ACUPUNCTURE TREATMENT FOR SCIATICA

The evidence gap in low back pain management strategies – Authors' reply

Permanent paraparesis and cauda equina syndrome after epidural blood patch for postdural puncture headache.

Low back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery. To assess use of health care resources for LBP and LEP management and analyze associated costs. This cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019. Newly diagnosed LBP or LEP. The primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated. A total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. The findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.

Back and neck pain and poor sleep quality in adolescents are associated even after controlling for confounding factors: An epidemiological study.

BackgroundAlthough results of case series support the use of spinal cord stimulation in failed back surgery syndrome patients with predominant low back pain, no confirmatory randomized controlled trial has been undertaken in this patient group to date. PROMISE is a multicenter, prospective, randomized, open-label, parallel-group study designed to compare the clinical effectiveness of spinal cord stimulation plus optimal medical management with optimal medical management alone in patients with failed back surgery syndrome and predominant low back pain.Method/DesignPatients will be recruited in approximately 30 centers across Canada, Europe, and the United States. Eligible patients with low back pain exceeding leg pain and an average Numeric Pain Rating Scale score ≥5 for low back pain will be randomized 1:1 to spinal cord stimulation plus optimal medical management or to optimal medical management alone. The investigators will tailor individual optimal medical management treatment plans to their patients. Excluded from study treatments are intrathecal drug delivery, peripheral nerve stimulation, back surgery related to the original back pain complaint, and experimental therapies. Patients randomized to the spinal cord stimulation group will undergo trial stimulation, and if they achieve adequate low back pain relief a neurostimulation system using the Specify® 5-6-5 multi-column lead (Medtronic Inc., Minneapolis, MN, USA) will be implanted to capture low back pain preferentially in these patients. Outcome assessment will occur at baseline (pre-randomization) and at 1, 3, 6, 9, 12, 18, and 24 months post randomization. After the 6-month visit, patients can change treatment to that received by the other randomized group. The primary outcome is the proportion of patients with ≥50% reduction in low back pain at the 6-month visit. Additional outcomes include changes in low back and leg pain, functional disability, health-related quality of life, return to work, healthcare utilization including medication usage, and patient satisfaction. Data on adverse events will be collected. The primary analysis will follow the intention-to-treat principle. Healthcare use data will be used to assess costs and long-term cost-effectiveness.DiscussionRecruitment began in January 2013 and will continue until 2016.Trial registrationClinicaltrials.gov: NCT01697358 (http://www.clinicaltrials.gov)

Objective: Heavy menstrual bleeding (menorrhagia) is a common problem, yet evidence is limited to inform therapeutic decisions.We compared the levonorgestrel-releasing intrauterine system(LNG-IUS) to usual medical treatment in a pragmatic randomised trial in primary care. Methods: We randomly assigned 571 women consulting their primary care providers with menorrhagia to LNG-IUS or to usual medical treatment as clinically appropriate (tranexamic acid, mefenamic acid, combined estrogen/progestogen or progestogen only). The primary outcome was a patient-reported measure ofimpact of menorrhagia, the validated Menorrhagia Multi-Attribute Scale (MMAS), assessed over 2 years. Secondary measures included generic quality of life (SF-36), sexual activity and surgical intervention.Results MMAS scores improved from baseline in both the LNG-IUS and usual medical treatment groups by 6 months (mean increases 32.7 points versus 21.4 points, respectively; P < 0.001for both) and were maintained over 2 years, but improvements were significantly greater with LNG-IUS (mean between-group difference 13.4 points, 95%CI, 9.9–16.9; P < 0.001).All domains of MMAS (practical difficulties, social life, family life,work/daily routine, psychological well being and physical health)improved significantly more with LNG-IUS, as were seven of the eight domains of SF-36. More women were still using LNG-IUSthan usual medical treatment at 2 years (64% versus 38%,P < 0.001). There were no significant between-group differences in surgical intervention rates or sexual activity scores. There were no serious adverse events in either group.Conclusions Among women presenting to primary care providers with menorrhagia, LNG-IUS was more effective than usual medical treatment at reducing the impact of this problem on their quality of life. In practice therefore, conventional treatments, such as tranexamic and mefenamic acid, remain helpful choices in women for whom LNG-IUS is considered unsuitable, or due to individual preference. For other women, LNG-IUS can be confidently recommended as an effective initial medical therapy for menorrhagia. Funding: This project was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) Programme (project number 02/06/02)

The effect of exercise in prevention of low back and pelvic girdle pain during pregnancy is uncertain. This study aimed to assess the effect of exercise on low back pain, pelvic girdle pain and associated sick leave. Literature searches were conducted in PubMed, EMBASE, Cochrane Library, Google Scholar, ResearchGate and ClinicalTrials.gov databases from their inception through May 2017. Randomized controlled trials (RCTs) were eligible for inclusion in the review if they compared an exercise intervention with usual daily activities and at least some of the participants were free from low back pain and/or pelvic girdle pain at baseline. Methodological quality of included studies was evaluated using the Cochrane Collaboration's tool. A random-effects meta-analysis was performed, and heterogeneity and publication bias were assessed. Eleven randomized controlled trials (2347 pregnant women) qualified for meta-analyses. Exercise reduced the risk of low back pain in pregnancy by 9% (pooled risk ratio (RR)=0.91, 95% CI 0.83-0.99, I2 =0%, seven trials, N=1175), whereas it had no protective effect on pelvic girdle pain (RR=0.99, CI 0.81-1.21, I2 =0%, four RCTs, N=565) or lumbopelvic pain (RR=0.96, CI 0.90-1.02, I2 =0%, eight RCTs, N=1737). Furthermore, exercise prevented new episodes of sick leave due to lumbopelvic pain (RR=0.79, CI 0.64-0.99, I2 =0%, three RCTs, N=1168). There was no evidence of publication bias. Exercise appears to reduce the risk of low back pain in pregnant women, and sick leave because of lumbopelvic pain, but there is no clear evidence for an effect on pelvic girdle pain. Exercise has a small protective effect against low back pain during pregnancy.

BackgroundPatients commonly seek outpatient physical therapy services for musculoskeletal disorders. Understanding these patient groups in Israel provides valuable insights into the healthcare system. We aimed to investigate physician referral patterns for physical therapy across different age and sex groups, focusing on neck and low back pain. Additionally, we sought to explore the therapeutic interventions provided by physical therapists for these conditions.MethodsFor this retrospective, cross-sectional study we utilized data from a national health maintenance organization covering > 4 million people at 100 physical therapy outpatient clinics. We measured the prevalence rates of physicians’ referral patterns for neck and low back pain according to age and sex, as well as therapeutic interventions prescribed by physical therapists. We used Z-tests to assess the differences in prevalence rates between women and men within the same age group. Logistic regression analyses were used to evaluate the likelihood of patients of a specific age group being referred to physical therapy compared with the total sample. We analyzed prevalence rates of different treatment protocols used by physical therapists according to these referrals.ResultsOverall, 1,593,592 physician referrals for physical therapy were made over 6 years for all musculoskeletal conditions. Of those, 32.4% were for spine disorders, with 21.2% for low back pain and 11.1% for neck pain, mostly chronic (80.6% and 72.7%, respectively). Women were more likely than men to be referred for both low back pain (odds ratio = 1.36, 95% confidence interval = 1.34–1.38, p < 0.001) and neck pain (1.40, 1.37–1.43, p < 0.001). All referral rates increased with age. The most common treatment provided by physical therapists for neck and low back pain was education and advice for an active lifestyle.ConclusionsThis study provides comprehensive data that highlight significant trends related to age, acuteness, and sex. Chronic low back and neck pain are the predominant reasons for physical therapy referrals, particularly among women and older adults. Physician referrals for neck and low back pain aligned with the epidemiology of such conditions in the Israeli population, underscoring the need for targeted rehabilitation strategies, early intervention programs, and effective healthcare service planning.

Degenerative spondylolisthesis (DS) is a disorder that causes the slip of one vertebral body over the one below due to degenerative changes in the spine. Lumbar DS is a major cause of spinal canal stenosis and is often related to low back and leg pain. We reviewed the symptoms, prognosis and conservative treatments for symptoms associated with DS. PubMed and MEDLINE databases (1950-2007) were searched for the key words "spondylolisthesis", "pseudospondylolisthesis", "degenerative spondylolisthesis", "spinal stenosis", "lumbar spine", "antherolisthesis", "posterolisthesis", "low back pain", and "lumbar instability". All relevant articles in English were reviewed. Pertinent secondary references were also retrieved. The prognosis of patients with DS is favorable, however, those who suffer from neurological symptoms such as intermittent claudication or vesicorectal disorder, will most probably experience neurological deterioration if they are not operated upon. Nonoperative treatment should be the initial course of action in most cases of DS, with or without neurologic symptoms. Treatment options include use of analgesics and NSAIDs to control pain; epidural steroid injections, and physical methods such as bracing and flexion strengthening exercises. An up-to-date knowledge on diagnosis and prevention of lumbar DS can assist in determination of future research goals. Additional studies are required to establish treatment protocols for the conservative treatment of DS.

Background: Low back pain after either post lumbar surgery syndrome or spinal stenosis in the absence of surgery is a vexing problem. Post lumbar surgery syndrome can occur in any age group, while low back and radicular pain from spinal stenosis is a disease of aging. As the population ages, the incidence of symptomatic spinal stenosis will increase. There are currently limited treatment options for either group. Further surgery is not uniformly effective in relieving pain after previous surgery. While therapies are being developed to treat pain due to spinal stenosis, no therapy other than adhesiolysis will treat pain due to scarring. Adhesiolysis was developed as a means of removing epidural scarring leading directly or indirectly to compression, inflammation, swelling, or a decreased nutritional supply of nerve roots. Adhesiolysis utilizes a number of modalities in the effort to break up epidural scarring, including the use of a wirebound catheter for mechanical adhesiolysis, placement of the catheter in the ventro-lateral aspect of the epidural space at the site of the exiting nerve root, and the use of high volumes of injectate, including local anesthetics and saline, either hypertonic or isotonic, along with steroids. Study Design: A systematic review of percutaneous adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. Objective: To evaluate the effectiveness of percutaneous adhesiolysis in the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis. The severity of risks and adverse events associated with percutaneous adhesiolysis were also evaluated. Methods: The available literature on percutaneous adhesiolysis for the treatment of refractory low back and leg pain due to post lumbar surgery syndrome or spinal stenosis was reviewed. The quality assessment and clinical relevance criteria utilized were the Cochrane Musculoskeletal Review Group criteria as utilized for interventional techniques for randomized trials and the criteria developed by the Newcastle-Ottawa Scale criteria for observational studies. The level of evidence was classified as good, fair, and limited (or poor) based on the quality of evidence developed by the U.S. Preventive Services Task Force (USPSTF). Data sources included relevant literature identified through searches of PubMed and EMBASE from 1966 to June 2012, and manual searches of the bibliographies of known primary and review articles. Outcome Measures: The primary outcome measure was pain relief of at least 6 months. Secondary outcome measures were improvement in functional status, change in psychological status, return to work, and reduction in opioid use or interventions. Results: For this systematic review, 15 studies were identified and selected for review. Of these, 5 randomized controlled trials and 2 observational studies met the inclusion criteria. Applying the USPSTF criteria, these studies indicate that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain caused by post lumbar surgery syndrome and that there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/ or leg pain caused by spinal stenosis The incidence of complications from percutaneous adhesiolysis is low and the complications are generally minimal and self-limited. The procedure should be considered to be low risk for serious adverse events when performed by well-trained physicians. Limitations: The limitations of this systematic review include the paucity of literature. Conclusion: In summary, there is fair evidence that percutaneous adhesiolysis is effective in relieving low back and/or leg pain due to post lumbar surgery syndrome or spinal stenosis. Key words: Spinal pain, chronic low back pain, leg pain, adhesiolysis, Racz procedure, post lumbar surgery syndrome, spinal stenosis

The internet is increasingly used as a primary source of information for patients with musculoskeletal pain. Private physiotherapy practices provide informative content on low back pain (LBP) and neck pain (NP) on their websites, but the extent to which this information is biopsychosocial, guidelines-consistent, and fear-inducing is unknown. The aim of this study was to analyse the information on websites of private physiotherapy practices in the Netherlands about LBP and NP regarding consistency with the guidelines and the biopsychosocial model and to explore the use of fear-inducing language. The content of all existing Dutch private physiotherapy practice websites was examined in a cross sectional study design. Content analysis was based on predetermined criteria of the biopsychosocial model and evidence-based guidelines. Descriptive statistics were applied. After removing duplicates and sites without information, 834 (10%) of 8707 websites remained. Information about LBP was found on 449 (54%) websites and 295 (35%) websites informed about NP. A majority of websites (LBP: n = 287, 64%; NP: n = 174, 59%) were biomedically oriented. Treatment advice was given 1855 times on n = 560 (67%) websites. Most of the recommended interventions were inconsistent with or not mentioned in the guidelines. Fear-inducing language was provided n = 1624 (69%) times. The majority of the information on the Dutch private physiotherapy websites was biomedical and not in line with the current guidelines and fear-inducing. This study revealed that the majority of private physiotherapy practice websites that provide information on LBP and NP are inconsistent with the biopsychosocial model and current guidelines. This information has a negative impact on patients' knowledge, attitudes, beliefs, and expectations, potentially affecting treatment outcomes. Consequently, most physiotherapy practice websites are unreliable sources of information on LBP and NP for patients. There is an urgent need to implement strategies to make websites reliable and helpful sources of information.

Women with diastasis recti abdominis might have weaker abdominal muscles and more abdominal pain, but no higher prevalence of pelvic floor disorders, low back and pelvic girdle pain than women without diastasis recti abdominis

Musculoskeletal changes occur during pregnancy; one-half of pregnant women experienced low back pain and/or pelvic pain during pregnancy. Prescription opioid use for Medicaid enrolled pregnant women has increased dramatically due to severe low back pain/pelvic pain. This study aimed to explore the prevalence of low back pain/pelvic pain and related risk factors among a broader population. This is a retrospective cohort study. This study utilized de-identified Medicaid claims data provided by the South Carolina Revenue and Fiscal Affairs Office, including individuals who gave birth between 2016 and 2021 during pregnancy. Low back pain/pelvic pain and a group of musculoskeletal risk factors were identified with International Classification of Diseases v10. Comparisons were made for the prevalence of low back pain and pelvic pain between those with pregnancy-related musculoskeletal risk and those without. Among 167,396 pregnancies, 65.6% were affected by musculoskeletal risk factors. The overall prevalence of low back pain was 15.6%, and of pregnancy-related pelvic pain was 25.2%. The overall prevalence for either low back pain or pelvic pain was 33.3% (increased from 29.5% in 2016 to 35.3% in 2021), with 24.6% being pregnancy-induced. Pregnancies with musculoskeletal risk factors were more likely to be diagnosed with low back pain (20.7% versus 5.7%, p < 0.001) or pelvic pain (35.3% versus 6.0%, p < 0.001) than those without. This study found a very high prevalence of musculoskeletal risk and a high prevalence of low back pain or pelvic pain, with an increasing trend, among South Carolina pregnancies enrolled in Medicaid during the period 2016-2021. Most of the diagnosed low back pain or pelvic pain were pregnancy induced. Musculoskeletal risk factors were associated with low back pain or pelvic pain.

Work posture, working conditions and musculoskeletal outcomes in agricultural workers

Background: In this article, we present the results of 50 patients whom we treated with epidural steroid injection, and our experience on the subject. Methods: Fifty patients who were followed in our clinic between January 2011 and August 2011 were assessed retrospectively. These were the patients who had chronic low back and leg pain due to lomber spinal degeneration and for whom operation was not recommended and lomber caudal epidural steroid was applied. Results: In our study, 50 patients having low back pain or leg pain or low back and leg pain together were assessed, and regression at rVAS score of 86% of the patients was detected for a short period after the intervention. VAS scores of 14% of the patients were not different. On long-term follow-up rVAS score analysis of the patients showed regression at 74% of the cases. Conclusion: Caudal steroid injection is a safe and efficient treatment method for the patients who have radicular pain, who do not respond to conservative treatment and for whom surgery is not recommended. Randomized double blind studies are needed to assess its superiority to other conservative methods. J Neurol Res. 2013;3(6):173-178 doi: http://dx.doi.org/10.4021/jnr212w