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.
A 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.
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DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Acute and chronic low back pain Patrick, Nathan; Emanski, Eric; Knaub, Mark A
The Medical clinics of North America,
07/2014, Letnik:
98, Številka:
4
Journal Article
Recenzirano
Low back pain is an extremely common presenting complaint that occurs in upward of 80% of persons. Treatment of an acute episode of back pain includes relative rest, activity modification, ...nonsteroidal anti-inflammatories, and physical therapy. Patient education is also imperative, as these patients are at risk for further future episodes of back pain. Chronic back pain (>6 months' duration) develops in a small percentage of patients. Clinicians' ability to diagnose the exact pathologic source of these symptoms is severely limited, making a cure unlikely. Treatment of these patients should be supportive, the goal being to improve pain and function.
Manual therapy and psychological approaches should be recommended only alongside an exercise programme, while acupuncture or electrotherapies should not be recommended Consider a short course of ...non-steroidal anti-inflammatory drugs (NSAIDs), or a weak opioid where an NSAID is ineffective or poorly tolerated, and do not offer paracetamol alone for low back pain; and consider neuropathic drugs such as gabapentin and epidural steroids for sciatica Low back pain is the leading cause of long term disability worldwide. 1 The lifetime incidence of low back pain is 58-84%, 2 and 11% of men and 16% of women have chronic low back pain. 3 Back pain accounts for 7% of GP consultations and results in the loss of 4.1 million working days a year. 2 More than 30% of people still have clinically significant symptoms after a year after onset of sciatica. 4 This guideline replaces the National Institute for Health and Care Excellence (NICE) guideline on early management of low back pain in adults (2009) and expands its remit. Guidelines into practice How has your discussion of treatment options been guided by risk stratification? (QI project) What proportion of your patients with low back pain are prescribed paracetamol or co-codamol (exclude those with acute pain prescribed co-codamol because an NSAID is contraindicated, not tolerated, or is ineffective)? (Audit) What proportion of your patients who present with low back pain are referred for imaging (exclude those with suspected cancer, infection, trauma, or inflammatory disease such as spondyloarthritis)? (Audit) Uncertainties for future research The Guideline Development Group identified the following areas as needing further research:
Non-specific low back pain Balagué, Federico, Dr; Mannion, Anne F, PhD; Pellisé, Ferran, MD ...
The Lancet (British edition),
02/2012, Letnik:
379, Številka:
9814
Journal Article
Recenzirano
Non-specific low back pain has become a major public health problem worldwide. The lifetime prevalence of low back pain is reported to be as high as 84%, and the prevalence of chronic low back pain ...is about 23%, with 11–12% of the population being disabled by low back pain. Mechanical factors, such as lifting and carrying, probably do not have a major pathogenic role, but genetic constitution is important. History taking and clinical examination are included in most diagnostic guidelines, but the use of clinical imaging for diagnosis should be restricted. The mechanism of action of many treatments is unclear, and effect sizes of most treatments are low. Both patient preferences and clinical evidence should be taken into account for pain management, but generally self-management, with appropriate support, is recommended and surgery and overtreatment should be avoided.
To systematically review and critically appraise the effectiveness of conservative and surgical interventions to reduce fear in studies of people with chronic low back pain, based on the analysis of ...randomized controlled trials for which fear was a primary or secondary outcome.
Electronic databases PubMed, CINAHL, PsycINFO, PEDro, and CENTRAL, as well as manual searches and grey literature were searched from inception until May 2019.
Randomized controlled trials analyzing the effectiveness of conservative and surgical interventions to reduce fear were included.
Two reviewers independently conducted the search strategy, study selection, data extraction, risk of bias assessment, and quality of the evidence judgment.
Sixty-one studies (n=7201) were included. A large number of fear-related search terms were used but only 3 fear constructs (kinesiophobia, fear-avoidance beliefs, fear of falling) were measured in the included studies. Multidisciplinary and psychological interventions as well as exercise reduced kinesiophobia. Fear-avoidance beliefs were reduced by the aforementioned interventions, manual therapy, and electrotherapy. A multidisciplinary intervention reduced the fear of falling. There was moderate evidence of multidisciplinary interventions and exercise to reduce kinesiophobia. There was moderate evidence of manual therapy and electrotherapy to reduce fear-avoidance beliefs.
The present systematic review highlights the potential effectiveness of conservative interventions to reduce kinesiophobia and fear-avoidance beliefs in individuals with chronic low back pain. This information can help health professionals to reduce fear when treating patients with this condition.
Pathobiology of Modic changes Dudli, Stefan; Fields, Aaron J.; Samartzis, Dino ...
European Spine Journal,
11/2016, Letnik:
25, Številka:
11
Journal Article, Book Review
Recenzirano
Odprti dostop
Purpose
Low back pain (LBP) is the most disabling condition worldwide. Although LBP relates to different spinal pathologies, vertebral bone marrow lesions visualized as Modic changes on MRI have a ...high specificity for discogenic LBP. This review summarizes the pathobiology of Modic changes and suggests a disease model.
Methods
Non-systematic literature review.
Results
Chemical and mechanical stimulation of nociceptors adjacent to damaged endplates are likely a source of pain. Modic changes are adjacent to a degenerated intervertebral disc and have three generally interconvertible types suggesting that the different Modic change types represent different stages of the same pathological process, which is characterized by inflammation, high bone turnover, and fibrosis. A disease model is suggested where disc/endplate damage and the persistence of an inflammatory stimulus (i.e., occult discitis or autoimmune response against disc material) create predisposing conditions. The risk to develop Modic changes likely depends on the inflammatory potential of the disc and the capacity of the bone marrow to respond to it. Bone marrow lesions in osteoarthritic knee joints share many characteristics with Modic changes adjacent to degenerated discs and suggest that damage-associated molecular patterns and marrow fat metabolism are important pathogenetic factors. There is no consensus on the ideal therapy. Non-surgical treatment approaches including intradiscal steroid injections, anti-TNF-α antibody, antibiotics, and bisphosphonates have some demonstrated efficacy in mostly non-replicated clinical studies in reducing Modic changes in the short term, but with unknown long-term benefits. New diagnostic tools and animal models are required to improve painful Modic change identification and classification, and to clarify the pathogenesis.
Conclusion
Modic changes are likely to be more than just a coincidental imaging finding in LBP patients and rather represent an underlying pathology that should be a target for therapy.
Background
Low back pain is costly and disabling. Prognostic factor evidence can help healthcare providers and patients understand likely prognosis, inform the development of prediction models to ...identify subgroups, and may inform new treatment strategies. Recent studies have suggested that people who have poor expectations for recovery experience more back pain disability, but study results have differed.
Objectives
To synthesise evidence on the association between recovery expectations and disability outcomes in adults with low back pain, and explore sources of heterogeneity.
Search methods
The search strategy included broad and focused electronic searches of MEDLINE, Embase, CINAHL, and PsycINFO to 12 March 2019, reference list searches of relevant reviews and included studies, and citation searches of relevant expectation measurement tools.
Selection criteria
We included low back pain prognosis studies from any setting assessing general, self‐efficacy, and treatment expectations (measured dichotomously and continuously on a 0 ‐ 10 scale), and their association with work participation, clinically important recovery, functional limitations, or pain intensity outcomes at short (3 months), medium (6 months), long (12 months), and very long (> 16 months) follow‐up.
Data collection and analysis
We extracted study characteristics and all reported estimates of unadjusted and adjusted associations between expectations and related outcomes. Two review authors independently assessed risks of bias using the Quality in Prognosis Studies (QUIPS) tool. We conducted narrative syntheses and meta‐analyses when appropriate unadjusted or adjusted estimates were available. Two review authors independently graded and reported the overall quality of evidence.
Main results
We screened 4635 unique citations to include 60 studies (30,530 participants). Thirty‐five studies were conducted in Europe, 21 in North America, and four in Australia. Study populations were mostly chronic (37%), from healthcare (62%) or occupational settings (26%). General expectation was the most common type of recovery expectation measured (70%); 16 studies measured more than one type of expectation.
Usable data for syntheses were available for 52 studies (87% of studies; 28,885 participants). We found moderate‐quality evidence that positive recovery expectations are strongly associated with better work participation (narrative synthesis: 21 studies; meta‐analysis: 12 studies, 4777 participants: odds ratio (OR) 2.43, 95% confidence interval (CI) 1.64 to 3.62), and low‐quality evidence for clinically important recovery outcomes (narrative synthesis: 12 studies; meta‐analysis: 5 studies, 1820 participants: OR 1.89, 95% CI 1.49 to 2.41), both at follow‐up times closest to 12 months, using adjusted data. The association of recovery expectations with other outcomes of interest, including functional limitations (narrative synthesis: 10 studies; meta‐analysis: 3 studies, 1435 participants: OR 1.40, 95% CI 0.85 to 2.31) and pain intensity (narrative synthesis: 9 studies; meta‐analysis: 3 studies, 1555 participants: OR 1.15, 95% CI 1.08 to 1.23) outcomes at follow‐up times closest to 12 months using adjusted data, is less certain, achieving very low‐ and low‐quality evidence, respectively. No studies reported statistically significant or clinically important negative associations between recovery expectations and any low back pain outcome.
Authors' conclusions
We found that individual recovery expectations are probably strongly associated with future work participation (moderate‐quality evidence) and may be associated with clinically important recovery outcomes (low‐quality evidence). The association of recovery expectations with other outcomes of interest is less certain. Our findings suggest that recovery expectations should be considered in future studies, to improve prognosis and management of low back pain.
The treatment-based classification (TBC) system for the treatment of patients with low back pain (LBP) has been in use by clinicians since 1995. This perspective article describes how the TBC was ...updated by maintaining its strengths, addressing its limitations, and incorporating recent research developments. The current update of the TBC has 2 levels of triage: (1) the level of the first-contact health care provider and (2) the level of the rehabilitation provider. At the level of first-contact health care provider, the purpose of the triage is to determine whether the patient is an appropriate candidate for rehabilitation, either by ruling out serious pathologies and serious comorbidities or by determining whether the patient is appropriate for self-care management. At the level of the rehabilitation provider, the purpose of the triage is to determine the most appropriate rehabilitation approach given the patient's clinical presentation. Three rehabilitation approaches are described. A symptom modulation approach is described for patients with a recent-new or recurrent-LBP episode that has caused significant symptomatic features. A movement control approach is described for patients with moderate pain and disability status. A function optimization approach is described for patients with low pain and disability status. This perspective article emphasizes that psychological and comorbid status should be assessed and addressed in each patient. This updated TBC is linked to the American Physical Therapy Association's clinical practice guidelines for low back pain.
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Dostopno za:
DOBA, FSPLJ, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
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