Pulsed Radiofrequency As a Surgical Free Approach To Low Back Pain

MedicalResearch.com Interview with:
Dr. Alessandro Napoli

Dipartimento di Scienze Radiologiche
Unità di Terapia con Ultrasuoni Focalizzati
Sapienza Università di Roma, Policlinico Umberto I
Rome

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Low back pain and sciatica are very common conditions affecting at least 80% of the population (once in life) with detrimental impact on quality of life. Pain cause is often a lumbar disc herniation with sciatic nerve compression. Treatment strategy is primarily conservative (drugs and physical therapy) and when symptoms are persisting for more than 4 consecutive weeks, surgery is advocated.

Many patients prefer to avoid surgery for multiple reasons (recurrence rate, risk-related to the intervention and post-surgical sequela).

Technology advances with percutaneous techniques allowed more recently to fill the gap between conservative strategy and surgery for the management of lumbar disc herniation and related low back pain extending to the leg(s). Patients are offered local injection for symptoms relief with limited results. Therefore, other non-to-mini invasive approaches are clinically tested for prolonged clinical efficacy. Pulsed radiofrequency is a promising percutaneous approach mainly used for chronic pain. We aimed to test pulsed radiofrequency in patients refractory to conservative treatments, indicated to surgery.

Our study demonstrated that radiofrequency with pulsed technique, performed under CT image guidance, is able to control pain in a surgical-free, single session, lasting 10 minutes. The procedure is highly attractive since can be considered nearly risk-free with high rate of success. In our series 80% of patients treated with pulsed radiofrequency resulted pain free (VAS pain score 0 out of 10) at 1, 3 and 12 months follow-up; 90% did not required anymore surgery.

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Yoga May Reduce Disability and Opioid Use In Veterans With Chronic Low Back Pain

MedicalResearch.com Interview with:

Erik Groessl PhD Associate Adjunct Professor Family Medicine and Public Health University of California, San Diego

Dr. Groessl

Erik Groessl PhD
Associate Adjunct Professor
Family Medicine and Public Health
University of California, San Diego

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Chronic low back pain (cLBP) is prevalent among military veterans, but cLBP treatment options have limited benefits and side effects. This has resulted in efforts to reduce opioid use and embrace nonpharmacological pain treatments.

Yoga has been shown to improve health outcomes and have few side effects in non-veteran community samples.

Our objective was to study the effectiveness and safety of yoga for military veterans with chronic low back pain.  In a study of 150 veterans with cLBP, we found that yoga participants had greater reductions in disability and pain than those receiving usual. Opioid medication use declined among all participants, and no serious side effects occurred.

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Evidence Does Not Support Gabapentinoids in Non-Specific Chronic Low Back Pain

MedicalResearch.com Interview with:

Harsha Shanthanna MBBS, MD, MSc Associate Professor, Anesthesiology Chronic Pain Physician St Joseph's Healthcare,McMaster University Hamilton, Canada Diplomate in National Board, Anesthesiology (India) Fellow in Interventional Pain Practice (WIP) European Diplomate in Regional Anesthesia and Pain (ESRA)

Dr. Shanthanna

Harsha Shanthanna MBBS, MD, MSc
Associate Professor, Anesthesiology
Chronic Pain Physician
St Joseph’s Healthcare,McMaster University
Hamilton, Canada
Diplomate in National Board, Anesthesiology (India)
Fellow in Interventional Pain Practice (WIP)
European Diplomate in Regional Anesthesia and Pain

MedicalResearch.com: What is the background for this study?

Response: Pregabalin (PG) and gabapentin (GB) are increasingly used for nonspecific Chronic Low Back Pain (CLBP) despite a lack of evidence. There have been concerns expressed over their increased prescribing for various non cancer pain indications in recent years. Their use requires slow titration to therapeutic doses and establishing maintenance on a long-term basis. With prolonged treatment, the potential gain over possible adverse effects and risks could become unclear.

We searched Cochrane, MEDLINE and EMBASE databases for randomized control trials reporting the use of gabapentinoids for chronic lower back pain treatment of 3 months or more in adult patients.

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JAMA Study Finds Radiofrequency For Treating Chronic Low Back Pain

MedicalResearch.com Interview with:

Esther Maas, PhD Postdoctoral Research Fellow Partnership for Work, Health and Safety School of Population and Public Health University of British Columbia Vancouver, BC 

Dr. Maas

Esther Maas, PhD
Postdoctoral Research Fellow
Partnership for Work, Health and Safety
School of Population and Public Health
University of British Columbia
Vancouver, BC 

MedicalResearch.com: What is the background for this study?

Esther Maas, PhD Chronic low back pain causes more disability than any other condition, and has major social and economic consequences. Radiofrequency denervation is a commonly used treatment in pain clinics for a subgroup of patients with chronic low back pain resulting from anatomical structures such as facet joints, sacroiliac joint and intervertebral disc. Radiofrequency denervation uses an electric current that damages the innervating nerve of the painful structure. Despite its frequent application, until now, there was only very low quality and conflicting evidence for its effectiveness. The aim of this study was to establish whether radiofrequency denervation in addition to a standardized exercise program is more effective than the standardized exercise program alone in the selected subgroup of patients with chronic low back pain.

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Electroacupuncture Reduced Leakage in Stress Urinary Incontinence

MedicalResearch.com Interview with:
Baoyan Liu, MD
Guang’an Men Hospital
China Academy of Chinese Medical Sciences
Beijing, China

Patient with Electroacupuncture

Patient with Electroacupuncture

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: The prevalence of stress urinary incontinence(SUI) is as high as 49% and varies according to the population studied and the definition of stress urinary incontinence.

SUI causes psychological burden, affects relationships, lowers physical productivity, and decreases quality of life in women. Yet, few effective therapies are available for treating stress urinary incontinence.

In this randomized clinical trial that included 504 women, the mean decrease in urine leakage, measured by the 1-hour pad test from baseline to week 6, was 9.9 g with
electroacupuncture vs 2.6 g with sham electroacupuncture, a significant difference.

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Yoga As Effective As Physical Therapy For Chronic Low Back Pain

MedicalResearch.com Interview with:

Robert B. Saper, MD, MPH Department of Family Medicine Boston Medical Center Boston, MA

Dr. Saper

Robert B. Saper, MD, MPH
Department of Family Medicine
Boston Medical Center
Boston, MA

MedicalResearch.com: What is the background for this study?

Response: There are a number of studies that show that yoga is effective for chronic low back pain (cLBP), but those studies included mostly white and middle-class individuals as research participants. cLBP disproportionately impacts those who are economically disadvantaged and minorities; they receive less referrals to specialists, less referrals to rehabilitation, and also less patient-education. Therefore, it was important to test whether yoga would be well- received by an underserved population, as well as be an effective form of treating chronic low back pain.

This study consisted of patients from diverse racial and economic backgrounds with multiple medical problems who were able to successfully participate and benefit from both yoga and physical therapy. This study used yoga classes that were specifically designed for people suffering from  chronic low back pain and compared the results of that treatment to those who did physical therapy.

MedicalResearch.com: What are the main findings?

Response: The results show that the yoga was as effective as physical therapy for reducing pain intensity and improving people’s physical function. Patients in the study who did yoga reported that their overall pain intensity went down, that they were able to be more physically active, and a number of patients were also able to reduce or even stop all of their pain medication. The study shows that when yoga is made available and affordable to a diverse population, people of both sexes, people who are disabled, and people of different races and economic backgrounds are both receptive to yoga and, more importantly, can benefit from it.

MedicalResearch.com: What should readers take away from your report?

Response: Doctors should know that a structured yoga program for cLBP is a reasonable, effective, and safe approach for patients with chronic  chronic low back pain. Patients with cLBP should talk with their doctors about different options for treatment of back pain, starting with non-drug approaches like yoga and physical therapy. Policy makers need to examine the potential benefits for patients and cost savings for covering non-pharmacological approaches to pain.

MedicalResearch.com: What recommendations do you have for future research as a result of this study?

Response: The cost effectiveness of yoga and physical therapy for chronic low back pain still needs to be looked at carefully, as well as how the medical community can implement yoga classes for back pain widely.

While medication, imaging and invasive procedures absolutely have their place, research and clinical guidelines show that non-pharmacological procedures as first treatment options may be best.

MedicalResearch.com: Is there anything else you would like to add?

Response: Yoga is increasingly popular in the United States, and many yoga teachers are available in urban areas. However, yoga teachers and yoga classes are still relatively rare in communities of color and disadvantaged areas. Therefore, it’s important that we begin to train, build, and make yoga more available to diverse communities. Changing the common view of yoga from a fitness exercise for the healthy and wealthy, to a therapeutic approach for people with chronic pain and other conditions, is also an ongoing challenge.

Finding that yoga is non-inferior to physical therapy makes a strong case that yoga programs like the one in this study should be covered by insurance and offered by health care facilities. When a therapy like yoga is shown to be as effective as standard therapies, it should be made available to everyone regardless of ability to pay. For patients who attended more classes or physical therapy sessions, their cLBP improvement was even greater.

MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.

Citation:

Saper RB, Lemaster C, Delitto A, Sherman KJ, Herman PM, Sadikova E, et al. Yoga, Physical Therapy, or Education for Chronic Low Back Pain: A Randomized Noninferiority Trial. Ann Intern Med. [Epub ahead of print 20 June 2017] doi: 10.7326/M16-2579

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

 

 

 

Statins Users May Have Higher Likelihood of Back Disorders

MedicalResearch.com Interview with:

Una Makris MD, MSc Clinical Investigator at the VA North Texas Health System Assistant Professor at UT Southwestern Medical Center Departments on Internal Medicine and Clinical Sciences

Dr. Makris

Una Makris MD, MSc
Clinical Investigator at the VA North Texas Health System
VA North Texas Health Care System
Assistant Professor at UT Southwestern Medical Center
Departments on Internal Medicine and Clinical Sciences
Dr. Makris is a Rheumatologist, clinically, and spends the majority of time focused on clinical research investigating how to improve outcomes for adults with back pain.

MedicalResearch.com: What is the background for this study?

Response: Back pain is the most common type of musculoskeletal (MSK) pain. We know that expenditures for back pain exceed $100 billion each year (and this was in 2005). Back pain results in tremendous disability (including reduced mobility) and impaired quality of life (not exclusive to physical consequences, but also including important psychosocial repercussions). We also know that statins are prescribed very often, and frequently in younger populations who are active. Some reports suggest that statins may have a protective effect on  musculoskeletal conditions such as back pain.

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Modest Effect of Spinal Manipulation For Back Pain

MedicalResearch.com Interview with:

Paul Shekelle, MD PhD MPH Chief of General internal Medicine VA Greater Los Angeles Healthcare System

Dr. Shekelle

Paul Shekelle, MD PhD MPH
Chief of General internal Medicine
VA Greater Los Angeles Healthcare System

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Back pain is one of the commonest symptoms for adult patients to seek health care. For a number of years now, VA has had chiropractic care integrated into the ambulatory care available at many large VA medical centers. Most patients referred from VA primary care to chiropractic clinic have chronic back pain. VA was interested in an evidence synthesis of the use of spinal manipulative therapy in acute low back pain. Spinal manipulative therapy is a manual technique delivered by almost all chiropractors, but also delivered by some physical therapists, osteopathic physicians, and some medical doctors.

The main findings are that spinal manipulative therapy is associated with, on average, a modest beneficial effect on pain and function. However, there are large difference sin outcome across studies, and this suggests that some patients may respond much better, and other may respond not at all.

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Stress Reduction and Cognitive Therapy Have Long Lasting Effect on Low Back Pain

MedicalResearch.com Interview with:

Dan Cherkin PhD Emeritus Senior Investigator Group Health Research Institute Seattle, WA 98101

Dr. Dan Cherkin

Dan Cherkin PhD
Emeritus Senior Investigator
Group Health Research Institute
Seattle, WA 98101

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We previously reported the results of a randomized trial examining the effectiveness of Mindfulness-based stress reduction (MBSR) and cognitive behavioral therapy (CBT) for persons with chronic low back pain (Cherkin et al, JAMA, March 22, 2016).

The current report examines whether the relative effectiveness of these approaches compared with usual care that we found after one year were still evident after two years. We found that there was little decrease in the magnitude of the effects of both MBSR and CBT between one and two years, but the two-year outcomes were statistically significant only for chronic low back pain. As previously reported for outcomes up to one year, there were no significant differences in outcomes between CBT and MBSR.

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NSAIDS Have Minimal Effect On Back Pain and Risk GI Side Effects

MedicalResearch.com Interview with:

Dr. Gustavo Machado BPhty (Hons) Cert.MDT The George Institute for Global Health Sydney Medical School, University of Sydney Sydney, New South Wales, Australia

Dr. Gustavo Machado

Dr. Gustavo Machado BPhty (Hons) Cert.MDT
The George Institute for Global Health
Sydney Medical School, University of Sydney
Sydney, New South Wales, Australia

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: People with back pain are usually told by their health care practitioners to take analgesic medications to relieve their pain. But our previous research published in the BMJ showed that paracetamol does not have a measurable impact on patient’s symptoms. This resulted in recent changes in guidelines’ recommendations. The 2017 National Institute for Health and Care Excellence (NICE) guidelines/UK no longer recommend paracetamol as a stand-alone intervention for back pain.

So now non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the analgesic of first choice. However, our results show that compared to placebo, commonly used NSAIDs, such as Ibuprofen (e.g. Nurofen) and Diclofenac (e.g. Voltaren), provide only small benefits for people with back pain while increasing the risk of gastrointestinal adverse effects by 2.5 times.

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Exercise and Education Prevent Back Pain, Devices Do Not

Daniel Steffens, Ph.D. The George Institute for Global Health The University of SydneyMedicalResearch.com Interview with:
Daniel Steffens, Ph.D.
The George Institute for Global Health
The University of Sydney

Medical Research: What is the background for this study?

Dr. Steffens: Back pain is a leading cause of disease burden globally. At present, a variety of interventions, such as exercise, education, back belts and shoe insoles, are commonly prescribed to prevent an episode of low back pain. Guidelines lack clear recommendations for prevention of low back pain and the effectiveness of the range of possible prevention strategies for low back pain is not clear. Our study aimed to investigate the effectiveness of these interventions for prevention of low back pain.
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Back Pain: Early Imaging Of Older Adults Results in More Costs, Not Better Outcomes

Jeffrey (Jerry) G. Jarvik MD MPH Professor, Radiology, Neurological Surgery and Health Services Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA  98104-2499MedicalResearch.com Interview with:
Jeffrey (Jerry) G. Jarvik MD MPH
Professor, Radiology, Neurological Surgery and Health Services
Adjunct Professor, Pharmacy and Orthopedics & Sports Medicine
Director, Comparative Effectiveness, Cost and Outcomes Research Center University of Washington Seattle, WA

Medical Research: What is the background for this study?

Dr. Jarvik: 
When I arrived at the Univ of WA over 20 years ago, my mentor, Rick Deyo, had just finished leading a project that was responsible for developing one of the first set of guidelines for the diagnosis and treatment of acute low back pain. These guidelines, published in a booklet by AHRQ (then called AHCPR), recommended that patients with acute low back pain not undergo imaging for 4-6 weeks unless a red flag was present. One of the exceptions was that patients older than 50 could get imaged immediately, the rationale being that older adults had a higher prevalence of potentially serious conditions such as cancer, infections, etc, that would justify the early imaging. As a practicing neuroradiologist, it was clear that a potential problem with this strategy is that the prevalence of age-related changes, which may or may not be related to back pain, also increases with age. So earlier imaging of older adults would almost certainly reveal findings, and these could easily start a series of unfortunate events leading to potentially poor outcomes and more healthcare resource use. Thus this policy of early imaging of older adults didn’t entirely make sense.

About 5 years ago, these guidelines hit home when I developed acute low back pain and since I was over 50 (barely) my doctor recommended that I get an imaging study. Being a knowledgeable patient and having a reasonable doctor, we mutually agreed not to get the study. I improved but that wasn’t the end of it. When we had the chance to apply for one of the CHOICE ARRA awards funded by AHRQ, we made answering this question of early imaging in older adults one of our primary goals.

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Back Pain? Which Sex Position is Best?

MedicalResearch.com Interview with:
Natalie Sidorkewicz, MSc (Kin) PhD (HSG) Student
Spine Biomechanics Laboratory
School of Public Health and Health Systems, Faculty of Applied Health Sciences
University of Waterloo
Waterloo, ON

Medical Research: What are the main findings of the study?

Answer: First, we successfully documented male spine motion and muscle activity during sex — this biomechanics study was the first of its kind.

Second, we used this data to develop general recommendations for low back pain patients whose pain is worsened by motions and postures. The general recommendations focus on changing how people move, and position themselves during sex. To make any sex position more spine-sparing, we recommend that the individual controlling the movement use their hips and knees more than their spine and that the individual not controlling the movement maintain a more neutral-spine position. An excellent working example is one of the sex positions that we studied: the missionary position. The man, who is controlling the movement with pelvic thrusting, is recommended to do so with more hip and knee movement than spine movement. The women, who is lying on her back, is recommended to use a back support placed underneath the natural curve of her spine to maintain a more neutral spine position. The general recommendations can be applied to any sex position for both men and women.

Finally, we developed specific guidelines for men whose back pain is worsened by two specific types of motion: flexion and extension. If a man’s low back pain is worsened by spine flexion movements, such as touching their toes or sitting for long periods of time, we would consider them to be flexion-motion-intolerant. The ideal sex position for a flexion-motion-intolerant patient would then be one that uses minimal spine flexion, so as not to worsen that patient’s pain. When we compared the five sex positions, we found that men used the least amount of spine flexion in doggy-style as well as the missionary position as long as the male was propped up on his hands (as opposed to his elbows).

If a man’s low back pain is worsened by spine extension movements, such as arching their back or lying on their stomach, we would consider them to be extension-motion-intolerant. The ideal sex position for an extension-motion-intolerant patient would then be one that uses minimal spine extension, so as not to worsen the patient’s pain. When we compared the five sex positions, we found that men used the least amount of spine extension in spooning and the missionary position as long as the male was propped up on his elbows (as opposed to his hands).
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Acetaminophen (Paracetamol) No Better than Than Placebo For Back Pain

MedicalResearch.com Interview with:
R Chris Williams PhD
Honorary Fellow, Musculoskeletal Division
The George Institute for Global Health
Sydney NSW 2000 Australia

Medical Research: What are the main findings of the study?

Dr. Williams: We found that in addition to advice and reassurance, ‘regular’ or ‘as needed’ paracetamol did not improve recovery time for people with low back pain, compared to placebo. We also found the pain intensity and a range of other relevant measures, such as patient’s physical function was not different between the treatment groups.

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Low Back Pain: Most Common Cause of Global Disability

Dr Damian Hoy University of Queensland School of Population Health Herston, AustraliaMedicalResearch.com Interview with:
Dr Damian Hoy
University of Queensland
School of Population Health
Herston, Australia

 MedicalResearch.com: What are the main findings of the study?

Dr. Hoy: The study was part of the Global Burden of Disease 2010 study, which was conducted by the University of Queensland, Harvard University, Johns Hopkins University, University of Washington, and hundreds of disease experts throughout the globe. It is the largest ever public health study. It compared the overall burden (in terms of both death and disability) of the most common 291 diseases/conditions in the world. Low back pain was found to cause more global disability than any other disease/condition. Global disability from low back pain is increasing. There is an urgent need for global, regional and national agencies to pay far greater attention to the disability caused by low back pain.

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