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.

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.

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.

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.

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.

A Model to Implement Standardized Virtual Care for Low Back Pain Amongst a Large Network of Providers in Urban and Rural Settings.

Prior to the COVID-19 pandemic, virtual care (VC) was not routinely offered for assessment of low back pain (LBP), a highly prevalent, disabling condition. COVID-19 related healthcare closures resulted in a rapid backlog of patients referred to a provincial interprofessional LBP program. Without management, these patients were at high risk of experiencing untoward outcomes. Virtual care became a logical option. However, many clinicians lacked experience and confidence with LBP virtual care (LBP-VC); and either were unfamiliar with, or did not have access to, requisite technology. Multi-stakeholder engagement was utilized to understand barriers, identify enablers, and ultimately promote VC for LBP. As a result of the multi-stakeholder engagement, the concept of a toolkit for LBP-VC, including clinical resources and guidelines, emerged. The toolkit contains preparatory steps for VC and a standardized approach to virtual LBP assessment. Key steps in the toolkit have potential applicability to other musculoskeletal populations.

Does m-health-based exercise (guidance plus education) improve efficacy in patients with chronic low-back pain? A preliminary report on the intervention's significance.

BACKGROUND: The utilization of mobile health (m-health) has rapidly expanded during the COVID-19 pandemic, and there is still a lack of relevant clinical data pertaining to chronic low-back pain (CLBP) management. This study was designed to compare the effectiveness of m-health-based exercise (via guidance plus education) versus exercise (via guidance) during CLBP management. METHODS: Participants (n = 40) were randomly assigned to intervention and control groups. The intervention group received m-health-based exercise (via guidance plus education), whereas the control group received m-health-based exercise (via guidance). The exercise prescription video and educational content were sent to participants by the application (app), Ding Talk. Repeated-measures analysis of variance was used to test the baseline's intervention effects, 6-week follow-up, and 18-week follow-up. We selected function (Roland and Morris Disability Questionnaire) and pain intensity (current, mean, and most severe Numeric Rating Scale in the last 2 weeks) as the primary outcomes, changes of negative emotion (depression, anxious), and quality of life as the secondary outcomes. RESULTS: Time's significant effect was found in pain, function, and health-related quality of life in both groups, but time did not show significant interaction effects. Participants were able to use m-based education with their anxiety and depression after treatment, but the relief only lasted until week 6. No differences were found on the aspect of mental health-related quality of life. CONCLUSION: Preliminary findings suggest that m-health-based exercise (via guidance) may be a convenient and effective method to treat CLBP. However, additional health education didn't help more. More rigorous controlled trials are needed to improve the therapeutic effect in future studies. TRIAL REGISTRATION: Chinese Clinical Trials Registry Number ChiCTR2000041459 . Registered on December 26, 2020.

Association between chronic low back pain and regular exercise, sedentary behaviour and mental health before and during COVID-19 pandemic: insights from a large-scale cross-sectional study in Germany.

BACKGROUND: Nonspecific chronic low back pain (CLBP) is a complex symptom with numerous possible causes and influencing factors. Understanding how modifiable factors affect the course of CLBP is important for preventing progression. As the COVID-19 pandemic has changed the lifestyle of many people, this study paper assessed whether it also changed the influence of modifiable lifestyle factors (regular exercise and sedentary behaviour) and mental health factors (anxiety and depression) on CLBP pain intensity and disability by comparing the strength of these associations before and during the pandemic. We hypothesised that the importance of regular physical activity and good mental health for CLBP patients would increase during the pandemic. METHODS: These questions were investigated in a cross-sectional study of insurance claims data and self-reported data from various questionnaires from 3,478 participants in a German CLBP health intervention (2014-2021) by calculating pre- and intra-pandemic odds ratios (OR) and 95% confidence intervals (CI) for each variable of interest and outcome. Potential confounders were also considered. Pandemic status was treated as an effect modifier. Based on the date of enrolment, participants were classified as "pre-pandemic" or "pandemic". RESULTS: Regularly exercising ≥ 4 h/week significantly reduced the odds of high disability for men (OR 0.49, 95% CI 0.31 - 0.79, p = 0.003) and women (OR 0.30, 95% CI 0.14 - 0.563, p = 0.002) and reduced the probability of severe pain in women (OR 0.37, 95% CI 0.21 - 0.65, p < 0.001). Each one-point increase in PHQ-4 score for anxiety and depression increased the OR of high pain intensity by 1.25 points (95% CI 1.18 - 1.34, p < 0.001). A clear impact of COVID-19 lockdowns was observed. In individuals who exercised ≥ 4 h/week the OR of high disability was 0.57 (95% CI 0.36 - 0.92, p = 0.021) in the pre-pandemic group compared to 0.29 (95% CI 0.12 - 0.56, p = 0.002) in the pandemic group. The probability of high disability increased from an OR of 1.42 (95% CI 1.33 - 1.52, p < 0.001) per marginal increase in the PHQ-4 scale before the pandemic, to an OR of 1.73 (95% CI 1.58 - 1.89, p < 0.001) during the pandemic. CONCLUSIONS: The magnitude of association of the factors that influenced high pain intensity and disability increased during the pandemic. On the one hand, the protective effect of regular exercising was greater in participants surveyed during lockdown. On the other hand, a higher risk through anxiety or depression during the lockdown was identified. An additional study with objective measures of sedentary behaviour and physical activity is needed to validate these results. More in-depth investigation of lockdown-induced associations between reduced daily physical activity, increased levels of anxiety and depression, and their effects on CLPB could also be worthwhile. TRIAL REGISTRATION: This study used routinely collected data from a CLBP intervention that was previously evaluated and registered in the German Registry of Clinical Trials under DRKS00015463 (04/09/2018). The original ethics approval, informed consent and self-reported questionnaire have remained unchanged and are still valid.

Optimizing chronic pain management through patient engagement with quality of life measures: a randomized controlled trial.

CONTEXT: Health-related quality of life (HRQOL) represents a new approach for guiding chronic pain management because it is patient-centered and more likely to be understood and accepted by patients. OBJECTIVES: To assess the value and utility of an eHealth intervention for patients with chronic low back pain (CLBP) that was primarily based on HRQOL measures and to measure the clinical outcomes associated with its use. METHODS: A randomized controlled trial was conducted within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry) using participants screened from November 2019 through February 2021. A total of 331 registry participants within the 48 contiguous states and the District of Columbia met the eligibility criteria, which included having CLBP and HRQOL deficits. Almost three-fourths of the participants were enrolled after onset of the COVID-19 pandemic. The participants were randomized to an eHealth intervention for HRQOL or wait list control. The primary outcome measures involved HRQOL based on the Patient-Reported Outcomes Measurement Information System (PROMIS), including the SPADE cluster (Sleep disturbance, Pain interference with activities, Anxiety, Depression, and low Energy/fatigue) and each of its five component scales. Secondary outcome measures involved low back pain intensity and back-related functioning. Changes over time for each outcome measure reported by participants in each treatment group were compared utilizing the student's t-test for statistical significance and Cohen's d statistic for clinical importance. Outcomes were reported as between-group differences in change scores and the d statistic, with positive values favoring the experimental treatment group. RESULTS: There were no significant differences between the experimental and control treatment groups for changes over time in any primary outcome measure. The d statistic (95% confidence interval) for the difference between the experimental and control treatment groups on the SPADE cluster was 0.04 (-0.18-0.25). The corresponding d statistics for the SPADE scales ranged from -0.06 (-0.27 to 0.16) for anxiety to 0.11 (-0.10 to 0.33) for sleep disturbance. There were also no significant or clinically important differences between the experimental and control treatment groups on the secondary outcome measures. Additionally, in subgroup analyses involving participants treated by osteopathic vs allopathic physicians, no significant interaction effects were observed. CONCLUSIONS: The eHealth intervention studied herein did not achieve statistically significant or clinically important improvements in any of the primary or secondary outcome measures. However, the validity and generalizability of the findings may have been limited by the unforeseen onset and impact of the COVID-19 pandemic shortly after beginning the trial.

Evaluating Auricular Point Acupressure for Chronic Low Back Pain Self-Management Using Technology: A Feasibility Study.

BACKGROUND: Chronic low back pain, one of the most common reasons for seeking healthcare services, causes significant negative impacts on individuals and society. Nonpharmacologic therapies and self-management are included in practice guidelines, but their implementation is challenging. AIM: To assess the feasibility of using an auricular point acupressure (APA) mobile app as a self-guided tool to learn and self-administer APA to manage chronic low back pain (cLBP) and to compare cLBP outcomes between 2 groups (app vs app + telehealth). DESIGN: A 2-phase study design was used. In phase 1, participants (app group, n = 18) had in-person study visits and installed the app to learn and self-administer APA to manage cLBP. In phase 2, all research activities occurred remotely due to the COVID-19 pandemic, so a second group was recruited (app + telehealth, n = 19). The app + telehealth group underwent a virtual session, installed the app, and were provided the opportunity for questions and verification on the accuracy of the self-administered APA. SETTING: The participants were recruited by distributing study flyers at outpatient clinics and referrals. PARTICIPANTS: Participants with chronic low back pain were eliglbe for the study. METHODS: Using a quasi-experimental design with a mixed methods approach, all participants were instructed to download the APA app, provided an APA kit (includes seeds embedded within pre-cut squares of adhesive tape), and advised to self-administer APA with guidance from the app for 4 weeks to manage their cLBP. Study outcomes were collected at the preintervention time point as well as postintervention and 1-month follow-up. Interviews were also conducted at the postintervention time point. RESULTS: Of the 37 participants enrolled, six dropped out, and the attrition rate was 16%. Adherence to APA practice was high (85%-94%). After 4 weeks of APA treatment, participants in the app + telehealth group experienced a 29% decrease in pain intensity during the postintervention time point and a 35% reduction during the 1-month follow-up. Similar improvements were noted in pain interference (28%) and physical function (39%) for participants in the app + telehealth group at the 1-month follow-up. These changes are slightly higher compared with those in the app group (21% pain intensity reduction, 23% improved pain interferences, and 26% improved physical function) during the 1-month follow-up. Overall, APA was found to be feasible using the app and the qualitative findings showed acceptability of the intervention in both groups. CONCLUSIONS: It is feasible to learn and self-administer APA with an app, supplemented with either in-person or telehealth sessions, presenting a promising intervention toward cLBP self-management. Telehealth was found to boost this intervention effectively.

An 8-Week Self-Administered At-Home Behavioral Skills-Based Virtual Reality Program for Chronic Low Back Pain: Double-Blind, Randomized, Placebo-Controlled Trial Conducted During COVID-19.

BACKGROUND: Chronic low back pain is the most prevalent chronic pain condition worldwide and access to behavioral pain treatment is limited. Virtual reality (VR) is an immersive technology that may provide effective behavioral therapeutics for chronic pain. OBJECTIVE: We aimed to conduct a double-blind, parallel-arm, single-cohort, remote, randomized placebo-controlled trial for a self-administered behavioral skills-based VR program in community-based individuals with self-reported chronic low back pain during the COVID-19 pandemic. METHODS: A national online convenience sample of individuals with self-reported nonmalignant low back pain with duration of 6 months or more and with average pain intensity of 4 or more/10 was enrolled and randomized 1:1 to 1 of 2 daily (56-day) VR programs: (1) EaseVRx (immersive pain relief skills VR program); or (2) Sham VR (2D nature content delivered in a VR headset). Objective device use data and self-reported data were collected. The primary outcomes were the between-group effect of EaseVRx versus Sham VR across time points, and the between-within interaction effect representing the change in average pain intensity and pain-related interference with activity, stress, mood, and sleep over time (baseline to end-of-treatment at day 56). Secondary outcomes were global impression of change and change in physical function, sleep disturbance, pain self-efficacy, pain catastrophizing, pain acceptance, pain medication use, and user satisfaction. Analytic methods included intention-to-treat and a mixed-model framework. RESULTS: The study sample was 179 adults (female: 76.5%, 137/179; Caucasian: 90.5%, 162/179; at least some college education: 91.1%, 163/179; mean age: 51.5 years [SD 13.1]; average pain intensity: 5/10 [SD 1.2]; back pain duration ≥5 years: 67%, 120/179). No group differences were found for any baseline variable or treatment engagement. User satisfaction ratings were higher for EaseVRx versus Sham VR (P<.001). For the between-groups factor, EaseVRx was superior to Sham VR for all primary outcomes (highest P value=.009), and between-groups Cohen d effect sizes ranged from 0.40 to 0.49, indicating superiority was moderately clinically meaningful. For EaseVRx, large pre-post effect sizes ranged from 1.17 to 1.3 and met moderate to substantial clinical importance for reduced pain intensity and pain-related interference with activity, mood, and stress. Between-group comparisons for Physical Function and Sleep Disturbance showed superiority for the EaseVRx group versus the Sham VR group (P=.022 and .013, respectively). Pain catastrophizing, pain self-efficacy, pain acceptance, prescription opioid use (morphine milligram equivalent) did not reach statistical significance for either group. Use of over-the-counter analgesic use was reduced for EaseVRx (P<.01) but not for Sham VR. CONCLUSIONS: EaseVRx had high user satisfaction and superior and clinically meaningful symptom reduction for average pain intensity and pain-related interference with activity, mood, and stress compared to sham VR. Additional research is needed to determine durability of treatment effects and to characterize mechanisms of treatment effects. Home-based VR may expand access to effective and on-demand nonpharmacologic treatment for chronic low back pain. TRIAL REGISTRATION: ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/25291.

Availability, content and quality of commercially available smartphone applications for the self-management of low back pain: a systematic assessment.

PURPOSE: Explore smartphone apps that may be recommended by clinicians for the self-management of low back pain. METHODS: Prospectively registered systematic assessment of self-contained apps for self-management of low back pain on the Google Play and Apple App stores (Oceania), including ≥1 NICE low back pain and sciatica clinical guideline-recommended component and functioning without health professional input. Outcomes were quality (Mobile App Rating Scale; MARS), and self-management (Self-Management Support Checklist; SMS-14) and behaviour change potential (App Behaviour Change Scale; ABACUS). RESULTS: 25 apps were included. The average quality of included apps was acceptable (Mean MARS score of 3.9 out of a maximum possible 5). The self-management support and behaviour change potential of included apps appeared low (mean SMS-14 score was 3.4/14; mean ABACUS score was 5.4/21). The apps showed no significant correlation between app consumer ratings and MARS scores. App quality was significantly correlated with app price (p = 0.049) but not consumer ratings, however, these findings were based on a small number of studies and the overall model was not significant. CONCLUSIONS: Smartphone apps for the self-management of low back pain are of average to good quality, with questionable potential for self-management and behaviour change. Clinicians should consider that few apps were designed to specifically incorporate self-management support and behaviour change potential when recommending apps to clients. Further development in these areas of app design would be of benefit.Implications for RehabilitationSmartphone apps have the potential to improve LBP self-management outcomes, however, apps are not well regulated and the quality of information and advice provided is often low quality.The findings from this systematic assessment indicate that LBP self-management apps have limited self-management support and behaviour change potential features.Recommendation of current smartphone apps for LBP should take into consideration that although apps are of acceptable quality they are not specifically designed with self-management support and behaviour change principles.App quality does not appear to be associated with consumer ratings, however, there may be a positive association between app price and quality which requires further investigation.

Effect of COVID-19 on management of patients with low back pain in the emergency department.

BACKGROUND: Patients presenting to Emergency Department (ED) with non-specific low back pain can receive more unnecessary, intensive and costly care than is recommended. The COVID-19 pandemic has provided an unprecedented opportunity to examine how health systems prioritise necessary care that provides clear benefits to patients. The purpose of this study was to examine the impact of COVID-19 on care of low back pain in the ED. METHODS: We performed a retrospective analysis of electronic medical record data on care for low back pain from three public hospitals in Sydney. We included patients diagnosed with spinal conditions who presented between March and May in 2019 and in 2020. Outcomes were the total number of patients presenting with spinal conditions to ED, the proportion diagnosed with non-specific low back pain, and the proportion receiving potentially unnecessary aspects of care (ambulance use, imaging, opioids, hospital admissions). We calculated relative risk with 95% CIs and examined plots with locally weighted smoothed curves. RESULTS: Presentations for spinal conditions over a three-month period to three EDs reduced from 694 in 2019 to 475 in 2020 (31% reduction, 95% CI = 26%-37%). The proportion of patients diagnosed with non-specific low back pain (83% in 2019 vs 86% in 2020), or receiving potentially unnecessary care were similar in 2019 and 2020 (Imaging = 25% vs 25%; Opioids = 54% vs 56%; Admitted = 18% vs 20%; pathology test = 24% vs 23%). The proportion of patients arriving by ambulance was higher during the pandemic; 29% in 2019 vs 41% in 2020 (RR = 1.39, 95% CI = 1.19-1.63). CONCLUSIONS: ED presentations for low back pain associated with spinal conditions decreased substantially during the COVID-19 pandemic. Use of potentially unnecessary aspects of care did not change or increased during the pandemic.

Impact of COVID-19 on utilization of nonpharmacological and pharmacological treatments for chronic low back pain and clinical outcomes.

CONTEXT: The novel coronavirus 2019 (COVID-19) pandemic has impacted the delivery of health care services throughout the United States, including those for patients with chronic pain. OBJECTIVES: To measure changes in patients' utilization of nonpharmacological and pharmacological treatments for chronic low back pain and related outcomes during the COVID-19 pandemic. METHODS: A pre-post study was conducted within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation (PRECISION Pain Research Registry) using data in the 3 months before and 3-6 months after the declaration of a national emergency related to COVID-19. Participants 21-79 years old with chronic low back pain were included in the study and provided self reported data at relevant quarterly encounters. Use of exercise therapy, yoga, massage therapy, spinal manipulation, acupuncture, cognitive behavioral therapy, nonsteroidal antiinflammatory drugs, and opioids for low back pain was measured. The primary outcomes were low back pain intensity and back related functioning measured with a numerical rating scale and the Roland Morris Disability Questionnaire, respectively. Secondary outcomes included health related quality of life scales measured with the Patient Reported Outcomes Measurement Information System, including scales for physical function, anxiety, depression, low energy/fatigue, sleep disturbance, participation in social roles and activities, and pain interference with activities. RESULTS: A total of 476 participants were included in this study. The mean age of participants at baseline was 54.0 years (standard deviation, ±13.2 years; range, 22-81 years). There were 349 (73.3%) female participants and 127 (26.7%) male participants in the study. Utilization of exercise therapy (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.23-0.57), massage therapy (OR, 0.46; 95% CI, 0.25-0.83), and spinal manipulation (OR, 0.53; 95% CI, 0.29-0.93) decreased during the pandemic. A reduction in NSAID use was also observed (OR, 0.67; 95% CI, 0.45-0.99). Participants reported a significant, but not clinically relevant, improvement in low back pain intensity during the pandemic (mean improvement, 0.19; 95% CI, 0.03-0.34; Cohen's d, 0.11). However, White participants reported a significant improvement in low back pain intensity (mean improvement, 0.28; 95% CI, 0.10-0.46), whereas Black participants did not (mean improvement, -0.13; 95% CI, -0.46 to 0.19; p for interaction=0.03). Overall, there was a significant and clinically relevant improvement in pain interference with activities (mean improvement, 1.11; 95% CI, 0.20-2.02; Cohen's d, 0.20). The use of NSAIDs during the pandemic was associated with marginal increases in low back pain intensity. CONCLUSIONS: Overall, decreased utilization of treatments for chronic low back pain did not adversely impact pain and functioning outcomes during the first 6 months of the pandemic. However, Black participants experienced significantly worse pain outcomes than their White counterparts.

Demographic Characteristics Associated With Utilization of Noninvasive Treatments for Chronic Low Back Pain and Related Clinical Outcomes During the COVID-19 Pandemic in the United States.

INTRODUCTION: This study was conducted to determine if limited access to health care during the COVID-19 pandemic impacted utilization of recommended nonpharmacological treatments, nonsteroidal anti-inflammatory drugs, and opioids by patients with chronic low back pain and affected clinical outcomes relating to pain intensity and disability. METHODS: Participants within the Pain Registry for Epidemiological, Clinical, and Interventional Studies and Innovation were eligible if they provided encounter data in the 3 months immediately before and after the national emergency proclamation date (NEPD). RESULTS: The mean age of the 528 study participants was 53.9 years and 74.1% were women. Utilization of exercise therapy, massage therapy, and spinal manipulation decreased during the pandemic. Increasing age was associated with decreased utilization of all nonpharmacological treatments except exercise therapy, and with increased opioid use during the pandemic. African American participants reported decreased utilization of yoga and spinal manipulation during the pandemic. Overall, mean change scores for pain intensity and disability before and after the NEPD were not significant. However, African American participants consistently reported worse pain intensity and disability outcomes during the pandemic. Marginally worse outcomes were observed less consistently for pain intensity with increasing age and for disability among women. DISCUSSION: Social distancing during the pandemic impacted the uptake of recommended nonpharmacological treatments for chronic low back pain that require visiting community-based facilities or interacting closely with providers. CONCLUSIONS: The pandemic threatens to exacerbate the impact of chronic low back pain, particularly among African American patients and the older population, by impeding access to guideline-informed noninvasive treatments.

Home-based fundamental approach to alleviate low back pain using myofascial release, stretching, and spinal musculature strengthening during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has caused global adoption of stay-at-home mandates in an effort to curb viral spread. This lockdown has had the unintended consequence of decreasing physical activity, and incidence of low back pain (LBP) is likely to rise as sedentary behavior increases. OBJECTIVE: In this article, we aim to provide a fundamental, novel approach to alleviate LBP including desk worker associated LBP exacerbated during the COVID-19 pandemic. METHODS: Individuals can alleviate their LBP through a simplistic, self-therapeutic approach: myofascial release and stretching of key musculature involved in LBP following a simple technique and associated time domain, as well as a 360-degree strengthening of the muscles surrounding the lower back. Additional muscular strength will support the lower back and lend resilience to aid in the mitigation of pain caused by poor work-related postural positions. RESULTS: We demonstrate several exercises and movements aimed at alleviating LBP. Additionally, we provide a summary graphic which facilitates ease of use of the exercise plan and represents a novel methodology for simple distribution of evidence-based pain reduction strategies. CONCLUSIOS: Through mitigation of sedentary behavior and adoption of the techniques described herein, LBP can be decreased and, in some cases, cured.