A Portable Wireless Solution for Back Pain Telemonitoring: A 3D-Based, Virtual Reality Approach

Neck and back pain are pervasive problems. Some have suggested that rising incidence may be associated with the evidence of rising prevalence.To describe the trends in diagnosis of painful neck and back conditions in a large national healthcare system.A retrospective observational cohort study to describe the incidence and prevalence of diagnosis of neck and back pain in a national cohort.Patients were identified by International Classification of Diseases, 9th Revision (ICD-9) codes in Department of Veterans Affairs (VA) national utilization datasets in calendar years 2002 to 2011.Descriptive statistics were used to analyze the data. Prevalent cases were compared with all veterans who sought health care in each year. Incident cases were identified following a 2 years clean period in which the patient was enrolled and received care, but not services for any back or neck pain conditions.From 2004 to 2011, 3% to 4% of the population was diagnosed with incident back pain problems, the rate increasing on average, 1.75% per year. During the same period, 12.3% to 16.2% of the population was diagnosed with a prevalent back pain problem, the rate increasing on average 4.09% per year.In a national population, the prevalence rate for diagnosis of neck and back pain grew 1.8 to 2.3 times faster than the incidence rate. This suggests that the average duration of episodes of care is increasing. Additional research is needed to understand the influences on the differential rate of change and to develop efficient and effective care systems.

Back pain is one of the most common triggers of performance failure in athletic and riding horses. Diagnosis of equine back pain has been very challenging for equine practitioners, particularly in chronic cases. Therefore, the identification of blood biomarkers would facilitate the clinical differentiation of chronic back pain. This study aimed to investigate serum biomarkers of glial cell activation, axonal damage, and inflammation for the diagnosis of equine chronic back pain. Serum samples from forty horses comprising chronic back pain (CBP), back pain concurrent with lameness (BPL), lameness (LN), and healthy control (HC) (n=10 per group) were screened for ionized calcium-binding adaptor molecule 1 (Iba-1), glial fibrillary acidic protein (GFAP), phosphorylated neurofilament-H (pNF-H) by ELISA, and proinflammatory cytokines (IL-1β, IL-6, and TNF-α) by multiplex assay. Serum concentrations of GFAP (3.81±1.72 ng/mL) and pNF-H (0.76±0.18 ng/mL) were significantly (p<0.05) higher in horses with CBP when compared with other groups. Iba-1 was not significantly higher in CBP horses. There was no significant difference between the pro-inflammatory cytokines among the groups. The levels of IL-1β, IL-6, and TNF-α were also increased in the CBP than the HC control horses but lower in relation to BPL and LN horses. In addition, serum Iba-1, GFAP, and pNF-H showed a high discriminatory capacity for horses with CBP with high sensitivity (50-100%) and specificity (70-100%). This study provides evidence that serum levels of the GFAP and pNF-H may be useful in the clinical differentiation of horses with chronic back pain.

Back pain is an uncommon chief complaint in the pediatric emergency department (ED). However, there are serious underlying conditions requiring prompt diagnosis and treatment. While the etiology is usually benign, variation exists in the evaluation. The study purpose was to describe pediatric patients who presented to the ED with back pain and evaluate for associations with laboratory and radiologic abnormalities indicative of underlying musculoskeletal pathology. A retrospective review was conducted of patients aged birth to 18 years who presented to a pediatric ED with a chief complaint of back pain during a 1-year period. Primary outcome was discharge diagnosis, categorized as nonpathologic back pain, pathologic back pain, and other etiologies. Descriptive statistics were used. Two-hundred thirty-two patient encounters were reviewed, with 177 included in data analysis. A nonpathologic diagnosis of back pain was found in 76.8% of visits. Back pain and back or muscle strain were the most common diagnoses. Pathologic back pain diagnoses represented 2.3% of visits. Radiologic imaging was performed in 37.9%. Positive findings were noted in 16.9% of radiographs; no abnormalities were noted on computed tomography scan or magnetic resonance imaging. Laboratory studies were conducted in 35%. Abnormal plain radiographs were associated with a pathologic diagnosis of back pain (P < 0.001). Most pediatric patients presenting to the ED with back pain were found to have a nonpathologic etiology and were discharged. Among those with a pathologic back pain diagnosis, abnormal radiograph findings were the only statistically significant factor, whereas laboratory studies, computed tomography scans, and magnetic resonance imaging scans were less indicative.

IntroductionLow back pain (LBP) imposes a considerable social and economic burden as one of the most serious public health issues in the developed nations and is one of the most common reasons for patient presentation to primary health care providers, outpatient clinics or A&E departments. Currently point prevalence of acute LBP adds up to 40%, 1-year prevalence exceeds 70% and life time prevalence equates 80%. Despite these facts, the complex pattern generating LBP is still not satisfactory understood. Additionally, the complexity of diagnostics and treatment in lumbar pain syndrome provokes insecurity and restraint especially in younger clinicians when faced with a patient suffering from acute back pain. To counter these problems, alleviate operational sequences in A&Es, outpatient departments and health care centers minimize the risk of mis- or underdiagnoses of life threatening internistic conditions respectively spinal emergencies and provide patients with appropriate diagnostics and treatment this algorithm has been originated. Materials and MethodsThe algorithm is based upon existing clinical guidelines of national and international scientific associations as well as on experienced data in the daily work of spine specialists. Hereby, consistency with the guidelines and recommendations of the literature on one hand and feasibility in the course of action in a day-to-day routine with as much practical relevance as possible on the other hand were the main goals to achieve. ResultsIn synopsis, an algorithm was formed which evaluates the crucial differential diagnosis of lumbar back pain according to their clinical relevance and targets a plot of action according to reasonable diagnostic and therapeutic steps. By distinct yes-no decisions within the scope of history taken together with instructions according to clinical, laboratory, and radiological investigational steps, even clinicians without long-time experience in spine surgery should be able to handle patients with acute LBP in any situation according to the guidelines and treatment needed. ConclusionThe designated target in developing this algorithm was to render assistance to colleagues of primary health care providers, outpatient clinics, and A&E departments in the complexity of diagnostics and treatment in lumbar pain syndrome and its differential diagnosis.I confirm having declared any potential conflict of interest for all authors listed on this abstractYesDisclosure of InterestNone declaredVan Tulderm, Becker A, Bekkeringt, Breena, Gil De Real, Hutchinsona, Koesb, Laerume, Malmivaaraa. European Guideline for the management of acute nonspecific back painChour, Fur, Carrinoj, Deyor. Imaging strategies fr Low back Pain: Systematic Review and Metaanalysis. The Lancet 2009;373:463–467Koesb, Van Tulderm, Lin C, Macedol, Mcauleyj, Maher C. An updated Overview of clinical guidelines for the managemnt of non-specific low back pain. European spine Journal 2010;19:2075–2094Chou R, Qaseema, Snow V, Casey D, Cross JT Jr., Shekellep, Owens. Diagnosis and treatment of low back pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American pain society. Annals of Internal Medicine 2007;147:478–491Haswell K, Gilmour J, Moore B. Clinical decision rules for identification of low back pain patients with neurologic involvement in primary care. Spine (Phila Pa 1976). 2008;;33(1):68–73New Zealand Guidelines Group. New Zealand acute low back pain guide

Prescription opioid use for nonmalignant chronic pain has grown in the US over the last decade. Those with chronic back pain have a higher risk of mortality from ischemic heart disease than those without. Studies have demonstrated a higher prevalence of cardiac disease in adults who report chronic pain. In addition, there is research that supports some association with pain sites and cardiovascular morbidity. Studies have also shown a high-grade chronic neck pain to be more associated with cardiovascular conditions when compared to moderate or low-grade chronic pain. Given this information, it is important to assess pain medication burden present in those who have a diagnosis of coronary artery disease and chronic lower back pain.

The prevalence and characteristics of intraprocedural back pain is not well studied in awake patients undergoing neuroendovascular procedures. We performed a prospective study as part of quality improvement initiative in which all patients who underwent neuroendovascular procedures in awake state were inquired regarding presence, severity (using a numeric rating scale score ranging from 0 [no pain] to 10 [worst pain possible]), and location (using anatomical chart) of back pain immediately after the procedure. The primary endpoint was the proportion of patients with moderate to severe pain (score of ≥3). A total of 100 (41.3%) of 242 patients reported intraprocedural back pain with a median severity of 5/10 (range 1-10). The mean age was 58.7±16.2years. The mean duration of the procedure was 82.3 minutes (range 15-410minutes). The pain was classified as moderate to severe in 86 of 100 patients. The locations of pain were identified in lumbar (n = 77), thoracic (n = 6), cervical (n = 7), cervical and lumbar (n = 8), and cervical with thoracolumbar (n = 2) regions. There was a significant relationship between patients' history of the previous neck and/or back surgery and frequency of moderate to severe back pain (P=.02). No significant relationship was observed between frequency of none to mild and moderate to severe back pain among the strata by patients' age, body mass index, or duration of procedures. The relatively high prevalence of intraprocedural back pain in patients undergoing neuroendovascular procedures in awake state must be recognized, and strategies to reduce the occurrence need to be identified.

With the unfortunate exception of the differential spinal block, diagnostic nerve blocking has become somewhat obsolete with the development of newer, more sophisticated diagnostic technology. Therapeutic nerve blocks remain useful in treating patients with various terminal cancers, some forms of back pain, tic douloreux, causalgia, reflex sympathetic dystrophy, and many trigger point syndromes. For dysfunctional and pain-disabled patients (rated as class 1 or 3 on Emory Pain Estimate Model), block therapy must be structured in comprehensive pain rehabilitation programs.

Case report - IntroductionBack pain is highly prevalent, affecting 40% of the paediatric population, with non-inflammatory causes accounting for the majority cases. However, the presentation of inflammatory back pain can be non-specific and a high degree of suspicion is necessary, particularly with the presence of risk factors such as HLA B27 positivity and personal and family history of psoriasis, inflammatory bowel disease, and acute uveitis.Case report - Case descriptionA previously well 14-year-old Caucasian girl was referred due to persistent lower back pain, HLA B27 positivity, and a history of acute uveitis. She reports that her pain began around the time of a road traffic accident two years previously. The pain was persistent but varied in intensity, worsened throughout the day, on bending forwards, and during bumpy car journeys, and on occasion was mildly relieved by ibuprofen. She later also developed neck pain and right lateral thigh pain. Despite her pain she was able to continue walking and swimming but found that she had to stop trampolining and cycling. She had recently been treated for a painful, red eye with topical treatment.On examination she had full range of movement of her spine and tenderness over her sacroiliac joints and plantar fascia insertion points, as well as more widespread muscle tenderness. Her bloods demonstrated normal inflammatory markers and MRI of her lumbar spine, pelvis, and sacroiliac joints showed a subtle disc degeneration with bulge at L5/S1 without nerve root compression or evidence of inflammation.An MDT approach was taken to manage her pain, with input from occupational therapy, discussing pain processing, pacing, pain management strategies, and sleep hygiene, and physiotherapy including hydrotherapy and a home exercise programme. Despite these interventions, her pain progressed and resulted in further functional impairment. Following MDT discussion, an MRI, already repeated after her first appointment, was performed for the third time which on this occasion demonstrated bilateral sacroiliitis with subchondral sclerosis, erosions, and bone marrow oedema. A diagnosis of enthesitis-related arthritis was made and treatment with diclofenac and etanercept was initiated.Case report - DiscussionWith HLA B27 positivity and a history of acute uveitis, she was clearly at risk of developing inflammatory arthritis, but without evidence of inflammation on imaging or bloods, treatment with immunomodulatory drugs was not indicated. With a high prevalence of non-inflammatory musculoskeletal pain in adolescent females and the significant rate of persistent chronic pain into adulthood for untreated patients, early MDT input in this patient’s management was essential. While management of non-inflammatory pain is primarily driven by therapists, this case highlights the benefit of communication within the MDT and the important role of the medical team, in regularly reviewing the diagnosis, particularly where symptoms evolve or do not follow the expected clinical course.Case report - Key learning pointsIn the presence of risk factors for spondyloarthropathy, a diagnosis of non-inflammatory back pain needs to be regularly reviewed and evolving symptoms, clinical deterioration, and patient or parent concerns need to be addressed. Although important, HLA B27 positivity has an overall penetrance of less than 20% and therefore does not exclude a diagnosis of non-inflammatory back pain. However, when coupled with history of uveitis or significant family history, repeat imaging should be considered.

Patient: Female, 28Final Diagnosis: Sacral stress fractureSymptoms: Lumbosacral pain during pregnancyMedication: —Clinical Procedure: Activity modification • conservative treatmentSpecialty: Orthopedics and TraumatologyObjective:Challenging differential diagnosisBackground:Sacral stress fracture during pregnancy is an uncommon condition with unclear pathophysiology, presenting with non-specific symptoms and clinical findings. To date, few cases have been published in the literature describing the occurrence of sacral stress fracture during pregnancy.Case Report:We report a 28-year-old primigravid patient who developed lumbosacral pain at the end of the second trimester. Symptoms were overlooked throughout pregnancy and the postpartum period, resulting in the development of secondary chronic gait and balance problems.Conclusions:Stress fracture of the sacrum should be included in the differential diagnosis of low back and sacral pain during pregnancy. Its prevalence is probably underestimated because of the lack of specificity of the symptoms. Plain radiographs are not appropriate due to radiation exclusion; magnetic resonance is the only method that can be applied safely. There is limited information on natural history but many patients are expected to have a benign course. However, misdiagnosis may lead to prolonged morbidity and the development of secondary gait abnormalities. Stress fracture of the sacrum should be included in the differential diagnosis of low back and sacral pain during pregnancy. A high index of suspicion is necessary to establish an early diagnosis and appropriate treatment.

Back pain in the pediatric population is a common complaint presenting to sports medicine clinics. There is a wide differential that should be considered, including mechanical, infectious, neoplastic, inflammatory, and amplified musculoskeletal pain. The history, pain quality, and examination are key components to help distinguish the etiologies of the pain and direct further evaluation. Laboratory investigations, including blood counts and inflammatory markers, can provide insight into the diagnosis. The HLA-B27 antigen can be helpful if a spon-dyloarthropathy is suspected. Imaging as clinically indicated typically begins with radiographs, and the use of MRI, CT, or bone scan can provide additional information. Proper diagnosis of back pain is important because prognosis and treatments are significantly different. We review the pertinent evaluation, differential diagnoses, and treatment of low back pain in the pediatric population.

The Current Approach to the Medical Diagnosis of Low Back Pain

Background/Aims Diagnostic delay in inflammatory and mechanical back pain (IBP and MBP) is a challenge, leading to time-off-work, mental health deterioration and chronicity of pain. Here we describe referral and follow-up characteristics in patients referred to a rheumatology service with back pain. By identifying these patients earlier and having a more proactive approach we may be able to reduce diagnostic delay and prevent some of this burden. Methods All new patients attending rheumatology outpatients at Guys and St Thomas’ Trust in London, UK are routinely sent a digital pre-appointment questionnaire to complete prior to initial visit. Between 21/06/2021 and 20/10/2022, 137 patients referred with back pain completed this questionnaire, which included the Assessment of SpondyloArthritis International Society (ASAS) IBP criteria. Clinical records were reviewed until June 2023. Results Our cohort had a mean (SD) age of 40.5(13.5) years, 50% were female and 66% were referred from primary care. Average symptom duration was 5.2(6.1) years. A primary diagnosis of axial spondyloarthritis was made in 41%, 53% were diagnosed with MBP and 6% had MBP on a background of other inflammatory disease. Incomplete data was an issue, with only 54% of the referrals having a CRP result, 50% having an ESR result and 22% with HLAB27 done and result available at referral. Rheumatology requested an MRI spine in 61% of back pain referrals. Of the 38% with a prior MRI, 15% did not have the result available at first rheumatology visit, 21% did not have the correct MRI protocol done and 17% had a further MRI spine done through rheumatology clinic. Overall, 92% of patients had at least one MRI spine done. The referral to new appointment wait time in this cohort was 19.4 (41.4) weeks and new visit to first follow-up visit duration of 18.2(13.0) weeks. Only 18% of patients were referred for back pain physiotherapy prior to being seen in rheumatology, with 20% referred at first rheumatology visit and 38% referred after this time. Of those with MBP, 96% were discharged with 82% being discharged after one follow-up i.e. after reviewing new investigation results. Conclusion Delay in time to diagnosis and management of back pain is considerable, with long referral to review and follow-up times and less than 1/5 patients referred for physiotherapy prior to being seen in secondary care. With 92% of patients having at least one MRI spine done, there is a call for front-loading new back pain referrals with appropriate MRI spine imaging at point of vetting along with appropriate blood tests, which we feel would help reduce diagnostic delay and be in line with the UK Getting It Right First Time (GIRFT) programme which advocates that quality care is given first time, every time. Disclosure N. Arumalla: None. E. Okoye: None. R. Jones: None. F. Humby: None. S. Subesinghe: None. T. Golding: None. T. Garrood: Shareholder/stock ownership; Serac Healthcare. Honoraria; UCB, Abbvie. Grants/research support; Versus Arthritis, Pfizer, Gilead, Guy’s and St Thomas’ Charity, NHSX. Other; Fresnius-Kabi. R. Byng-Maddick: None.

Twenty-one patients with back pain originating from the endplate injuries were selected to explore the methods of diagnosis and surgical treatment. All patients underwent examinations using radiography, CT, and MR imaging. Pain level of disc was determined through discography in each patient. The principal outcome judgments were pain and disability, and the efficacy of surgical treatment was assessed through the use of the visual analog scale (VAS) for pain and the Oswestry disability index (ODI) for functional recovery. All 21 patients with a diagnosis of back pain originating from endplate injuries according to discography were treated with anterior or posterior fusion surgery. The mean follow-up period was 3 years and 5 months (range, 2-6 years). Of the 21 patients, 20 (20/21) reported a disappearance or marked alleviation of low back pain and experienced a definite improvement in physical function. Statistically significant and clinically meaningful improvements in the VAS and ODI scores were obtained after treatment in the patients with chronic low back pain originating from the endplate injuries (P = 0.0001). The study suggests that discography and fusion surgery may be very effective methods for the diagnosis and treatment, respectively, of chronic back pain originating from the endplate injuries.

Background Diskogenic back pain is an unsolved mystery and accounts for a large number of patients with chronic low back pain. Various treatment modalities have been described, but treatment is still a matter of debate. We evaluated transforaminal epiduroscopic laser ablation (TELA) focusing on sinuvertebral nerve laser ablation for chronic diskogenic back pain. To our knowledge this is the first treatment described for diskogenic back pain that directly targets the sensitized sinuvertebral nerve extradiskally through a transforaminal approach. Methods A total of 52 patients with a diagnosis of chronic diskogenic back pain and treated with TELA between September 2015 and June 2016 were analyzed. Outcome was measured with the visual analog scale (VAS), Macnab criteria, and Oswestry Disability Index (ODI). Results Of the 52 patients, 55.8% were female, and the mean age was 42.40 ± 11.99 years. Pfirrmann disk degeneration grade was mostly grade IV (63.5%) and involved spinal levels L4–L5 and L5–S1. The average follow-up period was 15.88 ± 1.79 months. VAS decreased significantly after TELA (p &lt; 0.001). Improvement in ODI was also significant (p &lt; 0.001). Good to excellent outcome was 96.1% according to the Macnab criteria. Four patients had transient motor weakness. Conclusion TELA targeting to the sinuvertebral nerve was effective in 96.1% with good to excellent results and an immediate decrease in chronic diskogenic back pain. The sinuvertebral nerve may play an important role in chronic diskogenic back pain.

Low back pain is a major and increasing cause of disability in the United Kingdom. In 1993, 11% of the population reported that their activities had been restricted by back pain within the past four weeks. Satisfactory treatment of low back pain depends on an accurate diagnosis, but finding the cause for low back pain is often not possible because of difficulties in localising the source of the pain. In 1938 it was shown that many structures in the lumbar spine, when irritated, give rise to pain with very similar distributions. Despite technological advances the identification of an exact source of pain or an exact pathological diagnosis often remains elusive. It is important for doctors and patients to understand that the diagnosis of low back pain therefore depends on identifying some clinical syndromes on the basis of a patient's history and examination, with appropriate investigations to exclude serious pathology and support the clinical diagnosis. If this principle is misunderstood the result can be a misleading diagnosis and inappropriate treatment. Radiation of pain after injection of 0.1-0.3 ml 6% hypertronic saline into sacrospinal muscle (yellow) and multifidus muscle (red). Note similarity to distribution of sciatic pain. View this table: It is vital to distinguish mechanical causes of back pain from other causes as patients with mechanical causes are likely to respond to physical forms of treatment. The symptoms and signs of mechanical back pain differ considerably from those associated with back pain caused by underlying systemic disease. Most acute episodes of low back pain arise in the triad of joints that allow one vertebra to articulate with another (that is, the intervertebral disc anteriorly and the two facet joints posteriorly). The commonest primary pathology is degeneration of the nucleus pulposus in the lumbar disc. The disc itself is often not the source of pain; …