Intradiscal glucocorticoids injection in chronic low back pain with active discopathy: A randomized controlled study.

Active discopathy is associated with a specific phenotype of chronic low back pain (LBP). Local inflammation has a role in active discopathy-associated symptoms. To assess the efficacy of a single glucocorticoid intradiscal injection (GC IDI) in patients with chronic LBP with active discopathy. Prospective, parallel-group, double-blind, randomized, controlled study. (ClinicalTrials.gov: NCT00804531). 3 tertiary care centers in France. 135 patients with chronic LBP with active discopathy on magnetic resonance imaging (MRI). A single GC IDI (25 mg prednisolone acetate) during discography (n= 67) or discography alone (n= 68). The primary outcome was the percentage of patients with LBP intensity less than 40 on an 11-point numerical rating scale (0 [no pain] to 100 [maximum pain] in 10-point increments) in the previous 48 hours at 1 month after the intervention. The main secondary outcomes were LBP intensity and persistent active discopathy on MRI at 12 months and spine-specific limitations in activities, health-related quality of life, anxiety and depression, employment status, and use of analgesics and nonsteroidal anti-inflammatory drugs at 1 and 12 months. All randomly assigned patients were included in the primary efficacy analysis. At 1 month after the intervention, the percentage of responders (LBP intensity <40) was higher in the GC IDI group (36 of 65 [55.4%]) than the control group (21 of 63 [33.3%]) (absolute risk difference, 22.1 percentage points [95% CI, 5.5 to 38.7 percentage points]; P= 0.009). The groups did not differ in LBP intensity at 12 months and in most secondary outcomes at 1 and 12 months. Tertiary care setting. In chronic LBP associated with active discopathy, a single GC IDI reduces LBP at 1 month but not at 12 months. French Ministry of Health.

LB0001 Intradiscal glucocorticoid injection for patients with chronic low back pain associated with active discopathy: a randomized trial

Percutaneous Peripheral Nerve Stimulation (PNS) for the Treatment of Chronic Low Back Pain Provides Sustained Relief

To investigate physical activity level in patients with chronic low back and neck pain. 32 preoperative patients, 32 outpatients with low back or neck pain and 32 healthy controls were included in study. The physical activity level of the participants was evaluated with the International Physical Activity Questionnaire. The Oswestry Disability Index and Neck Pain Disability Index, Short Form-36, Pittsburgh Sleep Quality Index and Beck Depression Inventory were used for assessment of disability, quality of life, sleep quality and depression. Statistical significant differences was found in disability, sleep quality, depression, physical activity level and quality of life scores between three groups (p < 0.05). All scores of preoperative patients were significantly lower than outpatients except sleep parameter (p < 0.05). Sleep quality, disability and depression scores of patients with chronic neck pain were significantly lower and physical activity level and quality of life scores were significantly higher than patients' with chronic low back pain (p < 0.05). Physical activity modification was found in patients with chronic low back and neck pain. Physical activity level, disability, sleep, depression and quality of life scores of preoperative patients with low back pain more affected than neck patients.

BACKGROUND: Proprioceptive neuromuscular facilitation (PNF) is one of the neurophysiological techniques aimed at reducing pain and disability. This systematic review objective addresses the current evidence on PNF techniques’ effectiveness in chronic low back and neck pain. METHODS: Literature search in PubMed, Scopus, Cochrane, Wiley and Ovid databases were searched until 2021. The content of the titles and the abstracts were analysed to gather information about the effects of PNF in chronic back and neck pain with outcomes of pain and disability. The quality of the studies was analysed by the Joanna Briggs Institute (JBI) critical appraisal score. Meta-analysis was performed on Visual Analogue Scale (VAS), Numerical Rating Scale (NRS) for chronic low back pain and Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ) for disability. RESULTS: Nine studies addressed the different PNF based interventions on chronic low back pain, with a total of 416 participants. The intervention period ranged 3–6 weeks, and two studies conducted 12-weeks follow-up. Many studies measured pain using a VAS and NRS, whereas the disability through ODI and RMDQ. The JBI score ranged from 6/13 to 11/13. None of the PNF studies treated chronic neck pain. CONCLUSION: PNF might be beneficial for reducing low back pain and related disability. The long term effects of PNF on chronic low back pain, and also to determine its benefits on chronic neck pain are warranted in future studies.

Anxiety Levels, Fear-avoidance Beliefs, and Disability Levels at Baseline and at 1 Year among Subjects with Acute and Chronic Low Back Pain

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

The injection of mixture of plain bupivacaine and triamcinolone acetonide into the sacroiliac joint (SIJ) to relieve chronic low back pain is uncommon in the West African sub-region. The objective of this study was to demonstrate the efficacy or otherwise of fluoroscopic-guided SI joint injection in the management of chronic axial low back pain in Nigeria. This was a prospective observational interventional study. The study was carried out at a tertiary hospital in Nigeria. Twenty-six patients with SI joint pain, based on IASP diagnostic criteria, who presented to our unit over 36 months from March 2012 to March 2015 and. Fluoroscopic-guided injections of 5mls mixture of bupivacaine and triamcinolone acetonide into the sacro-iliac (SI) joints of 26 patients with SI joint pain out of 116 patients who were offered different interventions for chronic low back pain. The patients were followed up for year and pain intensity and functional status were assessed at 3-, 6- and 12 months post-intervention. Pain relief and functional improvement were the main outcome measures. The mean numeric rating score (NRS) and Oswestry Disability index (ODI) score in 14 (53.9%) patients at 12 months post-interventions were significantly lower compared with baseline values; 3.19 ± 1.10 vs 8.54 ±1.14 p=0.000 and 25.35 ± 5.40 vs 37.54 ±8.41, p=0.000 respectively. Fluoroscopic-guided steroid injection into the SI joint resulted into reduction in pain intensity and improved physical function in the majority of patients with SI joint pain. Not declared.

Study Design.Prospective study.Objective.To compare the burden between chronic nonspecific low back pain (LBP) and axial spondyloarthropathy (SpA).Summary of Background Data.Chronic nonspecific LBP and SpA are two debilitating yet different chronic musculoskeletal disorders. To compare their burden, propensity score matching is used to control for potential confounders and match the study subjects.Materials and Methods.Two prospectively collected cohorts of LBP (n=269) and SpA (n=218) patients were studied. Outcomes included current LBP, 36-item Short Form Questionnaire, Oswestry Disability Index, EuroQol 5-dimension 5-level Questionnaire, and EuroQol Visual Analog Scale. With the inherent differences between the two types of patients, propensity score matching was performed for comparing the two groups. Baseline covariates of age, sex, education level, occupation, smoking, and drinking history were selected for the estimation of propensity scores for each subject with the logistic regression model. Significant independent variables for the outcome of current back pain were included in the multivariate logistic regressions.Results.A total of 127 matched pairs were identified, with 254 patients. In the matched cohort, more patients with chronic LBP had current back pain (95.3%) as compared with SpA (71.7%). Patients with SpA were younger (P<0.001), with more males (P<0.001), and better educated (P=0.001). There was less current back pain and higher nonsteroidal anti-inflammatory drug use (P<0.001). Most SpA patients had lower Oswestry Disability Index than LBP patients and with low disease activity. Patients with LBP had worse outcome scores as compared with SpA patients given the same Visual Analog Scale. LBP patients had 8.6 times the odds (95% CI: 3.341–20.671; P<0.001) of experiencing current back pain compared with SpA patients.Conclusions.The disease activity of SpA patients is well controlled. However, patients with chronic LBP have worse pain severity, disability, and health-related quality of life. This has implications on resource utilization and the necessity of advancing LBP understanding and management.Level of Evidence.Type I prognostic study.

BACKGROUND: Chronic spinal pain is prevalent and long-lasting. Although provider-based nonpharmacologic therapies, such as chiropractic care, have been recommended, healthcare and coverage policies provide little guidance or evidence regarding long-term use of this care. OBJECTIVE: To determine the relationships between visit frequency and outcomes for patients using ongoing chiropractic care for chronic spinal pain. STUDY DESIGN: Observational 3-month longitudinal study. SETTING: Data collected from patients of 124 chiropractic clinics in 6 United States regions. METHODS: We examined the impact of visit frequency and patient characteristics on pain (pain 0-10 numeric rating scale) and functional outcomes (Oswestry Disability Index [ODI] for low-back pain and Neck Disability Index [NDI] for neck pain, both 0-100 scale) using hierarchical linear modeling (HLM) in a large national sample of chiropractic patients with chronic low back pain (CLBP) and/or chronic neck pain (CNP). This study was approved by the RAND Human Subjects Protection Committee and registered under ClinicalTrials.gov Identifier: NCT03162952. RESULTS: One thousand, three hundred, sixty-two patients with CLBP and 1,214 with CNP were included in a series of HLM models. Unconditional (time-only) models showed patients on average had mild pain and function, and significant, but slight improvements in these over the 3-month observation period: back and neck pain decreased by 0.40 and 0.44 points, respectively; function improved by 2.7 (ODI) and 3.0 points (NDI) (all P &lt; 0.001). Adding chiropractic visit frequency to the models revealed that those with worse baseline pain and function used more visits, but only visits more than once per week for those with CLBP were associated with significantly better improvement. These relationships remained when other types of visits and baseline patient characteristics were included. LIMITATIONS: This is an observational study based on self-reported data from a sample representative of chiropractic patients, but not all patients with CLBP or CNP. CONCLUSIONS: This 3-month window on chiropractic patients with CLBP and/or CNP revealed that they were improving, although slowly; may have reached maximum therapeutic improvement; and are possibly successfully managing their chronic pain using a variety of chiropractic visit frequencies. These results may inform payers when building coverage policies for ongoing chiropractic care for patients with chronic pain. KEY WORDS: Chronic low back pain, chronic neck pain, spinal pain, physical function, hierarchical linear modeling, healthcare utilization, chiropractic visits, insurance coverage

Introduction For patients with persistent and disabling chronic low back pain (CLBP) who failed to improve after less intensive interventions, a combined physical and psychological (CPP) program including exercises and a cognitive behavioral approach, is recommended.1–3 These patients with CLBP participating in a two-week CPP-program improve in functional status and quality of life during the program and these positive results are maintained at one4 and at two-year follow-up assessment.5 Purpose To evaluate the long-term results of a short, intensive, evidence based CPP-program. Material and Methods A consecutive cohort study with a mean follow up of 6.5 years (range: 5.5–7.5) was performed. At follow up a response rate of 85% ( n = 277) was achieved. Primary outcome was functional status (Oswestry Disability Index [ODI;0–100]). Secondary outcomes were pain intensity, quality of life, and patient reported satisfaction. A Repeated Measures analysis of variance was used to identify changes over time. The two-week residential program is in line with recommendations in international guidelines1–3 and provided in collaboration with orthopedic spine surgeons at Sint Maartenskliniek Nijmegen, The Netherlands. Results At pre-treatment assessment the mean age was 46.1years (SD9.3) and the mean CLBP-duration 12.3 years (SD10.9). The mean ODI-score showed improvement at post-treatment and maintenance of results over time (ODI df[1,276],F = 0.146, p = 0.703). Secondary outcomes showed the same pattern. At long-term follow up more than half of the CLBP-patients (59.2%) showed a clinically relevant improvement of ≥10 points on the ODI and 45.3% of the patients reached a functional status equivalent to an acceptable, normal healthy population value (ODI ≤ 22). This is comparable to the one-year follow-up assessment. 80.1% of the participants are satisfied with the treatment results and 76.2% would recommend the program to family/friends. Conclusion The positive short-term effectiveness at one-year follow up of a two-week CPP-program is demonstrated to maintain over time. Patients demonstrate continued improvement of functional status and quality of life after 6.5 years of follow up. Moreover, at long-term follow up a high percentage of patients were satisfied with the results of the program and they would recommend the program to family and/or friends. References National Institute for Health and Care Excellence. Clinical Guideline 88. Low back pain: Early management of persistent non-specific low back pain. May 2009 Chou R, Loeser JD, Owens DK, et al; American Pain Society Low Back Pain Guideline Panel. Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine 2009;34(10):1066–1077 Airaksinen O, Brox JI, Cedraschi C, et al; COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J 2006;15(Suppl 2):S192–S300 van Hooff ML, van der Merwe JD, O'Dowd J, et al. Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management. Eur Spine J 2010;19(9):1517–1526 van Hooff ML, Ter Avest W, Horsting PP, et al. A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain: two-year follow-up results of a prospective cohort. Eur Spine J 2012;21(7):1257–1264

Background: Spinal stenosis is one of the 3 most common diagnoses of low back and leg symptoms which also include disc herniation and degenerative spondylolisthesis. Spinal stenosis is a narrowing of the spinal canal with encroachment on the neural structures by surrounding the bone and soft tissue. In the United States, one of the most commonly performed interventions for managing chronic low back pain are epidural injections, including their use for spinal stenosis. However, there have not been any randomized trials and evidence is limited with regards to the effectiveness of epidural injections in managing chronic function-limiting low back and lower extremity pain secondary to lumbar spinal stenosis. Study Design: A randomized, double-blind, equivalence trial. Setting: An interventional pain management practice, a specialty referral center, a private practice setting in the United States. Objectives: To evaluate the effectiveness of caudal epidural injections with or without steroids in providing effective and long-lasting pain relief in the management of chronic low back pain in spinal stenosis and to evaluate the differences between local anesthetic with or without steroids. Methods: Patients were randomly assigned to one of 2 groups, with Group I patients receiving caudal epidural injections of local anesthetic (lidocaine 0.5%), whereas Group II patients received caudal epidural injections with 0.5% lidocaine 9 mL mixed with 1 mL of steroid. Randomization is being performed by computer-generated random allocation sequence by simple randomization. Outcomes Assessment: Multiple outcome measures were utilized which included the Numeric Rating Scale (NRS), the Oswestry Disability Index 2.0 (ODI), employment status, and opioid intake with assessment at 3 months, 6 months, and 12 months post-treatment. Significant pain relief was defined as 50% or more, whereas significant improvement in disability score was defined as reduction of 40% or more. Results: Significant pain relief (≥ 50%) was demonstrated in 55% to 65% of the patients and functional status improvement with 40% reduction in ODI scores in 55% to 80% of the patients. The overall average procedures per year were 3.4 ± 1.27 in Group I and 2.6 ± 1.35 in Group II with an average total relief per year of 30.3 ± 19.49 weeks in Group I and 23.1 ± 21.36 weeks in Group II over a period of 52 weeks. Limitations: The results of this study are limited by the lack of a placebo group and a preliminary report of 20 patients in each group, even though sample was justified. Conclusion: Caudal epidural injections with or without steroids may be effective in patients with chronic function-limiting low back and lower extremity pain with spinal stenosis in approximately 60% of the patients. Key words: Low back pain, lower extremity pain, spinal stenosis, epidural injections, steroids, local anesthetics

91. The viable disc tissue allograft supplementation (VAST) randomized controlled trial in patients with chronic discogenic low back pain: Correlating age with clinical outcome

The balneotherapy is a therapy that uses the mineral springs for the treatment of numerous diseases, and the physical properties of these waters may have a role in the mechanism of action of mineral water. Over the past decades, a re-assessment of the use of mineral water for the treatment of several diseases has taken place around the world. Chronic low back pain is a major public health problem in industrialized countries, it affects 80% of people and, in 85% of cases, the inaugural episode is followed by recorrencies. Its incidence and prevalence increases with age and is considered chronic when it persists for more than 7-12 weeks.The impoverished existing evidence contrasts with the popularity of these treatments and with the expenses incurred by insurers and health systems of some European countries (eg. Germany).The authors proposed reviewing the literature to clarify the present evidence regarding the effect of this therapeutic modality in the treatment of chronic low back pain. The meta-analysis of 2 randomized clinical trials concluded there was a significant reduction in pain intensity, measured on a 100mm visual analogue scale (VAS), in treated patients relative to controls. Individually, one of these studies also showed a decrease in analgesic consumption (p <0.01) and the other one showed an increase in functionality measured by the modified Schober test (p <0.001). One randomized study evaluated the VAS, lumbar mobility, and the Oswestry, EuroQoL-5D and Short Form-36 indices, with a significant improvement in all tests in the treatment group relative to the controls. The improvement observed in the first three lasted 10 weeks. It was also observed a significant decrease in the consumption of NSAIDs and analgesics in the treatment group, but the difference between groups was not statistically significant. Another randomized study showed an improvement in VAS (p <0,01), decrease in the paravertebral muscle spasms and sensitivity (p <0.01), as well as increased mobility (p <0.01) in patients treated for a period 3 months. In contrast, the improvement observed in the control group was only temporary and only in the VAS (p <0.01). In a nonrandomized study were evaluated pain intensity, Oswestry index, quality of life, use of NSAIDs/analgesics, and the subjective perception of disease for patients and observers. All parameters were significantly improved, and the effects lasted at least months. The mean age of the patients ranged from 39-44 to 64 years. The data collected showed significant improvements in pain, functionality, quality of life and consumption of NSAID/analgesic drugs in patients with chronic low back pain undergoing thermal therapy. As a major limitation, there were no double-blinded studies, since the physical and chemical properties of the mineral springs differ significantly from those found in tap water. We conclude that balneotherapy is an effective modality in the treatment of chronic low back pain in patients of middle age, being necessary more studies to validate thermal waters for individual springs, and pharmacoeconomic studies that evaluate the balneotherapy as a complementary modality in the management of low back pain is chronic.

Custom-made rigid lumbar corset can be a short-term pain release option for low back pain patients with Modic 1 active discopathy: A retrospective study