Comparison Of The Effectiveness Of Back School Exercises And Mckenzie Exercises In The Treatment Of Chronic Low Back Pain; A Randomized Controlled Trial”RCT

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

In cases of chronic non-specific neck and low back pain (CNLBP), where emotional disorders are identified, the involvement of a psychiatrist in patient management is considered. However, the effectiveness of this approach in patients with CNLBP and a confirmed anxiety or depressive disorder (F41, F33, F32) remains insufficiently studied. Objective: To conduct a comparative evaluation of the efficacy of a comprehensive approach (involving a psychiatrist, an educational programme incorporating elements of cognitive behavioural therapy (CBT), and personalised therapeutic exercise) versus a standard approach in the treatment of chronic non-specific low back pain (CNLBP) in patients diagnosed with an anxiety or depressive disorder (F41, F33, F32) by a psychiatrist. Material and methods. The study included 55 patients with CNLBP and anxiety (F41) or depressive disorder (F33, F32), who were randomized into two groups. The first group (comprehensive therapy – CT) consisted of patients (n=27) who received a comprehensive (multimodal) approach, including the involvement of a psychiatrist in patient management, 6 sessions of an individualized educational programme incorporating elements of CBT delivered by a certified specialist in chronic pain and emotional disorders, 4–5 individual sessions of therapeutic exercise (TE) with the development of a personalized exercise regimen, and recommendations on workplace ergonomics. The standard therapy (ST) group comprised patients (n = 28) who were treated using a standard therapy protocol (optimisation of drug therapy, a one-off educational programme to improve physical activity, and standard kinesiotherapy). The study protocol involved 6 months of therapy and fol-low-up with efficacy assessments at three time points – 1, 3 and 6 months after the start of treatment. A numerical rating scale (NRS) was used to assess pain intensity; the Spielberger test, which assesses state (ST) and trait (TT) anxiety, and the Beck Depression Inventory were used to assess anxiety and depressive disorders. The SF-12 questionnaire was used to assess quality of life, taking into account the division of this questionnaire into summary scales for physical (PCS-12) and mental health (MCS-12). To determine the impact of neck pain (NP), the Neck Disability Index (NDI) was used; to assess the impact of low back pain (LBP) on daily activities, the Oswestry Low Back Pain Disability Questionnaire was used. Results. Against the background of treatment, a more significant decrease in pain intensity according to the NRS was noted in the CT group than in the ST group – respectively, for NP to 1.46 ± 0.75 and 2.92 ± 1.0 after 3 months (p < 0.001) and to 0.69 ± 0.72 and 3.0 ± 1.41 after 6 months (p < 0.001), for LBP 2.04 ± 0.86 and 3.29 ± 1.31 after 3 months (p < 0.001), and to 1.04 ± 0.91 and 3.29 ± 1.48 after 6 months (p < 0.001), a decrease in functional impairment according to the Oswestry questionnaire to 15.57 ± 3.55 and 27.62 ± 3.27 after 3 months (p < 0.001) and up to 10.22 ± 2.54 and 29.67 ± 4.24 after 6 months (p < 0.001), a decrease in functional impairment according to the NDI to 12.54 ± 4.36 and 23.38 ± 4.5 after 3 months (p < 0.001) and up to 8.08 ± 2.81 and 25.23 ± 4.95 after 6 months (p < 0.001), an improvement in the quality of life according to PCS to 46.04 ± 4.31 and 43.21 ± 4.04 after 3 months (p < 0.05) and up to 50.07 ± 3.27 and 43.57 ± 3.17 after 6 months (p < 0.001), an improvement in the quality of life according to MCS to 47.3 ± 4.31 and 44.57 ± 3.13 after 3 months (p < 0.05) and up to 50.56 ± 2.86 and 44.75 ± 2.63 after 6 months (p < 0.001). During therapy, no significant differences were found between the CT and ST groups according to the Beck Depression Inventory, ST and TT, in both groups an improvement in the indicators was observed over time, however, when comparing the survey indicators after 3 and 6 months, the CT group showed a statistically significant improvement according to the Beck Depression Inventory (p = 0.04), while in the ST group no further changes were noted (p = 0.14). Conclusion. A comprehensive multidisciplinary approach (involving a psychiatrist) to the treatment of patients with chronic non-specific low back pain (CNLBP) and mental health disorders (anxiety and depressive disorders) leads to a more significant reduction in pain and an improvement in functional activity. Prescribed drug therapy for mental disorders improved the improvement in pain, functional activity and quality of life in the long term.

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.

Managing Nontraumatic Acute Back Pain

Chronic low back pain is a debilitating condition that impacts millions of individuals around the world, and also has an enormous economic impact. The impact of chronic pain does not only involve physical health, but can also play a detrimental role in a patient's mental health. Consequently, it is critical to approach these patients with multimodal management. Initially, a treatment plan which includes medications, psychotherapy, physical therapy, and invasive interventions can be utilized for chronic back pain. However, many patients experience refractory low back pain to these initial treatments, which can result in non-resolving chronic pain. As a result, many new interventions have been developed in recent years to treat refractory low back pain, including non-invasive transcranial magnetic stimulation. In recent years, there has been some limited and preliminary evidence for the treatment of chronic low back pain with transcranial magnetic stimulation, as further investigation on this intervention is warranted. After reviewing analytically high impact studies, our objective is to provide a narrative review of the treatment of chronic low back pain with repetitive transcranial magnetic stimulation (rTMS). We performed a comprehensive database search on PubMed, Embase, PsychInfo, Web of Science, and CINAHL for literature that pertains to the treatment of chronic low back pain with transcranial magnetic stimulation using these terms: "Chronic Low Back Pain and Transcranial Magnetic Stimulation", "Low Back Pain and Transcranial Magnetic Stimulation", "Chronic Back Pain and Transcranial Magnetic Stimulation", "Chronic Low Back Pain and TMS", "Low Back Pain and TMS", and "Chronic Back Pain and TMS". We aim to provide a narrative review of the role of rTMS in CLBP. Initial search results from September to November 2021 using the above-mentioned search criteria included 458 articles, of which 164 duplicates were removed and 280 were further excluded by a three-person (CO, NM and RA) screening process. Articles were further filtered based on various exclusion and inclusion criteria. The resulting 6 studies are discussed. The studies reviewed suggest the potential benefit in chronic lower back pain symptoms after various rTMS protocols and sites of stimulation. However, the included studies are not without issues in design for example: not randomized, not blinded, or have small sample size. This review highlights the need for scaled, better controlled research studies and standardization of treatment protocols to determine if rTMS for chronic lower back pain will be accepted as a standard treatment option for patients with chronic lower back pain symptoms.

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.

Chronic refractory low back and lower extremity pain is frustrating to treat. Percutaneous adhesiolysis and spinal endoscopy are techniques which can treat chronic refractory low back and lower extremity pain.Percutaneous adhesiolysis is performed by placing the catheter into the tissue plane at the ventrolateral aspect of the foramen so that medications can be injected. Adhesiolysis is used both for pain caused by scarring which is not resistant to catheter placement and other sources of pain, including inflammation in the absence of scarring.Mechanical lysis of scars with a catheter may or may not be necessary for percutaneous adhesiolysis to be effective. Spinal endoscopy allows direct visualization of the epidural space and has the possibility to use laser energy to treat pathology. A systematic review of the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis to treat chronic refractory low back and lower extremity pain. To evaluate and update the effectiveness of percutaneous adhesiolysis and spinal endoscopic adhesiolysis to treat chronic refractory low back and lower extremity pain. The available literature on percutaneous adhesiolysis and spinal endoscopic adhesiolysis in treating persistent low back and leg pain was reviewed. The quality of each article used in this analysis was assessed. The level of evidence was classified on a 5-point scale from strong, based upon multiple randomized controlled trials to weak, based upon consensus, as developed by the U.S. Preventive Services Task Force (USPSTF) and modified by ASIPP. Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to September 2015, and manual searches of the bibliographies of known primary and review articles. Pain relief of at least 50% and functional improvement of at least 40% were the primary outcome measures. Short-term efficacy was defined as improvement of 6 months or less; whereas, long-term efficacy was defined more than 6 months. For this systematic review, 45 studies were identified. Of these, for percutaneous adhesiolysis there were 7 randomized controlled trials and 3 observational studies which met the inclusion criteria. For spinal endoscopy, there was one randomized controlled trial and 3 observational studies. Based upon 7 randomized controlled trials showing efficacy, with no negative trials, there is Level I or strong evidence of the efficacy of percutaneous adhesiolysis in the treatment of chronic refractory low back and lower extremity pain. Based upon one high-quality randomized controlled trial, there is Level II to III evidence supporting the use of spinal endoscopy in treating chronic refractory low back and lower extremity pain. The evidence is Level I or strong that percutaneous adhesiolysis is efficacious in the treatment of chronic refractory low back and lower extremity pain. Percutaneous adhesiolysis may be considered as a first-line treatment for chronic refractory low back and lower extremity pain. The evidence is Level II to III that spinal endoscopy is effective in the treatment of chronic refractory low back and lower extremity pain. Spinal pain, chronic low back pain, post lumbar surgery syndrome, epidural scarring, adhesiolysis, endoscopy, radicular pain.

(i) Optimizing non-operative care

Background: Low-back pain is a major health and economical problem that affects populations around the world. Chronic low-back pain, in particular, is a major cause of medical expenses, work absenteeism, and disability. Objective: To explore the effect of adding cognitive-behavioral therapy to physical therapy interventions in patients with chronic non-specific back pain. Patients and methods: 20 male and female patients between 25 and 40 years old diagnosed as chronic non-specific back pain with central sensitization and fear avoidance behaviors symptoms participated in this study. Patients were randomly assigned into two groups. The first group was treated by cognitive behavioral therapy (graded exposure and graded activity) in addition to physiotherapy the second group was treated by physical therapy interventions which was given only 3 times/week for 4 consecutive weeks. Results: Descriptive statistics was used to identify each variable’s mean and standard deviation. A paired t-test was used to compare characteristics of patients between both groups. Pre-treatment results showed no significant difference in both measured variables of Oswestry, and pain in both groups (P > 0.05). On the other hand, post-treatment results showed a significant decrease in the Oswestry, and pain only in group A (the study group). Conclusion: Adding graded exposure and graded activity as an operant cognitive behavioural therapy approach to physical therapy program is more beneficial than physical therapy program alone. More data and follow up needed for this study.

This review evaluates the use of antidepressants in older patients for the treatment of nonspecific chronic lower back pain (LBP), emphasizing age-related physiological changes and common degenerative conditions in this age group. We conducted a comprehensive search targeting studies on antidepressant use in older patients with LBP. Selective serotonin reuptake inhibitors, while effective for mood regulation, show limited benefits for LBP. Serotonin–norepinephrine reuptake inhibitors, particularly duloxetine, demonstrate potential in managing LBP, though further research is needed to confirm these findings. Tricyclic antidepressants have shown potential for pain relief, with limited evidence for LBP, but have a substantial side effect profile, including cardiotoxicity, weight gain, and severe anticholinergic effects. The evidence for trazodone in the treatment of LBP is limited. When prescribing new medications for older adults, it is crucial to carefully consider the patient’s overall health, potential drug interactions, and sensitivity to side effects, ensuring that the benefits of treatment outweigh the risks. This review underscores the need for further research to understand the long-term effects and benefits of antidepressants in older patients with LBP, aiming to balance pain relief, mood stabilization, and minimized side effects.

Introduction : Low back pain may cause clinical symptoms such as: reflex inhibition and atrophy of multifidus muscles, lumbar paraspinal muscles atrophy, dysfunction and disability. The atrophy of multifidus muscles could be a main cause of recurring back pain.. Therefore, present study compared the effect of stability and McKenzie exercises on pain, disability and multifidus size in women with chronic non-specific low back pain. Materials and Methods: 60 non-athletic women with chronic non-specific low back pain allocated in this research. They randomly and equally divided in to two experimental groups, 30 subjects (Mean ± SD age, 33.37 ± 7.92 year) in stabilization exercise group and 30 participants (Mean ± SD age, 37.00 ± 9.97 year) in McKenzie exercises group. Both groups performed exercise training for 6 weeks. The level of pain, disability, and the cross sectional area of lumbar multifidus muscle was respectively measured by visual analog scale (VAS), Ostwestry disability index and Ultrasonography imaging. These data were collected just before intervention, after 6 weeks of exercise intervention, and also at the end of 4 weeks follow-up period. Independent sample t-test was used to analyze the data and P 0.05). Conclusion: Stabilization and McKenzie exercises may improve pain and disability in patients with chronic non-specific low back pain, while stabilization exercise results in size improvement of lumbar multifidus muscles at L5 level. Therefore stabilization exercises may be more effective to prevent recurrent chronic low back pain. Keywords : Non-specific chronic low back pain, Stabilization exercises, McKenzie exercises, Lumbar multifidus muscle

Low back pain

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.

Benefits and harms of treatments for chronic nonspecific low back pain without radiculopathy: systematic review and meta-analysis

Chronic low back pain is a multifactorial problem that leads to impaired functioning, vitality, and quality of life. Assessing quality of life in patients with chronic nonspecific low back pain depending on the type of pain that dominates is of clinical and scientific interest. Objective — to assess the quality of life of patients with chronic nonspecific lower back pain depending on the dominant type of pain in order to develop effective management strategies for this problem. Materials and methods. To achieve this goal, a questionnaire and examination were conducted among 102 people with chronic nonspecific lower back pain, aged 18—65, who were undergoing rehabilitation in the rehabilitation department of the University Clinic of the Bogomolets National Medical University. The subjects were surveyed, which included: socio-demographic and anthropometric data, lifestyle data, harmful habits, level of physical activity, and quality of life assessment using the SF-36 questionnaire. Results and discussion. The average age of the study participants was (37.7 ± 13.9) years, with 63 % women and 37 % men. It was found that in the majority (54 %), the nociceptive type dominated, in 22 % the nociceptive type, neuropathic pain in 16 %, and in 8 % of the subjects, it was not possible to determine the dominant type of pain. The lowest quality of life scores across all scales were observed in the group with dominant nociplastic pain. Among patients with the dominant nociceptive type of pain, compared to the group with nociceptive and neuropathic types, lower quality of life scores were found on the following scales: physical functioning (p &lt; 0.001, p = 0.307), role functioning (p &lt; 0.001, p = 0.006), emotional functioning (p &lt; 0.001, p &lt; 0.001), life energy (p &lt; 0.001, p = 0.001), social functioning (p &lt; 0.001, p = 0.002), pain (p &lt; 0.001, p = 0.002), general health (p &lt; 0.001, p = 0.003), mental health (p &lt; 0.001, p &lt; 0.001). Among patients with neuropathic pain, quality of life scores were significantly lower than in patients with nociceptive pain for physical functioning (p = 0.008) and general health (p = 0.023). Conclusions. Most individuals with chronic nonspecific low back pain had a nociceptive dominant type of pain. Among individuals with chronic nonspecific low back pain with different dominant pain types, statistically significantly lower quality of life scores on all scales were observed in the group with nociceptive pain. A multidisciplinary treatment strategy that includes psychological interventions, active rehabilitation interventions, and lifestyle modifications may provide a more comprehensive solution for improving the quality of life of patients with chronic nonspecific low back pain.