The effect of home-based and remote exercises on low back pain during the COVID-19 pandemic: a systematic review (preprint)

Purpose: The prevalence of low back pain (LBP) surged during the COVID-19 pandemic, posing challenges to face-to-face treatment. Therefore, this systematic review aims to determine the effectiveness of various digital solutions for controlling and treatment of LBP during the COVID-19 pandemic. Methods: The systematic review was performed from 2019 until 2023 across databases, including Google Scholar, ScienceDirect, Scopus, and PubMed, according to the eligibility criteria. This review fulfilled the following criteria according to the PICO system: population (individuals using virtual exercises at home for LBP), interventions (distance rehabilitation and digital application), comparison (intervention group performing exercises virtually at home, and control group receiving in-person services), outcome (methods used in the diagnosis of LBP). Only high-quality randomized controlled trial studies were included and assessed using the PEDro scale. All the studies were assessed to be of high quality. Results: After the final review, 15 articles with 3789 subjects met the inclusion criteria. Digital tools such as video calls, Artificial Intelligence programs, Virtual Reality Exercises, and video-based programs were commonly used in studies addressing LBP management. The included articles' scores ranged from 6.2 on the PEDro scale, which has a maximum of 10 points. Conclusions: The COVID-19 pandemic prompted heightened attention to digital treatments, yielding relatively acceptable results for patients and therapists. However, recent technological advances indicate future expansion in this field. Key aspects of this method include training individuals in self-management of LBP and promoting adherence. Nonetheless, the high diversity in the use of digital methods poses limitations on conclusive outcomes. Registration: The systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) [CRD42022377172;28/11/2022].

Lyme radiculopathy in a septuagenarian.

A man in his 70s presented to hospital in early summer with a 5-week history of progressive lower back and right thigh pain, sensory deficit and right leg weakness. There had been limited response to analgesics in the community. Primary investigations on admission revealed no cause for his symptoms. Five days into admission, history emerged of a possible tick bite with subsequent rash sustained 3 months earlier, raising the possibility of neuroborreliosis leading to radiculopathy. Cerebrospinal fluid demonstrated a lymphocytic pleocytosis. An elevated Borrelia burgdorferi antibody index confirmed a diagnosis of Lyme neuroborreliosis. The patient was treated successfully with 28 days of intravenous ceftriaxone, analgesia and physiotherapy. Within the literature, Lyme radiculopathy is a common presentation of neuroborreliosis and should be considered and investigated in patients without radiological evidence of a mechanical cause of worsening lower back pain in settings with endemic Lyme disease.

Care seek behavior for low back pain in southern Brazil during the COVID-19 pandemic: a panel data analysis.

BACKGROUND: During the COVID-19 pandemic, people with low back pain (LBP) might have avoided seeking care for their pain. We aimed to investigate how the COVID-19 pandemic has affected LBP care seeking behavior among adults. METHODS: Data from four assessments of the PAMPA cohort were analyzed. Participants who reported experiencing LBP during wave one both before and during social restrictions (n = 1,753 and n = 1,712, respectively), wave two (n = 2,009), and wave three (n = 2,482) were included. We asked participants about sociodemographic, behavioral, and health factors and outcomes related to LBP. Poisson regression analyses were conducted, and data are presented as prevalence ratios (PR) and respective 95% confidence interval (95%CI). RESULTS: Overall, care seeking behavior decreased by half in the first months of restrictions, from 51.5% to 25.2%. Although there was an increase in care seeking behavior observed in the other two assessments (nearly 10 and 16 months after restrictions), it was insufficient to reach pre-pandemic levels. In the first months of restrictions, a similar scenario was observed for specific care, such as general practitioner and exercise professional care, with proportions of pre-pandemic levels reached after 10 and 16 months. Women were more likely to seek care for LBP 10 and 16 months after restrictions (PR 1.30 95%CI 1.11; 1.52, PR 1.22 95%CI 1.06; 1.39, respectively). Also, those participants who worked, were physically active, and reported pain-related disability and high pain levels were more likely to seek care at all time points assessed. CONCLUSION: Overall, care-seeking behavior for LBP significantly decreased in the first months of restrictions and increased in the following months; however, this behavior remained lower than pre-pandemic levels.

Impact of patient gender on low back pain management before and after the COVID-19 pandemic in commercially insured and Medicare Advantage cohorts. A retrospective cohort study (preprint)

Background: Variability in the management of LBP has been extensively studied, however the degree to which this variability is associated with patient gender is less well understood. The purpose of this retrospective cohort study was to examine variability in the management of LBP associated with patient gender in commercially insured (CI) and Medicare Advantage (MA) cohorts before and after the COVID-19 pandemic. Methods: A US national sample of LBP episodes with a duration of less than 91 days experienced during 2019-2021 was analyzed. Independent variables included patient gender, whether an individual had CI or MA coverage, and the timing of LBP onset during pre-, early, and late COVID time periods. Dependent measures included the percent of individuals initially contacting eighteen types of health care provider (HCP) and receiving twenty-two types of health care services, and total episode cost. Measures associated with female patients were compared with a male patient baseline to examine patient gender related differences. Results: The study included 222,043 CI and 466,125 MA complete episodes of LBP. 114,322 (51.5%) of the CI and 281,597 (60.4%) of MA episodes were associated with female patients. Individual home address zip code population attributes were nearly identical in both CI and MA cohorts. During the pre-, early, and late COVID time periods, in both CI and MA cohorts, female patients were less likely than male patients to initially contact DCs (risk ratio (RR) CI pre-COVID 0.88, CI early COVID 0.90, CI late COVID 0.86, MA pre 0.70, MA early 0.70, MA late 0.73) and were more likely to initially contact rheumatologists (2.72, 2.62, 3.20, 2.15, 2.59, 2.08). In the CI cohort during the pre-, early, and late COVID time periods female patients more likely than male patients to initially contact physical therapists (PT) (RR pre-COVID 1.24, early COVID 1.17, late COVID 1.16) and licensed acupuncturists (LAC) (1.75, 1.53, 2.21). In both the CI and MA cohorts plain film radiology was the most provided service for both female (32-40% of episodes) and male (31-40%) patients. During all time periods in both CI and MA cohorts female patients were less likely than male patients to receive spinal surgery (risk ratio (RR) CI pre-COVID 0.53, CI early COVID 0.54, CI late COVID 0.53, MA pre- 0.45, MA early 0.46, MA late 0.42), prescription oral steroids (0.75, 0.73, 0.77, 0.82, 0.79, 0.83), and chiropractic manipulative therapy (CMT) (0.87, 0.89, 0.85, 0.70, 0.71, 0.73). In the CI cohort during all time periods female patients more likely than male patients to receive acupuncture (RR pre- 1.41, early 1.48, late 1.48). Conclusions: In both CI and MA cohorts, and compared to males, females with LBP were less likely to seek treatment from DCs and more likely to seek treatment from Rheumatologists. In the CI cohort females were more likely than males to seek treatment from PTs and LAcs. Females with LBP were less likely than males to undergo spinal surgery, receive a prescription oral steroid, or receive CMT.

Impact of the COVID-19 pandemic on low back pain management in commercially insured and Medicare Advantage cohorts. A retrospective cohort study (preprint)

Background: The COVID-19 (COVID) pandemic has been associated with care seeking and delivery system changes. Before COVID the management of low back pain (LBP) was variable and a common source of low-value care. The purpose of this retrospective cohort study was to examine how the management of LBP changed during the COVID pandemic in commercially insured (CI) and Medicare Advantage (MA) cohorts. Methods: A US national sample of LBP episodes with a duration of less than 91 days experienced during 2019-2021 was analyzed. Independent variables included whether an individual had CI or MA coverage, and the timing of LBP onset. Secondary independent variables included individuals home address State. Dependent measures included the percent of individuals initially contacting eighteen types of health care provider (HCP) and receiving twenty-two types of health care services, and total episode cost. Early and late COVID measures were compared with a pre-COVID baseline to examine COVID related change. The impact of the stringency of State level COVID public policy response was evaluated. Results: The study included 222,043 CI and 466,125 MA complete episodes of LBP. During the pre-COVID period the MA cohort was older (MA median 72 vs. CI 45), with higher percent female (61% vs. 52%), and from zip codes with a higher Area Deprivation Index (median 52 vs. CI 38). MA and CI cohort attributes remained nearly identical in the early and late COVID periods. Initial contact with licensed acupuncturists (LAc risk ratio (RR) 0.66) and physical therapists (PT RR 0.82) in the CI cohort, and with PTs (RR 0.78), urgent care (RR 0.86), and emergency medicine (RR 0.87) in the MA cohort experienced the largest decreases during the early COVID period. The largest increase in the CI cohort was to PCPs (RR 1.08), and in the MA cohort to PCPs (RR 1.11) and nurse practitioners (RR 1.09). During the late COVID period the largest decreases in the CI cohort were to neurologists (RR 0.84), PTs (RR 0.86), and physical medicine and rehabilitation physicians (RR PMR 0.87) and in the MA cohort to rheumatologists (RR 0.81), PMR (RR 0.89) and pain management physicians (RR 0.89). The largest increases during the late COVID period in the CI cohort were to radiologists (RR 1.22), hospitals (RR 1.07) and orthopedic surgeons (OS RR 1.04) and in the MA cohort to LAcs (RR 1.32), radiologists (RR 1.11) and hospitals (RR 1.10). Compared to the pre-COVID period during the early COVID period the percent of episodes including most health care services was unchanged or reduced. In the late COVID period in both the CI and MA cohorts the percent of episodes with imaging studies increased, MRI (RR CI 1.15, MA 1.21), CT (RR 1.16, 1.16), and plain film radiology (RR 1.06, 1.06). The stringency of State COVID public policy responses was not associated with significant variability in either the type of HCP initially contacted, or services received for LBP. Conclusions: In both CI and MA LBP cohorts COVID was associated with changes in the types of HCP initially contacted and subsequent services provided. Guideline concordant first-line service use declined during COVID, and the rate of diagnostic imaging was higher in the late COVID period than the pre-COVID period.

Management of low back pain in Australian emergency departments for culturally and linguistically diverse populations from 2016 to 2021.

BACKGROUND: Disparate care in the ED for minority populations with low back pain is a long-standing issue reported in the USA. Our objective was to compare care delivery for low back pain in Australian EDs between culturally and linguistically diverse (CALD) and non-CALD patients. METHODS: This is a retrospective review of medical records of the ED of three public hospitals in Sydney, New South Wales, Australia from January 2016 to October 2021. We included adult patients diagnosed with non-serious low back pain at ED discharge. CALD status was defined by country of birth, preferred language and use of interpreter service. The main outcome measures were ambulance transport, lumbar imaging, opioid administration and hospital admission. RESULTS: Of the 14 642 included presentations, 7656 patients (52.7%) were born overseas, 3695 (25.2%) preferred communicating in a non-English language and 1224 (8.4%) required an interpreter. Patients born overseas were less likely to arrive by ambulance (adjusted OR (aOR) 0.68, 95% CI 0.63 to 0.73) than Australian-born patients. Patients who preferred a non-English language were also less likely to arrive by ambulance (aOR 0.82, 95% CI 0.75 to 0.90), yet more likely to be imaged (aOR 1.12, 95% CI 1.01 to 1.23) or be admitted to hospital (aOR 1.16, 95% CI 1.04 to 1.29) than Native-English-speaking patients. Patients who required an interpreter were more likely to receive imaging (aOR 1.43, 95% CI 1.25 to 1.64) or be admitted (aOR 1.49, 95% CI 1.29 to 1.73) compared with those who communicated independently. CALD patients were generally less likely to receive weak opioids than non-CALD patients (aOR range 0.76-0.87), yet no difference was found in the use of any opioid or strong opioids. CONCLUSION: Patients with low back pain from a CALD background, especially those lacking English proficiency, are significantly more likely to be imaged and admitted in Australian EDs. Future interventions improving the quality of ED care for low back pain should give special consideration to CALD patients.

Low Back Pain Prevalence among Distance Learning Students.

Background: Low back pain as a symptom affects many individuals around the globe regardless of their economic status or sociodemographic characteristics. During the 2019 COVID-19 pandemic, students found themselves obligated to sit down for long periods of time. The aim of this current study is to investigate the impact of these prolonged periods of sitting down in front of computers on developing a new episode of low back pain. Methods and Materials: This research adopted an observational cross-section study design. Students who are currently enrolled or had experienced distance learning classes in the last 6 months were eligible to participate. An online-based questionnaire was developed by the investigators through reviewing the literature with relevant objectives. McNemar's test was used to compare certain variables between two periods before and during online distance learning. We used paired t-tests to compare pain intensity before, during, and after online learning, while a chi-square test was used to investigate correlations between factors influencing low back pain. Results: A total of 84 students participated in the study­46 (54.8%) females and 38 (45.2%) males. Before online distance learning, only 42.9% of participants reported low back pain, while only 20% had a back injury. The mean pain scores before, during, and after online distance learning were (2.85 ± 2.16, 4.79 ± 2.6, and 4.76 ± 2.7), respectively. The pain scores before online learning were significantly lower than pain scores during and after online distance learning (p < 0.05), respectively. Conclusion: The study findings suggested that low back pain prevalence increased among students during the COVID-19 pandemic. Future research should study participants' behavior during the online learning and assess the long-run impact of distance learning among high-school and undergraduate students.

Characterizing modifications to a comparative effectiveness research study: the OPTIMIZE trial-using the Framework for Reporting Adaptations and Modifications to Evidence-based Interventions (FRAME).

BACKGROUND: The OPTIMIZE trial is a multi-site, comparative effectiveness research (CER) study that uses a Sequential Multiple Assessment Randomized Trial (SMART) designed to examine the effectiveness of complex health interventions (cognitive behavioral therapy, physical therapy, and mindfulness) for adults with chronic low back pain. Modifications are anticipated when implementing complex interventions in CER. Disruptions due to COVID have created unanticipated challenges also requiring modifications. Recent methodologic standards for CER studies emphasize that fully characterizing modifications made is necessary to interpret and implement trial results. The purpose of this paper is to outline the modifications made to the OPTIMIZE trial using the Framework for Reporting Adaptations and Modifications to Evidence-Based Interventions (FRAME) to characterize modifications to the OPTIMIZE trial in response to the COVID pandemic and other challenges encountered. METHODS: The FRAME outlines a strategy to identify and report modifications to evidence-based interventions or implementation strategies, whether planned or unplanned. We use the FRAME to characterize the process used to modify the aspects of the OPTIMIZE trial. Modifications were made to improve lower-than-anticipated rates of treatment initiation and COVID-related restrictions. Contextual modifications were made to permit telehealth delivery of treatments originally designed for in-person delivery. Training modifications were made with study personnel to provide more detailed information to potential participants, use motivational interviewing communication techniques to clarify potential participants' motivation and possible barriers to initiating treatment, and provide greater assistance with scheduling of assigned treatments. RESULTS: Modifications were developed with input from the trial's patient and stakeholder advisory panels. The goals of the modifications were to improve trial feasibility without compromising the interventions' core functions. Modifications were approved by the study funder and the trial steering committee. CONCLUSIONS: Full and transparent reporting of modifications to clinical trials, whether planned or unplanned, is critical for interpreting the trial's eventual results and considering future implementation efforts. TRIAL REGISTRATION: ClinicalTrials.gov NCT03859713. Registered on March 1, 2019.

Remote work and back pain during the COVID-19 pandemic in adults and older population in South Brazil.

This article aims to investigate the association between remote work and Back Pain during the COVID-19 pandemic, and to analyze this relationship according to the body mass index. Population-based, cross-sectional study carried in two cities in southern Brazil, in individuals aged 18 years and over. Data were collected through household interviews from October to January 2020/21. Outcomes: back pain (cervical, thoracic, lumbar/acute, chronic) and pain intensity. Exposure variable: remote work. For the analyses, Poisson regression with robust adjustment for variance was used, stratified by BMI (eutrophic vs overweight/obese), and restricted to those who had worked in the past month. 1,016 had worked during the pandemic, average 42 years old (SD = 14), varying from 18 to 93 years. Remote work was performed by 7.7% of the individuals. Prevalence of back pain: 25.6% (95%CI: 19.5 to 31.7%). Overweight/obese remote workers felt pain acute cervical pain PR = 2.82 (95%CI: 1.15 to 6.92); chronic low back PR = 1.85 (95%CI: 1.04 to 3.29); acute thoracic PR = 1.81(95%CI: 3.76 to 8.68) compared to those who did not work. About one in four remote workers reported back pain during of the COVID-19 pandemic. BMI proved to be an important moderator between outcomes and exposure variable.

Inadvertent intrathecal drug injection while treating low back pain: a case report and review of the literature.

BACKGROUND: Undesired intrathecal injections represent an important subset of medical errors, albeit rare. Clinical effects depend on the type and concentration of drug(s) injected. Here we report on the case of a healthy woman with persistent low back pain, treated with a paravertebral injection of lidocaine, thiocolchicoside, and L-acetylcarnitine at an orthopedic practice. CASE REPORT: A 42-year-old Caucasian woman, with no relevant past medical history, received a lumbar paravertebral injection of lidocaine, thiocolchicoside, and L-acetylcarnitine for persistent low back pain. Approximately 30 minutes after injection, she experienced quick neurological worsening. Upon arrival at the Emergency Department, she was comatose, with fixed bilateral mydriasis, trismus, and mixed acidosis; seizures ensued in the first hours; slow progressive amelioration was observed by day 6; retrograde amnesia was the only clinical relevant remaining symptom by 6 months. CONCLUSIONS: To our knowledge, this is the first reported case of inadvertent intrathecal thiocolchicoside injection in an adult patient, as well as the first in the neurosurgical literature. Our experience suggests that injection therapy for low back pain should be administered in adequate settings, where possible complications may be promptly treated.

Occupational low back pain prevention capacity of nurses in China: A multicenter cross-sectional study.

Introduction: Nurses have a high prevalence of occupational low back pain, especially since the outbreak of the COVID-19 pandemic, which has increased the nurses' workloads. It has brought a huge burden on nurses and their professional development. Nurses' occupational low back pain prevention capacity is the logical starting point and core of interventions to prevent its occurrence. To date, there is no study investigating it with a scientific scale. Therefore, a multicenter cross-sectional study was conducted to explore the current status of nurses' capacity in occupational low back pain prevention and its influencing factors in China. Methods: Using a two-stage, purposive and convenience mixed sampling method, 1331 nurses from 8 hospitals across 5 provinces (Hubei, Zhejiang, Shandong, Henan, and Sichuan) in the southern, western, northern, and central areas of mainland China were involved in this study. The demographic questionnaire and occupational low back pain prevention behavior questionnaire were used for data collection. The descriptive analysis, univariate analysis, and multiple stepwise linear regression were used for data analysis. Results: The results showed that the occupational low back pain prevention behavior questionnaire score was 89.00 (80.00, 103.00) [M (Q1, Q3)], which indicated that nurses' ability was at a moderate level. Participation in prevention training before, perceived stress at work, and working hours per week were predictors for nurses' occupational low back pain prevention capacity. Discussion: To improve nurses' prevention ability, nursing managers should organize various training programs, strengthen regulations to reduce nurses' workload and stress, provide a healthy workplace, and offer incentives to motivate nurses.

Assessing the potential anti-neuroinflammatory effect of minocycline in chronic low back pain: Protocol for a randomized, double-blind, placebo-controlled trial.

INTRODUCTION: Both preclinical studies, and more recent clinical imaging studies, suggest that glia-mediated neuroinflammation may be implicated in chronic pain, and therefore might be a potential treatment target. However, it is currently unknown whether modulating neuroinflammation effectively alleviates pain in humans. This trial tests the hypothesis that minocycline, an FDA-approved tetracycline antibiotic and effective glial cell inhibitor in animals, reduces neuroinflammation and may reduce pain symptoms in humans with chronic low back pain. METHODS AND ANALYSIS: This study is a randomized, double-blind, placebo-controlled clinical trial. Subjects, aged 18-75, with a confirmed diagnosis of chronic (≥ six months) low back pain (cLBP) and a self-reported pain rating of at least four out of ten (for at least half of the days during an average week) are enrolled via written, informed consent. Eligible subjects are randomized to receive a 14-day course of either active drug (minocycline) or placebo. Before and after treatment, subjects are scanned with integrated Positron Emission Tomography/Magnetic Resonance Imaging (PET/MRI) using [11C]PBR28, a second-generation radiotracer for the 18 kDa translocator protein (TSPO), which is highly expressed in glial cells and thus a putative marker of neuroinflammation. Pain levels are evaluated via daily surveys, collected seven days prior to the start of medication, and throughout the 14 days of treatment. General linear models will be used to assess pain levels and determine the treatment effect on brain (and spinal cord) TSPO signal. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT03106740).

Electromyography-biofeedback for chronic low back pain: A qualitative cohort study.

BACKGROUND AND AIMS: Surface electromyography-biofeedback (sEMG-BF) may reduce the burden of CLBP by improving physical functioning, sleep, pain catastrophizing, anxiety, and depression. This qualitative study investigated the impact of weekly EMG-BF sessions on adults with CLBP. METHODS: Twenty-six individuals with CLBP participated in telephone interviews after completing an 8-week virtual sEMG-BF intervention. Trained interviewers conducted the 10-to-15-minute semi-structured interviews to understand participants' experience with the intervention. Common themes and subthemes were identified and analyzed using MAXQDA 2022 software. RESULTS: Participants were predominantly middle-aged females (M = 45, range of 19 - 66) who have had exposure to utilizing conventional therapies such as physical therapy, chiropractor, and massage for the treatment of CLBP. This study focused on participants who reported their experience of the main outcome study which included perceived reductions in CLBP symptoms, including pain and stress, and positive effects on self-awareness and sleep. Three overarching themes emerged and were further divided into subthemes: participants' involvement (virtual experience, accessibility of device, and future recommendations) perceived benefits (participants gained awareness, recommendations for future treatment, met expectations, and implementation), and desire for flexibility (obstacles and COVID-19 Impact). No adverse effects were reported by any of the participants within the study. CONCLUSIONS: Both physical and psychological improvements were reported by participants following an sEMG-BF intervention. Specific implementation procedures and critical barriers were identified. In particular, the ability to receive care for CLBP during the COVID-19 pandemic was important to participants.

Short-term impact of COVID-19 pandemic on low back pain: data from the PAMPA Cohort, Brazil.

BACKGROUND: To evaluate the short-term impact of COVID-19 pandemic on low back pain (LBP) outcomes in southern Brazil. METHODS: Data from the PAMPA Cohort were analyzed. Adults were recruited between June and July 2020 in the Rio Grande do Sul state using online-based strategies. Participants responded a self-reported, online questionnaire on LBP with two timepoints: before (retrospectively) and during COVID-19 pandemic. We assessed LBP experience, LBP-related activity limitation (no/yes), and LBP intensity (0 to 10 [strongest pain]). RESULTS: From a total sample of 2,321 respondents (mean age: 37.6 ± 13.5; 75.4% women), the prevalence of LBP did not change significantly from before (74.7% [95%CI 72.3; 76.9]) to the first months of pandemic (74.2% [95%CI 71.9; 76.3]). However, an increased pain levels (ß: 0.40; 95%CI 0.22; 0.58) and a higher likelihood for activity limitation due to LBP was observed (PR 1.14; 95%CI 1.01; 1.29). Longitudinal analyzes showed that age, gender, BMI, chronic diseases, physical activity, and anxiety and depression symptoms, were associated with LBP in the first pandemic months. CONCLUSION: Although the prevalence of LBP did not change at the first months of COVID-19 pandemic, LBP-induced impairment in daily activities and pain intensity was higher when compared to before the pandemic.

Exploring patients' lived experience on the barriers to accessing low back pain health services.

BACKGROUND: The burden of chronic low back pain (CLBP) is a major concern to public health. However, the treatment of CLBP in primary care has shown to be ineffective in South Africa. Understanding the barriers encountered by patients in accessing CLBP healthcare services is paramount in the development of context-specific intervention strategies. AIM: To explore the patients' lived experiences on the barriers to accessing diagnostic, referral and treatment services for CLBP. SETTING: A health facility-based study conducted at five primary public hospitals in KwaZulu-Natal, South Africa. METHODS: A phenomenological study by means of in-depth interviews using the general interview guide approach. Interviews were conducted by a research assistant with relevant experience and qualifications in qualitative methods. A total of 15 participants were recruited to participate in this study. All interviews were audio-recorded and transcribed. Data were analysed iteratively until saturation was reached, where no new themes were emerging. All the transcripts were exported to NVivo 12 Pro for analysis. RESULTS: The results of this study identified the following barriers: travel, long waiting periods, shortage of personnel, poor infrastructural development, inadequate healthcare personnel, communication barrier, social influence, beliefs around cause and effect, misdiagnosis and inappropriate and/or ineffective treatment approaches. CONCLUSION: This study concluded that barriers to patients' accessing diagnostic, referral and treatment services exist. Efforts should be made towards developing health systems in underserved communities.Contribution: This is the first study to be conducted in South Africa that explored the barriers associated with accessing healthcare services for chronic low back pain. Based on the results of this study, in order to improve health outcomes for low back pain there need to be a change of emphasis in primary health care by ensuring sufficient allocation of resources towards musculoskeletal disorders.

Top 20 Research Studies of 2021 for Primary Care Physicians.

This article summarizes the top 20 research studies of 2021 identified as POEMs (patient-oriented evidence that matters) that did not address the COVID-19 pandemic. Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists prevent adverse cardiovascular and renal outcomes in patients with type 2 diabetes mellitus and also reduce all-cause and cardiovascular mortality. Most older adults (mean age, 75 years) with prediabetes do not progress to diabetes. Among patients in this age group with type 2 diabetes treated with medication, an A1C level of less than 7% is associated with increased risk of hospitalization for hypoglycemia, especially when using a sulfonylurea or insulin. For patients with chronic low back pain, exercise, nonsteroidal anti-inflammatory drugs, duloxetine, and opioids were shown to be more effective than control in achieving a 30% reduction in pain, but self-discontinuation of duloxetine and opioids was common. There is no clinically important difference between muscle relaxants and placebo in the treatment of nonspecific low back pain. In patients with chronic pain, low- to moderate-quality evidence supports exercise, yoga, massage, and mindfulness-based stress reduction. For acute musculoskeletal pain, acetaminophen, 1,000 mg, plus ibuprofen, 400 mg, without an opioid is a good option. Regarding screening for colorectal cancer, trial evidence supports performing fecal immunochemical testing every other year. For chronic constipation, evidence supports polyethylene glycol, senna, fiber supplements, magnesium-based products, and fruit-based products. The following abdominal symptoms carry a greater than 3% risk of cancer or inflammatory bowel disease: dysphagia or change in bowel habits in men; rectal bleeding in women; and abdominal pain, change in bowel habits, or dyspepsia in men and women older than 60 years. For secondary prevention in those with established arteriosclerotic cardiovascular disease, 81 mg of aspirin daily appears to be effective. The Framingham Risk Score and the Pooled Cohort Equations both overestimate the risk of cardiovascular events. Over 12 years, no association between egg consumption and cardiovascular events was demonstrated. Gabapentin, pregabalin, duloxetine, and venlafaxine provide clinically meaningful improvements in chronic neuropathic pain. In patients with moderate to severe depression, initial titration above the minimum starting dose of antidepressants in the first eight weeks of treatment is not more likely to increase response. In adults with iron deficiency anemia, adding vitamin C to oral iron has no effect. In children with pharyngitis, rhinosinusitis, acute bronchitis, or acute otitis media, providing education combined with a take-and-hold antibiotic prescription results in 1 in 4 of those children eventually taking an antibiotic.

Low Back Pain in People With Lower Limb Amputation: A Cross-Sectional Study.

STUDY DESIGN: A cross-sectional study based on an online questionnaire. OBJECTIVE: The aim was to investigate the prevalence and intensity of low back pain (LBP) in people with lower limb amputation (LLA) and to analyze the association factors that can influence the genesis of LBP. SUMMARY OF BACKGROUND DATA: It is still unclear whether LBP is more prevalent in the amputated population than in its nonamputated counterpart. Given the multifactorial nature of LBP, it is necessary to explore possible factors that can influence its presence and intensity, to build a solid background to define a better rehabilitation pathway for the management of these people. METHODS: The online questionnaire included six sections: informed consent of the study, demographic information, comorbid conditions, history of LLA, history of LBP, and acceptance of the amputation. RESULTS: Between March and June 2021, 239 participants [mean age (SD): 49.2 (11.5); female 11%] completed the survey (response rate: 32%). From the results of this study, LBP in LLA showed a prevalence of 82% postamputation and 70% in the last year. A logistic regression with a backward method showed that participants who had problems in the not affected leg presented 1.58 (95% confidence interval: 0.70; 2.45) times higher odds to have LBP after the amputation. CONCLUSION: This study shows that the prevalence of LBP in lower limb amputees appears to be higher than in the general population, with similar levels of pain intensity and frequency. The highest percentage of people with a sedentary lifestyle not practicing any kind of sports emphasizes the importance of educating this population on the importance of physical activity. New strategies to invest in the education of this population in terms of physical activity are needed. LEVEL OF EVIDENCE: Level 4.

Cost analysis of chronic pain due to musculoskeletal disorders in Chile.

The magnitude of the cost of chronic pain has been a matter of concern in many countries worldwide. The high prevalence, the cost it implies for the health system, productivity, and absenteeism need to be addressed urgently. Studies have begun describing this problem in Chile, but there is still a debt in highlighting its importance and urgency on contributing to chronic pain financial coverage. This study objective is to estimate the expected cost of chronic pain and its related musculoskeletal diseases in the Chilean adult population. We conducted a mathematical decision model exercise, Markov Model, to estimate costs and consequences. Patients were classified into severe, moderate, and mild pain groups, restricted to five diseases: knee osteoarthritis, hip osteoarthritis, lower back pain, shoulder pain, and fibromyalgia. Data analysis considered a set of transition probabilities to estimate the total cost, sick leave payment, and productivity losses. Results show that the total annual cost for chronic pain in Chile is USD 943,413,490, corresponding an 80% to the five diseases studied. The highest costs are related to therapeutic management, followed by productivity losses and sick leave days. Low back pain and fibromyalgia are both the costlier chronic pain-related musculoskeletal diseases. We can conclude that the magnitude of the cost in our country's approach to chronic pain is related to increased productivity losses and sick leave payments. Incorporating actions to ensure access and financial coverage and new care strategies that reorganize care delivery to more integrated and comprehensive care could potentially impact costs in both patients and the health system. Finally, the impact of the COVID-19 pandemic will probably deepen even more this problem.