Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials

Managing Nontraumatic Acute Back Pain

Low back pain is defined as any pain that occurs between the last costal arch and the lower gluteal fold, and may have different intensities and durations, being considered chronic if it lasts for more than 12 weeks, becoming non-specific if its cause is not identified, compromising the quality of life of affected individuals. Currently, Strength Training (TF) has been included in the treatment of chronic non-specific low back pain, in order to improve the condition of people suffering from this condition. Thus, the objective of this research was to verify the impact of PT on the treatment of low back pain, highlighting the main aspects based on the inclusion of this practice in everyday life, showing the benefits arising from this method. For the present study, a review of scientific articles was carried out using the PubMed, Scielo and Google Scholar databases to complement information on low back pain and PD. Several evidences were found that positively contribute to the improvement of low back pain with the use of PT in pain conditions, increased functional capacity, improvement in activities of daily living (ADL), gain in muscular resistance, strength and hypertrophy, in addition to individuals showing themselves more active. It is concluded that TF proved to be effective in the treatment of non-specific chronic low back pain, improving its symptoms such as pain and disability, however, if applied by an unqualified professional and incorrectly, it can be harmful to health.

Objectives: To review the available evidence on the effectiveness of acupuncture in the treatment of low back pain. Data Sources:MEDLINE, National Guideline Clearinghouse, Guidelines Finder, Cochrane Library, DARE, Bandolier, UpToDate and Index of Portuguese Medical Magazines. Review Methods: Research using the MeSH terms acupuncture and low back pain and the DeCS terms acupuntura e dor lombar. The search was limited to articles published between January 2000 and May 2009 in english, portuguese and spanish. American Family Physicians Strength of Recommendation Taxonomy (SORT) was used to assess the level of evidence. Results: Two meta-analysis, six systematic reviews, three randomised controlled trials and three guidelines met inclusion criteria. Guidelines say that acupuncture might be helpful in the treatment of low back pain. Unspecific chronic low back pain: the meta-analysis, systematic reviews and randomised controlled trials demonstrated that acupuncture is more effective than notreatment and that the association of acupuncture with conventional treatment is more effective than isolated conventional treatment. The studies didnt demonstrate that acupuncture was more effective than placebo or conventional therapies. Acute low back pain: data are inconclusive. Conclusions: Acupuncture is effective in the treatment of unspecific chronic low back pain, isolated or in addition to other interventions (SORT A); it was not proved that acupuncture was superior to other interventions. In the treatment of acute low back pain, there was no evidence of effectiveness of acupuncture. It would be advisable to do high quality, long-term, controlled and randomised studies, addressing its cost-benefit.

Back pain is the second leading cause of disability among American adults and is currently treated either with conservative therapy or interventional pain procedures. However, the question that remains is whether we, as physicians, have adequate therapeutic options to offer to the patients who suffer from chronic low back pain but fail both conservative therapy and interventional pain procedures before they consider surgical options such as discectomy, disc arthroplasty, or spinal fusion. The purpose of this article is to review the potential novel therapies that are on the horizon for the treatment of chronic low back pain. We discuss medications that are currently in use through different phases of clinical trials (I–III) for the treatment of low back pain. In this review, we discuss revisiting the concept of chemonucleolysis using chymopapain, as the first drug in an intradiscal injection to reduce herniated disc size, and newer intradiscal therapies, including collagenase, chondroitinase, matrix metalloproteinases, and ethanol gel. We also review an intravenous glial cell-derived neurotrophic growth factor called artemin, which may repair sensory nerves compressed by herniated discs. Another new drug in development for low back pain without radiculopathy is a subcutaneous monoclonal antibody acting as nerve growth factor called tanezumab. Finally, we discuss how platelet-rich plasma and stem cells are being studied for the treatment of low back pain. We believe that with these new therapeutic options, we can bridge the current gap between conservative/interventional procedures and surgeries in patients with chronic back pain.

Introduction The Pilates® method incorporates a number of the guidelines recommended for therapeutic exercises considered to be effective in the treatment of chronic lower back pain, such as the contraction of the transversus abdominis and multifidus muscles, associated with breathing, while taking into account the individual characteristics of patients. Objective To assess the effects of the Pilates® method on the treatment of lower back pain. Method This systematic review includes papers published from 2000 to 2010 in the BIREME, LILACS, MEDLINE and SciELO databases. The keywords used were spinal stabilization, Pilates®, and back pain and their equivalents in Portuguese. Results Imbalance among the trunk’s agonist-antagonist muscles and the ineffective activation of the transversus abdominis are risk factors for the onset of lower back pain that can be mitigated with the practice of Pilates®-based exercises. Conclusion The method has clinical effects similar to those obtained with traditional stabilization exercises and Back School exercises in the treatment of chronic lower back pain and are considered more satisfactory than conservative treatments.

Treatment for chronic low back pain in primary care has a poor-quality outcome. There is evidence that multimodal therapy is the most successful approach to its management. We tried to evaluate whether giving primary care physicians evidence-based recommendations on therapy of chronic back pain or directly implementing a multimodal program would improve the outcome of patients with low back pain treated in primary care. In the first phase, physicians were asked to document the course of patients suffering from low back pain of at least 4 weeks' duration with no decrease in intensity, noting pain intensity before and after 6 months of conventional, nonsurgical treatments. In the present, second, phase of the study, recommendations issued by the Medicines Committee of the German Medical Profession and the U.S. Agency for Health Care Policy and Research for the management of back pain were presented to doctors in printed form and at conferences. In parallel with this, a multimodal program for the treatment of chronic low back pain (4 h/day for 20 days: medical training therapy, cognitive-behavioral therapy, physiotherapy, and patient education) was organized in a private health-oriented sports center in cooperation with three private physiotherapy practices, and a psychologist and a pain specialist from the outpatient pain clinic at the University Hospital in Erlangen. We examined how physicians changed the therapy and how effective it was, the latter as reflected in the mean sum value of the percent pre- to posttreatment changes in pain intensity, how much pain interfered with daily living, depressivity, and quality of life. Data after interventions were compared with baseline data from the first phase. Data relating to 36 patients following treatment by 14 primary care physicians who had been given information about therapy recommendations and to 51 patients who had participated in the multimodal therapy program were compared with baseline data recorded in 157 patients. Recommendations changed neither the therapy preferred by primary care physicians nor the quality of outcome of conventional treatment. In contrast, the multimodal program of therapy for chronic low back pain improved the outcome significantly more than conventional therapy (mean improvement in general outcome score 22 vs. 7%, respectively, compared with baseline data; P<0.001). Giving primary care physicians information on the therapy recommended for treatment of low back pain does not lead to any change in physicians' preferred therapy. Multimodal programs for treatment of chronic low back pain should be organized locally, with existing health care providers joining forces to improve the quality of outcome in chronic low back pain managed in primary care.

Effect of education on non-specific neck and low back pain: a systematic review of randomized controlled trials

Low back pain

The role of activity in the therapeutic management of back pain. Report of the International Paris Task Force on Back Pain.

Systematic review. The purpose of this review is to provide a critical appraisal of general and fusion-specific clinical practice guidelines on the treatment of chronic nonradicular low back pain and compare the quality and evidence base of fusion guidelines and select payer policies. SUMMARY OF BACKGROUND DATA.: The treatment of lumbar spondylosis associated with low back pain with lumbar arthrodesis, or fusion, has risen fourfold in the past two decades. Given the significant associated health care costs, there is an increase in clinical guidelines and payer policies influencing patient treatment options. Assessment of the medical necessity of a treatment, such as lumbar fusions, based on medical literature will frequently supersede the determination of the physician in the care of their patient. Concerns regarding the effectiveness and costs of the surgical treatment of spinal disorders presenting with low back pain has placed enormous scrutiny on the value of surgical treatments to our patients. As both clinical guidelines and payer policies have a major impact on the perceived effectiveness, or medical necessity, of lumbar fusions for the treatment of chronic nonradicular low back pain, a review of this topic was undertaken. An electronic literature search of PubMed, the National Guideline Clearinghouse and the International Network of Agencies for Health Technology Assessment was performed to identify clinical practice guidelines on assessment and treatment of chronic nonradicular low back pain, including those on use of lumbar fusion, as well as relevant technology assessments. A Google search for publicly available private and public payer policies related to fusion was also performed. A hand search was used to identify specific studies cited for support of the recommendations made. A modified Appraisal of Guidelines Research and Evaluation instrument was used to provide a standardized assessment method for evaluating the quality of development of the evidence base and recommendations in guidelines and selected health policies. This was combined with appraisal of the evidence base supporting the recommendations. Three systematic reviews of general guidelines from a PubMed search yielding 94 citations were included. A convenience sample of five guidelines with recommendations on fusion was taken from 182 citations identified by the National Guideline Clearinghouse and the International Network of Agencies for Health Technology Assessment searches. Two guidelines were developed by US professional societies, (neurosurgery and pain management), and three were European-based guidelines (Belgium, United Kingdom, and the European Cooperation in Science and Technology). The general guidelines were consistent with their recommendations for diagnosis, but inconsistent regarding recommendations for treatment. All guidelines and payer policies with recommendations on fusion included some set of the primary randomized controlled trials comparing fusion to other treatment options with the exception of one policy. However, no clear pattern with regard to the quality of development was identified based on the modified Appraisal of Guidelines Research and Evaluation tool. There were differences in specialty society recommendations. Three systematic reviews of evidence-based guidelines that provide general guidance for the assessment and treatment of chronic low back pain described consistent recommendations and guidance for the evaluation of chronic low back pain but inconsistent recommendations and guidance for treatment. Five evidence-based guidelines with recommendations on the use of fusion for the treatment of chronic low back pain were evaluated. There is some consistency across guidelines and policies that are government sponsored with regard to development process and critical evaluation of index studies as well as overall recommendations. There were differences in specialty society recommendations. There is heterogeneity in the medical payer policies reviewed possibly due to variations in the literature cited and transparency of the development process. A description of how recommendations are formulated and disclosure of any potential bias in policy development is important. Three-medical payer policies reviewed are of poor quality with one rated as good with respect to their development based on the modified Appraisal of Guidelines Research and Evaluation tool. Medical payer policies influence patient care by defining medical necessity for approving treatments, and should be held to the same standards for transparency and development as guidelines. The spine care community needs to develop (or update) high-quality treatment guidelines. The process should be transparent, methodologically rigorous, and consistent with the Appraisal of Guidelines Research and Evaluation and Institute of Medicine recommendations. This effort should be collaborative across specialty/society groups and would benefit from patient and public input. Payer policies and treatment guidelines need to be transparent and based on the highest quality evidence available. Clinicians from specialty/society groups, guideline developers and policy makers should collaborate on their development. This process would also benefit from public and patient input.

Low back pain

THU0600 Value of Mesotherapy for Treatment of Chronic Low Back Pain: A Randomized Trial

Tramadol/Acetaminophen combination tablets for the treatment of chronic lower back pain: A multicenter, randomized, double-blind, placebo-controlled outpatient study

Introduction Chronic low back pain is conceived of as a multifactorial syndrome that results in the loss of functional capacity. It affects the quality of life of an individual and its treatment requires a comprehensive therapeutic approach. Objective The aim of this study is to assess the efficacy of the Santhiflex™ Method in the treatment of chronic low back pain, as well as its effects on functional capacity, health-related quality of life and body posture. Materials and methods 20 patients with chronic low back pain were randomly distributed into two groups of 10: an experimental group, which was treated with the Santhiflex™ Method of psychomotor postural re-education; and a control group, which was given a lecture on postural orientation after the first evaluation. Results The obtained data were analyzed using standard statistical software, SPSS-17 for Windows (SPSS, Chicago, IL, USA) and the results were expressed as absolute and relative frequencies, and median with first and third quartiles. The nonparametric Wilcoxon test was used for within-group samples. Intergroup comparison was performed using the Mann-Whitney test. A value of p &lt; 0.05 was considered statistically significant. There were significant differences in the main factors assessed. Discussion The findings demonstrated a significant total improvement in low back pain scores in the EG, whereas there was no significant change in the CG. Conclusion The Santhiflex™ Method is effective in the treatment of low back pain and has positive effects on functional capacity and health-related quality of life.

BACKGROUND AND OBJECTIVES: Low back pain is defined as a painful disorder located between the first and the fifth lumbar vertebra, and it is considered to be an important public health problem. In Brazil, approximately 10 million people are disabled as a result of this condition. The objective this study was to assess the effects of the Pilates method on the treatment of chronic low back pain. METHODS: The present study is based on a randomized, controlled clinical trial involving 16 individuals, aged 30-60 years, of both gender, with chronic low back pain, divided into control group and experimental group, with eight individuals each. Twelve sessions of 40 minutes were performed, in which nine positions of the Pilates method were applied within the experimental group. The control group performed kinesiotherapeutic conventional exercises. The visual analog scale and the Oswestry Disability Questionnaire were used before and after the study period in both groups. RESULTS: The assessment of pain and disability in the pre- and post-evaluation periods showed no statistically significant difference. The control group also showed no statistical difference for the visual analog scale and Oswestry scores between the pre- and post-evaluation periods, whereas the experimental group showed a significant difference between the scores obtained in these two different periods for the Oswestry and visual analog scores. CONCLUSION: It is suggested that the method was effective for the group studied and proved to be suitable for the treatment of low back pain, but it did not prove superior to conventional physical therapy.