Interventions for improvement of primary care in patients with low back pain: how effective are advice to primary care physicians on therapies and a multimodal therapy program arising out of cooperation of outpatient health care structures?

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

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.

The purpose of this review is to critically appraise the literature for evidence supporting the health care resource utilization and cost-effectiveness of spinal cord stimulation (SCS) compared with conventional therapies (CTs) for chronic low back and leg pain. The PubMed, MEDLINE, Embase, CINAHL, and Rehabilitation & Sports Medicine databases were searched for studies published from January 2008 through October 2018, using the following MeSH terms: "spinal cord stimulation," "chronic pain," "back pain," "patient readmission," "economics," and "costs and cost analysis." Additional sources were added based on bibliographies and consultation with experts. The following data were extracted and analyzed: demographic information, study design, objectives, sample sizes, outcome measures, SCS indications, complications, costs, readmissions, and resource utilization data. Of 204 studies screened, 11 studies met inclusion criteria, representing 31,439 SCS patients and 299,182 CT patients. The mean age was 53.5 years for SCS and 55.6 years for CT. In eight of 11 studies, SCS was associated with favorable outcomes and found to be more cost-effective than CT for chronic low back pain. Compared with CT, SCS resulted in shorter hospital stays and lower complication rates and health care costs at 90 days. SCS was associated with significant improvement in health-related quality of life, health status, and quality-adjusted life-years. For the treatment of chronic low back and leg pain, the majority of studies are of fair quality, with level 3 or 4 evidence in support of SCS as potentially more cost-effective than CT, with less resource expenditure but higher complication rates. SCS therapy may yet play a role in mitigating the financial burden associated with chronic low back and leg pain.

P64. Intradiscal injection of autologous bone marrow aspirate concentrate improves low back pain at one year

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.

A multidisciplinary approach including drug and non-drug methods is recommended for the treatment of chronic low back pain (CLBP). Kinesiotherapy, psychological methods, and nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be highly effective for CLBP. All of the listed methods contribute to significant relief and relief of pain, increase the patient’s social and physical activity, and improve the emotional state. Psychological methods help patients cope with catastrophizing pain, increase daily activities, and reduce the likelihood of disease recurrence. Results from clinical studies and systematic reviews demonstrate the effectiveness of psychological techniques such as cognitive behavioral therapy (CBT) and mindfulness therapy (mindfulness) in the treatment of CLBP. Cognitive Functional Therapy (CFT) is a promising new psychological method that was created on the basis of CPT. Clinical studies have been conducted confirming the efficacy of CFT in CLBP. CFT is aimed at regular therapeutic exercises, normalization of motor activity with avoidance of excessive physical and static exertion, avoidance of sedentary lifestyle and normalization of sleep, which is often disturbed in chronic back pain. In practice, patients with CLBP often have low adherence to increased physical activity during the day, to therapeutic exercises. In most cases, this is due to the fact that in the first days of increased physical activity there is an increase in pain. Patients mistakenly fear further progression of pain and disease. Prescribing NSAIDs usually results in pain reduction as early as the first days of administration, so patients with chronic musculoskeletal pain have an increased desire to engage in physical activity and therapeutic exercises. The choice of a particular NSAID medication is made individually, taking into account the co-morbidities and the risk of possible side effects. We discuss the use of nimesulide in CLBP.

Background: Chronic low back pain is one of the major causes of disability and thus has a major socioeconomic impact. Intervertebral disc degeneration is the main cause of chronic low back pain. Treatment for chronic discogenic low back pain has traditionally been limited to either conservative management or surgical fusion. If conservative treatment fails, then surgical fusion is commonly considered. Current treatments are limited to treat the symptoms and not the underlying biologic alterations of the disc. Objective: Human umbilical cord tissue-derived mesenchymal stem cells (HUC-MSCs) contain stem cells and possess the ability to regenerate degenerative discs. Based on the results of previous in vitro and animal experiments, we conducted a preliminary study to test the feasibility and safety and to obtain an early indication for the therapeutic value of HUC-MSC transplantation in patients with chronic discogenic low back pain. Study Design: This is the first study involving treatment of chronic low back pain using HUCMSC transplantation. Setting: The study was performed at a spine center in China. Methods: Two patients with chronic discogenic low back pain were treated with HUC-MSC transplantation. An 11-point visual analog scale (VAS, 0 – 10) and Oswestry Disability Index (ODI, 0 – 100) were used to assess the back pain symptoms and the lumbar function, respectively. Results: After transplantation, the pain and function improved immediately in the 2 patients. The VAS and ODI scores decreased obviously during a 2-year follow-up period. Limitations: The shortcoming of this study is that it is a preliminary study with only 2 patients. Conclusion: The clinical outcomes indicated that HUC-MSC transplantation is a favorable alternative method for the treatment of chronic discogenic low back pain. Key words: Intervertebral disc degeneration, discogenic low back pain, chronic low back pain, lumbar discography, mesenchymal stem cells, human umbilical cord mesenchymal stem cells, transplantation

Recent advances in basic research on intervertebral disc have revealed the unique innervation pattern and the pathological changes related to generation of low back pain. In this presentation, we w...

Today, a wide range of efficient analgesic and non-analgesic drugs for the treatment of back pain are available. However, drugs should never be the only mainstay of a back pain treatment program. Non-steroidal antiinflammatory drugs (NSAID) are widely used in acute back pain. NSAIDs prescribed at regular intervals are effective to reduce simple back pain. The different NSAIDs are effective for the reduction of this pain. They have serious adverse effects, particularly at high doses, in the elderly, and on long-term administration. The new cyclooxygenase II-inhibitors have less gastrointestinal complications. But the long-term experiences are limited up to now. Considerable controversy exists about the use of opioid analgesics in chronic noncancer pain. Many physicians are concerned about the effectiveness and adverse effects of opioids. Other clinicians argue that there is a role for opioid therapy in chronic noncancer pain, e. g. especially in chronic low back pain. There is a low incidence of organ toxicity in patients who respond to opioids. The incidence of abuse and addiction is likewise relatively low. The potential for increased function and improved quality of life seems to outweigh the risks. However, there is a lack of randomised controlled trials (RCT) on opioid therapy in a multimodal pain treatment approach. Clinical experience and some studies suggest administration of sustained release opioids because of better comfort for the patient and less risks for addiction. The opioids should be selected due to the specific side effects of the different drugs. For patients with pre-existing constipation transdermal fentanyl should be preferred. Antidepressant medications have been used for the treatment of chronic back pain, though there is only little scientific evidence for their effectiveness. There is no evidence for the use of antidepressants in acute low back pain. Trials of muscle relaxants for patients with acute back pain have used a wide range of agents, e. g. benzodiazepines. They mostly reduce acute back pain, but they have significant adverse effects including drowsiness and psychological and physical dependence even after relatively short treatment. Benzodiazepines are not indicated in the treatment of chronic back pain. Drugs are sometimes necessary for the patients to begin and persevere a multimodal treatment program. Drug therapy should be terminated as soon as other treatment strategies succeed. Unfortunately, no studies exist evaluating the place of analgesics within a multimodal treatment program.

BackgroundUp to now, chronic low back pain without radicular symptoms is not classified and attributed in international literature as being "unspecific". For specific bracing of this patient group we use simple physical tests to predict the brace type the patient is most likely to benefit from. Based on these physical tests we have developed a simple functional classification of "unspecific" low back pain in patients with spinal deformities.MethodsBetween January 2006 and July 2007 we have tested 130 patients (116 females and 14 males) with spinal deformities (average age 45 years, ranging from 14 years to 69) and chronic unspecific low back pain (pain for > 24 months) along with the indication for brace treatment for chronic unspecific low back pain. Some of the patients had symptoms of spinal claudication (n = 16). The "sagittal realignment test" (SRT) was applied, a lumbar hyperextension test, and the "sagittal delordosation test" (SDT). Additionally 3 female patients with spondylolisthesis were tested, including one female with symptoms of spinal claudication and 2 of these patients were 14 years of age and the other 43yrs old at the time of testing.Results117 Patients reported significant pain release in the SRT and 13 in the SDT (>/= 2 steps in the Roland & Morris VRS). 3 Patients had no significant pain release in both of the tests (< 2 steps in the Roland & Morris VRS).Pain intensity was high (3,29) before performing the physical tests (VRS-scale 0–5) and low (1,37) while performing the physical test for the whole sample of patients. The differences where highly significant in the Wilcoxon test (z = -3,79; p < 0,0001).In the 16 patients who did not respond to the SRT in the manual investigation we found hypermobility at L5/S1 or a spondylolisthesis at level L5/S1. In the other patients who responded well to the SRT loss of lumbar lordosis was the main issue, a finding which, according to scientific literature, correlates well with low back pain. The 3 patients who did not respond to either test had a fair pain reduction in a generally delordosing brace with an isolated small foam pad inserted at the level of L 2/3, leading to a lordosation at this region.DiscussionWith the exception of 3 patients (2.3%) a clear distribution to one of the two classes has been possible. 117 patients were supplied successfully with a sagittal realignment test-brace (physio-logic® brace) and 13 with a sagittal delordosing brace (spondylogic® brace). There were patients with scoliosies and hyperkyphosiesbrace). Therefore a clear distribution of the patients from this sample to either chronic postural or chronic instability back pain was possible. In 2.3% a combined chronic low back pain from the findings obtained seems reasonable.ConclusionChronic unspecific low back pain is possible to clearly be classified physically. This functional classification is necessary to decide on which specific conservative approach (physical therapy, braces) should be used.Other factors than spinal deformities contribute to chronic low back pain.

High-Dose Spinal Cord Stimulation for Treatment of Chronic Low Back Pain and Leg Pain in Patients With FBSS, 12-Month Results: A Prospective Pilot Study

Evidence based standards for structure quality in out-patient management of chronic pain states do not exist. Therefore we tried to evaluate if german standards for outpatient management of chronic pain states which are based on opinions of experts for pain management influence the outcome quality of independent physicians for treatment of chronic low back pain. 35 independent physicians, selected on a voluntary basis from 2100 physicians of a bavarian greater district with 1,6 Mio. inhabitants, and one outpatient treatment facility for pain patients of the university of Erlangen-Nuremberg have been evaluated by questionnaires. Questions examined certain structural conditions of the treatment facility as compared to german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung"). 157 patients suffering from chronic low back pain documented before and after a treatment interval of 6 months their pain intensity during the last 24 hours (numeric rating scale), the interference of pain with daily living (german version of the Brief Pain Inventory) and their quality of life (SF-36). Pre-post changes have been used as parameters for outcome quality. Neither baseline data nor pre-post differences of outcome parameter did correlate significantly with the scores of structure quality (17-71% of maximum) of the treatment facilities. However, multimodal therapy programs have not been used for pain management. Structural indicators of german guidelines for outpatient treatment of pain patients ("Schmerztherapievereinbarung") are not sufficient to improve outcome quality of patients with chronic back pain. Multimodal therapy programs have been shown to be effective in chronic back pain and should be implemented in the guidelines.