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).

Physiotherapy for Sleep Disturbance in People With Chronic Low Back Pain: Results of a Feasibility Randomized Controlled Trial

Objective

To determine the feasibility of a randomized controlled trial investigating the effectiveness of physiotherapy for sleep disturbance in chronic low back pain (CLBP) (≥12wks).

Design

Randomized controlled trial with evaluations at baseline, 3 months, and 6 months.

Setting

Outpatient physiotherapy department in an academic teaching hospital.

Participants

Participants with CLBP were randomly assigned to a walking program (n=20; mean age ± SD, 46.4±13.8y), supervised exercise class (n=20; mean age ± SD, 41.3±11.9y), or usual physiotherapy (n=20; mean age ± SD, 47.1±14.3y). The 3-month evaluation was completed by 44 participants (73%), and 42 (70%) participants completed the 6-month evaluation.

Interventions

Participants received a physiotherapy-delivered 8-week walking program, an 8-week group supervised exercise class (1 class/wk), or 1-to-1 usual physiotherapy (advice, manual therapy, and exercise).

Main Outcome Measures

Sleep was assessed by the self-reported Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pittsburgh Sleep Diary, and objective actigraphy.

Results

Groups were comparable at baseline. Most (95%, n=57) of the participants had sleep disturbance. The acceptability of actigraphy was excellent at baseline (58 of 60 participants), but dropped at 3 months (26 of 44 participants). There were improvements on the PSQI and ISI in all groups at 3 and 6 months, with predominantly medium effect sizes (Cohen d=0.2–0.5).

Conclusions

The high prevalence of sleep disturbance indicated the feasibility of good recruitment in future trials. The PSQI would be a suitable screening tool and outcome measure alongside an objective nonobtrusive sleep outcome measure. The effectiveness of physiotherapy for sleep disturbance in CLBP warrants investigation in a fully powered randomized controlled trial.     

Extracorporeal Shock Wave Therapy Combined With Oral Medication and Exercise for Chronic Low Back Pain: A Randomized Controlled Trial

ObjectiveTo compare extracorporeal shock wave therapy combined with oral medication and an exercise program vs sham treatment with medication and exercise for the treatment of chronic low back pain (CLBP).DesignRandomized controlled trial.SettingOutpatient clinic at a university hospital.ParticipantsEligibility criteria were age older than 18 years and duration of CLBP exceeding 3 months. Exclusion criteria were concurrent treatment or history of surgery for CLBP, cancer, fractures, infections, and disk degeneration.InterventionThe intervention group received extracorporeal shock wave therapy once a week for 4 weeks along with oral medications and an exercise program. The control group received sham extracorporeal shock wave therapy along with oral medications and an exercise program.Main Outcome MeasuresVisual analog scale and Oswestry Disability Index (ODI) were used to assess pain and disability at baseline and after 3 months.ResultsThe pain score in the intervention group (N=16) was 6.6 at baseline and 3.0 after 1 month (P<.0001) and 1.8 after 3 months (P<.0001). In the control group (N=16), the pain score was 6.8 at baseline, 4.6 after 1 month (P<.0001), and 1.1 after 3 months (P<.0001). ODI scores decreased significantly in both groups compared with baseline values (first month: P<.001, third month: P<.05). The mean ODI score did not differ significantly between the groups (P=.942).ConclusionExtracorporeal shock wave therapy combined with oral medication and exercise was safe and effective in the short-term treatment of chronic low back pain.     

Hypnosis Enhances the Effects of Pain Education in Patients With Chronic Nonspecific Low Back Pain: A Randomized Controlled Trial

The potential benefits of combining pain education (PE) with clinical hypnosis (CH) has not yet been investigated in individuals with chronic pain. A total of 100 patients with chronic nonspecific low back pain were randomized to receive either: 1) PE alone, or 2) PE with CH. Outcomes were collected by a blinded assessor at 2 weeks and 3 months after randomization. The primary outcomes were average pain intensity, worst pain intensity (both assessed with 11-point numeric rating scales), and disability (24-item Roland Morris Disability Questionnaire) at 2 weeks. At 2 weeks, participants who received PE with CH reported lower worst pain intensity (mean difference?=?1.35 points, 95% confidence interval [CI]?=?.32–2.37) and disability (mean difference?=?2.34 points, 95% CI?=?.06–4.61), but not average pain intensity (mean difference?=?.67 point, 95% CI?=??.27 to 1.62), relative to participants who received PE alone. PE with CH participants also reported more global perceived benefits at 2 weeks (mean difference?=??1.98 points, 95% CI?=??3.21 to ?.75). At 3 months, participants who received PE with CH reported lower worst pain intensity (mean difference?=?1.32 points, 95% CI?=?.29–2.34) and catastrophizing (mean difference?=?5.30 points, 95% CI?=?1.20–9.41). No adverse effects in either treatment condition were reported. To our knowledge, this is the first trial showing that additional use of hypnosis with PE results in improved outcomes over PE alone in patients with chronic nonspecific low back pain.

Yoga for Chronic Neck Pain: A Pilot Randomized Controlled Clinical Trial

Yoga has been found effective in the treatment of chronic low back pain. We aimed to evaluate the effectiveness of Iyengar yoga in chronic neck pain by means of a randomized clinical trial. Seventy-seven patients (aged 47.9 ± 7.9, 67 female) with chronic neck pain who scored >40 mm on a 100-mm visual analog scale (VAS) were randomized to a 9-week Iyengar yoga program with weekly 90-minute classes (n = 38) or to a self-care/exercise program (n = 38). Patients were examined at baseline and after 4 and 10 weeks. The primary outcome measure was change of mean pain at rest (VAS) from baseline to week 10. Secondary outcomes included pain at motion, functional disability, quality of life (QOL), and psychological outcomes. Twelve patients in the yoga group and 11 patients in the self-care/exercise group were lost to follow-up, with higher study nonadherence in the self-care group (5 versus 10 patients). Mean pain at rest was reduced from 44.3 ± 20.1 to 13.0 ± 11.6 at week 10 by yoga and from 41.9 ± 21.9 to 34.4 ± 21.1 by self-care/exercise (group difference: −20.1, 95% confidence interval: −30.0, −10.1; P < .001). Pain at motion was reduced from 53.4 ± 18.5 to 22.4 ± 18.7 at week 10 by yoga and from 49.4 ± 22.8 to 39.9 ± 21.5 by self-care/exercise (group difference: −18.7, 95% confidence interval: −29.3, −8.1; P < .001). Significant treatment effects of yoga were also found for pain-related apprehension, disability, QOL, and psychological outcomes. Sensitivity analyses suggested minimal influence of dropout rates. Both programs were well tolerated. In this preliminary trial, yoga appears to be an effective treatment in chronic neck pain with possible additional effects on psychological well-being and QOL. The effectiveness of yoga in chronic neck pain should be further tested by comparative effectiveness studies with longer observation periods.     

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.     

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.     

The Effect of 2 Different Exercise Programs on Pain Intensity and Muscle Dimensions in Patients With Chronic Low Back Pain: A Randomized Controlled Trial

Objectives

The purpose of this study was to compare the effect of 2 exercise programs combined with electrotherapy on pain intensity and lumbar stabilizer muscles dimensions in patients with nonspecific chronic low back pain.

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.     

Cognitive Behavioral Therapy With Stabilization Exercises Affects Transverse Abdominis Muscle Thickness in Patients With Chronic Low Back Pain: A Double-Blinded Randomized Trial Study

ObjectiveNonspecific chronic low back pain (NCLBP) is a major public health and global socioeconomic burden with a variety of symptoms, such as fear-avoidance behaviors. This study aimed to evaluate the effect of cognitive behavioral therapy (CBT) associated with stabilization exercise (SE) on thickness of transverse abdominis (TrA) muscle in patients with NCLBP.MethodsForty patients with NCLBP were randomly assigned into experimental CBT associated with SE (n = 20) and control groups without SE (n = 20). Transverse abdominis muscle thickness was assessed during abdominal drawing in maneuver (ADIM) and active straight leg raise (ASLR) of the right lower limb using ultrasound imaging. Fear-avoidance belief and disability were evaluated using a fear-avoidance belief questionnaire (FABQ) and a Roland-Morris disability questionnaire (RMDQ) before and after intervention.ResultsMixed-model analysis of variance indicated that the effect of time was significant for the right and left TrA contraction thickness during ADIM and left TrA contraction thickness during ASLR (P < .05). However, the experimental group exhibited higher right and left TrA muscle thickness compared with the control group during ADIM (P = .001). Moreover, there were no significant differences between groups in the thickness of TrA muscle during ASLR (P > .05). The effect of time was significant for FABQ (P = .02) and RMDQ (P = .01); however, the effect of group was significant for the FABQ after intervention (P = .04).ConclusionsStabilization exercise associated with CBT is more effective than SE alone in improving fear avoidance belief and in increasing the thickness of the TrA muscle during ADIM task.     

Qigong and Exercise Therapy for Elderly Patients With Chronic Neck Pain (QIBANE): A Randomized Controlled Study

The aim of this study was to evaluate the effectiveness of qigong compared with exercise therapy and no treatment. Elderly patients with chronic neck pain (>6 months) were randomly assigned to qigong or exercise therapy (each 24 sessions over a period of 3 months) or to a waiting list control. Patients completed standardized questionnaires at baseline and after 3 and 6 months. The main outcome measure was average neck pain on the visual analogue scale after 3 months. Secondary outcomes were neck pain and disability (NPAD) and quality of life (SF-36). One hundred seventeen patients (age, 76 ± 8 years, 95% women) were included in the intention-to-treat analysis. The average duration of neck pain was 19.0 ± 14.9 years. After 3 months, no significant differences were observed between the qigong group and the waiting list control group (visual analogue scale mean difference, ?11 mm [CI, ?24.0; 2.1], P = .099) or between the qigong group and the exercise therapy group (?2.5 mm [ ? 15.4; 10.3], P = .699). Results for the NPAD were similar (qigong vs waiting list ?6.7 (?15.4; 2.1), P = .135; qigong vs exercise therapy 2.3 (?6.2; 10.8); P = .600). We found no significant effect after 3 months of qigong or exercise therapy compared with no treatment. Further studies should include outcomes more suitable to elderly patients, longer treatment, and patients with less chronic pain.PerspectiveIn a randomized controlled study, we evaluated whether a treatment of 24 qigong sessions over a period of 3 months is (1) superior to no treatment and (2) superior to the same amount of exercise therapy in elderly patients (age, 76 ± 8 years, 95% women) with long-term chronic neck pain (19.0 ± 14.9 years). After 3 and 6 months, we found no significant differences for pain, neck pain, disability, and quality of life among the 3 groups.     

Effect of Elastic Therapeutic Taping on Abdominal Muscle Endurance in Patients With Chronic Nonspecific Low Back Pain: A Randomized,Controlled, Single-Blind,Crossover Trial

Objective

The purpose of this study was to determine the immediate effect of elastic therapeutic taping and sham taping of the abdominal musculature on maximum hold time of endurance tests in patients with chronic nonspecific low back pain (CNLBP).

Cost Analysis Related to Dose-Response of Spinal Manipulative Therapy for Chronic Low Back Pain: Outcomes From a Randomized Controlled Trial

Objective

The purpose of this analysis is to report the incremental costs and benefits of different doses of spinal manipulative therapy (SMT) in patients with chronic low back pain (LBP).

Methods

We randomized 400 patients with chronic LBP to receive a dose of 0, 6, 12, or 18 sessions of SMT. Participants were scheduled for 18 visits for 6 weeks and received SMT or light massage control from a doctor of chiropractic. Societal costs in the year after study enrollment were estimated using patient reports of health care use and lost productivity. The main health outcomes were the number of pain-free days and disability-free days. Multiple regression was performed on outcomes and log-transformed cost data.

Results

Lost productivity accounts for most societal costs of chronic LBP. Cost of treatment and lost productivity ranged from $3398 for 12 SMT sessions to $3815 for 0 SMT sessions with no statistically significant differences between groups. Baseline patient characteristics related to increase in costs were greater age (P = .03), greater disability (P = .01), lower quality-adjusted life year scores (P = .01), and higher costs in the period preceding enrollment (P < .01). Pain-free and disability-free days were greater for all SMT doses compared with control, but only SMT 12 yielded a statistically significant benefit of 22.9 pain-free days (P = .03) and19.8 disability-free days (P = .04). No statistically significant group differences in quality-adjusted life years were noted.

Conclusions

A dose of 12 SMT sessions yielded a modest benefit in pain-free and disability-free days. Care of chronic LBP with SMT did not increase the costs of treatment plus lost productivity.     

Randomized Controlled Trial of Nurse-Delivered Cognitive-Behavioral Therapy Versus Supportive Psychotherapy Telehealth Interventions for Chronic Back Pain

This study evaluated a nurse-delivered, telehealth intervention of cognitive-behavioral therapy (CBT) versus supportive psychotherapy for chronic back pain. Participants (N?=?61) had chronic back pain (pain “daily”?≥6 months at an intensity of ≥4 of 10 scale) and were randomized to an 8-week, 12-session, CBT or to supportive care (SC) matched for frequency, format, and time, with each treatment delivered by a primary care nurse. The primary outcome was the Roland Morris Disability Questionnaire (RMDQ). Secondary outcomes included the numeric rating scale (NRS) and the Patient Global Impressions Scale (CGI). CBT participants (n?=?30) showed significant improvements on the RMDQ (mean = 11.4 [SD = 5.9] vs 9.4 [SD = 6.1] at baseline and post-treatment, respectively, P?<?.05; d?=?.33), NRS (mean = 4.9 [SD = 2.1] vs 4.0 [SD = 1.9], respectively, P?<?.05; d?=?.45), and on the CGI (39.1% reporting “much improved” or “very much improved”). SC participants (n?=?31) also showed significant improvements on the RMDQ (mean = 11.1 [SD = 5.4] vs 9.1 [SD = 5.2], respectively, P?<?.05; d?=?.38), the NRS, (mean = 5.0 [SD = 1.9] vs 3.8 [SD = 2.1], respectively, P?<?.05; d?=?.60), and 26.7% reporting “much improved” or “very much improved” on the CGI. Between groups comparisons of CBT and SC showed no differences on the study outcomes (Ps > .10). The results suggest that telehealth, nurse-delivered CBT, and SC treatments for chronic back pain can offer significant and relatively comparable benefits.

Integrative Acupuncture and Spinal Manipulative Therapy Versus Either Alone for Low Back Pain: A Randomized Controlled Trial Feasibility Study

Objectives

The objective of this study was to assess the feasibility of conducting a large-scale randomized controlled trial (RCT) examining whether an integrative care model combining spinal manipulative therapy (SMT) and acupuncture can lead to better outcomes for low back pain (LBP) than either therapy alone.

瑜伽练习对慢性腰背痛患者的治疗效果

目的探讨瑜伽练习对慢性腰背痛患者的治疗效果。方法便利抽样选择2012年3月至2013年5月,重庆市3所医疗机构收治的的慢性腰背痛患者148例,按人院先后将148例患者分为观察组76例和对照组72例。对照组接受常规康复治疗（物理和药物治疗）,观察组除康复治疗外,还接受12周的瑜伽练习。调查并比较两组患者干预前后的疼痛程度、功能障碍及生活质量评分。结果干预前两组患者的疼痛、功能障碍及生活质量的评分差异均无统计学意义（均P〉O．05）;干预后,观察组患者的最重疼痛、平均疼痛及功能障碍的评分均低于对照组（均P〈O．05）,躯体疼痛、社会功能、情感职能及精神健康的评分均高于对照组（均P〈O．05）,其他方面评分的差异均无统计学意义（均P〉O．05）。结论瑜伽练习能减轻慢性腰背痛患者的疼痛程度,改善其功能障碍,提高患者的生活质量。