Chronic Lumbar Pain Research Articles

The role of spinal injections towards optimizing patient selection for spinal surgery: A proof-of-concept study in 176 lower back pain patients

BackgroundManaging degenerative lumbar diseases is challenging due to the complexity of identifying symptom causes, especially when multiple pathologies coexist. This study evaluated the impact of patient-specific lumbar spine infiltrations on therapeutic strategies in patients with multiple spinal pathologies (MSP) or specific spinal pathologies (SSP).MethodsA retrospective cohort of 176 patients treated for subacute or chronic lumbar pain with targeted spinal infiltrations was analyzed. Patients were categorized based on the presence of MSP or SSP. The primary endpoint was the relief of lumbar spine-specific symptoms following each infiltration. Secondary endpoints included epidemiological factors and comorbidities, while tertiary endpoints focused on post-treatment recommendations and performed treatments.ResultsHigh rates of spinal pain (97.1% in both groups) and radiating symptoms (88.2% in SSP and 92.3% in MSP) were reported. Psychological conditions were significantly more prevalent in female patients (19.4% vs. 7.7%, p = 0.0307), whereas hip osteoarthritis was more common in male patients (20.5% vs. 9.2%, p = 0.0490). Among all infiltration types, lumbar transforaminal injections were the most effective, leading to pain reduction in 80.1% of SSP patients and 72.2% of MSP patients. Facet joint and sacroiliac joint infiltrations also frequently resulted in pain reduction in both groups. Overall, conservative treatment was recommended for most patients (73.3%), while only 22.7% of all evaluated patients were recommended for surgical intervention. Additionally, seven patients received a hip prosthesis.ConclusionsPatient-specific lumbar spine infiltrations effectively relieve pain, support therapeutic decision-making, and tend to favor conservative treatment approaches. These findings highlight the role of infiltration therapies in managing both mixed and specific lumbar spine pathologies, suggesting their potential to reduce the need for surgical interventions.

Erector Spinae Plane Block for Chronic Lumbosacral Pain: A Case Report

Chronic low back pain is a prevalent and debilitating condition that often resists traditional management strategies such as physical therapy, pharmacotherapy, and interventional procedures. The erector spinae plane (ESP) block, a relatively new regional anesthesia technique, has shown promise in managing various types of pain, including chronic conditions. This case report details the use of the ESP block in a male patient in his late 60’s with chronic low back pain unresponsive to conventional treatments, including acetaminophen, muscle relaxants, gabapentin, epidural steroid injections, diagnostic medial branch blocks, and sacroiliac joint injections. Given the refractory nature of his pain, a right-sided lumbar ESP block was performed under fluoroscopic guidance. This case highlights the potential of the ESP block as an effective treatment for chronic lumbar pain, particularly in patients who have not responded to other interventional modalities. The safety profile of the ESP block, coupled with its efficacy in this case, supports its consideration as a viable option in chronic pain management. Further studies and clinical experience will be essential in defining its role and establishing standardized protocols for its use in chronic pain settings.

Progress of intraosseous basivertebral nerve ablation for symptomatic Modic alterations

Chronic lumbar and back pain caused by degenerative vertebral endplates presents a challenging issue for patients and clinicians. As a new minimally invasive spinal treatment method, radiofrequency ablation of vertebral basal nerve in bone can denature the corresponding vertebral basal nerve through radiofrequency ablation of degenerative vertebral endplate. It blocks the nociceptive signal transmission of the vertebral base nerve, thereby alleviating the symptoms of low back pain caused by the degenerative vertebral endplate. At present, many foreign articles have reported the operation principle, operation method, clinical efficacy and related complications of radiofrequency ablation of the vertebral basal nerve. The main purpose of this paper is to conduct a comprehensive analysis of the current relevant research, and provide a reference for the follow-up clinical research.

Assessment of enthesopathy in conventional pelvis radiography: Another tool for spondyloarthritis diagnosis beyond sacroiliitis

Introduction/objectivesEnthesitis is a cardinal feature of spondylarthritis (SpA), and the pelvis is a common site of enthesitis. This study aimed to establish the association between pelvic enthesis involvement on pelvic X-ray and SpA diagnosis through a radiographic enthesis index (REI) and to assess the reliability and accuracy of this REI. Materials and methodsThe participants were SpA patients and a control group composed of patients with chronic lumbar pain without SpA. Three blinded observers assessed each pelvic radiography three times. Three zones were used: Zone I (ZI), the iliopubic ramus; Zone II (ZII), the pubic symphysis, and Zone III (ZIII), the ischiopubic ramus. A grading system was created from 0 to 3 [Grade 0, normal; Grade 1, minimal changes (subcortical bone demineralization and/or periosteal wishkering, seen as radiolucency and trabeculation of the cortical bone upon tendon insertion); Grade 2, destructive changes (Grade 1 findings and erosions at the enthesis site); and Grade 3, findings of Grade 2 plus >2 mm whiskering out of the cortical bone) for the REI. The sum of the results of the three zones was called the total REI. For statistical analysis, we used the weighted kappa statistic adjusted for prevalence and bias using Gwet's agreement coefficient. ResultsWe enrolled 161 patients, 111 of them with SpA (39.6 % with axial SpA and 47.7 % with peripheral SpA) and 50 without SpA. In the SpA group, 36.7 % and 25.7 % had REI Grades 2 and 3 in ZIII, respectively, while only 6 % of the controls had these grades. For ZI, the frequency of Grades 1 to 3 was 42.3 % in the SpA group (8.1 %, 14.4 %, and 19.8 %, respectively), compared to only 2 % in the controls. ZII was unaffected in most of the patients with SpA (82.9 %) and in the controls (98 %). In the control group, Grade 0 was the most common REI grade in all three zones. The agreement was almost perfect for each zone and between the independent readers. The ROC-curve analysis showed that the highest performance areas were the total REI, ZIII, and ZI. Most (75 %) of the SpA patients without sacroiliitis on X-ray were REI-positive. The sensitivity of the REI for SpA diagnosis was 82 %, while the sensitivity of sacroiliitis on X-ray was 38.7 %. ConclusionsThe assessment of pelvic enthesis using the REI on pelvic radiography may be useful for SpA diagnosis. Total REI, ZIII, and ZI had the highest accuracy and almost perfect reliability. The REI is especially helpful in patients without sacroiliitis on imaging.

464 Remote Cognitive Behavioral Therapy Utilizing an In-home Virtual Reality Toolkit (Vx Therapy TM) Reduces Pain, Anxiety, and Depression in Patients With Chronic Cervical and Lumbar Pain: A Potential Opiate Alternative in Multimodal Pain Management

INTRODUCTION: Virtual reality has reduced acute pain through visual and auditory distraction, as well as altered brain neurobiology. VR attenuates pain-induced brain activity without narcotic-related side effects or dependency. Cognitive behavioral therapy (CBT) has demonstrated improved pain-related anxiety, depression, physical disability, resiliency, and quality of life. CBT access remains a challenge in most care communities. METHODS: 145 patients with chronic neck and back pain (63 cervical, 46 non-radicular lumbar, 36 radicular lumbar) enrolled into a 14 week Vx therapy CBT program with therapist guided utilization of an in-home VR system with 50 modules (education, meditation, distraction, entertainment). Pain and anxiety severity scores were recorded before and immediately after VR use as well as time to pain recurrence. PROMIS measures of daily pain intensity, pain behavior, pain interference, anxiety, and depression were recorded at baseline and after 14 weeks of Vx therapy. RESULTS: PROMIS domains were significantly improved after Vx treatment vs baseline for the entire cohort and each subgroup. VR acutely reduced pain during use on average by 33% (p < 0.05) across all 14 weeks lasting a mean 2.5 hours. VR acutely reduced anxiety during use on average by 46% (p < 0.05) across all 14 weeks lasting a mean 2.7 hours. The effect was similar for all three diagnosis groups. CONCLUSIONS: Remote CBT guided in-home VR toolkit (Vx therapyTM) provided effective multi-hour sustained pain relief in patients with chronic neck and back pain with and without radiculopathy. Significant improvement in overall pain, anxiety, and depression and reduced pain interference was observed. This non-invasive, non-pharmaceutical Vx therapy is an ideal option to improve outcomes in post-opioid pain management.

Low back pain- Algorithm of diagnosis and management

Abstract: Introduction: Low back pain is a frequent condition, associated as a symptom with a multitude of organic or non-organic pathologies, resulting in the appearance of disability gener-ating negative economic and soc-professional consequences. Being a relatively common symptom among patients, we created this paper with the aim to high-light the importance of the clinical examination along with the correct direction of the patient to a profile depart-ment, the review of differential diagnoses, as well as the establishment of a particular recovery plan adapted to each case. Materials and Methods: We analyzed a series of recent articles using the PubMed and the Cochrane Library data-bases ,using the keywords words “low back pain” and “rehabilitation”, to obtain data on the clinical and paraclinical examination, positive and differential diagnosis of chronic low back pain, as well as on rehabilitation management. Results: Low back pain may appear due to vertebral conditions (inflammatory, infectious, trau-matic, neoplastic, degenerative, metabolic), or due to extravertebral causes. Along with the an-amnesis, clinical examination and im-agistic investigations, we establish the positive diagnosis and create an individualised rehabilitation plan. The reha-bilitation protocol is divided into stages , the final goal is to minimize the ischemia-pain-contracture chain. Conclusion: The pathology of the lumbosacral spine can be characterized by the word "diversity", being one of the causes of early disability of the population in the field of work. Our work highlights the importance of the clinical and paraclinical examination in outlining the differential diagnosis of chronic lumbar pain, as well as the role of the multidisciplinary team in complex individualized rehabilitation treatment.

Efficiency of dry needling along with standard physical treatment in people with lumbar pain syndrome

Introduction: The complaints that occur in the area of the lumbar spine are summarized under the term lumbar pain syndrome. These include lumbar discopathy, lumbago, lumboischialgia, sciatica, and other complaints associated with the lumbar region of the spine. The purpose of this study is to evaluate sociodemographic characteristics, assess the degree of disability patients experience due to lumbar pain syndrome, evaluate how many patients catastrophize their pain, and assess the effectiveness of the dry needling technique along with other physical therapy modalities in people with lumbar pain syndrome. Methods: The study was designed as a prospective study conducted from March 2022 to June 2022. 35 subjects of both sexes, aged 25-83, agreed to participate in the study. The subjects who enrolled were pre-dominantly suffering from chronic lumbar pain syndrome, and there were also a smaller number of subjects with acute lumbar pain syndrome. Results: The majority of respondents suffer from lumbar pain syndrome, which falls into the chronic category in 29 or 82.9% of cases. The mean score after the application of therapy on the Oswestry Disability Index (ODI) scale was 22.0 ± 16.23% and was statistically significantly lower. The average score after the application of the therapy on the visual analog scale (VAS) was 3.06 ± 2.31 and is statistically significantly lower (p < 0.05) compared to the period before the therapy. Conclusion: Dry needling in combination with standard physical procedures led to statistically significant improvements. The mean score on the pain catastrophe scale, VAS, and ODI was significantly lower than in the pre-therapy period.

Influence of pain prognosis and electrical stimulation modality on the amplitude of current elicited at sensory threshold in chronic lumbar pain sufferers

Influence of pain prognosis and electrical stimulation modality on the amplitude of current elicited at sensory threshold in chronic lumbar pain sufferers

Lumbosacral Paravertebral Tophaceous Gout on an Adolescent Mimicking Malignant Neoplasm in 18 F-FDG PET/CT.

Contrast-enhanced MRI was performed on a 17-year-old adolescent boy with chronic lumbar and lower-limb pain, which had worsened over the past 3 days. It revealed a suspicious malignant mass adjacent to right appendage of L5-S1 vertebrae, with mixed signals and heterogeneous and obvious enhancement. 18 F-FDG PET/CT was subsequently performed for staging. It showed an FDG-avid mass with mixed density in right psoas major muscle, involving adjacent appendage of L5-S1 vertebrae. Histopathological examination confirmed the mass to be gouty tophus, characterized by nodular homogeneous pink amorphous deposits around the cartilage tissue, surrounded by histiocytes and multinucleated giant cells.

Plasma Rich in Growth Factors (PRGF) in the Treatment of Patients With Chronic Cervical and Lumbar Pain: A Prospective Observational Clinical Study

BACKGROUND: Chronic back pain is a long-lasting disorder, whose main source of pain is often the intervertebral disc that undergoes a degenerative process associated with low-grade inflammation, leading to a reduced quality of life. OBJECTIVES: The aim of our study was to assess the efficacy of intradiscal and epidural injections of plasma rich in growth factors (PRGF) in patients with chronic clinical symptoms due to intervertebral disc (IVD) degeneration. STUDY DESIGN: Prospective observational study. SETTING: A single spine unit in a private clinic. METHODS: Thirty-two patients with cervical and lumbar chronic pain due to IVD degeneration were treated with 2 or 3 series of intradiscal and epidural PRGF infiltrations with 2 weeks between each procedure. The procedures were performed under fluoroscopic guidance and grade 3 sedation in an operating theater. Treatment efficacy was evaluated using the Spine Tango Core Outcome Measure Index questionnaire, Numeric Rating Scale for back pain, and the Oswestry Disability Index questionnaire. In addition, the number of patients who successfully achieved the minimal clinically important change was also determined. These assessments were evaluated at pretreatment (baseline) and at one, 3, and 6 months posttreatment. RESULTS: The Oswestry Disability Index, COMI Spine Tango Core Outcome Measure Index total score, and Numeric Rating Scale showed a statistically significant reduction from the baseline level to the posttreatment first month, third month, and sixth month (P < 0.001). Moreover, 78.1% of the patients reached a pain reduction superior to 30% one month posttreatment, and 87.5% at 6 months posttreatment, which is considered as a clinically significant improvement. LIMITATIONS: This study was prospective and did not have a control group. Only patient-reported outcomes were evaluated. CONCLUSIONS: This observational, prospective study of patients with chronic back pain showed that 2-3 intradiscal and epidural injections of PRGF significantly decreased pain and disability at one month posttreatment and this improvement was maintained, and in some patients even improved, at 3, and 6 months posttreatment. KEY WORDS: Platelet-rich plasma, plasma rich in growth factors, degenerative disc disease, intervertebral disc degeneration, back pain, growth factors, regenerative medicine

Remote cognitive behavioral therapy utilizing an in-home virtual reality toolkit (Vx Therapy) reduces pain, anxiety, and depression in patients with chronic cervical and lumbar spondylytic pain: A potential alternative to opioids in multimodal pain management

Background ContextVirtual reality (VR) reduces pain through visual and auditory distraction without narcotic-related side effects or dependency. Cognitive behavioral therapy (CBT) improves pain-related disability and quality of life, but patient access remains a challenge. We hypothesized that in-home weekly CBT coordinated with daily use of a proprietary VR toolkit will reduce pain, anxiety, and depression for patients with non-operative chronic cervical and lumbar spondylitic pain with and without radiculopathy. MethodsA total of 145 patients with chronic spondylitic pain (63 cervical, 46 noradicular lumbar, 36 radicular lumbar) were enrolled into a guided 14-week VR+CBT program (Vx Therapy) consisting of weekly encounters with a trained therapist and 50 modules. Pain/anxiety severity scores and time to pain recurrence were recorded prospectively by patients. PROMIS measures of overall daily pain intensity, behavior, interference, anxiety, and depression were recorded at baseline and conclusion of the program. ResultsA total of 52% of the 145 patients were male. The average (SD) age of the cohort was 51 (10.7) years (range: 24–76 years). Mean score for all PROMIS domains were significantly improved after 14 weeks of Vx Therapy (pain intensity 36±24 vs. 28±21, interference 39±25 vs. 24±21, behavior 35±21 vs. 25±16, anxiety 51±28 vs. 41±26, depression 58±32 vs. 48±32) for the entire cohort and each diagnosis group. Virtual reality acutely reduced pain on average by 33% (4.5±2.5 vs. 6.7±2.2, p<.05) across all 14 weeks, lasting a mean 2.8 hours after use. Duration of pain relief increased by the final vs. first month (4.5 hours vs. 2.5 hours, p<.05). Virtual reality acutely reduced anxiety on average by 46% (3.5±3 vs. 6.4±2, p<.05) across all 14 weeks lasting a mean 2.7 hours after use. The effect was similar for all 3 groups. ConclusionsFourteen weeks of a remote CBT guided in-home VR toolkit provided effective and sustained pain, anxiety, and depression relief in patients with chronic degenerative neck/back pain with and without radiculopathy. The non-invasive, non-pharmacological nature of Vx Therapy makes it an ideal option for pain management in the post-opioid epidemic era.

Endoscopic Rhizotomy in Management of Facetogenic Chronic Lumbar Pain

Background Facet Arthritis causing Chronic Low Back Pain (CLBP) is an increasingly controversial field. The diagnosis of Facetogenic pain is still deemed difficult by many physicians, and its pathophysiology, as well as its management are still not quite understood. From the available literature, we can conclude that Lumbo-sacral Facet Arthritis is attributed to a degenerative process affecting the facet joint, which is described as the articulation between the superior articular process of one vertebrae and the inferior articular process of a vertebrae above. This degenerative process is commonly attributed to the „wear-and-tear' theory coming with age, highly comparative to the same degenerative process affecting any other joint. Aim of the Work to evaluate its effectiveness in controlling short term and long term pain caused by lumbar facet arthritis resulting in Chronic Low Back Pain (CLBP), and its effectiveness in decreasing disabilities caused by the debilitating symptoms of progressive arthritis in the lumbar facet joints. Patients and Methods was done to evaluate a novel technique, the Endoscopic Rhizotomy, as one of the minimally invasive procedures that is implemented in the management of Lumbar Facet Arthritis. All the available papers in literature describing this intervention from May 2000 to December 2020 were included. Results The initial search resulted in 468 articles from five databases including PubMed, Science Direct, Cochrane Library, Scopus, and Google Scholar. 16 studies are retrieved from additional databases. The total number before duplicates removal is 484 records. Conclusion that Endoscopic Rhizotomy is a very safe procedure, with a very low complication rate. We also concluded that Endoscopic Rhizotomy significantly relieves Facetogenic CLBP, with up to 3 years of pain relief. The procedure improved the subjective and objective quality of the patients. With comparison to the traditional Radiofrequency Ablation (RFA), Endoscopic Rhizotomy does not use radiation and allows direct visualization, in addition to being superior to RFA considering improving both pain and disability post-operative. It is considered a single day procedure, and the patient can return to work the 2nd day, fully-functioning. Without doubt, several factors, however, have to be taken into account when offering the patient such a procedure, as the presence of spinal deformities, instabilities, hypermobility, and the overall assessment of the patient‟s condition.

Commentary on the article "Radiofrequency Neurotomy Does Not Cause Fatty Degeneration of the Lumbar Paraspinal Musculature in Patients with Chronic Lumbar Pain-A Retrospective 3D-Computer-Assisted MRI Analysis Using iSix Software" by Oswald et al.

Journal Article Accepted manuscript Commentary on the article “Radiofrequency Neurotomy Does Not Cause Fatty Degeneration of the Lumbar Paraspinal Musculature in Patients with Chronic Lumbar Pain—A Retrospective 3D-Computer-Assisted MRI Analysis Using iSix Software” by Oswald et al Get access Min Cheol Chang Min Cheol Chang Department of Rehabilitation Medicine, College of Medicine, Yeungnam University, Daegu, Republic of Korea Corresponding Author: Min Cheol Chang, MD, Department of Physical Medicine & Rehabilitation, College of Medicine, Yeungnam University, 170 Hyeonchung-ro, Nam-gu, Daegu, 42415, Republic of Korea, Tel: +82-53-620-3270, e-mail: wheel633@gmail.com. Search for other works by this author on: Oxford Academic PubMed Google Scholar Pain Medicine, pnad083, https://doi.org/10.1093/pm/pnad083 Published: 20 June 2023 Article history Received: 03 March 2023 Accepted: 15 June 2023 Published: 20 June 2023

Percutaneous Spinal Interventions for Chronic Pain Management.

Chronic neck and back pain are two of the most common and disabling complaints seen in primary care and neurology practices. Most commonly these come in the form of cervical and lumbar radiculopathy, lumbar spinal stenosis, and cervical and lumbar facet arthropathy. Treatment options are widespread and include nonpharmacological, pharmacological, surgical, and interventional options. The focus of this review will be to discuss the most common interventional procedures performed for chronic cervical and lumbar back pain, common indications for performing these interventions, as well as associated benefits and risks. These interventions alone may not suffice to improve the quality of life in those suffering from chronic pain. However, an understanding of the interventional pain options available and the evidence behind performing these interventions can help providers incorporate these into a multimodal approach to provide effective pain management that may allow patients an improved quality of life.

A comparison of pulsed radiofrequency and radiofrequency denervation for lumbar facet joint pain

BackgroundLumbar facet joint pain is a common disorder. The main symptom is chronic lumbar pain, which can reduce quality of life. Radiofrequency has often been used to treat lumbar facet joint pain. However, the effectiveness of this technique has been controversial. This study was conducted to compare the effectiveness of pulsed radiofrequency (PRF) and radiofrequency denervation (RD) for lumbar facet joint pain.MethodsOne hundred and forty-two patients with lumbar facet joint pain were allocated to two treatment groups: PRF group (N = 72) and RD group (N = 70). Patients enrolled in the study were assessed using a visual analogue scale (VAS), Roland-Morris questionnaire (RMQ), Oswestry disability index (ODI) and Short-Form 36 (SF-36) questionnaire before therapy, 3 months and 12 months later.ResultsThere were no significant differences in VAS, RMQ score, ODI score and SF-36 score at 3 months (p > 0.05). Significant differences in pain control were observed in both groups at 12 months (3.09 ± 1.72 vs. 2.37 ± 1.22, p = 0.006). There was a significant difference in RMQ score (11.58 ± 3.58 vs. 8.17 ± 2.34, p < 0.001) and ODI score (43.65 ± 11.01 vs. 35.42 ± 11.32, p < 0.001) at 12 months. The total SF-36 score was higher in the RD group than in the PRF group at 12 months (58.45 ± 6.97 vs. 69.36 ± 6.43, p < 0.001). In terms of complications, skin numbness occurred in three patients. Mild pain such as burning and pinking at the puncture site in two patients. One patient experienced a decrease in back muscle strength and back muscle fatigue. These complications disappeared in 3 weeks without any treatment. There were no serious adverse events in the PRF group.ConclusionRadiofrequency is an effective and safe treatment option for patients with lumbar facet joint pain. RD could provide good and lasting pain relief, with significant improvement in lumbar function and quality of life at long-term follow-up.

178 Adjunctive Use of Preoperative SPECT Imaging for Evaluation of Chronic Cervical and Lumbar Pain

INTRODUCTION: Radionuclide bone scintigraphy with single photon emission computed tomography (SPECT) has been used to evaluate foci of inflammation within the spinal axis. Studies have reported its use as an tool for recognition of pain foci and spondolytic change. As an adjunctive test SPECT may prove to give valuable insight into areas of focal inflammation within the spinal axis and therefore serve as a tool for guiding operative and nonoperative intervention in patients with degenerative spine disease. METHODS: We performed a retrospective case series to identify patients with chronic neck/back pain who underwent SPECT imaging for pre-operative evaluation. Patient demographics, area of uptake, correlation with pain morphology, type of intervention, and degree of symptom resolution were quantified. Patients were excluded if they had prior surgery/intervention at the level corresponding to symptomatology. RESULTS: Thirty-two patients underwent SPECT imaging. Patients presented with axial back pain (97%) and radicular pain (42%). Radiotracer uptake was seen in facet and/or disc space at the level of symptomology in 44% of patients, facet alone (22%), disc space alone (22%), and uncovertebral joint (12%). Interventions included facet injections (26 patients), basovertebral plexus ablation (7 patients), and open/minimally-invasive surgery (9 patients). Two patients underwent anterior cervical discectomy and the remainder of our cohort underwent lumbar instrumentation and fusion. All but one surgical patient (97%) reported significant relief of symptoms. CONCLUSIONS: SPECT imaging may be useful adjunctive imaging modality to evaluate for focal areas of inflammation not readily observed on MRI or CT. Our experience suggests that SPECT can identify areas of pathology that responsive to various types of intervention.

The Risk of Applying Moving Cupping Therapy to A Patient with Chronic Lumbar Pain Previously Treated with Gold Thread Therapy

Gold thread therapy (GTT) continuously stimulates acupoints and is used to treat chronic conditions/diseases such as chronic lumbar pain. During the procedure gold thread is embedded into the skin and although gold thread is medically pure, GTT is an irreversible treatment where there is limited evidence on its safety. Here, we report a case of a 79-year-old woman being treated for low back pain who developed side effects following moving cupping therapy at a site of GTT (performed in the 1970s). Adverse reactions causing radiating pain persisted more than at least 9 days following moving cupping therapy. The symptoms of pain were evaluated using the numerical rating scale, and changes in tenderness and the state of bruising was recorded. Low back pain improved but the radiating low leg pain did not improve. This case highlights the need for caution when performing moving cupping therapy where GTT has been previously performed.

Comparison between Mulligan Sustained natural apophyseal glides (snags) VS McKenzie exercises in Chronic Mechanical Low back pain

Background: Low back pain is a common musculoskeletal problem of the modern society as 70-80% people of any age and gender get affected by this in their lifetime which affect their normal activities of daily living. Aim: To compare the efficacy between Mulligan SNAGs and McKenzie exercises in improving pain level, range of motions and functional status in chronic mechanic al low back pain patients. Method: A randomized control trial study was conducted on 45 patients suffering from chronic mechanical low back pain at Physiotherapy Department of Mayo Hospital Lahore from16th December to 21th January 2021.The patients were randomly allocated in three group’s i.e; Conventional and two trial groups by computerized generated list. In Conventional group; 15 patients were treated with conventional therapy. In trial groups; one was treated with Mulligan SNAGs and Conventional therapyand the other trial group were treated with McKenzie exercises and Conventional therapy 3 sessions per week. Pain measured by Numeric Pain Rating Scale (NPRS), Lumbar spine's ranges measured by Goniometer and functional status measured by Oswestry Disability Index (ODI) at the completion of the 4 weeks treatment session. Results: NPRS scoring and Ranges showed significant improvement in all groups but NPRS significantly improved in McKenzie exercises group and significant improvement in ROM showed in Mulligan SNAGs group in all movements but there was no significant difference found between three groups comparison in improving the functional status with p-value =0.243. Practical implication: The study provides the opportunity to the patients to consider physiotherapy as an effective treatment for the mechanical low back pain. It also provides the statistical knowledge about these physiotherapy techniques and their effectiveness in treating the low back pain. Conclusion: Both the Mulligan SNAGs and McKenzie exercises are effective in treatment of Chronic lumbar pain as pain is most reduced through McKenzie exercise (3.33±1.29, p&lt;0.000) while ranges of spine is improved through Mulligan SNAGs mobilization in all directions. Keywords: Chronic Mechanical Low back pain, Mulligan SNAGs mobilization, McKenzie exercises

Treatment of spondyloarthritis (facet syndrome) by puncture techniques

Objective. The aim of the study was to determine effectiveness of radiofrequency denervation of facet joints in combination with periarticular administration of local anaesthetics and steroids for elimination of pain in patients with low lumbar pain and predominantly spondyloarthritis. Material and methods. 78 patients with lower lumbar pain syndrome and arcuate joints arthrosis as a leading clinical manifestation underwent radiofrequency denervation of facet joints and periarticular administration of local anaesthetic and steroid drug (main group). The control group involved 136 patients with lumbar pain and dominating spondylarthritis treated only by radiofrequency denervation of facet joints. Results. Both in the early and late periods after treatment, reliable results were obtained in treatment of chronic lower lumbar pain caused mainly by arcuate joints damage both in the main and control groups. However, there was a significant difference between the main group and the control group in the early period (in three months after treatment), in favour of the main group. In the late period (in 1 year after treatment) a reliable treatment result was obtained both in the main and control groups, but there was no difference in the treatment results between these groups. Conclusions. Periarticular administration of local anaesthetics and steroids is effective in the short term, and radiofrequency denervation of facet joints is effective in both the short and longer term.

Management of patients with chronic low back pain and fibromyalgia

Management of patients with chronic low back pain and fibromyalgia is an urgent problem of modern medicine. In real clinical practice, fibromyalgia (FM) is often undiagnosed, with chronic back pain no combined diseases are detected, so patients do not receive comprehensive therapy, as demonstrated by two clinical observations. One patient suffered from chronic lumbodynia (skeletal-muscular lumbar pain against the background of lower lumbar facet joint lesions), chronic insomnia, anxiety disorders. The second patient suffered from FM combined with osteoarthritis of the hip joints and sacroiliac joint. Comprehensive personalized treatment, which included identifying and treating comorbidities, working with patients’ misconceptions about the causes of pain, predicting and planning physical activity, conducting an educational program with elements of cognitive behavioral therapy (CBT), regular exercise therapy, and pharmacotherapy, led to significant improvement in the patients’ condition. In both observations, a persistent (for 6 months) positive effect in the form of pain reduction, improvement of the functional state, emotional status, and sleep of the patients was achieved.he study also discusses the issues of effective therapy of chronic musculoskeletal chronic lumbar pain and FM, doctors’ poor awareness of FM and criteria for its diagnosis. It is noted that regular therapeutic exercises, restriction of excessive physical and static loads form the basis of management of patients with chronic back pain. Patients with chronic back pain often have misconceptions about their disease, its prognosis, and effective therapies, so identifying and resolving these problems using CBT contributes to a positive treatment outcome.