Treatment Of Chronic Low Back Pain Research Articles

Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER), a pragmatic trial for conservative chronic low back pain treatment

BackgroundChronic low back pain (cLBP) is a common and highly disabling problem world-wide. Although many treatment options exist, it is unclear how to best sequence the multitude of care options to provide the greatest benefit to patients. MethodsThe Sequential and Comparative Evaluation of Pain Treatment Effectiveness Response (SCEPTER) trial uses a pragmatic, randomized, stepped design. Enrollment targets 2529 participants from 20 Veterans Affairs (VA) medical centers. Participants with chronic low back pain will first be randomized to one of three options: 1) an internet-based self-management program (Pain EASE); 2) a tailored physical therapy program (Enhanced PT); or 3) continued care with active monitoring (CCAM), a form of usual care. Participants not achieving a 30% or 2-point reduction on the study's primary outcome (Brief Pain Inventory Pain Interference (BPI-PI) subscale), 3 months after beginning treatment may undergo re-randomization in a second step to cognitive behavioral therapy for chronic pain, spinal manipulation therapy, or yoga. Secondary outcomes include pain intensity, back pain-related disability, depression, and others. Participants will be assessed every three months until 12 months after initiating their final trial therapy. Companion economic and implementation analyses are also planned. ResultsThe SCEPTER trial is currently recruiting and enrolling participants. ConclusionsTrial results will inform treatment decisions for the stepped management of chronic low back pain - a common and disabling condition. Additional analyses will help tailor treatment selection to individual patient characteristics, promote efficient resource use, and identify implementation barriers of interventions.Trial Registration: clinicaltrials.gov Identifier: NCT04142177

Non-invasive brain neuromodulation techniques for chronic low back pain.

Structural and functional changes of the brain occur in many chronic pain conditions, including chronic low back pain (CLBP), and these brain abnormalities can be reversed by effective treatment. Research on the clinical applications of non-invasive brain neuromodulation (NIBS) techniques for chronic pain is increasing. Unfortunately, little is known about the effectiveness of NIBS on CLBP, which limits its application in clinical pain management. Therefore, we summarized the effectiveness and limitations of NIBS techniques on CLBP management and described the effects and mechanisms of NIBS approaches on CLBP in this review. Overall, NIBS may be effective for the treatment of CLBP. And the analgesic mechanisms of NIBS for CLBP may involve the regulation of pain signal pathway, synaptic plasticity, neuroprotective effect, neuroinflammation modulation, and variations in cerebral blood flow and metabolism. Current NIBS studies for CLBP have limitations, such as small sample size, relative low quality of evidence, and lack of mechanistic studies. Further studies on the effect of NIBS are needed, especially randomized controlled trials with high quality and large sample size.

The effect and mechanism of traditional Chinese exercise for chronic low back pain in middle-aged and elderly patients: A systematic review.

BackgroundIncreasing lines of evidence indicate that traditional Chinese exercise (TCE) has potential benefits in improving chronic low back pain (CLBP) symptoms. To assess the clinical efficacy of TCE in the treatment of CLBP, we performed a systematic review of existing randomized controlled trials (RCTs) of CLBP and summarized the neural mechanisms underlying TCE in the treatment of CLBP.MethodsA systematic search was conducted in four electronic databases: PubMed, Embase, the Cochrane Library, and EBSCO from January 1991 to March 2022. The quality of all included RCTs was evaluated by the Physiotherapy Evidence Database Scale (PEDro). The primary outcomes included pain severity and pain-related disability.ResultsA total of 11 RCTs with 1,256 middle-aged and elderly patients with CLBP were included. The quality of all 11 included RCTs ranged from moderate to high according to PEDro. Results suggested that TCE could considerably reduce pain intensity in patients with CLBP. Overall, most studies did not find any difference in secondary outcomes (quality of life, depression, and sleep quality).ConclusionThe neurophysiological mechanism of TCE for treating CLBP could be linked to meditation and breathing, posture control, strength and flexibility training, and regulation of pain-related brain networks. Our systematic review showed that TCE appears to be effective in alleviating pain in patients with CLBP.

Treatment of nonsurgical refractory back pain with high-frequency spinal cord stimulation at 10 kHz: 12-month results of a pragmatic, multicenter, randomized controlled trial.

Spinal cord stimulation (SCS) at 10 kHz (10-kHz SCS) is a safe and effective therapy for treatment of chronic low-back pain. However, it is unclear from existing evidence whether these findings can be generalized to patients with chronic back pain that is refractory to conventional medical management (CMM) and who have no history of spine surgery and are not acceptable candidates for spine surgery. The authors have termed this condition "nonsurgical refractory back pain" (NSRBP) and conducted a multicenter, randomized controlled trial to compare CMM with and without 10-kHz SCS in this population. Patients with NSRBP, as defined above and with a spine surgeon consultation required for confirmation, were randomized 1:1 to patients undergoing CMM with and without 10-kHz SCS. CMM included nonsurgical treatment for back pain, according to physicians' best practices and clinical guidelines. Primary and secondary endpoints included the responder rate (≥ 50% pain relief), disability (Oswestry Disability Index [ODI]), global impression of change, quality of life (EQ-5D-5L), and change in daily opioid use and were analyzed 3 and 6 months after randomization. The protocol allowed for an optional crossover at 6 months for both arms, with observational follow-up over 12 months. In total, 159 patients were randomized; 76 received CMM, and 69 (83.1%) of the 83 patients who were assigned to the 10-kHz SCS group received a permanent implant. At the 3-month follow-up, 80.9% of patients who received stimulation and 1.3% of those who received CMM were found to be study responders (primary outcome, ≥ 50% pain relief; p < 0.001). There was also a significant difference between the treatment groups in all secondary outcomes at 6 months (p < 0.001). In the 10-kHz SCS arm, outcomes were sustained, including a mean 10-cm visual analog scale score of 2.1 ± 2.3 and 2.1 ± 2.2 and mean ODI score of 24.1 ± 16.1 and 24.0 ± 17.0 at 6 and 12 months, respectively (p = 0.9). In the CMM arm, 74.7% (56/75) of patients met the criteria for crossover and received an implant. The crossover arm obtained a 78.2% responder rate 6 months postimplantation. Five serious adverse events occurred (procedure-related, of 125 total permanent implants), all of which resolved without sequelae. The study results, which included follow-up over 12 months, provide important insights into the durability of 10-kHz SCS therapy with respect to chronic refractory back pain, physical function, quality of life, and opioid use, informing the current clinical practice for pain management in patients with NSRBP.

Effect of Yogaasanana in Chronic Low Back Pain

Chronic low back pain (CLBP) affects millions of people worldwide, and appears to be increasing in prevalence. It is associated not only with pain, but also with increased disability, psychological symptoms, and reduced quality of life. There are various treatment options for CLBP, but no single therapy stands out as being the most effective. In the past 10 years, yoga interventions have been studied as a CLBP treatment approach. The objective of this paper is to review the current literature supporting the efficacy of yoga for CLBP. In nations with abundant resources, more than 70% of people eventually have low back pain (CLBP). However, recuperation is not always successful; 82 percent of non-recent-onset patients are still in pain after a year. Many chronic patients, whose natural histories were previously deemed to be favourable, spend months or years looking for treatment. We carried out a systematic review with the following clinical inquiries in mind: What results do oral medication treatments produce? What results does injectable therapy produce? What outcomes might non-drug therapies expect? Up until May 2007, we conducted searches in Medline, Embassy, The Cochrane Library, and other significant databases. (BMJ Clinical Evidence reviews are updated on a regular basis; for the most recent version of this review. We incorporated hazards warnings from pertinent agencies as the UK Medicines and Healthcare products Regulatory Agency and the US Food and Drug Administration (FDA) (MHRA). Our inclusion criteria were satisfied by 74 systematic reviews, RCTs, or observational studies. We graded the strength of the interventional evidence using the GRADE system. The effectiveness and safety of the following interventions are discussed in this systematic review: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyography biofeedback, exercise, injections (epidural steroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), and spinal manipulation (TENS).

Differences and Correlations of Anxiety, Sleep Quality, and Pressure-Pain Threshold between Patients with Chronic Low Back Pain and Asymptomatic People.

Background Chronic low back pain (CLBP) is a clinically common and expensive disease. Patients frequently take sick leaves because of pain and dysfunction, and their unpleasant life and work experiences cause psychological depression and anxiety and affect their quality of life. Sleep disturbance is a common problem among patients with low back pain (LBP) with more than 50% complaining about poor sleep quality. This study aimed to explore the correlations between anxiety, sleep quality, and pressure-pain threshold (PPT) and their differences between patients with CLBP and asymptomatic people. Methods Forty patients with CLBP and 40 asymptomatic people were recruited. Relevant data, including State-Trait Anxiety Inventory, Pittsburgh Sleep Quality Index, and PPT, were individually and independently collected by blinded physiotherapists with a practicing certificate and then statistically analyzed. An independent sample t-test was used to determine the intergroup differences between patients with CLBP and asymptomatic populations. Pearson correlation coefficient was employed for correlation analysis. Results The CLBP group had significantly higher anxiety scores (41.64 ± 9.88 vs. 36.69 ± 8.31; t = −2.496, p=0.015) than the asymptomatic group. A significant difference was found in the total score of the Pittsburgh Sleep Quality Index (6.41 ± 2.43 vs. 5.09 ± 2.18; t = −2.628, p=0.010) but not in the trait anxiety (44.00 ± 7.83 vs. 42.67 ± 9.51; t = −0.695, p=0.489) of the two groups. State−Trait Anxiety Inventory showed a low to moderate negative correlation with PPT. No remarkable correlation was observed between Pittsburgh Sleep Quality Index and PPT. Conclusions Patients with CLBP showed considerably worse state anxiety and sleep quality than asymptomatic people; however, no substantial difference in PPT was found between the two groups. The results suggest that in clinical practice, the focus should include pain and related social and psychological factors. CLBP treatment could be considered from multiple perspectives and disciplines.This trial is registered with Chinese Clinical Trial Registry (Trial registration: ChiCTR-TRC-13003701).

Artificial Intelligence and Computer Aided Diagnosis in Chronic Low Back Pain: A Systematic Review.

Low Back Pain (LBP) is currently the first cause of disability in the world, with a significant socioeconomic burden. Diagnosis and treatment of LBP often involve a multidisciplinary, individualized approach consisting of several outcome measures and imaging data along with emerging technologies. The increased amount of data generated in this process has led to the development of methods related to artificial intelligence (AI), and to computer-aided diagnosis (CAD) in particular, which aim to assist and improve the diagnosis and treatment of LBP. In this manuscript, we have systematically reviewed the available literature on the use of CAD in the diagnosis and treatment of chronic LBP. A systematic research of PubMed, Scopus, and Web of Science electronic databases was performed. The search strategy was set as the combinations of the following keywords: “Artificial Intelligence”, “Machine Learning”, “Deep Learning”, “Neural Network”, “Computer Aided Diagnosis”, “Low Back Pain”, “Lumbar”, “Intervertebral Disc Degeneration”, “Spine Surgery”, etc. The search returned a total of 1536 articles. After duplication removal and evaluation of the abstracts, 1386 were excluded, whereas 93 papers were excluded after full-text examination, taking the number of eligible articles to 57. The main applications of CAD in LBP included classification and regression. Classification is used to identify or categorize a disease, whereas regression is used to produce a numerical output as a quantitative evaluation of some measure. The best performing systems were developed to diagnose degenerative changes of the spine from imaging data, with average accuracy rates >80%. However, notable outcomes were also reported for CAD tools executing different tasks including analysis of clinical, biomechanical, electrophysiological, and functional imaging data. Further studies are needed to better define the role of CAD in LBP care.

Somatoform's placement and validity in the hierarchical taxonomy of psychopathology (HiTOP)

Limitations of a polythetic-categorical classification system has sparked ongoing quantitative efforts to establish a valid and reliable method for diagnosing mental illness. Dimensional methods of classification, such as the Hierarchical Taxonomy of Psychopathology (HiTOP), have been found to ameliorate the limitations of a categorical approach – despite the provisional placement of a Somatoform spectrum. The current investigation sought to elucidate the placement of the Somatoform spectrum within the HiTOP model, and to further corroborate discriminant and convergent validity of the Somatoform spectrum. Using a sample of patients seeking chronic low-back pain treatment (n = 200), superior model fit suggested Somatoform fits better as a separate spectrum from Internalizing and placing Somatoform as a subfactor of Internalizing did not improve model fit. Discriminant and convergent validity with an external criteria demonstrated distinctiveness of the Somatoform spectrum from the Internalizing spectrum in the HiTOP model.

The Effectiveness of Facet Joint Local Corticosteroid Injection in Diagnosis and Treatment of Facet Joint Syndrome

Objectives: To evaluate outcomes of lumbar facet joint injection with local corticosteroid in treatmentof chronic low back pain according to Oswestry disability Index(ODI).Patients and Methods: Interventional prospective study on 23 patients attended the outpatient clinic ofOrthopedic Surgery in Cairo University Hospitalscomplaining of chronic low back pain not responsiveto medical treatment and physiotherapy from September 2018 to august 2019.Results: The mean age of the patients was 41.17 ± 9.74 years and 47.8% were males. Facet jointcorticosteroid injection resulted in significant reduction of pain severity of patients as it ranged 5:10(mean 7.3 ±1.5) pre-injection and improved to 0 :6 (mean 3.6 ± 1.7) 3-month post injection(Pvalue:0.001)while the ODI score ranged 26:80 (mean 47.4 ±15.7) pre-injection and improved to 4:46 (mean 28.8 ±10.4) three months post injection(Pvalue 0.001).Conclusion: intra-articular facet joint injection is crucial in the diagnosis and treatment of facet jointsyndrome.

Facilitated Health Coaching Improves Activity Level and Chronic Low back Pain Symptoms

ABSTRACT Introduction Behavioral treatments, like increasing physical activity (PA), are recommended for chronic low back pain (CLBP). Finding methods for promoting behavior change with potential for translatability as well as effective behavioral targets remains challenging. Purpose This randomized controlled pilot study evaluated the effectiveness of low-dose facilitated health coaching with activity monitors to improve PA and sedentary behaviors (SB), symptoms, and Patient Global Impression of Change (PGIC) in CLBP. A secondary purpose was identifying behaviors associated with symptom change to inform future trials. Methods Seventy-one adults with CLBP were randomized to receive a wearable activity monitor alone (WAM) or with one primary session of health coaching and two check-ins based on motivational interviewing (WAM + HC) or a wait-list control (WLC) condition for 12 wk. Moderate and vigorous PA (MVPA), light PA (LPA), total and prolonged SB (i.e., sedentary &gt;60 min per bout), and pain (Short Form McGill Pain Questionnaire (MPQ)) were assessed before and after intervention along with PGIC. Regression analyses examined group differences in MVPA, LPA, total and prolonged SB, MPQ, and PGIC after intervention as well as behavioral predictors of symptom improvement (change in MPQ). Results WAM + HC improved MPQ scores (β = −0.25, P = 0.02), LPA (β = 0.23, P = 0.04), MVPA (β = 0.21, P = 0.03), and total SB (β = −0.24, P = 0.03) compared with WLC over time. Both WAM + HC and WAM had significantly higher PGIC compared with WLC (P &lt; 0.05). Change in prolonged SB was the only significant predictor of change in MPQ (β = 0.48, P = 0.01). Conclusions WAM + HC may be effective for changing activity-related behaviors and improving CLBP. Furthermore, reducing prolonged SB may be a meaningful target for future interventions in CLBP. Research focused on reducing prolonged SB including larger samples, and examining changes in symptoms will be important for identifying optimal translational treatment strategies for CLBP.

Tanezumab for the treatment of osteoarthritis pain.

Tanezumab is a novel humanized IgG2 monoclonal antibody that works by selectively targeting, binding to and inhibiting nerve growth factor (NGF). NGF is upregulated in response to injury and inflammation, and preclinical data indicate it plays a role in pain signaling by inducing peripheral and central sensitization. Tanezumab potentially reduces sensitization and pain by blocking the interaction between NGF and the tropomyosin receptor kinase A (TrkA), and it has been studied extensively for the treatment of pain in patients with osteoarthritis (OA). In 2017, tanezumab was granted fast track designation in the U.S. for the treatment of chronic pain in patients with OA, as well as for the treatment of chronic low-back pain. This review discusses the mechanism of action, preclinical data and phase I, II and III studies of efficacy and safety of tanezumab in patients with OA.

Virtual Reality in the Management of Chronic Low Back Pain: A Scoping Review.

Virtual reality (VR) is a burgeoning treatment option for chronic pain. Its use has been heterogenous in the literature. This scoping review assesses the current literature for the use of VR in the treatment of chronic low back pain (CLBP). The following themes were identified by the analysis: safety and feasibility of VR, quality of life associated with VR treatment for CLBP, efficacy of VR to treat CLBP, and efficacy of VR to treat functional changes associated with CLBP. Gaps were identified after analysis of the extant literature. Although the nascent research uncovered in this scoping review found good evidence for safety and tolerability of VR, more studies of safety, acceptance, and satisfaction are recommended including focused studies of spinal pain risks specific to use of VR. Overall, the methodological quality of studies reviewed in this scoping review was poor and outcomes were limited to short-term posttreatment outcomes.

The effectiveness of post-professional physical therapist training in the treatment of chronic low back pain using a propensity score approach with machine learning.

Low back pain (LBP) is a leading cause of disability in the United States creating substantial hardships through negative social, financial, and health effects. Chronic low back pain (CLBP) accounted for above half of patients treated in physical therapy (PT) clinics for LBP. However, research shows small benefit from PT in CLBP treatment. Preliminary evidence suggests clinician-level training variables may affect outcomes, but requires further investigation to determine whether patients with CLBP benefit from treatment by providers with post-professional training. This study examined the relationship between clinician training levels and patient-reported outcomes in CLBP treatment. Physical therapies were surveyed using a large patient outcome assessment system to determine and categorise them by level of post-professional education. To account for the possibility that clinicians with higher levels of training are referred more-complex patients, a machine learning approach was used to identify predictive variables for clinician group, then to construct propensity scores to account for differences between groups. Differences in functional status score change among pooled data were analysed using linear models adjusted for propensity scores. There were no clinically meaningful differences in patient outcomes when comparing clinician post-professional training level. The propensity score method proved to be a valuable way to account for differences at baseline between groups. Post-professional training does not appear to contribute to improved patient outcomes in the treatment of CLBP. This study demonstrates that propensity score analysis can be used to ensure that differences observed are true and not due to differences at baseline.

Comparison of the effectiveness of interferential current and PEMF treatments in patients with chronic mechanical low back pain

Aim: We aimed to compare the effects of interference current (IFC) and pulsed electromagnetic field (PEMF) therapies combined with conventional physical therapy on pain, functional situation, and quality of life (QOL) in patients with mechanical chronic low back pain (CLBP).Methods: In this prospective randomized controlled study, 40 CLBP patients were divided into two groups: group I (Hot pack, ultrasound (US), and IFC combination therapy (n=20)), group II (Hot pack, US, and PEMF combination therapy (n=20)). A total of 10 sessions of therapy were performed on the participants, one session a day, five days a week, for two weeks. Evaluations were performed three times at before the treatment (BT), immediately after the treatment (AT) and 8 weeks after the treatment (AT-8), using the The Numerical Rating Scale (NRS), Roland-Morris Disability Questionnaire (RMDQ), EuroQol-Health-related Quality of Life Questionnaire (EQ-5D-3L), Fingertip-to-floor test (FtF).Results: There was no difference in age, BMI, gender and baseline values in all two groups. No significant difference was found for RMDQ (F(2.76)=0.174; P=0.840), NRS(F(2.76)=0.155; P=0.857), and EQ (F(2.76)=0.273; P=0.762) scores in time–group interaction (F(2.76)=0.174; P=0.840). No significant differences were found between the groups in terms of RMDQ, NRS, EQ-5D-3L, and FtF scores (p&gt;0.05). Conclusion: It has been proved that PEMF or IFC therapies in addition to conventional physical therapy programs are effective in mechanical CLBP treatment in terms of pain, functional status, and quality of life.

The effects of proprioceptive neuromuscular facilitation in treating chronic low back pain: A systematic review and meta-analysis.

Proprioceptive neuromuscular facilitation (PNF) has been widely used in the clinical treatment of chronic low back pain (LBP) in recent years. However, its role remains controversial and it is unclear whether PNF offers more advantages for patients with chronic LBP. The purpose of this systematic review is to evaluate the evidence on the effect of PNF on pain, waist function, pulmonary function and dynamic balance in patients with chronic LBP. Seven English and Chinese electronic databases were searched to identify articles published from 1970 to February 2020. Relevant randomized controlled trials (RCTs) were selected by two independent reviewers to investigate PNF in treatment of chronic LBP. Data extraction was performed by the same reviewers. Twelve eligible trials involving 410 participants were included in this meta-analysis. Compared with the control group, the aggregated results suggested that PNF showed beneficial effects in relieving pain (SMD =-1.17; 95% CI: -1.50 to -0.84; p< 0.00001) and improving waist functional disability (MD =-1.63; 95% CI: -1.89 to -1.37; p< 0.00001). In addition, PNF was shown to have a significant effect on pulmonary function (MD = 0.65; 95% CI: 0.26 to 1.03; p= 0.001). However, the results of the study show that PNF could not significantly improve dynamic balance in patients with chronic LBP compared with the control group (MD =-0.04; 95% CI: -2.16 to 2.08; p= 0.97). A high risk of bias occurred in the areas of blinding (i.e., participants/personnel and outcome assessment). PNF showed more beneficial effects in pain relief and waist function improvement in patients with chronic LBP in the short term (4 to 8 weeks of intervention) or at 12-week follow-up and also played a positive role in pulmonary function. However, no significant effect of PNF on dynamic balance was found compared with the control group. However, these results have certain limitations, and these conclusions were supported by low-quality data. Therefore, articles that are methodologically reasonable and more authoritative are required to verify the effects. In addition, articles with long-term follow-up and other outcomes are needed to confirm additional findings.

Non randomised trial of GRAVITY system therapy effectiveness in chronic, low intensity low back disc disease

Abstract Study aim: Chronic low back pain (CLBP) is a therapeutically challenging pain syndrome. Physical exercises are the most common therapy used in CLBP treatment. The aim of the study was to verify if GRAVITY system exercise can be effective in the therapy of chronic discogenic low back pain. The GRAVITY system exercise aims at strengthening full body muscles using the trainee’s own body weight only. Material and methods: The study was registered at ClinicalTrials.gov Identifier: NCT04765293. We used TREND statement. The study populations were 50 patients with CLBP. The study population (group I) consisted of 25 patients who had GRAVITY system exercise. The clinical control group were 25 patients who received standard treatment in an outpatient clinic of National Health Fund. Before the start of the training, the patients’ had their muscle strength responsible for stabilizing the lumbar segment measured. We also measured patients’ Oswestry Disability Index (ODI) prior to and after the therapy cycle. The therapy was conducted twice a week for 40 minutes over the period of 4 weeks. The clinical control group were 25 patients who received treatment from the National Health Fund and had only standardised physical therapy (laser, ultrasound, cryotherapy and magnetic therapy) sessions for two weeks. Results. We found statistically significant reduction in pain and disability in the study population after the treatment, but muscle strength did not increase significantly. Conclusions: 1. GRAVITY system exercise might efficient in pain and disability reduction. Muscle strength did not increase after therapy. 2. Pain and disability had positive correlation with female sex, decreased physical activity and sedentary work.

Mediational Analysis of Yoga's Effect on Chronic Low-Back Pain in Veterans: What Factors Really Matter?

Considerable evidence supports yoga as a treatment for chronic low-back pain (CLBP), yet more research is needed on the mechanisms of yoga. Yoga may be particularly helpful for military veteran populations, where there is a high prevalence of CLBP due to intensive training requirements. Our objective was to examine possible mechanisms by which yoga reduced disability in a clinical trial of yoga for veterans with CLBP. Using data from a prior randomized controlled trial, we used mediation analysis to examine factors that may mediate or influence the effects of yoga on disability over time. The 12-week yoga intervention study measured outcomes at baseline, 6 weeks, 12 weeks, and 6 months. Fatigue and pain were the variables that met all statistical criteria for mediation of the effect of yoga on disability. The total effect of yoga on disability was significant (β = -2.28; 95% CI -3.93 to -0.64), and this consisted of a direct effect of yoga (β = -1.40; 95% CI -3.02 to 0.25) and a statistically significant indirect effect (β = -0.88, 95% CI -1.91 to -0.15) that was mediated by pain and fatigue. The indirect effect accounted for 38% of yoga's effect on back-pain disability. Fatigue and pain were not significant as individual mediators. The other mediators-self-efficacy, spinal range of motion, grip strength, core strength, and balance-did not meet published criteria for mediation. Our results suggest that in veterans with CLBP, yoga may reduce pain and fatigue and contribute to reductions in disability. Although pain may be an expected precursor of disability, the finding that fatigue mediates the relationship between a mind-body intervention like yoga and disability appears novel. Fatigue should be measured more widely in yoga research and considered when designing interventions for specific populations such as military veterans with chronic pain.

Cost-effectiveness analysis of a chronic back pain multidisciplinary biopsychosocial rehabilitation (MBR) compared to standard care for privately insured in Germany

BackgroundMultidisciplinary biopsychosocial rehabilitation (MBR) is highly recommended for chronic lower back pain (CLBP) treatment, but its economic benefit remains to be clearly demonstrated. The purpose of this study is to analyse the effect of a 12-month MBR programme of behavioural change coaching and device-supported exercise on direct medical costs, sick leave and health-related quality of life (HRQOL) at 24 months.MethodsAn incremental cost-effectiveness analysis was conducted in Germany from a private health insurance perspective using data from a multi-centre, two-arm randomised controlled trial with parallel-group Zelen's randomisation and 24-month follow-up. After removing dissimilarities in characteristics between MBR and usual care (control) via propensity score matching, treatment effects were calculated using a difference-in-difference approach.ResultsBase-case analysis of the MBR (n=112) and usual care group (n=111) showed an incremental cost-effectiveness ratio (ICER) of €8,296 per quality-adjusted life year (QALY) gained, indicating that the intervention was cost-effective. Compared to the controls, MBR reduced economically unaccounted sick leave due to back pain in the last six months by 17.5 days (p = 0.001) and had a positive effect on health-related quality of life (HRQOL) (0.046, p=0.026). Subgroup analysis of participants with major impairment demonstrated that a dominant intervention was possible, as reflected by an ICER of - €7,302 per QALY. Savings were driven by a - €1,824 reduction in back pain-specific costs. Moreover, sick leave was 27 days (p = 0.006) less in the MBR group.ConclusionsThis first cost-effectiveness study with combined data from a private health insurer and a controlled trial in Germany demonstrated that long term MBR for the treatment of CLBP is cost-effective. Subgroups with major impairment from back pain benefitted more from the intervention than those with minor impairment. MBR significantly reduced sick leave in all participants. Hence, it is a profitable intervention from a societal point of view.Trial registrationThe trial of the evaluation study was retrospectively registered in the German Clinical Trials Register under trial number DRKS00015463 retrospectively (dated 4 Sept 2018).

Psychosocial Moderators and Mediators of Sensorimotor Exercise in Low Back Pain: A Randomized Multicenter Controlled Trial.

The effects of exercise interventions on unspecific chronic low back pain (CLBP) have been investigated in many studies, but the results are inconclusive regarding exercise types, efficiency, and sustainability. This may be because the influence of psychosocial factors on exercise induced adaptation regarding CLBP is neglected. Therefore, this study assessed psychosocial characteristics, which moderate and mediate the effects of sensorimotor exercise on LBP. A single-blind 3-arm multicenter randomized controlled trial was conducted for 12-weeks. Three exercise groups, sensorimotor exercise (SMT), sensorimotor and behavioral training (SMT-BT), and regular routines (CG) were randomly assigned to 662 volunteers. Primary outcomes (pain intensity and disability) and psychosocial characteristics were assessed at baseline (M1) and follow-up (3/6/12/24 weeks, M2-M5). Multiple regression models were used to analyze whether psychosocial characteristics are moderators of the relationship between exercise and pain, meaning that psychosocial factors and exercise interact. Causal mediation analysis were conducted to analyze, whether psychosocial characteristics mediate the exercise effect on pain. A total of 453 participants with intermittent pain (mean age = 39.5 ± 12.2 years, f = 62%) completed the training. It was shown, that depressive symptomatology (at M4, M5), vital exhaustion (at M4), and perceived social support (at M5) are significant moderators of the relationship between exercise and the reduction of pain intensity. Further depressive mood (at M4), social-satisfaction (at M4), and anxiety (at M5 SMT) significantly moderate the exercise effect on pain disability. The amount of moderation was of clinical relevance. In contrast, there were no psychosocial variables which mediated exercise effects on pain. In conclusion it was shown, that psychosocial variables can be moderators in the relationship between sensorimotor exercise induced adaptation on CLBP which may explain conflicting results in the past regarding the merit of exercise interventions in CLBP. Results suggest further an early identification of psychosocial risk factors by diagnostic tools, which may essential support the planning of personalized exercise therapy.Level of Evidence: Level I.Clinical Trial Registration: DRKS00004977, LOE: I, MiSpEx: grant-number: 080102A/11-14. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00004977.

P-PA002. Chronic low back pain treated with Perineural subcutaneous injection of dextrose 5% in water (D5W): A case series

Introduction . Most people will experience low back pain (LBP) problem minimally once in their lifetime. Chronic LBP (CLBP) is a primary source of incapacitation, struggling and expense, commonly resulting in significant anxiety and disturbance with daily activities leading to a significant level of disability. Several studies showed pain reduction with Perineural Subcutaneous Injection (PSI) over related sensory nerve pathways in LBP. PSI is an injection of D5W close to subcutaneous nerves to reduce neuropathic inflammation, treating the nerves and restore their normal function. This study presents the outcomes of PSI for CLBP treatment. Methods . The subject in this study were six patients with CLBP who had failed conventional therapies in the neurological outpatient clinic in Dr. Sardjito General Hospital Yogyakarta Indonesia. They were administered PSI treatment, injected with D5W about 0,5 cc each in the subcutaneous tissue on 5-8 tender points of the low back region. Visual Analogue Scale (VAS) score was assessed before treatment. Two to four weeks after treatment the patients were asked about their VAS score. Results : Two males, and 4 females from 45 until 65 years old were treated with PSI. All patients reported pain reduction of 50% - 70% as measured by VAS scores. Conclusion . PSI of D5W has potential benefits for CLBP and needs to be considered in clinical practice and further research is required.