back pain

Sciatica is a type of pain that is caused by irritation of the sciatic nerve. This nerve travels from the low back down the legs. Sciatica most commonly happens when a disk in your spine gets damaged or worn out and presses on the sciatic nerve.

Author/s:

Grace Y Zhang, Michael A Incze

Clin-STAR corner: 2021 update in musculoskeletal pain in older adults with a focus on osteoarthritis-related pain

Rowan Hutchins — Sun, 17 Sep 2023 05:00:00 +0000

Date Added:

September 17, 2023

Journal/Publication:

Journal of the American Geriatrics Society

Publisher:

American Geriatrics Society

Publication Date:

April 25, 2023

Issue:

Volume:

Pages:

2373-2380

URL:

Clin-STAR corner: 2021 update in musculoskeletal pain in older adults with a focus on osteoarthritis-related pain

Type:

Meta-analyses, Reviews, and Guidelines

DOI (1):

https://doi.org/10.1111/jgs.18369

Keywords

PMID (1):

37186060

MeSH

Musculoskeletal Pain* / drug therapy

osteoarthritis

Knee* / complications

Knee* / therapy

A summary of what we know about managing chronic musculoskeletal pain in older people. James W. Mold, MD, MPH

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Chronic musculoskeletal (MSK) pain remains a leading cause of disability and functional impairment among older adults and is associated with substantial societal and personal costs. Chronic pain is particularly challenging to manage in older adults because of multimorbidity, concerns about treatment-related harm, as well as older adults' beliefs about pain and its management. This narrative review presents data on nine high-quality, peer-reviewed clinical trials published primarily over the past two years that focus on MSK pain management in older adults, of which four were comprehensively reviewed. These studies address contributors to knee osteoarthritis (OA) pain (insomnia), provide evidence for digital delivery or artificial intelligence driven behavioral interventions and potentially more efficient/equally effective modes of delivering glucocorticoids for OA; each of the selected studies have potential for scalability and meaningful impact in the care of older adults.

Author/s:

Owoicho Adogwa, M. Cary Reid, Sai Chilakapati, Una E. Makris

Nonspecific Low Back Pain

Saige Blanchard — Tue, 10 May 2022 05:00:00 +0000

Date Added:

May 10, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

May 5, 2022

Issue:

Volume:

386

Pages:

1732-1740

URL:

Nonspecific Low Back Pain

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1056/NEJMcp2032396

Keywords

back pain

Nonspecific Low Back Pain

MeSH

A review of what we think we know about non-specific low back pain. James W. Mold, MD, MPH

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Low back pain typically defined as pain below the costal margin and above the inferior gluteal folds with or without leg pain 1 is worldwide the most prevalent and most disabling of the conditions that are considered to benefit from rehabilitation 2 In a systematic review that included 165 studies from 54 countries the mean point prevalence of low back pain in the general adult population was approximately 12 with a higher prevalence among persons 40 years of age or older and among women the lifetime prevalence was approximately 40 3 Low back pain is classified as specific pain and other symptoms that are caused by specific pathophysiological mechanisms of nonspinal or spinal origin or nonspecific back pain with or without leg pain without a clear nociceptive-specific cause 4 Nonspinal causes of specific low back pain include hip conditions diseases of the pelvic organs e g prostatitis and endometriosis and vascular e g aortic aneurysm or systemic disorders spinal causes include herniated disk spinal stenosis fracture tumor infection and axial spondyloarthritis Lumbar disorders with radicular pain due to nerve-root involvement have a higher prevalence 5 to 10 than other spinal causes the two most frequent causes of such back pain are herniated disk and spinal stenosis 5 The overall prevalence of the other spinal disorders is low among patients with acute low back pain For example among 1172 patients who presented to primary care clinicians in Australia with acute low back pain only 11 0 9 were found to have serious spinal conditions mostly fractures during 1 year of follow-up 6 The authors of a Dutch study that involved primary care patients reported axial spondyloarthritis in almost one quarter of adults 20 to 45 years of age who presented with chronic low back pain 7 although these findings have not been replicated In contrast to low back pain caused by specific identifiable causes nonspecific low back pain probably develops from the interaction of biologic psychological and social factors 4 and it accounts for approximately 80 to 90 of all cases of low back pain 1 Low back pain is usually classified according to pain duration as acute 6 weeks subacute 6 to 12 weeks or chronic 12 weeks

Author/s:

Chiarotto, A., Koes, B. W.

Non-steroidal anti-inflammatory drugs for acute low back pain

Devin Evans — Fri, 23 Apr 2021 05:00:00 +0000

Date Added:

April 23, 2021

Journal/Publication:

Cochrane Database of Systematic Reviews

Publisher:

Cochrane Library

Publication Date:

April 16, 2021

Issue:

Volume:

URL:

Non-steroidal anti-inflammatory drugs for acute low back pain

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1002/14651858.CD013581

Keywords

back pain

Pain

Tylenol

PMID (1):

32297973

MeSH

low back pain

Anti-Inflammatory Agents, Non-Steroidal

Sciatica

Apparently NSAIDS aren’t much more effective than placebo or Tylenol for acute low back pain, but don’t discount the effectiveness of a good, safe placebo. James W. Mold, MD, MPH

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Background: Acute low back pain (LBP) is a common health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are often used in the treatment of LBP, particularly in people with acute LBP. In 2008, a Cochrane Review was published about the efficacy of NSAIDs for LBP (acute, chronic, and sciatica), identifying a small but significant effect in favour of NSAIDs compared to placebo for short-term pain reduction and global improvement in participants with acute LBP. This is an update of the previous review, focusing on acute LBP.

Objectives: To assess the effects of NSAIDs compared to placebo and other comparison treatments for acute LBP.

Search methods: We searched CENTRAL, MEDLINE, Embase, PubMed, and two trials registers for randomised controlled trials (RCT) to 7 January 2020. We also screened the reference lists from relevant reviews and included studies.

Selection criteria: We included RCTs that assessed the use of one or more types of NSAIDs compared to placebo (the main comparison) or alternative treatments for acute LBP in adults (≥ 18 years); conducted in both primary and secondary care settings. We assessed the effects of treatment on pain reduction, disability, global improvement, adverse events, and return to work.

Data collection and analysis: Two review authors independently selected trials to be included in this review, evaluated the risk of bias, and extracted the data. If appropriate, we performed a meta-analysis, using a random-effects model throughout, due to expected variability between studies. We assessed the quality of the evidence using the GRADE approach. We used standard methodological procedures recommended by Cochrane.

Main results: We included 32 trials, with a total of 5356 participants (age range 16 to 78 years). Follow-up ranged from one day to six months. Studies were conducted across the globe, the majority taking place in Europe and North-America. Africa and the Eastern Mediterranean region were not represented. We considered seven studies at low risk of bias. Performance and attrition were the most common biases. There was often a lack of information on randomisation procedures and allocation concealment (selection bias); studies were prone to selective reporting bias, since most studies did not register their trials. Almost half of the studies were industry-funded. There is moderate quality evidence that NSAIDs are slightly more effective in short-term (≤ 3 weeks) reduction of pain intensity (visual analogue scale (VAS), 0 to 100) than placebo (mean difference (MD) -7.29 (95% confidence interval (CI) -10.98 to -3.61; 4 RCTs, N = 815). There is high quality evidence that NSAIDs are slightly more effective for short-term improvement in disability (Roland Morris Disability Questionnaire (RMDQ), 0 to 24) than placebo (MD -2.02, 95% CI -2.89 to -1.15; 2 RCTs, N = 471). The magnitude of these effects is small and probably not clinically relevant. There is low quality evidence that NSAIDs are slightly more effective for short-term global improvement than placebo (risk ratio (RR) 1.40, 95% CI 1.12 to 1.75; 5 RCTs, N = 1201), but there was substantial heterogeneity (I² 52%) between studies. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events when using NSAIDs compared to placebo (RR 0.86, 95% CI 0.63 to 1.18; 6 RCTs, N = 1394). There is very low quality evidence of no clear difference between the proportion of participants who could return to work after seven days between those who used NSAIDs and those who used placebo (RR 1.48, 95% CI 0.98 to 2.23; 1 RCT, N = 266). There is low quality evidence of no clear difference in short-term reduction of pain intensity between those who took selective COX-2 inhibitor NSAIDs compared to non-selective NSAIDs (mean change from baseline -2.60, 95% CI -9.23 to 4.03; 2 RCTs, N = 437). There is moderate quality evidence of conflicting results for short-term disability improvement between groups (2 RCTs, N = 437). Low quality evidence from one trial (N = 333) reported no clear difference between groups in the proportion of participants experiencing global improvement. There is very low quality evidence of no clear difference in the proportion of participants experiencing adverse events between those who took COX-2 inhibitors and non-selective NSAIDs (RR 0.97, 95% CI 0.63 to 1.50; 2 RCTs, N = 444). No data were reported for return to work.

Authors' conclusions: This updated Cochrane Review included 32 trials to evaluate the efficacy of NSAIDs in people with acute LBP. The quality of the evidence ranged from high to very low, thus further research is (very) likely to have an important impact on our confidence in the estimates of effect, and may change the estimates. NSAIDs seemed slightly more effective than placebo for short-term pain reduction (moderate certainty), disability (high certainty), and global improvement (low certainty), but the magnitude of the effects is small and probably not clinically relevant. There was no clear difference in short-term pain reduction (low certainty) when comparing selective COX-2 inhibitors to non-selective NSAIDs. We found very low evidence of no clear difference in the proportion of participants experiencing adverse events in both the comparison of NSAIDs versus placebo and selective COX-2 inhibitors versus non-selective NSAIDs. We were unable to draw conclusions about adverse events and the safety of NSAIDs for longer-term use, since we only included RCTs with a primary focus on short-term use of NSAIDs and a short follow-up. These are not optimal for answering questions about longer-term or rare adverse events.

Author/s:

Van der Gaag, W.H., Roelofs, P.D., Enthoven, W.T., Van Tulder, M.W., Koes, B.W.

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

Devin Evans — Wed, 24 Feb 2021 06:00:00 +0000

Date Added:

February 24, 2021

Journal/Publication:

Journal of the American Medical Association Network Open

Publication Date:

February 1, 2021

Issue:

Volume:

URL:

Risk Factors Associated With Transition From Acute to Chronic Low Back Pain in US Patients Seeking Primary Care

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jamanetworkopen.2020.37371

Keywords

PMID (1):

33591367

MeSH

Patients with acute low back pain are more likely to progress to chronic low back pain if they are prescribed opioids or referred for imaging studies or subspecialists (after controlling for other risk factors). James W. Mold, MD, MPH

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Importance: Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP.

Objective: To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care.

Design, setting, and participants: This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020.

Exposures: SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral).

Main outcomes and measures: Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records.

Results: Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001).

Conclusions and relevance: In this cohort study, the transition rate to chronic LBP was substantial

Author/s:

Stevans, Joel M., Delitto, Anthony, Khoja, Samannaaz, Patterson, Charity G., Smith, Clair N., Schneider, Michael J., Freburger, Janet K., Greco, Carol M., Freel, Jennifer A., Sowa, Gwendolyn A., Wasan, Ajay D., Brennan, Gerard P., Hunter, Stephen J., Minick, Kate I., Wegener, Stephen T., Ephraim, Patti L., Friedman, Michael", Jason M., Robert B.

Recognizing Axial Spondyloarthritis: A Guide for Primary Care

Devin Evans — Wed, 04 Nov 2020 06:00:00 +0000

Date Added:

November 4, 2020

Publisher:

Mayo Clinic Proceedings

Publication Date:

July 29, 2020

Issue:

Volume:

Pages:

2499-2508

URL:

Recognizing Axial Spondyloarthritis: A Guide for Primary Care

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/j.mayocp.2020.02.007

Keywords

back pain

Axial Spondyloarthritis

primary care

PMID (1):

32736944

MeSH

A systematic review of what we know currently about axial spondyloarthritis, formerly known as ankylosing spondylitis. James W. Mold, MD, MPH

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Axial spondyloarthritis (axSpA) is an important cause of chronic low back pain and affects approximately 1% of the US population. The back pain associated with axSpA has a characteristic pattern referred to as inflammatory back pain (IBP). Features of IBP include insidious onset before age 45 years, association with morning stiffness, improvement with exercise but not rest, alternating buttock pain, and good response to treatment with nonsteroidal anti-inflammatory drugs. In patients with IBP, it is essential to look for other features associated with spondyloarthritis (SpA), such as enthesitis, dactylitis, peripheral arthritis, extra-articular manifestations (eg, psoriasis, uveitis, or inflammatory bowel disease), human leukocyte antigen B27 positivity, and a family history of SpA. Axial SpA is underrecognized, and a delay of several years between symptom onset and diagnosis is common. However, with new and effective therapies available for the treatment of active axSpA, early recognition and diagnosis are of critical importance. For this narrative review, we conducted a literature search of English-language articles using PubMed. Individual searches were performed to identify potential articles of interest related to axSpA (search terms: ["axSpA" OR "axial SpA" OR "axial spondyloarthritis" OR "ankylosing spondylitis"]) in combination with terms related to IBP ("inflammatory back pain" OR "IBP" OR "chronic back pain" OR "CBP" OR "lower back pain" OR "LBP"), diagnosis (["diagn∗" OR "classification"] AND ["criteria" OR "recommend∗" OR "guidelines"]), and referral ("refer∗"). No date range was formally selected, as we were interested in providing an overview of the evolution of these concepts in clinical practice. We supplemented the review with insights based on our clinical expertise. Patients with chronic back pain should be screened for IBP and other SpA features; suspicion for axSpA should trigger referral to a rheumatologist for further evaluation.

Author/s:

Magrey, Marina N., Danve, Abhijeet S., Ermann, Joerg, Walsh, Jessica A.

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain The SPACE Randomized Clinical Trial

Tracy Ashby — Mon, 07 Jan 2019 06:00:00 +0000

Date Added:

January 21, 2021

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

March 6, 2018

Issue:

Volume:

319

Pages:

872-882

URL:

Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain The SPACE Randomized Clinical Trial

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1001/jama.2018.0899

Keywords

PMID (1):

29509867

MeSH

Analgesics

analgesics, opioid

analgesics, non-narcotic

chronic pain

osteoarthritis, knee

In this RCT, comparing non-opioids to opioids for management of chronic pain in the lower back or knee due to OA the researchers found that non-opioid medications were more effective for relieving pain with fewer side effects.

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Importance Limited evidence is available regarding long-term outcomes of opioids compared with nonopioid medications for chronic pain.

Objective To compare opioid vs nonopioid medications over 12 months on pain-related function, pain intensity, and adverse effects.

Design, Setting, and Participants Pragmatic, 12-month, randomized trial with masked outcome assessment. Patients were recruited from Veterans Affairs primary care clinics from June 2013 through December 2015; follow-up was completed December 2016. Eligible patients had moderate to severe chronic back pain or hip or knee osteoarthritis pain despite analgesic use. Of 265 patients enrolled, 25 withdrew prior to randomization and 240 were randomized.

Interventions Both interventions (opioid and nonopioid medication therapy) followed a treat-to-target strategy aiming for improved pain and function. Each intervention had its own prescribing strategy that included multiple medication options in 3 steps. In the opioid group, the first step was immediate-release morphine, oxycodone, or hydrocodone/acetaminophen. For the nonopioid group, the first step was acetaminophen (paracetamol) or a nonsteroidal anti-inflammatory drug. Medications were changed, added, or adjusted within the assigned treatment group according to individual patient response.

Main Outcomes and Measures The primary outcome was pain-related function (Brief Pain Inventory [BPI] interference scale) over 12 months and the main secondary outcome was pain intensity (BPI severity scale). For both BPI scales (range, 0-10; higher scores = worse function or pain intensity), a 1-point improvement was clinically important. The primary adverse outcome was medication-related symptoms (patient-reported checklist; range, 0-19).

Results Among 240 randomized patients (mean age, 58.3 years; women, 32 [13.0%]), 234 (97.5%) completed the trial. Groups did not significantly differ on pain-related function over 12 months (overall P = .58); mean 12-month BPI interference was 3.4 for the opioid group and 3.3 for the nonopioid group (difference, 0.1 [95% CI, −0.5 to 0.7]). Pain intensity was significantly better in the nonopioid group over 12 months (overall P = .03); mean 12-month BPI severity was 4.0 for the opioid group and 3.5 for the nonopioid group (difference, 0.5 [95% CI, 0.0 to 1.0]). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall P = .03); mean medication-related symptoms at 12 months were 1.8 in the opioid group and 0.9 in the nonopioid group (difference, 0.9 [95% CI, 0.3 to 1.5]).

Conclusions and Relevance Treatment with opioids was not superior to treatment with nonopioid medications for improving pain-related function over 12 months. Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Trial Registration clinicaltrials.gov Identifier: NCT01583985

Author/s:

Krebs, Erin E., Gravely, Amy, Nugent, Sean, Jensen, Agnes C., DeRonne, Beth, Goldsmith, Elizabeth S., Kroenke, Kurt, Bair, Matthew J, Noorbaloochi, Siamak