ontario from the perspective of directors and deans, 2) estimate the attitudes and self-reported behaviours towards using evidence-based practice (EBP), and beliefs about pain management among supervisory clinicians and chiropractic interns, 3) identify potential barriers and enablers to using SMS, and 4) design a theory-based tailored Knowledge Translation (KT) intervention to increase the use of SMS.

Methods

Mixed method design. We administered three self-administered questionnaires to assess clinicians’ and interns’ attitudes and behaviours toward EBP, beliefs about pain management, and practice style. In addition, we conducted 3 focus groups with clinicians and interns based on the Theoretical Domain Framework (TDF) to explore their beliefs about using SMS for patients with spine pain. Data were analysed using deductive thematic analysis by 2 independent assessors. A panel of 7 experts mapped behaviour change techniques to key barriers identified informing the design of a KT intervention.

Results

Participants showed high level of EBP knowledge, positive attitude of EBP, and moderate frequency of EBP use. A number of barrier factors were identified from clinicians (N = 6) and interns (N = 16) corresponding to 7 TDF domains: Knowledge; Skills; Environmental context and resources; Emotion; Beliefs about Capabilities; Memory, attention & decision making; and Social Influence. To address these barriers, the expert panel proposed a multifaceted KT intervention composed of a webinar and online educational module on a SMS guided by the Brief Action Planning, clinical vignettes, training workshop, and opinion leader support.

Conclusion

SMS strategies can help maximizing the health care services for patients with spine pain. This may in turn optimize patients’ health. The proposed theory-based KT intervention may facilitate the implementation of SMS among clinicians and interns.

Electronic supplementary material

The online version of this article (10.1186/s12891-018-2241-1) contains supplementary material, which is available to authorized users.

Both positive and negative beliefs are important in patients with spine pain: findings from the Occupational and Industrial Orthopaedic Center registry

BACKGROUND CONTEXT

Negative beliefs are known to influence treatment outcome in patients with spine pain (SP). The impact of positive beliefs is less clear.

PURPOSE

We aimed to assess the influence of positive and negative beliefs on baseline and treatment responses in patients with SP.

STUDY DESIGN/SETTING

A retrospective cross-sectional and longitudinal analysis of prospectively collected data of outpatient physical therapy patients with SP was carried out. Questionnaires administered before and during treatment included the STarT Back distress scale (negative beliefs), and expectation and self-efficacy questions (positive beliefs).

PATIENT SAMPLE

Patients with SP with a baseline assessment and follow-up assessment comprised the study sample.

OUTCOME MEASURE

Perceived disability was measured using the Oswestry Disability Index (ODI) or the Neck Disability Index (NDI). A clinical meaningful change (minimum clinically important difference [MCID]) was defined as decrease in ODI or NDI of ≥30%.

METHODS

We used the Akaike Information Criterion from the first imputed dataset of the prediction model to select predictor variables. Prediction models were fitted to the outcome variables.

RESULTS

In the cross-sectional analysis, 1,695 low back pain (LBP) episodes and 487 neck pain (NP) episodes were analyzed. STarT Back Screening Tool (SBST)-distress was positively associated with perceived disability in both LBP (beta 2.31, 95% confidence interval [CI] 1.75-2.88) and NP (beta 2.57, 95% CI 1.47-3.67). Lower self-efficacy was negatively associated with more perceived disability for LBP (beta 0.50, 95% CI 0.29-0.72) but not for NP, whereas less positive expectations was associated with more perceived disability in NP (beta 0.57, 95% CI 0.02-1.12) but not in LBP. In the longitudinal analysis, 607 LBP episodes (36%) and 176 (36%) NP episodes were included. SBST-distress did not predict treatment outcome in spine patients. In LBP, patients with a lower positive expectation were less likely to experience an MCID in perceived disability (odds ratio [OR] per point increase 0.89, 95% CI 0.83-0.96), and there was a similar trend in NP (OR per point increase 0.90, 95% CI 0.79-1.03). In patients with LBP, lower self-efficacy at baseline was associated with a higher likelihood that an MCID was achieved (OR per point increase 1.09, 95% CI 1.01-1.19). In NP, self-efficacy was not included in the final model.

CONCLUSIONS

Our study demonstrates that both negative and positive beliefs are associated with perceptions of disability. However, in this study, only positive beliefs were associated with treatment outcome.