Pain Neurophysiology Education and Therapeutic Exercise for Patients With Chronic Low Back Pain: A Single-Blind Randomized Controlled Trial

Objective

To assess the effect of a pain neurophysiology education (PNE) program plus therapeutic exercise (TE) for patients with chronic low back pain (CLBP).

Chronic Low Back Pain: Evidence-Informed Management Considerations for Nurse Practitioners

Chronic low back pain (CLBP) is a condition that commonly consumes many resources and creates economic burden for the health care system. Evidence-informed care is crucial to guide management and prevent unnecessary procedures, including diagnostic imaging. Conservative therapy is currently recommended as the first-line and the most cost-effective treatment. Antibiotic therapy and surgical procedures are considered last resort treatment options for CLBP. The aim of this article is to summarize CLBP options for nurse practitioners (NP).     

Duloxetine Versus Placebo in Patients With Chronic Low Back Pain: A 12-Week,Fixed-Dose,Randomized, Double-Blind Trial

This randomized, double-blind, placebo-controlled study assessed efficacy and safety of duloxetine in patients with chronic low back pain (CLBP). Adults (n = 401) with a nonneuropathic CLBP and average pain intensity of ≥4 on an 11-point numerical scale (Brief Pain Inventory [BPI]) were treated with either duloxetine 60 mg once daily or placebo for 12 weeks. The primary measure was BPI average pain. Secondary endpoints included Patient's Global Impressions of Improvement (PGI-I), Roland Morris Disability Questionnaire (RMDQ-24), BPI-Severity (BPI-S), BPI-Interference (BPI-I), and response rates (either ≥30% or ≥50% BPI average pain reduction at endpoint). Health outcomes included Short Form-36, European Quality of Life–5 Dimensions, and the Work Productivity and Activity Impairment questionnaire. Safety and tolerability were assessed. Compared with placebo-treated patients, duloxetine-treated patients reported a significantly greater reduction in BPI average pain (P ≤ .001). Similarly, duloxetine-treated patients reported significantly greater improvements in PGI-I, BPI-S, BPI-I, 50% response rates, and some health outcomes. The RMDQ and 30% response rate showed numerical improvements with duloxetine treatment. Significantly more patients in the duloxetine group (15.2%) than patients in the placebo group (5.4%) discontinued because of adverse events (P = .002). Nausea and dry mouth were the most common treatment-emergent adverse events with rates significantly higher in duloxetine-treated patients.     

Prednisone for Emergency Department Low Back Pain: A Randomized Controlled Trial

Background

Although oral corticosteroids are commonly given to emergency department (ED) patients with musculoskeletal low back pain (LBP), there is little evidence of benefit.

Objective

To determine if a short course of oral corticosteroids benefits LBP ED patients.

Methods

Design: Randomized, double-blind, placebo-controlled trial. Setting: Suburban New Jersey ED with 80,000 annual visits. Participants: 18–55-year-olds with moderately severe musculoskeletal LBP from a bending or twisting injury ≤ 2 days prior to presentation. Exclusion criteria were suspected nonmusculoskeletal etiology, direct trauma, motor deficits, and local occupational medicine program visits. Protocol: At ED discharge, patients were randomized to either 50 mg prednisone daily for 5 days or identical-appearing placebo. Patients were contacted after 5 days to assess pain on a 0–3 scale (none, mild, moderate, severe) as well as functional status.

Results

The prednisone and placebo groups had similar demographics and initial and discharge ED pain scales. Of the 79 patients enrolled, 12 (15%) were lost to follow-up, leaving 32 and 35 patients in the prednisone and placebo arms, respectively. At follow-up, the two arms had similar pain on the 0–3 scale (absolute difference 0.2, 95% confidence interval [CI] −0.2, 0.6) and no statistically significant differences in resuming normal activities, returning to work, or days lost from work. More patients in the prednisone than in the placebo group sought additional medical treatment (40% vs. 18%, respectively, difference 22%, 95% CI 0, 43%).

Conclusion

We detected no benefit from oral corticosteroids in our ED patients with musculoskeletal LBP.     

脊柱手法治疗对慢性非特异性腰痛的疗效观察

目的:观察脊柱手法治疗与常规理疗方案(中、高频)对慢性非特异性腰痛患者的临床疗效.方法:将40例慢性非特异性腰痛患者随机分为研究组20例和对照组20例.对照组予以常规理疗方案(中、高频)治疗,研究组另外予以脊柱手法治疗.2组患者均于治疗前、治疗后、治疗后1个月、3个月,进行视觉模拟评分(VAS)、Oswe-stry 功...     

慢性腰腿痛患者疾病认知水平和症状严重度与生活质量的相关性

目的调查慢性腰腿痛患者疾病相关知识的认知水平、症状严重度和生活质量状况,并探讨三者之间的相关性。方法 2010年12月至2011年3月,采用便利抽样法选择在上海某三级甲等医院门诊就诊或住院的100例慢性腰腿痛患者为研究对象,采用一般资料调查表、疾病相关知识认知水平调查表、日本骨科学会腰痛评估问卷(Japanese orthopaedic association back pain evaluation questionnaire,JOA)和健康调查量表(the 36-item short form health survey,SF-36)对其进行调查。结果慢性腰腿痛患者对疾病相关知识的认知评分为1~11分,平均(6.73±2.64)分;JOA评分为3~28分,平均(16.92±4.92)分;SF-36评分为203~749分,平均(460.51±122.87)分。慢性腰腿痛患者对疾病相关知识的认知评分、JOA评分与SF-36评分均呈正相关(P0.05或P0.01),疾病相关知识的认知评分与JOA评分之间无相关性(r=0.159,P=0.113)。结论慢性腰腿痛患者对疾病相关知识的认知水平较低,自身症状较为严重,生活质量偏低。临床护理工作者应对慢性腰腿痛患者进行有针对性的健康教育,提高其认知水平,缓解其相关症状,从而提高其生活质量。     

几种慢性下腰痛疾患患者与健康者的静态姿势比较

运用计算机控制的平衡稳定性测试法对31例健康者和31例下腰痛患者按性别、年龄配对平均分为两组进行测试，观察两组在双足并立与双足分开站立姿势下睁眼与闭眼的身体稳定情况，并对本测试所测的所有参数的敏感性及应用价值进行分析。结果表明：慢性下腰痛患者组与健康者组比较身体稳定性降低；左右与前后方向上最大摆幅与摆速、平均摆速、重心移动轨迹的总长度、移动轨迹占据的面积、区域速度等指标敏感，且并足较分足敏感。     

社区慢性腰背痛患者自我效能水平及其影响因素

目的调查社区慢性腰背痛患者自我效能水平并分析其影响因素。方法 2014年4月至2015年1月,便利抽样法选取南京市玄武区、栖霞区、河西新区以及常州市天宁区等8个社区的慢性腰背痛患者157例为研究对象,采用一般情况调查表、长海痛尺、慢性病管理自我效能感量表、简易应对方式问卷、简明健康状况量表、中文版恐惧-回避行为量表、社会支持评定量表和综合医院焦虑抑郁量表对其进行调查。结果慢性腰背痛患者自我效能得分为(6.55±1.89)分。患者对于腰背痛感觉描述中使用频率最高的是"痉挛牵扯痛"、"持续固定痛"和"腰痛"。不同婚姻状况及文化程度患者的自我效能评分的差异均有统计学意义(均P0.05)。慢性腰背痛患者自我效能与其当前疼痛、积极应对、生理功能、生理职能、躯体疼痛、总体健康、活力、社会职能、情感职能、情感健康、恐惧-回避信念总分、社会支持总分、焦虑得分和抑郁得分等14个变量均具有相关性(均P0.05)。多元线性回归结果显示,生理职能、总体健康、社会支持和积极应对是慢性腰背痛患者自我效能的主要影响因素。结论建议相关部门针对社区慢性腰背痛患者自我效能的主要影响因素制定相关政策,从而提高其自我效能水平。     

Treatment of 94 Outpatients With Chronic Discogenic Low Back Pain with the DRX9000: A Retrospective Chart Review

Background: This study's goal was a retrospective chart audit of 100 outpatients with discogenic low back pain (LBP) lasting more than 12 weeks treated with a 2‐month course of motorized spinal decompression via the DRX9000 (Axiom Worldwide, Tampa, FL, U.S.A.). Methods: Patients at a convenience sample of four clinics received 30‐minute DRX9000 sessions daily for the first 2 weeks tapering to 1 session/week. Treatment protocol included lumbar stretching, myofascial release, or heat prior to treatment, with ice and/or muscle stimulation afterwards. Primary outcome was verbal numerical pain intensity rating (NRS) 0 to 10 before and after the 8‐week treatment. Results: Of the 100 initial subjects, three withdrew their protected health information, and three were excluded because their LBP duration was less than 12 weeks. The remaining 94 subjects (63% female, 95% white, age = 55 (SD 16) year, 52% employed, 41% retired, LBP median duration of 260 weeks) had diagnoses of herniated disc (73% of patients), degenerative disc disease (68%), or both (27%). Mean NRS equaled 6.05 (SD 2.3) at presentation and decreased significantly to 0.89 (SD 1.15) at end of 8‐week treatment (P < 0.0001). Analgesic use also appeared to decrease (charts with data = 20) and Activities of Daily Living improved (charts with data = 38). Follow‐up (mean 31 weeks) on 29/94 patients reported mean 83% LBP improvement, NRS of 1.7 (SD 1.15), and satisfaction of 8.55/10 (median 9). Conclusions: This retrospective chart audit provides preliminary data that chronic LBP may improve with DRX9000 spinal decompression. Randomized double‐blind trials are needed to measure the efficacy of such systems. ?     

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting “responder analyses” in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.PerspectiveA task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.     

Identifying and Engaging Neuronal Oscillations by Transcranial Alternating Current Stimulation in Patients With Chronic Low Back Pain: A Randomized,Crossover, Double-Blind,Sham-Controlled Pilot Study

Chronic pain is associated with maladaptive reorganization of the central nervous system. Recent studies have suggested that disorganization of large-scale electrical brain activity patterns, such as neuronal network oscillations in the thalamocortical system, plays a key role in the pathophysiology of chronic pain. Yet, little is known about whether and how such network pathologies can be targeted with noninvasive brain stimulation as a nonpharmacological treatment option. We hypothesized that alpha oscillations, a prominent thalamocortical activity pattern in the human brain, are impaired in chronic pain and can be modulated with transcranial alternating current stimulation (tACS). We performed a randomized, crossover, double-blind, sham-controlled study in patients with chronic low back pain (CLBP) to investigate how alpha oscillations relate to pain symptoms for target identification and whether tACS can engage this target and thereby induce pain relief. We used high-density electroencephalography to measure alpha oscillations and found that the oscillation strength in the somatosensory region at baseline before stimulation was negatively correlated with pain symptoms. Stimulation with alpha-tACS compared to sham (placebo) stimulation significantly enhanced alpha oscillations in the somatosensory region. The stimulation-induced increase of alpha oscillations in the somatosensory region was correlated with pain relief. Given these findings of successful target identification and engagement, we propose that modulating alpha oscillations with tACS may represent a target-specific, nonpharmacological treatment approach for CLBP. This trial has been registered in ClinicalTrials.gov (NCT03243084).

Role of Facet Joints in Chronic Low Back Pain in the Elderly: A Controlled Comparative Prevalence Study

Abstract: Evaluation of the age related prevalence of persistent low back pain has been estimated to be consistently higher in the elderly compared to the younger population. Facet joints have been shown to be the cause of chronic low back pain in 15% to 45% of the patients in controlled studies. Prevalence of facet joint mediated pain has not been studied in the elderly. The study population consisted of 100 patients. Group I consisted of 50 patients that were 64 years of age or younger. Group II consisted of 50 patients 65 years of age or older. The patients were randomly allocated into 1 of the 2 groups. Facet joints were investigated with diagnostic blocks initially using lidocaine 1% followed by bupivacaine 0.25%, usually 2 weeks apart.
The prevalence of facet joint mediated pain was determined to be 30% in the adults and 52% in the elderly, which was significantly higher with a false positive rate of 26% in adults and 33% in the elderly.
In conclusion, the results of this study show that facet joint mediated pain is a significant problem in all patients suffering with chronic low back pain with the prevalence of 52% in the elderly and 30% in adults.     

Long‐term Safety and Tolerability of Tapentadol Extended Release for the Management of Chronic Low Back Pain or Osteoarthritis Pain

Background: Tapentadol is a novel, centrally acting analgesic with 2 mechanisms of action: µ‐opioid receptor agonism and norepinephrine reuptake inhibition. This randomized, open‐label phase 3 study (ClinicalTrials.gov Identifier: NCT00361504) assessed the long‐term safety and tolerability of tapentadol extended release (ER) in patients with chronic knee or hip osteoarthritis pain or low back pain. Methods: Patients were randomized 4:1 to receive controlled, adjustable, oral, twice‐daily doses of tapentadol ER (100 to 250 mg) or oxycodone HCl controlled release (CR; 20 to 50 mg) for up to 1 year. Efficacy evaluations included assessments at each study visit of average pain intensity (11‐point numerical rating scale) over the preceding 24 hours. Treatment‐emergent adverse events (TEAEs) and discontinuations were monitored throughout the study. Results: A total of 1,117 patients received at least 1 dose of study drug. Mean (standard error) pain intensity scores in the tapentadol ER and oxycodone CR groups, respectively, were 7.6 (0.05) and 7.6 (0.11) at baseline and decreased to 4.4 (0.09) and 4.5 (0.17) at endpoint. The overall incidence of TEAEs was 85.7% in the tapentadol ER group and 90.6% in the oxycodone CR group. In the tapentadol ER and oxycodone CR groups, respectively, TEAEs led to discontinuation in 22.1% and 36.8% of patients; gastrointestinal TEAEs led to discontinuation in 8.6% and 21.5% of patients. Conclusion: Tapentadol ER (100 to 250 mg bid) was associated with better gastrointestinal tolerability than oxycodone HCl CR (20 to 50 mg bid) and provided sustainable relief of moderate to severe chronic knee or hip osteoarthritis or low back pain for up to 1 year.     

Efficacy of IDET for Relief of Leg Pain Associated with Discogenic Low Back Pain

Abstract: Intradiscal electrothermal annuloplasty (IDET) is an effective treatment for chronic discogenic low back pain (LBP). However, efficacy of IDET for the treatment of referred leg pain has not been examined. This study was performed to assess the long‐term efficacy of IDET for the treatment of referred leg pain in chronic discogenic LBP patients. Data were retrospectively analyzed as an IDET case series from January 1999 to December 2000. The IDET procedure was performed at 1–3 symptomatic levels confirmed by pressure‐controlled discography. General pain outcome was evaluated by Visual Analog Scale (VAS). LBP and leg pain were assessed separately using five‐point pain scales (subsets of the North American Spine Society [NASS] LBP outcome assessment instrument: 0 = no pain, 4 = worst pain) at the 18‐month follow‐up. Among 129 patients who underwent IDET, 30 patients underwent subsequent back surgery and were excluded from the study, giving a total of 99 patients. Eighty‐three patients (83.8%) had leg pain without sciatica. Fifty‐two (52.5%), 21 (21.2%), and 8 (8.0%) patients showed LBP > leg pain, LBP = leg pain and LBP < leg pain, respectively. Fifty‐three out of 83 patients (63.9%) showed post‐IDET improvement in pain, with a mean VAS score of 3.28 ± 2.31. Thirty patients (36.1%) showed no improvement. A statistically significant (P < 0.05) improvement in subjective back and referred leg pain was observed. Improvements in back and referred leg pain were well‐correlated (r = 0.721, P < 0.01). A relatively large number of LBP patients who underwent IDET (84%) presented with referred leg pain without sciatica. The IDET procedure afforded improvements in leg pain that correlated well with improvements in back pain (0.75/4 and 0.88/4, respectively). These data suggest that IDET may relieve associated limb pain in chronic discogenic LBP patients.