Articles: low-back-pain.
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The 0 to 10 numeric rating scale of pain intensity is a standard outcome in randomized controlled trials (RCTs) of pain treatments. For individuals taking analgesics, there may be a disparity between "observed" pain intensity (pain intensity with concurrent analgesic use) and pain intensity without concurrent analgesic use (what the numeric rating scale would be had analgesics not been taken). Using a contemporary causal inference framework, we compare analytic methods that can potentially account for concurrent analgesic use, first in statistical simulations, and second in analyses of real (non-simulated) data from an RCT of lumbar epidural steroid injections. ⋯ We propose alternative methods that should be considered in the analysis of pain RCTs. PERSPECTIVE: This article presents the conceptual framework behind a new quantitative pain and analgesia composite outcome, the QPAC1.5, and the results of statistical simulations and analyses of trial data supporting improvements in power and bias using the QPAC1.5. Methods of this type should be considered in the analysis of pain RCTs.
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Randomized Controlled Trial
Amoxicillin did not Reduce Modic Change Oedema in Patients with Chronic Low Back pain - subgroup Analyses of a Randomised Trial (the AIM study).
Exploratory subgroup analyses of a randomised trial [Antibiotics in Modic changes (AIM) study]. ⋯ 2.
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Lumbar disc herniation (LDH) is a global issue associated with potentially debilitating long-term consequences, including chronic low back pain (LBP). Short-term outcomes (<2 years) of patients with LDH have been extensively studied and demonstrate improvements in back and leg pain for both operative and conservative management. However, these improvements may not be sustained long-term (>2 years); patients with LDH may develop recurrent disc herniations, progressive degenerative disc disease, and LBP regardless of management strategy. Therefore, our objective is to determine the prevalence of chronic LBP after LDH, understand the relationship between LDH and chronic LBP, and investigate the relationship between radiological findings and postoperative pain outcomes. ⋯ Patients with LDH are more likely to experience long-term LBP compared to the general population (46.2% vs. 11.9%). Additionally, understanding the relationship between radiological findings and pain outcomes remains a major challenge as the presence of radiological changes and the degree of LBP do not always correlate. Therefore, higher quality studies are needed to better understand the relationship between radiological findings and pain outcomes.
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Observational Study
The slow de-implementation of non-evidence-based treatments in low back pain hospital care - trends in treatments using Dutch hospital register data from 1991 to 2018.
Low back pain (LBP) is the leading cause of disability worldwide and has an excessive societal burden. Accumulating evidence has shown that some medical approaches such as imaging in absence of clear indications, medication and some invasive treatments may contribute to the problem rather than alleviating it. ⋯ Medically intensive approaches to low-back pain care contribute to the high societal burden of this disease. There have been calls to avoid such care. Using Dutch hospital data, we showed that de-implementation of five non-recommended hospital low-back pain treatments, if at all, took several decades (i.e. ≥17 years) after availability of evidence and guidelines. Slow de-implementation has likely resulted in considerable waste of resources and avoidable harm to hospital patients; better ways for de-implementation of non-evidence-based care are needed.
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Previously, we observed that B cells and autoantibodies mediated chronic nociceptive sensitization in the mouse tibia fracture model of complex regional pain syndrome and that complex regional pain syndrome patient antibodies were pronociceptive in fracture mice lacking mature B cells and antibodies (muMT). The current study used a lumbar spinal disk puncture (DP) model of low back pain in wild-type (WT) and muMT mice to evaluate pronociceptive adaptive immune responses. Spinal disks and cords were collected 3 weeks after DP for polymerase chain reaction and immunohistochemistry analyses. ⋯ Serum collected from WT DP mice and injected into muMT DP mice caused nociceptive sensitization, as did intrathecal injection of IgM collected from WT DP mice, and IgM immune complexes were observed in lumbar spinal disks and cord of WT DP mice. Serum from WT tibia fracture mice was not pronociceptive in muMT DP mice and vice versa, evidence that each type of tissue trauma chronically generates its own unique antibodies and targeted antigens. These data further support the pronociceptive autoimmunity hypothesis for the transition from tissue injury to chronic musculoskeletal pain state.