Nonradicular Low Back Pain Research Articles

What are the effects of systemic corticosteroids for people with non-radicular low back pain?

What are the effects of systemic corticosteroids for people with non-radicular low back pain?

Systemic corticosteroids for radicular and non-radicular low back pain.

Corticosteroids are medications with anti-inflammatory and immunosuppressant properties. Systemic corticosteroids administered through the oral, intravenous, or intramuscular routes have been used to treat various types of low back pain, including radicular back pain (not due to spinal stenosis), non-radicular back pain, and spinal stenosis. However, there is uncertainty about the benefits and harms of systemic corticosteroids for low back pain. To evaluate the benefits and harms of systemic corticosteroids versus placebo or no corticosteroid for radicular low back pain, non-radicular low back pain, and symptomatic spinal stenosis in adults. We used standard, extensive Cochrane search methods. The latest search date was September 2021. We included randomized and quasi-randomized trials in adults of systematic corticosteroids versus placebo or no corticosteroid. We used standard Cochrane methods. The major outcomes were pain, function, need for surgery, serious adverse effect, and presence of hyperglycemia. The minor outcomes were quality of life, successful outcomes, non-serious adverse events, and withdrawal due to adverse events. We used GRADE to assess the certainty of evidence for each outcome. Thirteen trials (1047 participants) met the inclusion criteria. Nine trials included participants with radicular low back pain, two trial with low back pain, and two trials with spinal stenosis. All trials blinded participants to receipt of systemic corticosteroids. Seven trials were at low risk of bias, five at unclear risk, and one at high risk of selection bias. Two trials were at high risk of attrition bias. Doses and duration of systemic corticosteroid therapy varied. Radicular low back pain For radicular low back pain, moderate-certainty evidence indicated that systemic corticosteroids probably slightly decrease pain versus placebo at short-term follow-up (mean difference (MD) 0.56 points better, 95% confidence interval (CI) 1.08 to 0.04 on a 0 to 10 scale) and may slightly increase the likelihood of experiencing improvement in pain at short-term follow-up (risk ratio (RR) 1.21, 95% CI 0.88 to 1.66; absolute effect 5% better (95% CI 5% worse to 15% better). Systemic corticosteroids may not improve function at short-term follow-up (standardized mean difference (SMD) 0.14 better; range 0.49 better to 0.21 worse) and probably increase the likelihood of improvement in function at short-term follow-up (RR 1.52, 95% CI 1.22 to 1.91; absolute effect 19% better, 95% CI 8% better to 30% better). Systemic corticosteroids were associated with greater improvement in function versus placebo at long-term follow-up (MD -7.40, 95% CI -12.55 to -2.25 on the 0 to 100 Oswestry Disability Index) and greater likelihood of functional improvement (RR 1.29, 95% CI 1.06 to 1.56), based on a single trial. There was no difference in likelihood of surgery (RR 1.00, 95% CI 0.68 to 1.47). Evidence indicated that systemic corticosteroids (administered as a single dose or as a short course of therapy) are not associated with increased risk of any adverse event, serious adverse events, withdrawal due to adverse events, or hyperglycemia, but estimates were imprecise as some trials did not report harms, and harms reporting was suboptimal in trials that did provide data. Limitations included variability across trials in interventions (e.g. corticosteroid used, dose and duration of treatment), clinical settings, and participants (e.g. duration of symptoms, methods for diagnosis); limited utility of subgroup analyses due to small numbers of trials; methodologic limitations or suboptimal reporting of methods by some trials; and too few trials to formally assess for publication bias using graphical or statistical tests for small sample effects. Non-radicular low back pain Evidence on systemic corticosteroids versus placebo for non-radicular pain was limited and suggested that systemic corticosteroids may be associated with slightly worse short-term pain but slightly better function. Spinal stenosis For spinal stenosis, limited evidence indicated that systemic corticosteroids are probably no more effective than placebo for short-term pain or function. Systemic corticosteroids appear to be slightly effective at improving short-term pain and function in people with radicular low back pain not due to spinal stenosis, and might slightly improve long-term function. The effects of systemic corticosteroids in people with non-radicular low back pain are unclear and systemic corticosteroids are probably ineffective for spinal stenosis. A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harms, but evidence is limited.

Association between radicular low back pain and constipation: a retrospective cohort study using a real-world national database.

Previous observational studies have reported an association between lumbosacral radiculopathy (LSR), a form of low back pain (LBP) with nerve root involvement, and constipation. However, it is unclear whether this association is due to confounding variables such as comorbidities and medications. This study explores the possible association between LSR and constipation, with the hypothesis that adults with LSR have increased odds of developing constipation compared with those with nonradicular LBP. Adults aged 18 to 49 years with incident LSR and nonradicular LBP were identified from a national 70 million patient electronic health records network (TriNetX). Propensity score matching (PSM) was used to control for covariates and determine the odds ratio (OR) of constipation over a 1-year follow-up. Lumbar stenosis, cauda equina syndrome, and inflammatory bowel diseases were excluded. After PSM, 503,062 patients were in each cohort. Before PSM, the likelihood of constipation was identical between cohorts (LSR 10.8% vs 10.9%; OR [confidence interval] = 0.99 [0.98-1.0], P = 0.251). This association was unchanged after PSM (LSR 10.8% vs 11.1%; OR [confidence interval] = 0.98 [0.97-0.99]; P = 0.003). The study hypothesis can be refuted given that the OR approximated the null in a large propensity-matched sample. Patients with LSR have equivalent odds of constipation compared with those with nonradicular LBP, suggesting that LSR is not a direct cause of constipation. The similar risk of constipation between cohorts could be explained by factors common to LBP in general, such as pain severity, physical inactivity, and constipating medications.

A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first-line medication for acute low back pain (LBP). It is unclear if the choice of NSAID impacts outcomes. We compared ibuprofen, ketorolac, and diclofenac for the treatment of acute, nonradicular LBP. This was a three-armed, double-blind, comparative effectiveness study, in which we enrolled patients at the conclusion of an ED visit for musculoskeletal LBP and determined outcomes by telephone 5days later. Patients were randomized to receive a 5-day supply of 600mg of ibuprofen, 10mg of ketorolac, or 50mg of diclofenac, each to be used every 8h as needed. Every participant also received LBP education. The primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ), a 24-item instrument on which lower scores indicate better LBP functional outcomes, between ED visit and day 5. Secondary outcomes included pain intensity, measured using the descriptors none, mild, moderate, and severe, and the presence of stomach irritation. A total of 868 patients were screened and 66 patients were enrolled in each of the three arms. Baseline characteristics were similar. Improvements in RMDQ by day 5 were as follows: ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p=0.34). Mild or no pain on day 5 was as follows: ibuprofen 38 of 61 (62%), ketorolac 47 of 59 (80%), and diclofenac 45 of 62 (71%; 95% CI for rounded mean difference of 17% between ibuprofen and ketorolac=1, 33%, p=0.04, number needed to treat=6 [95% CI=3-69]). Stomach irritation was reported by 16 of 62 (26%) ibuprofen patients versus three of 61 (5%) in the ketorolac arm and six of 64 (9%) in the diclofenac arm (p<0.01). There were no important differences between groups with regard to the primary outcome. These data do not rule out that possibility that ketorolac results in better pain relief and less stomach irritation than ibuprofen.

The Real Time Geometric Effect of a Lordotic Curve-Controlled Spinal Traction Device: A Randomized Cross Over Study

Background: A standard spinal traction (ST) device was designed to straighten the spine without considering physiological lumbar lordosis. Using lordotic curve-controlled traction (LCCT), which maintains the lordotic curve during traction, the traction force would be applied to the posterior spinal structure effectively. Thus, the purpose of our study was to evaluate real-time biomechanical changes while applying the LCCT and ST. Methods: In this study, 40 subjects with mild non-radicular low back pain (LBP) were included. The participants underwent LCCT and ST in random order. Anterior and posterior intervertebral distance, ratios of anterior/posterior intervertebral distance (A/P ratio), and lordotic angles of intervertebral bodies (L2~L5) were measured by radiography. Results: Mean intervertebral distances were greater during LCCT than those measured prior to applying traction (p < 0.05). Mean A/P ratio was also significantly greater during LCCT than during ST or initially (p < 0.05). In particular, for the L4/5 intervertebral segment, which is responsible for most of the lordotic curve, mean LCCT angle was similar to mean lordotic angle in the standing position (10.9°). Conclusions: Based on measurements of radiologic geometrical changes with real-time clinical setting, the newly developed LCCT appears to be a useful traction device for increasing intervertebral disc spaces by maintaining lordotic curves.

Non-radicular low back pain: Assessment and evidence-based treatment.

Low back pain (LBP) is a common presentation in general practice. Clinical workup must exclude sinister underlying diseases. Treatment of central LBP is difficult given the numerous treatment options available. The aim of this article is to help clinicians assess patients with LBP and formulate evidence-based treatment decisions. Patient presentations can be stratified according to the presence of red flags andpain type (ie non-spinal, radicular, non‑organic and central). The vast majority ofpatients with acute central back pain experience improvement of their symptoms. Treatment options includeeducation, lifestyle modification, heat, massage, graduated return to early activity, nonsteroidal anti-inflammatory medications and muscle relaxants when appropriate. Chronic LBP treatment can also include paracetamol and physiotherapy. Second-line treatment caninclude psychological therapy, multidisciplinary rehabilitation, targeted injections and antidepressants. Tapentadol is a safe and effective medication fortreating severe LBP. Pain specialist referral should be considered ifpatients require controlled analgesia. Surgical treatment has narrow indications in central non-radicular back pain and is considered as a last-line treatment in selected patients.

Dolor sacroilíaco: Epidemiología, fisiopatología, diagnóstico y tratamiento

El dolor sacroilíaco es una causa generalmente subdiagnosticada de dolor lumbar, que afecta del 15% a 30% de los pacientes con dolor lumbar bajo crónico no radicular. La articulación sacroilíaca (ASI) recibe continuo stress durante la bipedestación y marcha, siendo estabilizada por estructuras ligamentarias, capsulares y miofasciales fuertes, que reciben una abundante inervación. Destaca la dificultad en el diagnóstico del dolor sacroilíaco; debido a su naturaleza heterogénea. éste se debe sospechar en todo paciente con síndrome de dolor lumbar no radicular, unilateral y no central. El examen físico debería descartar patología de cadera y columna lumbar. La realización de maniobras de provocación del dolor sacroilíaco aporta en el diagnóstico, teniendo la combinación de 3 o más maniobras positivas una sensibilidad de 85% y especificidad de 79%. Se ha recurrido a inyecciones diagnósticas con anestésicos locales, tanto intraarticulares como de ligamentos circundantes. El tratamiento del dolor sacroilíaco es multimodal e individualizado para cada paciente. El tratamiento conservador –basado en terapia física y antiinflamatorios no esteroidales– es la terapia de primera línea. Las infiltraciones esteroidales tanto intra como extraarticulares pueden proveer alivio en un grupo de pa-cientes con inflamación activa. La denervación de los ramos dorsales laterales con radiofrecuencia ha mostrado ser un tratamiento exitoso en pacientes con dolor sacroilíaco, logrando 6 meses a 1 año de alivio del dolor. En pacientes con dolor refractario, la fusión de la articulación sacroilíaca es una opción, prefiriéndose la técnica mínimamente invasiva de fijación trans-sacroilíaca.

Discogenic non-radicular low back pain: a clinical case report

Back pain is often considered under the diagnostic heading “nonspecific pain” because of difficulties in identifying the primary source of pain in everyday clinical practice. However, despite the difficulties in identifying the specific etiology of chronic low back pain, diagnostic procedures can identify its source in 90% of patients. We report a clinical case of typical discogenic pain. The 6-week pain, which developed after barbell exercising in a 42-year-old man, resulted in the loss of professional employment. The pain was localized to the midline of the lower back (axial pain) and intensified in a sitting position. Computed tomography images demonstrated subchondral changes in L5-S1 vertebral bodies (Modic-1). A holistic diagnostic approach, including a vibration test, made it possible to diagnose the degenerative disc disease (L5-S1 intervertebral disk disease) with subacute discogenic pain. The patient received Dexalgin®25 at a dose of 25 mg x 3 times a day in combination with omeprazole 20 mg per day for 5 days, then the patient was switched to Nimesil 200 mg per day in two divided doses. A complex drug of the SYSADOA group containing glucosamine and chondroitin was used as adjuvant therapy. Pain intensity was reduced by 70 % at 6 weeks (2 points on VAS scale, which corresponds to the level of mild pain syndrome) as compared to the baseline level. This clinical case stresses the importance of accurate diagnosis of back pain and demonstrates the potential for successful combination non-surgical treatment of discogenic pain in primary outpatient settings.

In adult patients with acute nonradicular low back pain, does early increased activity, as compared with bed rest, result in pain relief and increased functionality?

In adult patients with acute nonradicular low back pain, does early increased activity, as compared with bed rest, result in pain relief and increased functionality?

Ibuprofen Plus Acetaminophen Versus Ibuprofen Alone for Acute Low Back Pain: An Emergency Department-based Randomized Study.

Patients with low back pain (LBP) are often treated with nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs are modestly effective for LBP, but many patients with LBP continue to suffer despite treatment with these medications. We compared pain and functional outcomes 1 week after emergency department (ED) discharge among patients randomized to a 1-week course of ibuprofen plus acetaminophen versus ibuprofen plus placebo. This was a randomized, double-blind study conducted in two urban EDs. Patients presenting with acute, nontraumatic, nonradicular LBP of no more than 2weeks' duration were eligible for enrollment immediately prior to discharge from an ED if they had a score>5 on the Roland Morris Disability Questionnaire (RMDQ), a 24-item validated instrument, indicating more than minimal functional impairment. All patients were given a standardized 10-minute LBP educational session prior to discharge. The primary outcome was improvement on the RMDQ between ED discharge and 1 week later. One secondary outcome was pain intensity, as measured on a 4-point descriptive scale (severe, moderate, mild, none) at 1 week. Enrollment began in October 2018. A total of 120 patients met selection criteria and were randomized. Baseline demographic characteristics were comparable between the two groups. By 1 week after the ED visit, patients randomized to ibuprofen plus placebo reported a mean (±SD) improvement in the RMDQ of 11.9 (±9.7), while those randomized to ibuprofen plus acetaminophen reported a mean (±SD) improvement of 11.1 (±10.7). The 95% CI for the between-group difference of 0.8 was -3.0 to 4.7. At 1 week, moderate or severe pain was reported by 15 of 53 (28%) patients in the ibuprofen plus placebo group and 16 of 57 (28%) patients in the ibuprofen plus acetaminophen group (95% CI for between-group difference of 0%= -17% to 17%). Among ED patients with acute, nontraumatic, nonradicular LBP, adding acetaminophen to ibuprofen does not improve outcomes within 1 week.

384EMF Adjunctive Lidocaine 5% Patches in the Treatment of Acute Nonradicular Low Back Pain in Patients Discharged From the Emergency Department: An Interim Analysis

Low back pain (LBP) accounts for 2.63 million annual emergency department (ED) visits in the United States. With an increased emphasis on safe analgesic prescribing practices, identification and evaluation of opioid-sparing analgesics are needed. Lidocaine 5% patches are prescription non-opioid topical anesthetic patches often used in the treatment of focal musculoskeletal pain syndromes in the ED including LBP despite limited data supporting their use. We report here preliminary data from our ongoing trial on the efficacy of lidocaine 5% patches in the treatment of acute non-radicular LBP as an adjunctive therapy in patients discharged from the ED.

A Randomized, Placebo-Controlled Trial of Ibuprofen Plus Metaxalone, Tizanidine, or Baclofen for Acute Low Back Pain

Patients with low back pain are often treated with nonsteroidal anti-inflammatory drugs and skeletal muscle relaxants. We compare functional outcomes and pain among patients with acute low back pain who were randomized to a 1-week course of ibuprofen plus placebo versus ibuprofen plus 1 of 3 skeletal muscle relaxants: baclofen, metaxalone, and tizanidine. This was a randomized, double-blind, parallel-group, 4-arm study conducted in 2 urban emergency departments (EDs). Patients with nonradicular low back pain for less than or equal to 2 weeks were eligible if they had a score greater than 5 on the Roland-Morris Disability Questionnaire, a 24-item inventory of functional impairment caused by low back pain. All participants received 21 tablets of ibuprofen 600 mg, to be taken 3 times a day as needed. Additionally, they were randomized to baclofen 10 mg, metaxalone 400 mg, tizanidine 2 mg, or placebo. Participants were instructed to take 1 or 2 of these capsules 3 times a day as needed. All participants received a 10-minute educational session. The primary outcome was improvement on the Roland-Morris Disability Questionnaire between ED discharge and 1week later. Secondary outcomes included pain intensity 1 week after ED discharge (severe, moderate, mild, or none). Three hundred twenty patients were randomized. One week later, the mean Roland-Morris Disability Questionnaire score of patients randomized to placebo improved by 11.1 points (95% confidence interval [CI] 9.0 to 13.3), baclofen by 10.6 points (95% CI 8.6 to 12.7), metaxalone by 10.1 points (95% CI 8.0 to 12.3), and tizanidine by 11.2 points (95% CI 9.2 to 13.2). At 1-week follow-up, 30% of placebo patients (95% CI 21% to 41%) reported moderate to severe low back pain versus 33% of baclofen patients (95% CI 24% to 44%), 37% of metaxalone patients (95% CI 27% to 48%), and 33% of tizanidine patients (95% CI 23% to 44%). Adding baclofen, metaxalone, or tizanidine to ibuprofen does not appear to improve functioning or pain any more than placebo plus ibuprofen by 1 week after an ED visit for acute low back pain.

A Comparison of NSAIDs for Acute, Non-radicular Low Back Pain.

A Comparison of NSAIDs for Acute, Non-radicular Low Back Pain.

3523 Innovative Approaches to Clinical Research on Placebo Effects: A Regulatory Science Perspective

OBJECTIVES/SPECIFIC AIMS: To analyze contemporary study design methods and clinical trial approaches in placebo research. METHODS/STUDY POPULATION: An analysis was conducted on the following studies: I. “Managing” the Placebo Effect: The Single-Blind Placebo Lead-in Response in Two Pain Models by RN Haden, et al. The objective of the study was to consider elements of the placebo response in the context of two pain models using a “single-blind placebo lead-in” design (SBPLI) by engaging the “placebo response” prior to randomization to active drug and placebo-controlled conditions. The methods of the study included two pilot drug trials using knee osteoarthritis (KOA) and non-radicular low back pain (LBP) subjects, SBPLI protocols were conducted. In the first study, 36 subjects with non-radicular CLBP were enrolled in a double-blind, randomized, placebo-controlled trial of hydromorphone ER. In the second study, a total of 42 subjects with chronic KOA pain were enrolled in a double-blind, randomized, placebo-controlled study of milnacipran. Gender and/or diagnosis affected placebo responses as observed in changes in patient self-reported pain, depressive and pain anxiety symptoms were examined. Additionally, the placebo response on performance-based tests (stair climbing, range of motion (ROM), sit to stand repetitions, and 6-minute treadmill distance) was evaluated. II. Randomized Placebo-Controlled Placebo Trial to Determine the Placebo Effect Size by L. Gerdesmeyer, et al. The objective of the study was to analyze the pure placebo effect on clinical, chronic pain through a blinded RCT. The methods of the study included 182 patients suffering from chronic plantar heel pain for over 6 months, who failed to respond to conservative treatments, were screened and 106 of these patients were enrolled into this study. The patients were randomly assigned to receive either a blinded placebo shockwave treatment or an unblinded placebo shockwave treatment. The primary outcome measure was the differences in percentage change of visual analogue scale (VAS) scores 6 weeks after the intervention. The secondary outcome measure was the differences in Roles and Maudsley pain score (RMS) 6 weeks after intervention. III. Open-label placebo treatment in chronic low back pain: a randomized controlled trial by C. Carvalho, et al. The objective of the study was to investigate whether placebo effects in chronic low back pain could be harnessed ethically by adding open-label placebo (OLP) treatment to treatment as usual (TAU) for 3 weeks. The methods of the study included 97 randomized participants in a 3-week randomized control trial comparing current treatment plus OLP to current treatment alone (TAU). RESULTS/ANTICIPATED RESULTS: N/a DISCUSSION/SIGNIFICANCE OF IMPACT: The aforementioned studies provide placebo researchers with contemporary and reliable methodologies to examine placebo effects on participants. These methodologies provide scientists with clinical translational research methodology styles based on the foundation of regulatory science.

Effectiveness of Slump Stretching on Low Back Pain: A Systematic Review and Meta-analysis.

The slump test is a type of neurodynamic test that is believed to evaluate the mechanosensitivity of the neuromeningeal structures within the vertebral canal. The objective of this review was to investigate the effectiveness of slump stretching on back pain and disability in patients with low back pain (LBP). We searched eight electronic databases (PubMed/Medline, Scopus, Ovid, CINAHL, Embase, PEDro, Google Scholar, CENTRAL). The publication language was restricted to English, and we searched the full time period available for each database, up to October 2017. Our primary outcomes were pain and disability, and the secondary outcome was range of motion (ROM). We identified 12 eligible studies with 515 LBP patients. All included studies reported short-term follow-up. A large effect size (standardized mean difference [SMD] = -2.15, 95% confidence interval [CI] = -3.35 to -0.95) and significant effect were determined, favoring the use of slump stretching to decrease pain in patients with LBP. In addition, large effect sizes and significant results were also found for the effect of slump stretching on disability improvement (SMD = -8.03, 95% CI = -11.59 to -4.47) in the LBP population. A qualitative synthesis of results showed that slump stretching can significantly increase straight leg raise and active knee extension ROM. There is very low to moderate quality of evidence that slump stretching may have positive effects on pain in people with LBP. However, the quality of evidence for the benefits of slump stretching on disability was very low. Finally, it appears that patients with nonradicular LBP may benefit most from slump stretching compared with other types of LBP.

Real-time fusion-imaging in low back pain: a new navigation system for facet joint injections.

The aim of the current study is to present our experience in lumbar spine interventional procedures performed with a newly developed multimodal echo-navigator (EcoNav) and to evaluate short-term clinical outcomes of a series of patients affected by facet joint disease (FJD) treated with steroid and anaesthetic injection under fusion-imaging guidance, compared to a cohort of patients that received the same treatment under computed tomography (CT) guidance. Sixty-five consecutive patients (34 females; mean age 68.3 ± 12.8years) with a clinical diagnosis of non-radicular low back pain lasting for more than 6-weeks and magnetic resonance (MR) or CT confirmed FJD were enrolled for image-guided FJI. Twenty-eight patients underwent FJI with fusion-guided technique, while CT-guided procedures were performed in the other cases. Clinical and procedural data were recorded and compared at a mean follow-up of 6.1 ± 2.0months. A significant improvement in clinical parameters was observed for both fusion-guided and CT-guided group. Comparing both groups, no statistically significant difference could be detected neither at baseline conditions nor during the follow-up period. No significant periprocedural complication occurred in both groups. A satisfaction rate of 92.3 and 81.1% was reported for fusion-guided and CT-guided group, respectively. EcoNav fusion-imaging system represents a safe, feasible, effective and reproducible guidance option in FJD infiltration procedures, also avoiding use of ionising radiations.

Pain One Week After an Emergency Department Visit for Acute Low Back Pain Is Associated With Poor Three-month Outcomes.

Low back pain (LBP) is responsible for more than 2.5 million visits to U.S. emergency departments (EDs) annually. Nearly 30% of patients who present to an ED with acute LBP report functional impairment or pain 3 months later. These patients are at risk of chronic LBP, a highly debilitating condition. In this study, we assessed whether three variables assessable shortly after symptom onset could independently predict poor 3-month outcomes among LBP patients who present to an ED. This was a planned analysis of data from two randomized comparative effectiveness studies of patients with acute, nontraumatic, nonradicular LBP. Patients were enrolled during an ED visit, contacted by telephone 1 week after the ED visit, and then followed up by telephone 3 months later. The coprimary 3-month outcomes were LBP-related functional impairment and persistent moderate or severe LBP. Two of the three hypothesized predictor variables were assessed during the index visit: 1) the STarT Back Screening Tool score, a nine-item, multidimensional tool validated and widely used in the outpatient setting, and 2) the patient's own anticipated duration of LBP. The third hypothesized predictor was presence of pain assessed by phone 1 week after the ED visit. We then determined whether these three predictor variables were independently associated with poor outcomes at 3 months, after controlling for medication received, age, andsex. A total of 354 patients were enrolled. Of these, 309 (87%) provided 3-month impairment data and 311 (88%) provided 3-month pain data. At 3 months, 122 of 309 (39%) patients reported functional impairment and 51 of 311(16%) patients reported moderate or severe LBP. Among the three hypothesized predictor variables, 58 of 352 (16%) patients with available data reported a moderate or high STarT Back Screening Tool score, 35 of 321 (11%) patients with available data reported anticipated duration of LBP>1 week, and 235 of 346 (68%) patients reported pain at 1-week telephone follow-up. After age, sex, and medication received were controlled for in a multivariable logistic regression model, only pain at 1 week was independently associated with 3-month impairment (odds ratio [OR]= 2.42, 95% CI= 1.39-4.22) and 3-month moderate or severe pain (OR= 3.83, 95% CI= 1.53-9.58). More than one-third of patients reported functional impairment 3 months after an ED visit for acute, nontraumatic, nonradicular LBP. Moderate or severe LBP was less common, reported in about half as many patients (16%). Of the three hypothesized predictor variables, only persistent pain at 1 week was independently associated with poor outcomes at 3 months. Despite its important role in the outpatient setting, the STarT Back Tool was not associated with poor outcomes in this ED cohort.

Sacroiliac joint: A review

Sacroiliac joint (SIJ) pain is one of the common but underdiagnosed source of mechanical low back pain. The incidence is estimated to be in the range of 15%–30% in patients with nonradicular low back pain. The signs and symptoms of SIJ pain mimic pain arising from other causes of low back pain. There is no single symptom or physical examination finding that can firmly diagnose SIJ as a source of patient's pain. There is good evidence suggesting that a combination of three or more positive provocative tests strongly suggests SIJ dysfunction. Intra-articular injection with local anesthetic is considered the gold standard for diagnosis of SIJ pain. Many treatment modalities are available for SIJ pain, ranging from conservative management to surgical interventions. This review article covers all the aspects of SIJ pain, with treatment section mainly covering evidence-based interventional procedures.

A Randomized, Double-Blind, Placebo-Controlled Trial of Naproxen With or Without Orphenadrine or Methocarbamol for Acute Low Back Pain

In US emergency departments (EDs), patients with low back pain are often treated with nonsteroidal anti-inflammatory drugs and muscle relaxants. We compare functional outcomes among patients randomized to a 1-week course of naproxen+placebo versus naproxen+orphenadrine or naproxen+methocarbamol. This was a randomized, double-blind, comparative effectiveness trial conducted in 2 urban EDs. Patients presenting with acute, nontraumatic, nonradicular low back pain were enrolled. The primary outcome was improvement on the Roland-Morris Disability Questionnaire (RMDQ) between ED discharge and 1 week later. All patients were given 14 tablets of naproxen 500 mg, to be used twice a day, as needed for low back pain. Additionally, patients were randomized to receive a 1-week supply of orphenadrine 100 mg, to be used twice a day as needed, methocarbamol 750 mg, to be used as 1 or 2 tablets 3 times per day as needed, or placebo. All patients received a standardized 10-minute low back pain educational session before discharge. Two hundred forty patients were randomized. Baseline demographic characteristics were comparable. The mean RMDQ score of patients randomized to naproxen+placebo improved by 10.9 points (95% confidence interval [CI] 8.9 to 12.9). The mean RMDQ score of patients randomized to naproxen+orphenadrine improved by 9.4 points (95% CI7.4 to 11.5). The mean RMDQ score of patients randomized to naproxen+methocarbamol improved by 8.1 points (95% CI 6.1 to 10.1). None of the between-group differences surpassed our threshold for clinical significance. Adverse events were reported by 17% (95% CI 10% to 28%) of placebo patients, 9% (95% CI 4% to 19%) of orphenadrine patients, and 19% (95% CI 11% to 29%) of methocarbamol patients. Among ED patients with acute, nontraumatic, nonradicular low back pain, combining naproxen with either orphenadrine or methocarbamol did not improve functional outcomes compared with naproxen+placebo.

238 A Randomized Clinical Trial of Naproxen + Placebo, Orphenadrine, or Methocarbamol for Acute Low Back Pain

Low back pain (LBP) causes more than 2.5 million visits to US EDs annually. LBP patients are often treated with non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs). We compared functional outcomes and pain one week and three months after ED discharge among patients randomized to a one-week course of naproxen+ placebo vs naproxen+orphenadrine vs. naproxen+ methocarbamol. Orphenadrine and methocarbamol are each used in more than 250,000 ED visits annually. This was a randomized, double-blind, comparative efficacy trial conducted in two urban EDs. Patients presenting with acute, non-traumatic, non-radicular LBP of ≤ 2 weeks duration were eligible for enrollment immediately prior to discharge from an ED if they had a score >5 on the Roland-Morris Disability Questionnaire (RMDQ), a validated 24-item inventory of functional impairment due to LBP. Higher scores on the RMDQ indicate greater functional disability. The primary outcome was improvement on the RMDQ between ED discharge and one week later. Secondary outcomes included pain intensity one week and three months after ED discharge, as measured on a four-point descriptive scale (severe, moderate, mild, none). All patients were given 14 tablets of naproxen 500mg, to be taken twice a day, as needed for LBP. Additionally, patients were randomized to receive a one-week supply of orphenadrine 100mg, to be taken twice a day as needed for LBP, methocarbamol 750mg, to be taken as one or two tablets, three times per day, as needed for LBP, or placebo. All patients received a standardized 10-minute LBP educational session prior to discharge. Using a between-group mean difference of 5 RMDQ points, a previously validated threshold for clinical significance, a 2-tailed α=0.05 and β=0.2, we calculated a required sample size of 240 patients. Enrollment commenced in March 2016 and continued for 11 months. 1,473 patients were screened for eligibility. 240 patients met entry criteria and were randomized. Baseline demographic characteristics were comparable between the two groups. 234 patients (98%) provided one-week outcome data. The mean RMDQ of patients randomized to naproxen + placebo improved by 10.9 (95% CI: 8.9, 12.9) RMDQ points. The mean RMDQ of patients randomized to naproxen + orphenadrine improved by 9.4 (95% CI: 7.4, 11.5). The mean RMDQ of patients randomized to naproxen + methocarbamol improved by 8.1 (95% CI: 6.1, 10.1). None of the between-group differences achieved the threshold for clinical significance. At one-week follow-up, 34% (95% CI: 25, 45%) of naproxen+placebo patients reported moderate or severe LBP versus 33% (95% CI: 24, 44%) of naproxen+orphenadrine patients and 39% (95% CI: 29, 50%) of naproxen+methocarbamol patients. At three-month follow-up, 19% (95% CI: 11, 30%) of naproxen+placebo patients reported moderate or severe LBP versus 17% (95% CI: 10, 28%) of naproxen+orphenadrine patients and 21% (95% CI: 13, 33%) of naproxen+methocarbamol patients. Adverse events were reported by 17% (95% CI: 10, 28%) of naproxen+placebo patients, 9% (95% CI: 4, 19%) of naproxen+orphenadrine patients, and 19% (95% CI: 11, 29%) of naproxen+methocarbamol patients. Among ED patients with acute, non-traumatic, non-radicular LBP, combining naproxen with either orphenadrine or methocarbamol did not improve functional outcomes or pain one week and three months after ED discharge when compared to naproxen + placebo.