Effective concentration (EC50) of sevoflurane for intraocular pressure measurement in anaesthetised children with glaucoma: A dose-finding study.

Background and Aim: Sevoflurane, a preferred anaesthetic for children, exhibits a dose-dependent reduction in intraocular pressure (IOP). However, consensus is lacking regarding optimal end-tidal sevoflurane concentration for safe IOP measurement. This study aimed to identify the concentration at which IOP measurement could be attempted without inducing movements in paediatric patients after inhalational induction. Methods: Two paediatric groups (1-12 months and 12-36 months) with glaucoma undergoing examination under anaesthesia were recruited. After induction with 8% sevoflurane and 100% oxygen, the first child had an end-tidal sevoflurane concentration maintained at 2% for 4 min, followed by IOP measurement. Success was defined as 'no movement', and subsequent concentrations (adjusted in 0.2% steps) were determined using the Dixon and Massey method based on the previous patient's responses. Results: The study included 75 children. The effective concentration of sevoflurane causing 'no movement' during IOP measurement in 50% of the study population for successful IOP measurement was 1.98% (95% confidence interval [CI] 1.63, 2.17, P = 0.017) for 1-12 months group and 0.55% (95% CI 0.39, 0.66, P = 0.002) for 12-36 months group. Probit regression analysis yielded effective concentration of sevoflurane causing 'no movement' during IOP measurement in 95% of the study population values of 2.47% (95% CI 2.24, 4.58, P = 0.017) for 1-12 months group and 0.94% (95% CI 0.78, 1.57, P = 0.002) for 12-36 months group. Conclusion: In paediatric patients, a higher end-tidal sevoflurane concentration of 2% is needed for IOP measurement in 1-12 months age group compared to 0.5% required in 12-36 months age group, achieving success in 50% of the study population.

How low back pain is managed-a mixed methods study in 32 countries. Part 2 of Low Back Pain in Low- and Middle-Income Countries Series.

BACKGROUND: The Lancet Series of Low Back Pain (LBP) highlighted the lack of LBP data from low- and middle-income countries (LMICs). The study aimed to describe (1) what LBP care is currently delivered in LMICs, and (2) how that care is delivered. METHODS: An online mixed-methods study. A Consortium for LBP in LMICs (n=65) was developed with an expert panel of leading LBP researchers (>2 publications on LBP) and multidisciplinary clinicians and patient partners with five years of clinical/lived LBP experience in LMICs. Quantitative data were analyzed using descriptive statistics. Two researchers independently analyzed qualitative data using deductive and inductive coding and developed a thematic framework. FINDINGS: Forty-seven (85%) of 55 invited panel members representing 32 LMICs completed the survey (38% women; 62% men). The panel included clinicians (34%), researchers (28%), educators (6%), and patient partners (4%). Pharmacotherapies and electrophysiological agents were the most used LBP treatments. The Thematic Framework comprised of eight themes: (1) Self-management is ubiquitous; (2) Medicines are the cornerstone; (3) Traditional therapies have a place; (4) Society plays an important role; (5) Imaging use is very common; (6) Reliance on passive approaches; (7) Social determinants influence LBP care pathway; and (8) Health systems are ill-prepared to address LBP burden. INTERPRETATION: LBP care in LMICs did not consistently align with the best available evidence. Findings will help research prioritization in LMICs and guide global LBP clinical guidelines. FUNDING: The lead author's Fellowship was supported by the International Association for the Study of Pain.

To Study the Distress, Anxiety, Depression, and Sleep Effects of the COVID-19 Pandemic on Essential Workers.

Essential care workers like police personnel, social workers, and office and administrative staff of health institutions are also at increased risk of coronavirus disease 2019 (COVID-19) exposure along with healthcare workers. The present study aims to estimate the distress, anxiety, depression, and sleep impact of COVID-19 pandemic on essential workers through an online survey. This cross-sectional study (included 369 participants) was conducted in Chandigarh through an online survey using three psychological scales: Peritraumatic Distress Inventory (PDI), Insomnia Severity Index, and Depression Anxiety Stress Scale. Three-hundred-sixty-nine frontline warriors from hospital and community settings were included in the study. The respondents include police personnel (274; 73.66%), office staff (24; 6.45%), social workers (53; 14.24%), and media staff (21; 5.65%). Maximum distress was reported by media/transport officials on duty (85.7%). The majority of them scored high (>14), and slightly less than one-fourth (23.8%) scored significantly abnormal (>23) on PDI. About 42.9% reported moderate insomnia, 52.4% exhibited severe anxiety, and 33.3% of media/transport participants reported severe depression. Psychological morbidity is high in media/transport and social workers working in the community during the COVID-19 pandemic.

Effectiveness of integrated approach of yoga therapy versus usual care in management on chronic low back pain patients: A randomized controlled pilot study.

BACKGROUND: Chronic low back pain is associated with both psychological and functional limitation. Yoga therapy has been shown to improve both the aspects. The present study was planned to evaluate integrated approach of yoga therapy with usaul care. AIMS: This controlled randomized trial was done to evaluate the clinical and molecular changes resulting from integrated approach of yoga therapy (IAYT) as an adjunct regimen and compared it with usual care for the management of chronic low back pain patients. MATERIAL AND METHODS: We enrolled 29 adult patients with non-specific chronic low back pain (CLBP). Patients were randomly divided into two groups. The control group received the usual care of treatment as per institutional protocol. The yoga group received IAYT as an adjunct to usual care. Primary outcomes were pain intensity assessed by verbal numerical rating scale (VNRS) and functional ability assessed by Modified Oswestry Disability Index (MODI). Secondary outcomes were pain catastrophizing, quality of life, fear of movement related to CLBP, type of pain, levels of ß-endorphin and TNF-α, and salivary CGRP. All parameters were measured at baseline, 1 and 3 months. RESULTS: A Significant decrease in VNRS score at 1 and 3 months was observed in both the groups with the yoga group showing a more significant reduction in pain over time than the control group (p = 0.036). MODI improved significantly only in the yoga group at 1 and 3 months. Intergroup comparison revealed significantly better MODI over time in the yoga group (p < 0.001). DN4, PDQ, PCS, HADS (anxiety), and Euro QOL had a statistically significant improvement at 1 and 3 months in the yoga group compared with the control group. The HADS (depression) had a statistically significant reduction scores in the yoga group at 3 months compared with the control group (p = 0.012). There was a significant reduction in TNF-α values in the yoga group compared with baseline (p = 0.004). CONCLUSION: IAYT therapy helped in addressing the psychological components of pain and improved quality of life patients with chronic low back pain compared with usual care.

One step at a time. Shaping consensus on research priorities and terminology in telehealth in musculoskeletal pain: an international modified e-Delphi study.

BACKGROUND: Telehealth has emerged as an alternative model for treatment delivery and has become an important component of health service delivery. However, there is inconsistency in the use of terminologies and a lack of research priorities in telehealth in musculoskeletal pain. The purpose of this international, multidisciplinary expert panel assembled in a modified three-round e-Delphi survey is to achieve a consensus on research priorities and for the standard terminology for musculoskeletal pain telehealth practice. METHODS: In this international modified e-Delphi survey, we invited an expert panel consisting of researchers, clinicians, consumer representatives, industry partners, healthcare managers, and policymakers to participate in a three-round e-Delphi. Expert panels were identified through the Expertscape website, PubMed database, social media, and a snowball approach. In Round 1, potential research priorities and terminologies were presented to panel members. Panel members rated the agreement of each research priority on a 5-point Likert scale and an 11-point numerical scale, and each terminology on a 5-point Likert scale for the "telehealth in musculoskeletal pain " field over rounds. At least 80% of the panel members were required to agree to be deemed a consensus. We analyzed the data descriptively and assessed the stability of the results using the Wilcoxon matched-pairs signed rank test. RESULTS: We performed an international e-Delphi survey from February to August 2022. Of 694 invited people, 160 panel members participated in the first round, 133 in the second round (83% retention), and 134 in the third round (84% retention). Most of the panel members were researchers 76 (47%), clinicians 57 (36%), and consumer representatives 9 (6%) of both genders especially from Brazil 31 (19%), India 22 (14%), and Australia 19 (12%) in the first round. The panel identified fourteen telehealth research priorities spanned topics including the development of strategies using information and communication technology, telehealth implementation services, the effectiveness and cost-effectiveness of telehealth interventions, equity of telehealth interventions, qualitative research and eHealth literacy in musculoskeletal pain conditions from an initial list of 20 research priorities. The consensus was reached for "digital health" and "telehealth" as standard terminologies from an initial list of 37 terminologies. CONCLUSION: An international, multidisciplinary expert consensus recommends that future research should consider the 14 research priorities for telehealth musculoskeletal pain reached. Additionally, the terms digital health and telehealth as the most appropriate terminologies to be used in musculoskeletal telehealth research. REGISTER: Open Science Framework ( https://osf.io/tqmz2/ ).

Identifying Risk Factors and Health Concerns Associated With Chronic Low Back Pain Among Northern Indians: A Community-based Study.

BACKGROUND: Chronic low back pain (CLBP) is a common and significant cause of disability globally. In their lifetime, 70% to 80% of adults will have low back discomfort at some point. Even though CLBP is a very disabling disorder, information about its prevalence and associated factors is sparse in the literature. OBJECTIVES: We aimed to determine the prevalence of CLBP and its risk factors among an adult population, as well as related health concerns and health-seeking behaviors. STUDY DESIGN: Cross-sectional study. SETTING: A tertiary care setting in Chandigarh, India from November 2017 through February 2020. METHODS: Adults of either gender who provided informed consent were included in the study. Sociodemographic and CLBP awareness data were collected using a standard questionnaire. Prevalence was expressed as proportion of sample, with 95% CI. For categorical and quantitative data, the chi squared and independent t test were utilized. Logistic regression was applied to identify significant risk variables and outcomes. A P value of <= 0.05 was considered significant. RESULTS: A total of 2,847 patients were enrolled, with a mean (SD) age of 38 (14) years; 61% of them were men. These patients had a CLBP lifetime prevalence of 16% (95% CI, 15-17; 457/2,847). In addition, 62% (285/457) of these patients visited their doctor/physician more than 10 times and 23% (103/457) sought the advice of 2 physicians to treat their CLBP. Increasing age (odds ratio[OR], 1.040, 95% CI, 1.032-1.049; P < 0.001), being underweight (OR, 3.315; 95% CI, 1.494-7.359; P < 0.003) and increasing pain frequency (OR, 1.616; 95% CI, 1.139-2.293; P < 0.007) were identified as potential CLBP risks. LIMITATIONS: The study was carried out in a single tertiary hospital in northern India; hence its results cannot be extrapolated. Also, we were unable to categorize CLBP based on how severe the symptoms were, such as complaint-only or debilitating. CONCLUSION: An effective, supervised program addressing the younger productive population to maintain a healthy weight, give up smoking, and encourage an active lifestyle should be implemented. KEY WORDS: Chronic low back pain, prevalence, health concerns, risk factors, public health.

Mental health of health care workers during the hour of crisis - A study from tertiary care hospital in North India.

Background and Aims: This cross-sectional study aimed to analyze the psychosocial, behavioral, and sleep impact of coronavirus disease-19 (COVID-19) pandemic on healthcare workers (HCWs) at a tertiary-care hospital in Northern India. Materials and Methods: An online questionnaire including three psychological scales - peritraumatic distress inventory (PDI), insomnia Severity Index (ISI), and Depression anxiety stress scale was circulated among the HCWs at a tertiary-care hospital in Northern India. Results: Three hundred and ninety-six HCWs (Mean age standard deviation: 34.8 [8.1%] years; 181 females) responded. Place of posting was active COVID area (27.2%), reserve active COVID team (23.2%), trained reserve pool (29.5%), and non-COVID areas (19.9%). More than half of all the respondents (51%) had abnormal PDI score (>14) with a propensity to develop posttraumatic stress disorder. Furthermore, there was a significantly higher prevalence of abnormal PDI scores in those involved in active COVID care units (74%) versus non-COVID care unit (24%, P = 0.001). More than 60% of all the respondents had abnormal ISI score suggesting significant insomnia. Stress was seen in 71% of all the respondents while 82% were anxious and 77% participants had depressive symptoms. Hence, the psychological morbidity among the HCWs was high. Conclusion: Our study found a much higher prevalence of peritraumatic distress, insomnia, anxiety, stress, and depression among the HCWs, more so in those working in COVID areas. Factors indigenous to Indian population in terms of psychological health must be studied and addressed to reduce this psychological morbidity since the battle with COVID is long.

Cross-cultural Adaptation and Validation of Hindi Version of Roland Morris Disability Questionnaire for Chronic Low Back Pain in Indian Population.

STUDY DESIGN: A cross-cultural adaptation, validation, and psychometric analysis. OBJECTIVE: The main aim was to assess the validity and reliability of the Hindi version of the Roland Morris Disability Questionnaire (Hi-RMDQ) for chronic low back pain. SUMMARY OF BACKGROUND DATA: Roland Morris Disability Questionnaire is a standardized, self-administered tool for disability assessment in patients with chronic low back pain. However, its Hindi version has not been validated. MATERIALS AND METHODS: Cognitive debriefing was carried out with 10 patients to ensure the comprehensibility of the Hi-RMDQ. Following this, 120 patients were asked to complete the finalized questionnaire along with the modified Oswestry Disability Index Questionnaire, Quebec Back Pain Disability Score, and the Verbal Numeric Rating Scale. The patients were then asked to again fill out the finalized questionnaire after 72 hours. The internal consistency and retest reliability of the Hindi translated version of the questionnaire was tested. Its correlation with the other scores was also analyzed. RESULTS: The translated questionnaire showed excellent internal consistency (Cronbach α=0.989) and excellent retest reliability (intraclass correlation coefficient=0.978). There was a positive and statistically significant association between the Hi-RMDQ, modified Oswestry Disability Index Questionnaire ( r =0.807; P <0.01), Quebec Back Pain Disability Score ( r =0.839; P <0.01), and Verbal Numeric Rating Scale ( r =0.713; P <0.01). CONCLUSION: The Hi-RMDQ version is an easy-to-use, acceptable, reliable, and valid tool to measure disability in the Indian population with nonspecific back pain with or without leg pain. LEVEL OF EVIDENCE: 3.

Cross-Cultural Adaptation and Validation of the Hindi Version of EuroQol (EQ-5D-3L) Health Questionnaire in Patients With Chronic Low Back Pain.

OBJECTIVE: The present study is an attempt to validate the Hindi version of the EuroQoL (EQ-5D-3L) questionnaire for patients with chronic low back pain (CLBP). DESIGN: Prospective clinical study. SETTING: The study was conducted on an outpatient basis with the subjects being followed via online platform on day 3. SUBJECT: Native Indian patients above 18 years of age having CLBP who could speak and read Hindi were enrolled in the study. METHODS: This study is a cross-sectional study on 132 patients presenting with CLBP. Hi-SF-36 was used as a reference scale. Pain was evaluated using the numeric rating scale. Psychometric properties including internal consistency, test-retest reliability on day 3 and convergent validity were evaluated. Confirmation factor analysis was carried out in order to establish the relationship between the five dimensions of Hi-EQ-5D-3L and the eight domains of Hi-SF-36. RESULTS: The Cronbach alpha of 0.984 for index value and 0.944 for visual analog scale confirmed internal consistency of the Hi-EQ-5D. Intraclass correlation coefficient was found to be excellent for EQ index value (0.969, 95% CI: 0.954-0.979) and very good for visual analog scale (0.894, 95% CI: 0.844-0.928). Spearman rho correlation coefficients for the index value correlated strongly with all domains except role emotion ( r =0.181 on day 0 and r =0.239 on day 3). A good relationship between Hi-SF-36 and Hi-EQ-5D-3L was confirmed through factor analysis. CONCLUSION: The Hindi version of the EQ-5D-3L demonstrated comprehensibility, reliability and proved to be a valid instrument for the evaluation of health-related quality of life in CLBP patients.

Correlates of loneliness and dissatisfaction following SARS pandemic lockdown: Child and parent perspective.

Background Studying loneliness among children is important because it causes much social pain and is considered to be a risk factor for many mental and physical problems. Methods We did an online survey between July and September 2020 among students and their parents from a cluster of government and private schools chosen from north, south, east and west of Chandigarh. The survey consisted of child and parent versions of the Loneliness and Social Dissatisfaction Questionnaire, Parent-Child Relationship (PCR) Questionnaire and Conflict Behaviour Questionnaire SF. Parental distress was assessed using the Depression, Anxiety and Stress Scale-21. Results The majority of children and parent participants reported high loneliness and dissatisfaction among children. A significant positive association was found between children and parent reported loneliness and dissatisfaction, and between child reported PCR and parent perception of PCR. A child's appraisal of her loneliness had a significant negative association with depression among parents. Parent's perception of child loneliness and dissatisfaction was negatively associated with PCR and parental anxiety. High loner boys reported poor quality of relationship and more conflicts with their parents than girls. Children who share cordial relations with their parents had fewer conflicts and also scored low on loneliness. Conclusion These results suggest that the issue of loneliness and dissatisfaction among children has attained epidemic proportions in the Covid-19 era, and active interventions are needed to safeguard the mental health of children. Our study emphasizes the need to plan guidance strategies with a joint effort of schools and families to strengthen within family relations of children.

Opioid sparing strategies for perioperative pain management other than regional anaesthesia: A narrative review.

Opioids play a crucial role in pain management in spite of causing increased hospital morbidity and related costs. It may also cause significant risks such as postoperative nausea and vomiting (PONV), sedation, sleep disturbances, urinary retention and respiratory depression (commonly referred to as opioid related adverse effects) in postoperative patients. In order to evade these opioid related side effects and also improve pain management, multimodal analgesia i.e., combination of different analgesics, was introduced more than a decade ago. Both pharmacological and non-pharmacological techniques are available as opioid sparing analgesia. Research from around the world have proved pharmacological techniques ranging from acetaminophen, NSAIDs (non-steroidal anti-inflammatory drugs), N-methyl-D-aspartate receptor antagonists (NDMA), alpha-2 agonists, anticonvulsants such as gamma aminobutyric acid analogues, beta-blockers, capsaicin, lignocaine infusion to glucocorticoids to be effective. On the other hand, non-pharmacological methods include techniques such as cognitive behavioral therapy, transcutaneous electrical nerve stimulation (TENS), electroanalgesia, acupuncture and hypnosis. However, research regarding the effect of these non-pharmacological techniques on pain management is still needed.

Comparison of ultrasound guided pulsed radiofrequency of genicular nerve with local anesthetic and steroid block for management of osteoarthritis knee pain.

Background: To compare ultrasound-guided pulsed radiofrequency (PRF) of the genicular nerve with the genicular nerve block using local anesthetic and steroid for management of osteoarthritis (OA) knee pain. Methods: Thirty patients with OA knee were randomly allocated to receive either ultrasound-guided PRF of the genicular nerve (PRF group) or nerve block with bupivacaine and methylprednisolone acetate (local anesthetic steroid [LAS] group). Verbal numeric rating scale (VNRS) and Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) scores were measured at pre-procedure and 1-, 4-, and 12-weeks post-procedure. Results: VNRS scores decreased significantly (P < 0.001) in both the groups at 12 weeks and other follow up times compared to baseline. Seventy-three percent of patients in the PRF group and 66% in the LAS group achieved effective pain relief (≥ 50% pain reduction) at 12 weeks (P > 0.999). There was also a statistically significant (P < 0.001) improvement in WOMAC scores in both groups at all follow up times. However, there was no intergroup difference in VNRS (P = 0.893) and WOMAC scores (P = 0.983). No complications were reported. Conclusions: Both ultrasound-guided PRF of the genicular nerve and blocks of genicular nerve with local anesthetic and a steroid provided comparable pain relief without any complications. However, PRF of the genicular nerve is a procedure that takes much more time and equipment than the genicular nerve block.

Hindi Translation and Cross-cultural Validation of Child Version of Loneliness and Dissatisfaction, Parent-child Relationship and Conflict Behavior Questionnaires.

Objectives: We sought to translate the parallel forms (parent and child versions) of English versions of the Loneliness and Dissatisfaction Questionnaire (LSDQ-C), Parent Child Relationship (PCRQ-C), and Conflict Behavior Questionnaire (CBQ-C) into Hindi and evaluate their psychometric properties. Methods: Hindi translation and cross-language adaptation of LSDQ-C, PCRQ-C, and CBQ-C were done following WHO guidelines. Children aged 10-18 years old studying in either government or private schools of Chandigarh were enrolled through snowball convenient random sampling technique. Psychometric properties were assessed using intraclass correlation (ICC), Chronbach's alpha, test-retest reliability, paired t-test, and split-half reliability. Results: Item wise test-retest reliability of the Hindi version of all scales was assessed, and for most items, the ICC value was > 0.80, indicting good to excellent reliability. ICC value was in the acceptable range for a few items for the child version of the scales (0.70). Split half reliability was > 0.80. Our findings suggest good to excellent agreement between the English and Hindi version of all the scales. Conclusions: The internal consistency, split-half reliability, and test-retest reliability are good to excellent. Thus, the Hindi version of parallel forms (parent and child versions) LSDQ, PCR, and CBQ as translated in this study is a valid instrument.

Multimodal opioid sparing onco-anesthesia: A consensus practice guideline from Society of Onco-Anesthesia and Perioperative Care (SOAPC).

Opioids are an indispensable part of perioperative pain management of cancer surgeries. Opioids do have some side effects and abuse potential, and some laboratory data suggest a possible association of cancer recurrence with perioperative opioid use. Opioid-free anesthesia and opioid-sparing anesthesia are emerging new concepts worldwide to safeguard patients from adverse effects of opioids and potential abuse. Opioid-free anesthesia could lead to ineffective pain management, leaving the perioperative physician with limited options, while opioid-sparing anesthesia may be a rational approach. This consensus guideline includes general considerations of the safe use of perioperative opioids along with concomitant use of central neuraxial or regional blockade and systematic nonopioid analgesics. Region-specific onco-surgeries with their specific recommendations and consensus statements for judicious use of opioids are suggested. Use of epidural analgesia or regional catheter during thoracic, abdominal, pelvic, and lower limb surgeries and use of regional nerve blocks/catheter in head neck, neuro, and upper limb onco-surgeries, wherever possible along with nonopioids analgesics, are suggested. Short-acting opioids in small aliquots may be allowed to control breakthrough pain for expedient control of pain. The purpose of this consensus practice guideline is to provide the practicing anesthesiologists with best practice evidence and consensus recommendations by the expert committee of the Society of Onco-Anesthesia and Perioperative Care for safe opioid use in onco-surgeries.

Multidimensional dynamic healthcare personnel (HCP)-centric model from a low-income and middle-income country to support and protect COVID-19 warriors: a large prospective cohort study.

OBJECTIVES: Healthcare personnel (HCP) are at an increased risk of acquiring COVID-19 infection especially in resource-restricted healthcare settings, and return to homes unfit for self-isolation, making them apprehensive about COVID-19 duty and transmission risk to their families. We aimed at implementing a novel multidimensional HCP-centric evidence-based, dynamic policy with the objectives to reduce risk of HCP infection, ensure welfare and safety of the HCP and to improve willingness to accept and return to duty. SETTING: Our tertiary care university hospital, with 12 600 HCP, was divided into high-risk, medium-risk and low-risk zones. In the high-risk and medium-risk zones, we organised training, logistic support, postduty HCP welfare and collected feedback, and sent them home after they tested negative for COVID-19. We supervised use of appropriate personal protective equipment (PPE) and kept communication paperless. PARTICIPANTS: We recruited willing low-risk HCP, aged <50 years, with no comorbidities to work in COVID-19 zones. Social distancing, hand hygiene and universal masking were advocated in the low-risk zone. RESULTS: Between 31 March and 20 July 2020, we clinically screened 5553 outpatients, of whom 3012 (54.2%) were COVID-19 suspects managed in the medium-risk zone. Among them, 346 (11.4%) tested COVID-19 positive (57.2% male) and were managed in the high-risk zone with 19 (5.4%) deaths. One (0.08%) of the 1224 HCP in high-risk zone, 6 (0.62%) of 960 HCP in medium-risk zone and 23 (0.18%) of the 12 600 HCP in the low-risk zone tested positive at the end of shift. All the 30 COVID-19-positive HCP have since recovered. This HCP-centric policy resulted in low transmission rates (<1%), ensured satisfaction with training (92%), PPE (90.8%), medical and psychosocial support (79%) and improved acceptance of COVID-19 duty with 54.7% volunteering for re-deployment. CONCLUSION: A multidimensional HCP-centric policy was effective in ensuring safety, satisfaction and welfare of HCP in a resource-poor setting and resulted in a willing workforce to fight the pandemic.

Efficacy and Safety of Opioid Analgesics for the Management of Chronic Low Back Pain: An Evidence from Bayesian Network Meta-Analysis.

BACKGROUND: Chronic low back pain (CLBP) incurs huge costs owing to increased healthcare expenditure, disability, insurance, and work absenteeism. Opioid analgesics are commonly used for the management of CLBP. OBJECTIVE: To compare and rank the opioids used in the management of CLBP, in terms of efficacy and safety. STUDY DESIGN: Systematic review and network meta-analyses (NMA). METHOD: The search was conducted in Embase, PubMed, Cochrane databases for randomized controlled trials (RCTs) that had evaluated the efficacy and safety of opioids in CLBP. Two authors independently performed data extraction and quality assessment. The proportion of patients reporting either 30% or 50% reduction in pain from baseline to follow-up on the numeric rating scale, was measured as efficacy outcome. Pairwise meta-analyses and Bayesian NMA, within the random-effects model, were used to synthesize data. Effect estimates from Bayesian NMA were presented as odds ratio (OR) with 95% credible intervals (CrI). Heterogeneity and convergence were assessed by using I 2 and deviation information criteria. RESULTS: Twenty-three RCTs with a total of 8,420 patients, evaluating 13 different opioids were included in this NMA. For 30% pain reduction, oxymorphone (OR: 5.36; 95% CrI: 1.02-30.3), tramadol with acetaminophen (OR: 2.37; 95% CrI: 1.08-5.17), and buprenorphine (OR: 2.29; 95% CrI: 1.05-5.07) shown statistically significant more effective than placebo. For 50% pain reduction, the statistically significant difference is observed with buprenorphine (OR: 2.38 95% CrI: 1.08-5.24), oxymorphone (OR: 5.10; 95% CrI: 1.31-20.41), and tramadol with acetaminophen (OR: 2.11; 95% CrI: 1.07-4.21). Hydrocodone (OR: 0.33; 95% CrI: 0.14-0.77) was found statistically safer compared to the other opioids. LIMITATIONS: Only 5 trials had more than a 12-week study duration. We need clinical trials with longer follow-up as CLBP management requires a longer duration, and long-term prescribing of opioids associated with severe adverse event profile, development of tolerance, and dependence. CONCLUSIONS: Oxymorphone has an advantage over other opioids to reduce pain by 30% and 50% in patients with CLBP.

Psychosocial morbidity profile in a community based sample of low back pain patients.

Low back pain (LBP) is a major health concern and is closely associated with psychosocial morbidity and diminished Health-related quality of life (HRQoL). This is minimally investigated in community-based samples of developing nations like India. This study is aimed to specifically investigate the exposure-outcome associations between LBP and burden of disability (Modified Oswestry questionnaire (MODQ)), psychological morbidities (Depression, Anxiety and Stress Scale (DASS-21)), and HRQoL (Short Form -12 version 2 (SF12V2). A Cross-sectional study using a community-based sample of LBP positive population was conducted. The range of treatment options sought was also collected. Chi-square tests and independent t-test were used to analyze the data. Of 1531 recruited participants, 871(57%) were identified as LBP positive of whom 60% were females. Mean (SD) of age and pain intensity of LBP patients was 33 (11) years and numeric rating scale4.2 (2.6) respectively. Two-third reported minimal/moderate disability. Mean (SD) scores of depression 11.87 (4.05), anxiety (8.32), stress 13.7 (5.98), physical and mental summary scores of SF-12v2 were 47.9 (7.4) and 42.2 (10.4). A multitude of remedial options was sought for the ailment. LBP causes significant disability and psychological morbidity among affected population. This may adversely affect their HRQoL and subsequently productivity. Acupuncture was a preferred treatment sought by Indian LBP patients.