Pain control and functional recovery as therapeutic goals in patients with chronic musculoskeletal pain: two experiences with tapentadol hydrochloride.

OBJECTIVE: This study aimed to evaluate pain control, functioning, and quality of life (QoL) recovery in patients with chronic low back pain (cLBP) or post-traumatic osteoarthritis (OA) pain in the ankle/foot area, treated with tapentadol prolonged release and unresponsive to other treatments. PATIENTS AND METHODS: Two observational retrospective studies were conducted using clinical practice datasets of patients with chronic pain in cLBP and OA foot/ankle at different time points (total follow-up=60-90 days). The studies assessed pain intensity by the Numerical Rating Scale (NRS) pain scale (patients were classified as responder in case of ≥30% pain reduction), QoL by the 5-level EQ-5D (EQ-5D-5L) questionnaire, patient satisfaction by the 7-point Patients' Global Impression of Change (PGIC) scale; cLBP health status by the Roland Morris Disability Questionnaire (RMDQ); foot and ankle functional status by European Foot and Ankle Society (EFAS) score; and treatment-related AEs. RESULTS: For the cLBP setting, 37 patients were enrolled, of which 86.50% were classified as responders (n=32; CI: 75.5% ÷ 97.5%). For the foot/ankle OA pain setting, 21 patients were enrolled. Pain assessment at final follow-up was available only for 11 patients, of which 72.73% (n=8; CI: 39.0% ÷ 94.0%) were classified as responders. Statistically significant improvements were seen in the RMDQ, EQ-5D-5L, and PGIC scores in cLBP. Improvements in the EFAS, EQ-5D-5L, and PGIC scores were seen in OA as well. The incidence of treatment-related adverse reactions was low in both studies. CONCLUSIONS: In the study population, tapentadol prolonged release was effective and well tolerated in treating cLBP and post-traumatic foot/ankle OA chronic pain when used in a multimodal manner. The reduction in pain was accompanied by clinically relevant improvements in patients' functionality and QoL.

Chiropractic spinal manipulation and likelihood of tramadol prescription in adults with radicular low back pain: a retrospective cohort study using US data.

OBJECTIVES: Patients receiving chiropractic spinal manipulation (CSM) for low back pain (LBP) are less likely to receive any opioid prescription for subsequent pain management. However, the likelihood of specifically being prescribed tramadol, a less potent opioid, has not been explored. We hypothesised that adults receiving CSM for newly diagnosed radicular LBP would be less likely to receive a tramadol prescription over 1-year follow-up, compared with those receiving usual medical care. DESIGN: Retrospective cohort study. SETTING: US medical records-based dataset including >115 million patients attending academic health centres (TriNetX, Inc), queried 9 November 2023. PARTICIPANTS: Opioid-naive adults aged 18-50 with a new diagnosis of radicular LBP were included. Patients with serious pathology and tramadol use contraindications were excluded. Variables associated with tramadol prescription were controlled via propensity matching. INTERVENTIONS: Patients were divided into two cohorts dependent on treatment received on the index date of radicular LBP diagnosis (CSM or usual medical care). PRIMARY AND SECONDARY OUTCOME MEASURES: Risk ratio (RR) for tramadol prescription (primary); markers of usual medical care utilisation (secondary). RESULTS: After propensity matching, there were 1171 patients per cohort (mean age 35 years). Tramadol prescription was significantly lower in the CSM cohort compared with the usual medical care cohort, with an RR (95% CI) of 0.32 (0.18 to 0.57; p<0.0001). A cumulative incidence graph demonstrated that the reduced incidence of tramadol prescription in the CSM cohort relative to the usual medical care cohort was maintained throughout 1-year follow-up. Utilisation of NSAIDs, physical therapy evaluation and lumbar imaging was similar between cohorts. CONCLUSIONS: This study found that US adults initially receiving CSM for radicular LBP had a reduced likelihood of receiving a tramadol prescription over 1-year follow-up. These findings should be corroborated by a prospective study to minimise residual confounding.

The effect of long-term alendronic acid treatment on Modic changes in the lumbar spine: a gender and age-matched study.

BACKGROUND: Low back pain (LBP) affects a significant proportion of the adult population. Potent anti-resorptive drugs such as intravenous zoledronic acid have been demonstrated to reduce Modic changes (MCs) upon magnetic resonance imaging (MRI) of the spine and concomitantly decrease associated LBP. It is uncertain whether oral alendronic acid has a similar effect. METHODS: 82 subjects were recruited in this case-control study. Treatment subjects (n = 41) received oral alendronic acid treatment for at least 1-year and were matched by gender and age (± 2) to control subjects (n = 41) not receiving any anti-osteoporotic medication. The prevalence, type, and extent of MCs were quantified upon T1 and T2-weighted MRIs of the lumbosacral spine. RESULTS: Treatment subjects received oral alendronic acid for 124.0 ± 62.1 weeks at the time of MRI assessment and exhibited a lower prevalence of MCs over the lumbosacral spine (18/41 vs. 30/41, p < 0.001) as compared to control subjects. Amongst both groups, type 2 MCs were predominant. Quantification of type 2 MCs in treatment subjects revealed a significant reduction in area (113 ± 106 mm2 vs. 231 ± 144 mm2, p < 0.01) and volume (453 ± 427 mm3 vs. 925 ± 575 mm3, p < 0.01) affected by type 2 MCs in comparison to matched controls. CONCLUSION: Oral alendronic acid may be useful in the treatment of MC-associated LBP in patients with concomitant osteoporosis.

The Effect of Sedation on Diagnostic Lumbar Medial Branch Blocks for Facetogenic Low Back Pain: An Observational Study.

BACKGROUND: Lumbar medial branch blocks (MBB) are some of the most commonly performed pain procedures in the United States. Diagnostic MBBs are performed to confirm if the generator of low back pain is the facet joint. However, with diagnostic injections, false positive blocks may occur. OBJECTIVES:   Our prospective observational study aims to investigate the effects of midazolam sedation on patients' perceived intensity of pain relief following lumbar MBB. STUDY DESIGN: This is a single-center multi-site prospective observational study registered on clinicaltrials.gov (NCT04453449). SETTING: The study was approved by the Henry Ford Health System Institutional Review Board (IRB) in June 2020 (IRB# 14010) and registered on clinicaltrials.gov in July 2020 (NCT04453449). This manuscript adheres to the applicable EQUATOR STROBE guidelines for an observational cohort study. METHODS: Patients that underwent MBB without sedation were compared to sedated patients. Patients were asked to complete the Numeric Rating Scale (NRS) at baseline, one day after their diagnostic blocks, as well as 4 weeks and 8 weeks after their lumbar radiofrequency ablation (RFA). The primary outcome is the difference between baseline NRS pain scores and the lowest reported score in the 8 hours following MBB. For patients who proceed to RFA, the frequency of false positive blocks was evaluated. A patient was considered to have a false positive block when they failed to achieve 50% pain relief from RFA after 2 successful sequential MBBs. RESULTS: There was no significant difference in the NRS pain score change between the sedated and non-sedated groups for diagnostic block one (P = 0.167) and diagnostic block 2 (P = 0.6145). There was no significant difference of false positive rates between non-sedation and sedation patients at 4-weeks post-RFA (P = 0.7178) and at 8-weeks post-RFA (P = 1.000). LIMITATIONS: Some of the limitations of this study include its nonrandomized design, patient self-reported pain scores, as well as the small variability in the injection technique of proceduralists and in the anatomical location of the injection site. CONCLUSIONS: This study showed that midazolam did not change patients' perceived intensity of pain following MBB, as well as false positive rates after RFA. Larger studies are required to draw definitive conclusions.

Combined Ultrasound and Fluoroscopy versus Ultrasound versus Fluoroscopy-Guided Caudal Epidural Steroid Injection for the Treatment of Unilateral Lower Lumbar Radicular Pain: A Retrospective Comparative Study.

Background and Objectives: This study aimed to evaluate the mid-term effectiveness and safety of a combined ultrasound (US) and fluoroscopy (FL)-guided approach in comparison to US-guided and FL-guided caudal epidural steroid injections (CESI) for treating unilateral lower lumbar radicular pain. Materials and Methods: A total of 154 patients who underwent CESI between 2018 and 2022 were included. Patients were categorized into three groups based on the guidance method: combined US and FL (n = 51), US-guided (n = 51), and FL-guided (n = 52). The study design was retrospective case-controlled, utilizing patient charts and standardized forms to assess clinical outcomes, adverse events, complications during the procedures. Results: In all groups, Oswestry Disability Index and Verbal Numeric Scale scores improved at 1, 3, and 6 months after the last injection, with no significant differences between groups (p < 0.05). The treatment success rate at all time points was also similar among the groups. Logistic regression analysis showed that injection method, cause, sex, age, number of injections, and pain duration did not independently predict treatment success. Blood was aspirated before injection in 2% (n = 1), 13.5% (n = 7), and 4% (n = 2) of patients in the combined US and FL groups, FL-guided groups, and US-guided groups, respectively. Intravascular contrast spread was detected in one patient in the combined method groups and seven in the FL-guided groups. Conclusions: When comparing pain reduction and functional improvement, there was no significant difference between the three methods. The combined method took less time compared to using FL alone. The combined approach also showed a lower occurrence of intravascular injection compared to using FL alone. Moreover, blood vessels at the injection site can be identified with an ultrasound using the combined method. Given these advantages, it might be advisable to prioritize the combined US- and FL-guided therapy when administering CESI for patients with unilateral lumbar radicular pain.

Predictors of success of pharmacological management in patients with chronic lower back pain: systematic review.

BACKGROUND: Conservative management is recommended as the first therapeutic step in chronic low back pain (LBP), but there is no available evidence regarding the possible effect of patients' baseline characteristics on the therapeutic outcomes. A systematic review of the literature was performed to investigate this point. METHODS: In February 2024, all the level I studies investigating the role of pharmacological management for chronic LBP were accessed. Data concerning the patient demographic at baseline were collected: number of patients and related mean BMI and age, duration of the symptoms, duration of the follow-up, percentage of females, Numeric Rating Scale (NRS), the Roland Morris Disability Questionnaire (RMQ), Oswestry Disability Index (ODI). The outcomes at the last follow-up were evaluated through NRS, RMQ, and ODI. A multiple linear model regression diagnostic through the Pearson Product-Moment Correlation Coefficient (r) was used. RESULTS: Data from 47 articles (9007 patients) were obtained. The analysis yielded the following significant associations: age at baseline and NRS at follow-up (r = - 0.22; P = 0.04), NRS at baseline with NRS (r = 0.26; P = 0.03) and RMQ (r = - 0.58; P = 0.02) at follow-up, RMQ at baseline and the same at follow-up (r = 0.69; P = 0.0001). CONCLUSION: Older age, higher BMI, presence of comorbidities, higher ODI and a long history of symptoms or surgical treatments do not reduce the efficacy of pharmacological management of chronic LBP. However, pharmacological therapy is not an effective option for patients with high baseline RMQ. LEVEL OF EVIDENCE: I systematic review of RCTs.

[Efficiency evaluation of the Neuromidin in the treatment of pain of the patients with discogenic lumbosacral radiculopathy: results of a multicenter post-registration prospective open comparative trial]. / Otsenka effektivnosti Neiromidina pri lechenii bolevogo sindroma u patsientov s diskogennoi poyasnichno-kresttsovoi radikulopatiei: rezul'taty mnogotsentrovogo postregistratsionnogo prospektivnogo otkrytogo sravnitel'nogo issledovaniya.

OBJECTIVE: Evaluation of the effect of Neuromidine on the dynamics of pain syndrome in the treatment of patients with discogenic lumbosacral radiculopathy. MATERIAL AND METHODS: Patients with a confirmed diagnosis of discogenic lumbosacral radiculopathy no more than one year old and moderate intensity of pain syndrome on a visual analog scale were included in the main group (OH, n=62, age - 53.1±15.6 yrs) and the comparison group (HS, n=40, age - 53.7±12.9 yrs). OG patients received Neuromidine (15 mg/1 mL 1 once a day IM for 10 days, then 20 mg 3 times a day for 8 weeks) in addition to the standard drug therapy, HS patients received only standard drug therapy. The duration of the study was 8 weeks. The degree of decrease in the intensity and dynamics of pain syndrome, activity and frequency of pain in the lumbar spine, changes in the level of physical activity, and the severity of emotional disorders were evaluated. The level of inflammatory markers in the blood and the dynamics of monosynaptic spinal H-reflex parameters were evaluated. RESULTS: Before the study, there were no statistically significant differences there were no results of clinical and laboratory-instrumental examination between groups. After 8 weeks, the reduction of pain by VAS in the main group was statistically significant in contrast to the comparison group (p=0.0001). In the main group there was a statistically significant increase in the mean cognitive impairment score (p=0.0029), as well as an improvement in psycho-emotional state with a significant decrease in GAD-7 (p=0.0002) and PHQ-9 (p=0.0096). After 8 weeks of therapy, IL-6 level in the main group was statistically significantly lower (p=0.0027) than in the comparison group. The results of H-reflex study revealed an increase in its amplitude and some shortening of latency at the end of Neuromidine therapy. The drug had no undesirable side effects and was well tolerated. CONCLUSION: Administration of Neuromidine 15 mg/1 ml once a day intramuscularly for 10 days followed by 20 mg 3 times a day for 8 weeks has an effective analgesic effect as adjuvant therapy in patients with discogenic lumbosacral radiculopathy. The inclusion of Neuromidine in the complex treatment of patients with pain syndrome in discogenic radiculopathy is superior in efficacy to standard drug therapy.

Case 328.

HISTORY: A 45-year-old female patient with diffuse osteoarticular pain, particularly low back pain, was referred by a rheumatologist for an updated radiologic evaluation. The patient had experienced these symptoms for many years and was diagnosed with human leukocyte antigen B27-negative spondyloarthritis approximately 11 years prior, based on findings of bilateral erosive sacroiliitis at pelvic radiography (Fig 1A) and bone scintigraphy with technetium 99m methylene diphosphonate (Fig 1B). After 3 years of treatment with a tumor necrosis factor-α inhibitor (adalimumab), which was effective for pain, the patient was lost to follow-up. At the current presentation, approximately 8 years after being lost to follow-up, the patient presented with worsening low back pain. The presence of nonobstructing kidney stones on US images confounded the underlying cause of worsening pain. The patient also experienced fatigue and depressed mood. Routine blood tests revealed a normal blood cell count, creatinine level of 0.64 mg/dL (56.58 µmol/L) (normal range, 0.30-1.1 mg/dL [26.52-97.24 mmol/L]), C-reactive protein level of 1.1 mg/dL (normal, <1 mg/dL), and vitamin D level of 21 ng/mL (52.42 nmol/L) (normal range, 30-100 ng/mL [74.88-249.60 nmol/L]). Noncontrast MRI of the thoracic and lumbar spine (Fig 2), MRI of the sacroiliac joints (Fig 3), and CT of the abdomen and pelvis (Fig 4) were performed.

Efectividad de los protocolos de fisioterapia para pacientes con dolor lumbar crónico. Una revisión sistemática / Effectiveness of physiotherapy protocols for patients with chronic low back pain: A systematic review

Introducción: El dolor lumbar crónico es una de las principales causas de incapacidad laboral en el mundo. Requiere un abordaje interdisciplinario para la evolución del paciente. Hasta el momento, no existe consenso en el manejo del dolor lumbar crónico, lo que generó la inquietud de esta revisión sistemática. Objetivo: Identificar la efectividad de los protocolos de fisioterapia en el manejo del dolor lumbar crónico. Metodología: Se realizó una búsqueda sistemática en las bases de datos Pubmed, ScienceDirect, Scopus, Oxford, Wiley, Cochrane Library Plus, PEDro, Epistemonikos, Hinari y LILACS, Google Scholar, Teseo y PROSPERO, desde el inicio de las bases hasta agosto de 2021. Los criterios de selección se definieron según la intervención y el tema del artículo. Resultados: Se incluyeron 26 estudios en la síntesis cualitativa, se excluyeron artículos que no cumplieran con los criterios de inclusión. Se encontró efecto en el control del dolor y la disminución de la discapacidad y las principales intervenciones son: fortalecimiento muscular del Core y miembros inferiores, estiramiento de miembros inferiores, movilidad lumbopélvica y educación o escuela de espalda. La frecuencia en el tratamiento osciló entre 2 y 3 veces por semana durante 5 semanas. Conclusiones: Se encontró mayor efectividad en el tiempo de control del dolor y la disminución de la discapacidad, relacionados principalmente con el fortalecimiento muscular del Core y las estrategias educativas.(AU)

Introduction: Chronic low back pain is one of the main causes of incapacity for work in the world. It requires an interdisciplinary approach for the evolution of the patient. Until now, there is no consensus on the management of chronic low back pain, which generated the concern of this systematic review. Aim: To identify the effectiveness of physiotherapy protocols in the management of chronic low back pain. Methodology: A systematic search was carried out in the Pubmed, ScienceDirect, Scopus, Oxford, Wiley, Cochrane Library Plus, PEDro, Epistemonikos, Hinari and LILACS, Google Scholar, Teseo and PROSPERO databases, from the beginning of the databases until August, 2021. The selection criteria were defined according to the intervention and topic of the article. Results: Twenty-six studies were included in the qualitative synthesis, articles that did not meet the inclusion criteria were excluded. An effect was found in the control of pain and the reduction of disability and the main interventions are: muscular strengthening of the core and lower limbs, stretching of the lower limbs, lumbopelvic mobility and education or back school. The treatment frequency ranged from 2 to 3 times per week for 5 weeks. Conclusions: Greater effectiveness was found in pain control time and disability reduction, mainly related to core muscle strengthening and educational strategies.(AU)

Diseño de una herramienta para la clasificación de pacientes en base a su actitud farmacoterapéutica / Design of a tool for classifying patients based on their pharmacotherapeutic attitude

Introducción: la percepción y alivio del dolor exhiben variabilidad entre individuos. Edad, género, etnia, nivel educativo, nivel real de estrés, estado de ánimo o las condiciones médicas pueden modificar la interpretación personal del dolor y las respuestas al tratamiento farmacológico. Estas diferencias pueden desempeñar un papel significativo en los efectos, en ocasiones no deseados, del tratamiento analgésico.Objetivos: definir perfiles tipo de pacientes con Síndrome de Espalda Fallida ante actitudes con la enfermedad, el tratamiento, la asistencia sanitaria y el seguimiento que reciben de sus profesionales sanitarios. Crear herramienta para la identificación del perfil de paciente.Material y métodos: estudio de series de casos clínicos, observacional, descriptivo y transversal. Población de estudio: pacientes Unidad Dolor Hospital Universitario Nuestra Señora de La Candelaria (HUNSC) en Tenerife en 3 fases: recopilación datos historia clínica (F0), visita inicial (F1) y entrevista personal (F2).Resultados: se obtienen 5 tipologías de pacientes según las respuestas a 17 ítems. A partir de estas respuestas, se calculan ecuaciones de regresión para predecir el tipo de paciente. Se agrupan en: “Clásicos”, “Dependientes”, “Críticos”, “Inconscientes” y “Responsables”. Por otro lado, se obtienen dos herramientas con 17 ítems y otra con 7 ítems optimizados a fin de simplificar el proceso.Conclusiones: estas herramientas permiten a la Farmacia Comunitaria (FC) identificar a los pacientes en función de sus características con el fin de poder dirigir estrategias personalizadas para cada uno de ellos.(AU)

Relationships between the Spinal Dural Pulsations and the Short-Term Efficacy of Lumbar Epidural Steroid Injection.

Background: Lumbar spinal stenosis (LSS) causes low back pain, leg pain, numbness in the leg, and neurogenic intermittent claudication. Epidural steroid injection (ESI) has been used for treating spinal stenosis symptoms. We hypothesized that dural pulsation was variable for lumbar spinal stenosis. In cases of the presence of dural pulsation, the pain relief after the ESI was better than in the absence of dural pulsation. This study aimed at investigating the relationships between the presence or absence of spinal dural pulsations and the efficacy of ESI. Methods: A total of 71 patients were enrolled in this prospective study. Prior to the ESI, the dural pulsation was measured using a 5-1 MHz array ultrasound transducer. The visual analogue scale (VAS) score was measured pre-ESI and 2 weeks post-ESI and 4 weeks post-ESI. At 4 weeks post-ESI, dural pulsation was rechecked. Results: The VAS scores improved after the ESI procedure regardless of the presence or absence of dural pulsation. There was a correlation between the pulsation of the dura and post-ESI VAS scores. However, VAS was not significantly different for different grades of stenosis. Conclusion: The ESI was effective in patients with spinal stenosis in short-term follow-up. Dural pulsation of the spinal cord was a positive predictive factor for the ESI effect, but the grade of spinal stenosis severity had no effect on the effectiveness of ESI.

Topical Diclofenac Versus Oral Ibuprofen Versus Diclofenac + Ibuprofen for Emergency Department Patients With Acute Low Back Pain: A Randomized Study.

STUDY OBJECTIVE: Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for a variety of musculoskeletal injuries. It is not known whether topical NSAIDs should be used for patients presenting with acute nonradicular musculoskeletal low back pain. METHODS: We conducted a randomized, placebo-controlled double-blind study in which patients 18 to 69 years of age visiting the emergency department (ED) with acute, nontraumatic, nonradicular, musculoskeletal low back pain were randomized at the time of discharge to treatment with 400 mg oral ibuprofen + placebo topical gel, 1% diclofenac topical gel + oral placebo, or 400 mg ibuprofen + 1% diclofenac topical gel. We measured outcomes using the Roland Morris Disability Questionnaire (RMDQ), a 24-item yes/no instrument about the effect of back pain on a respondent's daily activities. The primary outcome was change in RMDQ score between ED discharge and 2 days later. Medication-related adverse events were elicited by asking whether the study medications caused any new symptoms. RESULTS: In total, 3,281 patients were screened for participation, and 198 were randomized. Overall, 36% of the population were women, the mean age was 40 years (standard deviation, 13), and the median RMDQ score at baseline was 18 (25th to 75th percentile: 13 to 22), indicating substantial low back-related functional impairment. In total, 183 (92%) participants provided primary outcome data. Two days after the ED visit, the ibuprofen + placebo group had improved by 10.1 (95% confidence interval [CI] 7.5 to 12.7), the diclofenac gel + placebo group by 6.4 (95% CI 4.0 to 8.8), and the ibuprofen + diclofenac gel by 8.7 (95% CI 6.3 to 11.1). The between-group differences were as follows: ibuprofen versus diclofenac, 3.7 (95% CI 0.2 to 7.2); ibuprofen versus both medications 1.4 (95% CI -2.1 to 4.9); and diclofenac versus both medications, 2.3 (95% CI -5.7 to 1.0). Medication-related adverse events were reported by 3/60 (5%) ibuprofen patients, 1/63 (2%) diclofenac patients, and 4/64 (6%) patients who received both. CONCLUSION: Among patients with nontraumatic, nonradicular acute musculoskeletal low back pain discharged from an ED, topical diclofenac was probably less efficacious than oral ibuprofen. It demonstrated no additive benefit when coadministered with oral ibuprofen.

Reinforcing informed medication prescription for low back pain in the emergency department (RIME): a controlled interrupted time series implementation study protocol.

INTRODUCTION: Management guidelines for low back pain (LBP) recommend exclusion of serious pathology, followed by simple analgesics, superficial heat therapy, early mobilisation and patient education. An audit in a large metropolitan hospital emergency department (ED) revealed high rates of non-recommended medication prescription for LBP (65% of patients prescribed opioids, 17% prescribed benzodiazepines), high inpatient admission rates (20% of ED LBP patients), delayed patient mobilisation (on average 6 hours) and inadequate patient education (48% of patients). This study aims to improve medication prescription for LBP in this ED by implementing an intervention shown previously to improve guideline-based management of LBP in other Australian EDs. METHODS AND ANALYSIS: A controlled interrupted time series study will evaluate the intervention in the ED before (24 weeks; 20 March 2023-3 September 2023) and after (24 weeks; 27 November 2024-12 May 2024) implementation (12 weeks; 4 September 2023-26 November 2023), additionally comparing findings with another ED in the same health service. The multicomponent implementation strategy uses a formalised clinical flow chart to support clinical decision-making and aims to change clinician behaviour, through clinician education, provision of alternative treatments, educational resources, audit and feedback, supported by implementation champions. The primary outcome is the percentage of LBP patients prescribed non-recommended medications (opioids, benzodiazepines and/or gabapentinoids), assessed via routinely collected ED data. Anticipated sample size is 2000 patients (n=1000 intervention, n=1000 control) based on average monthly admissions of LBP presentations in the EDs. Secondary outcomes include inpatient admission rate, time to mobilisation, provision of patient education, imaging requests, representation to the ED within 6 months and healthcare costs. In nested qualitative research, we will study ED clinicians' perceptions of the implementation and identify how benefits can be sustained over time. ETHICS AND DISSEMINATION: This study received ethical approval from the Metro North Human Research Ethics Committee (HREC/2022/MNHA/87995). Study findings will be published in peer-reviewed journals and presented at international conferences and educational workshops. TRIAL REGISTRATION NUMBER: ACTRN12622001536752.

EMERGENCY DEPARTMENT INTRAARTICULAR CORTICOSTEROID INJECTION FOR SACROILIAC JOINT DYSFUNCTION.

BACKGROUND: Sacroiliac joint (SIJ) dysfunction is a common but underrecognized source of low back pain (LBP). With provocative testing, emergency physicians can diagnose SIJ dysfunction and begin appropriate treatment in the emergency department (ED). DISCUSSION: For patients with significant pain from SIJ dysfunction, ultrasound-guided SIJ injection of anesthetic and corticosteroid can reduce patients' pain considerably. CONCLUSIONS: For patients who are good candidates for SIJ injection, emergency physicians can begin treatment in the ED, before the patient follows up with a specialist.

Techniques in medicine: ipsilateral transforaminal epidural steroid injection in Bertolotti's syndrome.

Bertolotti's syndrome, also known as lumbosacral transitional vertebrae, is a relatively rare spinal condition characterized by an anatomical variation in the lower spine. Conservative approaches such as physical therapy, anti-inflammatory medications and lifestyle modifications may be recommended for mild cases. In more severe cases or when conservative measures fail to provide relief, injections such as may be considered to alleviate pain. This case is unique in that we document a challenging technique of ipsilateral transforaminal epidural steroid injection in a patient with Bertolotti's syndrome.

What a pain in the back: a review of current treatment options with a focus on naproxen sodium.

Non-specific low back pain (LBP) represents a challenging and prevalent condition that is one of the most common symptoms leading to primary care physician visits. While established guidelines recommend prioritizing non-pharmacological approaches as the primary course of action, pharmacological treatments are advised when non-pharmacological approaches are ineffective or based on patient preference. These guidelines recommend non-steroidal anti-inflammatory drugs (NSAIDs) or skeletal muscle relaxers (SMRs) as the first-line pharmacological options for acute or subacute LBP, while NSAIDs are the exclusive first-line pharmacological option for chronic LBP. Although SMRs are generally effective for acute LBP, the available evidence does not support the view that they improve functional recovery, and their comparative efficacy to NSAIDs and other analgesics remains unknown, while studies have shown them to introduce adverse events without significantly reducing LBP. Moreover, opioids continue to be widely prescribed for LBP, despite limited evidence for effectiveness and known risks of addiction and overdose. Broader use of non-opioid pharmacotherapy, including the appropriate use of OTC options, is critical to addressing the opioid crisis. The balance of evidence indicates that NSAIDs have a favorable benefit-risk profile when compared to other available pharmacological treatment options for non-specific LBP, a condition that is primarily acute in nature and well-suited for self-treatment with OTC analgesics. While clinical guidelines do not differentiate between NSAIDs, evidence indicates that OTC naproxen sodium effectively relieves pain across multiple types of pain models, and furthermore, the 14-h half-life of naproxen sodium allows sustained, all day pain relief with reduced patient pill burden as compared to shorter acting options. Choosing the most appropriate approach for managing LBP, including non-pharmacological options, should be based on the patient's condition, severity of pain, potential risks, and individual patient preference and needs.

Targeting the endocannabinoid system for the management of low back pain.

Low back pain (LBP) is a major unmet clinical need. The endocannabinoid system (ECS) has emerged as a promising therapeutic target for pain, including LBP. This review examines the evidence for the ECS as a therapeutic target for LBP. While preclinical studies demonstrate the potential of the ECS as a viable therapeutic target, clinical trials have presented conflicting findings. This review underscores the need for innovative LBP treatments and biomarkers and proposes the ECS as a promising avenue for their exploration. A deeper mechanistic understanding of the ECS in LBP could inform the development of new pain management strategies.

La actividad de la artritis psoriásica con afectación axial se correlaciona con el PsAID12 / The activity of psoriatic arthritis with axial involvement correlates with the PsAID12

Objetivo: Determinar el impacto de la enfermedad en pacientes con artritis psoriásica (APs) en la práctica clínica diaria, y evaluar su relación con la actividad axial.Métodos: Se realizó un estudio transversal multicéntrico en pacientes consecutivos vistos desde enero 2021 hasta diciembre 2021 que cumplieron con los criterios CASPAR, con clínica dolor lumbar inflamatorio y prueba de imagen positiva, con o sin afectación periférica. También se recogieron datos demográficos, clínicos, analíticos, índice Health Assessment Questionnaire, PsAID12 e índices de actividad axial (BASDAI y ASDAS-PCR). Se dividió a los pacientes en 2 grupos según el alto o bajo impacto del cuestionario PsAID. Las variables continuas se mostraron como mediana (Q1-Q3) y las categóricas como porcentajes y frecuencias. Resultados: Se incluyeron 72 pacientes con afectación axial de los 269 evaluados con APs, 40 varones (55,6%), con una mediana de edad de 54,1 años y duración de la enfermedad de 7 años. El 28,3% de los pacientes eran obesos y el nivel sérico de PCR fue de 0,45mg/dl (0,08-1,10). El BASDAI fue de 4,2 (2,0-6,2) y el ASDAS-PCR de 2,4 (1,5-3,2), estando en baja actividad o remisión el 39,6%. La mediana de la puntuación total de PsAID fue de 3,9 (1,6-5,4), evaluado en 61 pacientes. Los pacientes que alcanzaron un PsAID12≤4 fueron el 63%, predominantemente varones, presentaron valores de PCR menores y se asoció a una menor puntuación de BASDAI y ASDAS-PCR. Conclusiones: Los pacientes con afectación axial reflejaban un bajo impacto de la enfermedad medido por PsAID12 y este se correlacionaba con baja actividad medido por BASDAI y el ASDAS-PCR.(AU)

Objective: To determine the impact of the disease in patients with PsA in daily clinical practice and to evaluate its relationship with its axial activity. Methods: A cross-sectional study was conducted in consecutive patients attended from January 2021 to December 2021 who met the CASPAR criteria, with clinical of inflammatory back pain and positive axial imaging, with or without peripheral involvement. Demographic, clinical, analytical data, HAQ index, PsAID12 and activity index (BASDAI and ASDAS-PCR) were also collected. Patients were divided into two groups, those with high impact and those with low impact according to PsAID results. Continuous variables are shown as median (Q1-Q3) and categorical variables as percentages and frequencies. Results: Of the 269 patients evaluated with PsA, 72 patients with axial involvement were included, 40 men (55.6%), with a median age of 54.1 years and disease duration of 7 years. 28.3% of the patients were obese and serum CRP level was 0.45mg/dl (0.08-1.10). BASDAI was 4.2 (2.0-6.2) and ASDAS-PCR was 2.4 (1.5-3.2), which translates into 39.6% of patients in low activity or remission. The median PsAID total score was 3.9 (1.6–5.4), evaluated in 61 patients. The patients who achieved a PsAID12≤4 were 63%, mostly men and with lower CRP levels than PsAID≥4 patients. In addition, low impact measured by the PsAID12 was associated with low results in BASDAI and ASDAS-PCR. Conclusions: Axial involvement reflected lower impact of the disease measured by PsAID12 and it is correlated with low activity measured by BASDAI and ASDAS-PCR.(AU)

A randomized controlled trial: The efficacy and safety of Bushen Huoxue formula in the management of lower back pain from lumbar disc herniation.

BACKGROUND: Lower back pain (LBP) arising from lumbar disc herniation (LDH) poses a challenging health issue, often necessitating therapeutic interventions. Bushen Huoxue formula (BSHXF) has proved as a potential treatment option with great clinical effect. However, comprehensive investigations into its efficacy and safety in conjunction with celecoxib for managing LBP from LDH are lacking. The objective of this article is to investigate the efficacy and safety of BSHXF in the management of patients with LBP from LDH. METHODS: This single center, randomized clinical trial was conducted from March 2023 to September 2023 and all patients suffered from LBP of LDH. Participants were randomly assigned to the BSHXF group (celecoxib and BSHXF) or the control group (celecoxib and placebo). The patients received treatment for 2 weeks. Assessment was conducted before treatment, the last day of the treatment, 4 weeks and 8 weeks after the treatment. Oswestry Disability Index (ODI), Visual Analog Scale (VAS), Roland-Morris Disability Questionnaire (RMDQ), Timed up and go test (TUGT), trunk range of movement (Trunk ROM), Hospital Anxiety and Depression Scale (HADS) were used for the evaluation. RESULTS: A total of 206 subjects completed treatment, among whom 104 participants were randomized to the BSHXF group and 102 participants were randomized to the control group. There were no significant differences between groups in terms of the observed indicators (P > .05). After treatment, patients in BSHXF group obtained significant lower scores at 2-week, 4-week, 8-week of VAS, ODI, RMDQ, TUGT, Trunk ROM and HADS than the baseline data (P < .05). The ODI score was significantly lower than the control group at 2-week, 4-week, 8-week (2w: 11.30 ±â€…5.80 vs 14.23 ±â€…6.33, P < .001; 4w: 10.95 ±â€…4.93 vs 13.54 ±â€…6.35, P < .001; 8w: 10.27 ±â€…5.25 vs 12.84 ±â€…6.57, P = .002). Similarly, the scores of VAS, RMDQ, TUGT, Trunk ROM scores of the BSHXF group markedly decreased at 2, 4, and 8-week when compared to their control group (P < .05). Furthermore, no significant difference showed up in the score of HADS between the between the BSHXF and the control group after treatment (P > .05). CONCLUSION: This randomized clinical trial found that BSXHF can help significantly improve the clinical outcomes of celecoxib including pain intensity reduction and lumbar function improvement in LBP patients.