Treatment Of Chronic Low Back Pain Research Articles

Physical Therapy Informed by Acceptance and Commitment Therapy (PACT) Versus Usual Care Physical Therapy for Adults With Chronic Low Back Pain: A Randomized Controlled Trial

Chronic low back pain (CLBP) is a major cause of global disability and improving management is essential. Acceptance and commitment therapy (ACT) is a promising treatment for chronic pain but has not been modified for physical therapy. This randomized controlled trial (RCT) compared physical therapy informed by ACT (PACT) against standard care physical therapy for patients with CLBP. Patients with CLBP (duration ≥12 weeks, mean 3 years) were recruited from physical therapy clinics in 4 UK public hospitals. The Roland-Morris Disability Questionnaire (RMDQ) at 3 months’ post-randomization was the primary outcome. Two hundred forty-eight participants (59% female, mean age = 48) were recruited and 219 (88.3%) completed measures at 3 and/or 12 months’ follow-up. At 3 months, PACT participants reported better outcomes for disability (RMDQ mean difference = 1.07, p = .037, 95% CI = −2.08 to −.07, d = .2), Patient Specific Functioning (p = .008), SF12 physical health (p = .032), and treatment credibility (p < .001). At 12 months’ follow-up, there were no significant differences between groups. PACT was acceptable to patients and clinicians and feasible to deliver. Physical therapists incorporated psychological principles successfully and treatment was delivered with high (≥80%) fidelity. Our results may inform the management of CLBP, with potential benefits for patients, health care providers, and society. PerspectivePsychologically informed physical therapy has great potential but there are challenges in implementation. The training and support included in the PACT trial enabled the intervention to be delivered as planned. This successfully reduced disability in the short but not long term. Findings could inform physical therapists’ treatment of CLBP.

Use of Health Technologies for Low Back Pain in the Military Health System

Low back pain (LBP) is a widespread condition that poses specific occupational risks for active-duty military personnel. Barriers to treatment are also greater for military personnel and veterans. The authors conducted a review of the literature to identify technology solutions to help offset barriers to treatment for military personnel and veterans. Researchers conducted a PubMed search using subject headings and natural language terms and phrases. Three research psychologists screened abstracts and full text articles. After application of exclusion criteria, 28 key articles on treatment of LBP leveraging technology were included. There is evidence in medical literature for the efficacy of health technology in the treatment of LBP. Telehealth can be effective in reducing pain levels, and more convenient and cost-effective than treatment as usual (TAU). Smartphone and mobile apps are effective for managing LBP by providing self-management tools and tracking methods. Internet-based programs are highly accessible, cost-effective, and less stigmatized than TAU. Wearable technologies, such as biofeedback and electronic sensors, are effective for reducing pain and improve physical rehabilitation assessment and treatment for chronic LBP. Findings for emerging technologies are reviewed and discussed. Considerable evidence exists for incorporating technology into treatment programs for LBP. The most promising technologies were as follows: telehealth, internet-based programs, and mobile apps. Benefits of using technology in treatment programs included not only reduction in pain symptoms, but also enabling self-management, allowing anonymous participation, portability of treatment, and cost effectiveness.

Immediate effect of pain neuroscience education for recent onset low back pain: an exploratory single arm trial

ABSTRACTStudy Design: A prospective, single-arm, pre-postintervention study.Objective: To determine the preliminary usefulness of providing pain neuroscience education (PNE) on improving pain and movement in patients presenting with non-chronic mechanical low back pain (LBP).Background: PNE has been shown to be an effective intervention for the treatment of chronic LBP but its usefulness in patients with non-chronic LBP has not been examined.Methods: A single group cohort pilot study was conducted. Eighty consecutive patients with LBP < 3 months completed a demographics questionnaire, leg and LBP rating (Numeric Pain Rating Scale – NPRS), disability (Oswestry Disability Index), fear-avoidance (Fear-Avoidance Beliefs Questionnaire), pain catastrophizing (Pain Catastrophizing Scale), central sensitization (Central Sensitization Inventory), pain knowledge (Revised Neurophysiology of Pain Questionnaire), risk assessment (Keele STarT Back Screening Tool), active trunk flexion and straight leg raise (SLR). Patients received a 15-minute verbal, one-on-one PNE session, followed by repeat measurement of LBP and leg pain (NPRS), trunk flexion and SLR.Results: Immediately after intervention, LBP and leg pain improved significantly (p < 0.001), but the mean change did not exceed minimal clinically important difference (MCID) of 2.0. Active trunk flexion significantly improved (p < 0.001), with the mean improvement (4.7 cm) exceeding minimal detectible change (MDC). SLR improved significantly (p = 0.002), but mean change did not exceed MDC.Conclusions: PNE may be an interesting option in the treatment of patients with non-chronic mechanical LBP. The present pilot study provides the rationale for studying larger groups of patients in controlled studies over longer periods of time.

Chronic Low Back Pain: Current Pharmacotherapeutic Therapies and a New Biological Approach

Chronic low back pain (CLBP) syndrome represents one of the leading causes of long-term disability worldwide. The prevalence of CLBP has been rising significantly in relation to increasing average life expectancy. CLBP results from chronification of acute low back pain. There are many factors contributing to the CLBP crisis; common etiopathogenetic factors include e.g., functional blockage of intervertebral joints. The treatment of CLBP is complex. An important part of treatment consists of pain pharmacotherapy, for which several groups of drugs are used. The problem lies in the side effects of many of these traditionally used medications. Therefore, new and safer treatment methods are being sought. Innovative options for CLBP pharmacology include injections containing collagen, which can be combined with other traditionally used drugs, which helps reduce dosages and increase the overall safety of CLBP therapy.

Electrophysiological Function of the Lumbar Multifidus and Erector Spinae Muscles in Elderly Patients With Chronic Low Back Pain.

This was a cross-sectional electrophysiological study. The main objective of this study was to evaluate electrophysiological activation of lumbar multifidus (LM) and erector spinae (ES) in elderly patients with chronic low back pain (CLBP) classified by LBP developmental mechanisms. Local and global muscles that function independently for stabilization and moment production, respectively, are crucial for stability and mobility of the lumbar spine. There is little research conducted on the electrophysiological functions of the LM as a local muscle and the ES as a global muscle in the lumbar spine, and their interrelation in patients with CLBP. Elderly patients aged 65 years and above, with CLBP were assigned into motion-induced LBP (49 patients) or walking-induced LBP cohorts (57 patients), and compared with a control group (53 patients without LBP). Electrophysiological activation of the LM and ES was performed using surface electromyography (EMG) and mechanomyography (MMG) during lumbar extension and flexion. Electromechanical coupling efficiency (EMCE) was calculated using the ratio of MMG to EMG. EMG and MMG amplitudes in the LM tended to be lower in patients with LBP than in the control group. EMG and MMG amplitudes in the ES tended to be higher in patients with LBP than in the control group. EMCE was significantly higher in both the LM and ES during lumbar extension and flexion in the motion-induced LBP cohort than in the walking-induced LBP cohort; however, ES dominance was seen in the motion-induced LBP cohort, both in lumbar extension and flexion, according to the EMCE ratio. ES dominance was seen in the motion-induced LBP cohort, both in lumbar extension and flexion, according to the EMCE ratio. Subgrouping of patients according to the induction of LBP seems to be important for CLBP treatment, and the electrophysiological assessment for the deep and superficial back muscles may be beneficial to elderly patients.

Discussions on real-world acupuncture treatments for chronic low-back pain in older adults

Chronic low-back pain (CLBP) is one of the most common pain conditions. Current clinical guidelines for low-back pain recommend acupuncture for CLBP. However, there are very few high-quality acupuncture studies on CLBP in older adults. Clinical acupuncture experts in the American Traditional Chinese Medicine Association (ATCMA) were interested in the recent grant on CLBP research announced by the National Center for Complementary and Integrative Health. The ATCMA experts held an online discussion on the subject of real-world acupuncture treatments for CLBP in older adults. Seven participants, each with more than 20 years of acupuncture practice, discussed their own unique clinical experience while another participant talked about the potential mechanism of acupuncture in pain management. As a result of the discussion, a picture of a similar treatment strategy emerged across the participants for CLBP in older adults. This discussion shows that acupuncture may have complicated mechanisms in pain management, yet it is effective for the treatment of chronic pain involving maladaptive neuroplasticity; therefore, it should be effective for CLBP in older adults.

Deep heating therapy via MF radiowaves versus superficial heating therapy in the treatment of nonspecific chronic low back pain: A double blind randomized trial.

Nonspecific Chronic Low Back Pain (CLBP) is a condition difficult to treat due to multiple etiopathogenesis and there is wide consensus on the multidisciplinary approach. In physiotherapy, the Medium Frequencies (MF) diathermy has recently been introduced but without enough evidence of effectiveness. To explore the effects of a deep heating therapy (DHT) produced by a MF diathermy for the treatment of CLBP compared with a superficial heating therapy (SHT). The study was a double blind randomized trial. Forty-nine patients affected by CLBP were randomly subdivided in 2 groups and treated with either DHT (450KHz) or SHT via electric resistance applying the same instrument on the lumbar spine. NRS (Numerical Rating Scale) for pain and ODI (Oswestry Disability Index) for disability were used as outcome measures. The follow up was: T1, 15 days (end of the therapy); T2, 30 days; T3, 45 days after T0. Both therapies were effective in reducing pain throughout the follow up with greater improvement in DHT group at T1. DHT resulted to have a higher efficacy with respect to SHT in reducing disability (ODI) throughout all follow ups. This study provides evidence of the positive effects of MF radio waves diathermy in the treatment of CLBP.

CYP2D6 genotype can help to predict effectiveness and safety during opioid treatment for chronic low back pain: results from a retrospective study in an Italian cohort.

BackgroundOpioids are widely used for chronic low back pain (CLBP); however, it is still unclear how to predict their effectiveness and safety. Codeine, tramadol and oxycodone are metabolized by CYP/CYP450 2D6 (CYP2D6), a highly polymorphic enzyme linked to allele-specific related differences in metabolic activity.PurposeCYP2D6 genetic polymorphisms could potentially help to predict the effectiveness and safety of opioid-based drugs in clinical practice, especially in the treatment of CLBP.Patients and methodsA cohort of 224 Italian patients with CLBP treated with codeine or oxycodone was retrospectively evaluated to determine whether adverse reactions and effectiveness were related to CYP2D6 single-nucleotide polymorphisms. CYP2D6 genotyping was performed using the xTAG® CYP2D6 Kit v3 (Luminex) to determine CYP2D6 metabolizer phenotype (poor, intermediate, rapid and ultrarapid). Subjects from the cohort were categorized into two groups according to the occurrence of side effects (Case) or benefit (Control) after chronic analgesic treatment. The impact of CYP2D6 polymorphism on treatment outcome was tested at the metabolizer phenotype, diplotype and haplotype levels.ResultsCYP2D6 polymorphism was significantly associated with opioid treatment outcome (Omnibus P=0.018, for both global haplotype and diplotype distribution test). CYP2D6*6 and *9 carriers, alleles characterized by a reduced (*9) or absent (*6) enzymatic activity, were significantly (P<0.05) associated with therapeutic failure. CYP2D6 ultrarapid metabolizers (CYP2D6*2N patients) showed an increased risk of side effects, as would be predicted. Despite their low frequency, CYP2D6 *1/*11, *4/*6 and *41/* 2N diplotypes showed significant (P<0.05) associations of efficacy and side effects with chronic opioid treatment.ConclusionOur results showed that reduced CYP2D6 activity is correlated with lack of therapeutic effect. We found that the pharmacogenetic analysis of CYP2D6 could be helpful in foreseeing the safety and effectiveness of codeine or oxycodone treatment in CLBP.

Effects of unstable shoes on trunk muscle activity in patients with chronic low back pain

IntroductionUnstable shoes were developed as a walking device to strengthen the lower extremity muscles and reduce joint loading. Many studies have reported increased muscle activity throughout the gait cycle in most of the lower limb muscles in healthy adults using these shoes. However, no previous studies have explored the effects of wearing unstable shoes on trunk muscle activity in patients with chronic low back pain (CLBP). Therefore, the aim of the present study was to compare the activity of selected trunk muscles in patients with CLBP during a gait test while walking wearing unstable shoes or conventional flat shoes (control). MethodsThirty-five CLBP patients (51.1 ± 12.4 y; 26 ± 3.8 kg/m2; 9.3 ± 5.2 Roland Morris Disability Questionnaire score) were recruited from the Orthopedic Surgery Service at the Hospital to participate in this cross-sectional study. All the participants underwent gait analysis by simultaneously collecting surface electromyography (EMG) data from erector spinae (ES), rectus abdominis (RA), obliquus internus (OI), and obliquus externus (OE) muscles, while walking on a treadmill with flat control shoes or experimental unstable shoes. ResultsThe results showed significantly higher %EMG activity in the ES (mean difference: 1.8%; 95% CI: 1.3–2.2), RA (mean difference: 1.5%; 95% CI: 0.3–2.7), and OI (mean difference: 1.5%; 95% CI: 0.2–2.8) in the unstable versus the flat-shoe condition, with a large effect size for the ES (Cohen's d = 1.27). ConclusionsBased on these findings, the use of unstable shoes may be implicated in promoting spine stability, particularly in improving neuromuscular control of the trunk muscles in CLBP treatment.

A Cross-Sectional Study Assessing Treatment Preference of People With Chronic Low Back Pain

ObjectiveTo assess treatment preference and attributes of 2 exercise-based treatments for people with chronic low back pain (LBP). DesignCross-sectional study. SettingAcademic research setting. ParticipantsIndividuals (N=154) with chronic LBP. InterventionsNot applicable. Main Outcome MeasuresParticipants completed a treatment preference assessment (TPA) measure that described 2 treatments for chronic LBP (strength and flexibility [SF] and motor skill training [MST]). Participants rated each treatment on 4 attributes: effectiveness, acceptability/logicality, suitability/appropriateness, and convenience. An overall score for each treatment was calculated as the mean of the 4 attribute ratings. The participants indicated either (1) no treatment preference or (2) preference for SF or MST. ResultsOne hundred four participants (67.5%) had a treatment preference; of those, 95 (91.3%) preferred SF and 9 (8.7%) preferred MST. The SF preference group rated SF higher than MST overall and on all attributes (all Ps <.01, ds ranged from .48-1.07). The MST preference group did not rate the treatments differently overall or on any of the attributes (all Ps >.05, ds ranged from .43-.66). Convenience of SF (P=.05, d=.79) and effectiveness (d=1.20), acceptability/logicality (d=1.27), and suitability/appropriateness (d=1.52) of MST (all Ps <.01) were rated differently between the 2 preference groups. ConclusionsWhen presented with 2 treatment options, a majority of patients preferred SF over MST. Convenience was a particularly important attribute affecting preference. Assessing treatment preference and attributes prior to treatment initiation allows the clinician to identify factors that may need to be addressed to enhance adherence to, and outcomes of, treatment.

Cognitive Behavioral Therapy (CBT) for Subacute Low Back Pain: a Systematic Review.

Chronic low back pain (CLBP) is a major source of physical and psychiatric morbidity and mortality, and the current overreliance on opioid analgesics has contributed to a burgeoning epidemic in the USA. Cognitive behavioral therapy (CBT) is an empirically supported treatment for CLBP, but little information exists regarding its potential efficacy for CLBP's precursor condition, subacute low back pain (sALBP), defined here as having a 7-12-week duration. Earlier intervention with CBT at the sALBP stage could produce larger clinical benefits. This systematic review was undertaken to characterize and highlight this knowledge gap. Of 240 unique articles identified by comprehensive database searches, only six prospective, sALBP-focused, randomized controlled trials (RCTs) published within the past 20years met criteria for inclusion in this review. These studies varied widely in their sample sizes, precise definition of sALBP, nature of CBT intervention, and outcome measures. Five of the six showed significant improvements associated with CBT, but the heterogeneity of the studies prevented quantitative comparisons. CBT has not been adequately studied as a potential early intervention treatment for sALBP patients. None of the six identified papers studied US civilians or leveraged innovations such as teletherapy-able to reach patients in remote or underserved areas-underscoring critical gaps in current back pain treatment. Given the severity of the US opioid epidemic, non-pharmacologic options such as CBT should be rigorously explored in the sALBP population.

The Effect of Epidural Morphine-Bupivacaine Combined with a Low Dose of Naloxone on Respiratory Function and Analgesia in Patients with Chronic Low-Back Pain

Context: Hypoventilation and apnea after epidural morphine is a serious concern after surgery and an issue in chronic pain. A low dose of naloxone added to morphine can prevent this complication. Objective: To determine that the low dose of naloxone added to epidural morphine analgesic could change the effect of this opioid in chronic low back pain. In addition, we evaluate its effect on respiratory function and patient satisfaction. Patients: Twenty-seven adults suffering from chronic low back pain (LBP) who were candidates for epidural injection treatment. Intervention: This was a randomized double-blind, uniform crossover, controlled clinical trial. The patients were treated with mixture of morphine-bupivacaine and mixture of morphine-bupivacaine-naloxone. Main outcome measure: The primary goals were to evaluate pain intensity and respiratory function after epidural injection of morphine or morphine combined with naloxone. Secondary end-points were the incidence and the side effects (pruritus, nausea, vomiting, and urinary retention) of neuraxial injection of morphine or morphine combined with naloxone for 14 days after each epidural injection. Results: There was no significant difference between morphine and morphine combined with naloxone on mean peripheral capillary oxygen saturation (SpO2m), the lowest peripheral capillary oxygen saturation (SpO2), and the respiratory disturbance index (RDI). Morphine combined with naloxone seemed to decrease pain more than morphine alone, but the result was not significant (p=0.2116). In the group that received morphine and naloxone, pain decreased sooner by half from baseline pain (at day 2 versus at day 6) than the other group. Vomiting, pruritus, and urinary retention were seen with no significant difference in both groups. Conclusion: We conclude that epidural administration of naloxone can preserve the analgesic effect of morphine in treatment of chronic LBP. Naloxone does not have any effects on respiratory function. It reduces itching, nausea, and pruritus after epidural injection of morphine. We cannot be certain whether this is the ideal dose or whether any changes in the doses might produce fewer side effects without interfering with analgesia.

Feasibility, Safety, and Efficacy of Subcutaneous Peripheral Nerve Field Stimulation for the Treatment of Refractory Low Back Pain: A Two-year Single-center Study

Chronic low back pain (CLBP) is challenging to treat. Minimal invasive neurostimulation therapies, such as subcutaneous peripheral nerve field stimulation (SPNS), improve pain relief and quality of life. The goal of the present study was to assess the usefulness, safety, and efficacy of SPNS in patients with CLBP.Twenty-six consecutive patients with CLBP were prospectively included in the study. For trial neurostimulation, two electrodes were implanted vertically at a depth of 1 cm into the subcutaneous tissue, ≤10 cm from the region of maximum pain. Trial neurostimulation was performed in all patients for 14 days. A successful outcome was defined as at least 50% pain relief. To monitor the effects of permanent neurostimulation, the Visual Analog Scale (VAS), the Oswestry Disability Index (ODI), and quality of life (EQ-5D-3L) were scored preoperatively and at 6-month and 24-month follow-ups.Thirteen patients responded to trial stimulation and had a permanent neurostimulator implanted. The use of pain medication, including opioid analgesics, was reduced in 92% of patients after 24 months. VAS, ODI, and EQ-5D-3L scores were significantly improved in these patients at the 24-month follow-up. The complication rate was 23% (3/13 patients). In non-responders, VAS and ODI at 24 months dropped significantly as well but the decrease was less pronounced compared to responders and had not led to a decrease in pain medication.SPNS is a novel, safe, and effective treatment for CLBP and may have advantages over interventional treatments including intrathecal therapy and spinal cord stimulation.

Effectiveness, costs and cost-effectiveness of chiropractic care and physiotherapy compared with information and advice in the treatment of non-specific chronic low back pain: study protocol for a randomised controlled trial

BackgroundLow back pain is a global public health problem and a leading cause of disability all over the world. The lifetime prevalence of low back pain is 70–80% and a significant proportion of people affected develop chronic low back pain (CLBP). Besides a severe negative impact on people’s health and health-related quality of life, CLBP is associated with substantial costs for society. Medical costs for the management of CLBP and costs for production losses due to absenteeism from work are sizeable. Pharmaceuticals, physical activity, manipulation, and multidisciplinary rehabilitation interventions are examples of widely used treatments for CLBP. However, the scientific basis to recommend the use of one treatment over another is limited and more research is needed to study the effects, costs and cost-effectiveness of treatments for CLBP in clinical practice.The aim of the study is to evaluate the effectiveness (back pain-related functional limitation, back pain intensity, general health, health-related quality of life, and working status), costs (medical costs and costs for production losses) and cost-effectiveness of chiropractic care and physiotherapy when added to information and advice in the treatment of patients with non-specific CLBP in Sweden.Methods/designThis is a pragmatic randomised controlled trial, where participants are recruited through six primary care rehabilitation units (PCRUs) in Stockholm County Council, Sweden. Individuals with non-specific CLBP are individually randomised to one of four treatment groups: ‘information and advice’; ‘physiotherapy, and information and advice’; ‘chiropractic care, and information and advice’; or ‘chiropractic care, physiotherapy, and information and advice’. A sample size of 600 participants will be recruited during a period of 33 months. A computer-based questionnaire is used to collect data on back pain-related functional limitation (Oswestry Disability Index), pain intensity (Numeric Rating Scale), general health (self-rated health), health-related quality of life (EQ-5D-3L), and working status (measured as percentage of full-time work). Data will be collected at baseline, and at 3, 6, and 12 months after baseline.DiscussionThe results from our study should be considered when producing evidence-based guidelines and recommendations on which treatment strategies to use for CLBP.Trial registrationISRCTN registry, ID: ISRCTN15830360. Registered prospectively on 2 February 2017.

Are paraspinous intramuscular injections of botulinum toxin a (BoNT-A) efficient in the treatment of chronic low-back pain? A randomised, double-blinded crossover trial

BackgroundTreatment for patients with chronic low-back pain (LBP) is a public health issue. Intramuscular injections of botulinum toxin A (BoNT-A) have shown an analgesic effect on LBP in two previous randomized controlled studies. The objective of the study was to verify the efficacy of paravertebral injections of BoNT-A in patients with LBP.MethodsPatients were included in this phase 3 randomized double-blinded trial comparing the efficacy of BoNT-A versus placebo in a crossover study on LBP. Both groups received 200 units of BoNT-A in paravertebral muscles or a placebo, and vice versa at Day 120. The main judgment criterion was LBP intensity 1 month after the injections, evaluated by using a visual pain scale (VAS). Secondary assessment criteria included: LBP intensity 90 and 120 days after injection day; number of days when an allowed antalgic oral treatment was needed in between each evaluation; functional disability measured by the Quebec Back Pain Disability Scale; quality of life; inability to work; patient satisfaction in relation to the treatment’s effect; spinal mobility; and strength of spinal muscles, measured by isokinetic technique.ResultsNineteen patients completed the study. There was no significant difference between the groups’ average LBP during the last 8 days at Day30 (p = 0.97). There was no significant difference between the two groups regarding the secondary assessment criteria (p > 0.05).ConclusionsInjections of BoNT-A in the paravertebral muscles were not found to be effective to relieve chronic LBP. The limits of the study are that the dose of BoNT-A used was lower than in other studies, and that the limited number of patients included may explain the negative results.Trial registrationsIdentifiers: NCT03181802. Unique Protocol ID: CHUBX2003.

Efficacy of Bee Venom Acupuncture for Chronic Low Back Pain: A Randomized, Double-Blinded, Sham-Controlled Trial.

Bee venom acupuncture (BVA) is an effective treatment for chronic low back pain (CLBP) through the pharmacological effects of bee venom and the simultaneous stimulation of acupoints. However, evidence of its efficacy and safety in humans remains unclear. Using a double-blind, randomized study, 54 patients with non-specific CLBP were assigned to the BVA and sham groups. All participants underwent six sessions of real or sham BVA for 3 weeks, in addition to administration of 180 mg of loxonin per day. The primary outcome, that is, “bothersomeness” derived from back pain, was assessed using the visual analog scale. Secondary outcomes included pain intensity, dysfunction related to back pain (Oswestry Disability Index), quality of life (EuroQol 5-Dimension), and depressive mood (Beck’s depression inventory). Outcomes were evaluated every week during the treatment period and followed up at weeks 4, 8, and 12. After 3 weeks of the treatment, significant improvements were observed in the bothersomeness, pain intensity, and functional status in the BVA group compared with the sham group. Although minimal adverse events were observed in both groups, subsequent recovery was achieved without treatment. Consequently, our results suggest that it can be used along with conventional pharmacological therapies for the treatment of CLBP.

Cost-effectiveness of Mindfulness-based Stress Reduction Versus Cognitive Behavioral Therapy or Usual Care Among Adults With Chronic Low Back Pain

Economic evaluation alongside a randomized trial of cognitive-behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) versus usual care alone (UC) for chronic low back pain (CLBP). To determine 1-year cost-effectiveness of CBT and MBSR compared to 33 UC. CLBP is expensive in terms of healthcare costs and lost productivity. Mind-body interventions have been found effective for back pain, but their cost-effectiveness is unexplored. A total of 342 adults in an integrated healthcare system with CLBP were randomized to receive MBSR (n = 116), CBT (n = 113), or UC (n = 113). CBT and MBSR were offered in 8-weekly 2-hour group sessions. Cost-effectiveness from the societal perspective was calculated as the incremental sum of healthcare costs and productivity losses over change in quality-adjusted life-years (QALYs). The payer perspective only included healthcare costs. This economic evaluation was limited to the 301 health plan members enrolled ≥180 days in the years pre-and postrandomization. Compared with UC, the mean incremental cost per participant to society of CBT was $125 (95% confidence interval, CI: -4103, 4307) and of MBSR was -$724 (CI: -4386, 2778)-that is, a net saving of $724. Incremental costs per participant to the health plan were $495 for CBT over UC and -$982 for MBSR, and incremental back-related costs per participant were $984 for CBT over UC and -$127 for MBSR. These costs (and cost savings) were associated with statistically significant gains in QALYs over UC: 0.041 (0.015, 0.067) for CBT and 0.034 (0.008, 0.060) for MBSR. In this setting CBT and MBSR have high probabilities of being cost-effective, and MBSR may be cost saving, as compared with UC for adults with CLBP. These findings suggest that MBSR, and to a lesser extent CBT, may provide cost-effective treatment for CLBP for payers and society. 2.

The effect of Kinesio® taping on pain, functionality, mobility and endurance in the treatment of chronic low back pain: A randomized controlled study.

Low back pain is one of the most important causes of morbidity. This study was designed to evaluate the effect of Kinesio® taping on pain, functionality, mobility and endurance in chronic low back pain treatment. Patients with chronic low back pain were randomly divided into three groups. Therapeutic ultrasound, hot packs, and transcutaneous electrical nerve stimulation were applied to each group for ten sessions during two weeks, and therapeutic exercises were applied in the clinic under physiotherapist supervision starting from the sixth session. Kinesio® tape was applied to the patients in the first group after each treatment session, and placebo tape was applied to the patients in the second group. No taping was applied to the third group, which constituted the control group. All the patients were evaluated pre and post-treatment in respect of pain, functional status (Oswestry scale), flexibility and endurance. The study included 60 patients (32females). When the initial demographic and clinical characteristics of the groups were evaluated, all assessment results, except the Oswestry scores, were similar (p= 0.000). When the average changes in the clinical evaluations were evaluated after the treatment, a statistically significant improvement demonstrating the superiority of the taping group was observed in pain, functionality, flexibility and endurance values (p= 0.000, 0.000, 0.000, 0.000). Kinesio® taping in chronic low back pain is an easy and effective method which increases the effectiveness of the treatment significantly in a short period when applied in addition to exercise and electrotherapy methods.

Benefits and safety of gabapentinoids in chronic low back pain: A systematic review and meta-analysis of randomized controlled trials.

Background and objectiveChronic Low Back Pain (CLBP) is very common, with a lifetime prevalence between 51% and 80%. In majority, it is nonspecific in nature and multifactorial in etiology. Pregabalin (PG) and Gabapentin (GB) are gabapentinoids that have demonstrated benefit in neuropathic pain conditions. Despite no clear rationale, they are increasingly used for nonspecific CLBP. They necessitate prolonged use and are associated with adverse effects and increased cost. Recent guidelines from the National Health Service (NHS), England, expressed concerns on their off-label use, in addition to the risk of misuse. We aimed to assess the effectiveness and safety of gabapentinoids in adult CLBP patients.MethodsElectronic databases of MEDLINE, EMBASE, and Cochrane were searched from their inception until December 20th, 2016. We included randomized control trials reporting the use of gabapentinoids for the treatment of CLBP of >3 months duration, in adult patients. Study selection and data extraction was performed independently by paired reviewers. Outcomes were guided by Initiative on Methods, Measurement and Pain Assessment in Clinical Trials guidelines, with pain relief and safety as the primary outcomes. Meta-analyses were performed for outcomes reported in 3 or more studies. Outcomes were reported as mean differences (MDs) or risk ratios (RRs) with their corresponding 95% confidence intervals (CIs), and I2 in percentage representing the percentage variability in effect estimates that could be explained by heterogeneity. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) was used to assess the quality of evidence.ResultsOut of 1,385 citations, eight studies were included. Based on the interventions and comparators, studies were analyzed in 3 different groups. GB compared with placebo (3 studies, n = 185) showed minimal improvement of pain (MD = 0.22 units, 95% CI [−0.5 to 0.07] I2 = 0%; GRADE: very low). Three studies compared PG with other types of analgesic medication (n = 332) and showed greater improvement in the other analgesic group (MD = 0.42 units, 95% CI [0.20 to 0.64] I2 = 0; GRADE: very low). Studies using PG as an adjuvant (n = 423) were not pooled due to heterogeneity, but the largest of them showed no benefit of adding PG to tapentadol. There were no deaths or hospitalizations reported. Compared with placebo, the following adverse events were more commonly reported with GB: dizziness-(RR = 1.99, 95% CI [1.17 to 3.37], I2 = 49); fatigue (RR = 1.85, 95% CI [1.12 to 3.05], I2 = 0); difficulties with mentation (RR = 3.34, 95% CI [1.54 to 7.25], I2 = 0); and visual disturbances (RR = 5.72, 95% CI [1.94 to 16.91], I2 = 0). The number needed to harm with 95% CI for dizziness, fatigue, difficulties with mentation, and visual disturbances were 7 (4 to 30), 8 (4 to 44), 6 (4 to 15), and 6 (4 to 13) respectively. The GRADE evidence quality was noted to be very low for dizziness and fatigue, low for difficulties with mentation, and moderate for visual disturbances. Functional and emotional improvements were reported by few studies and showed no significant improvements.Conclusions and relevanceExisting evidence on the use of gabapentinoids in CLBP is limited and demonstrates significant risk of adverse effects without any demonstrated benefit. Given the lack of efficacy, risks, and costs associated, the use of gabapentinoids for CLBP merits caution. There is need for large high-quality trials to more definitively inform this issue.Trial registrationPROSPERO CRD42016034040

VP191 Peripheral Nerve Field Stimulation For Chronic Low Back Pain

INTRODUCTION:Despite numerous medical, pharmacological and surgical approaches for chronic low back pain (LBP), many patients continue to complain of severe disabling pain. Peripheral nerve field stimulation (PNfS), alone or combined with spinal cord stimulation, is a neuromodulation procedure that have been recently developed and implemented in our hospital. We conducted a Health Technology Assessment (HTA) to determine if PNfS may be considered as a standard of practice in the management of intractable LBP and failed back surgery syndrome (FBSS).METHODS:An interdisciplinary group of experts was involved in the project. A systematic review (SR) was performed in several databases and grey literature to identify clinical practice guidelines, SR and observational studies published through September 2016. A survey was conducted among other chronic pain centers in Canada to document PNfS use in LBP and FBSS treatment.RESULTS:Data on effectiveness and safety of PNfS in chronic LBP treatment were scarce. Short-term results (3-12 months) from small sample and low quality studies suggest that PNfS, alone or combined with spinal cord stimulation, is associated with pain intensity and opioid use reductions. Effects on functional status and quality of life remain undetermined. Most frequent adverse events reported with PNfS devices are lead migrations, discomfort or pain and surgical site infections. No other Canadian pain centers were found to use PNfS in chronic LBP or FBSS.CONCLUSIONS:PNfS is potentially a beneficial treatment option for patients with chronic low back pain or FBSS. However, the value of this innovative treatment remains unknown. Among factors to be clarified are target population (any chronic low back pain or FBSS), use of PNfS alone or combined with spinal cord stimulation, long-term effects, and comparison with conventional medical management. PNfS use in chronic LBP has to be assessed through a rigorous framework before its introduction as a standard medical practice.