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Acute low back pain (LBP) is highly prevalent, with a presumed favorable prognosis; however, once chronic, LBP becomes a disabling and expensive condition. Acute to chronic LBP transition rates vary widely owing to absence of standardized operational definitions, and it is unknown whether a standardized prognostic tool (ie, Subgroups for Targeted Treatment Back tool [SBT]) can estimate this transition or whether early non-guideline concordant treatment is associated with the transition to chronic LBP. To assess the associations between the transition from acute to chronic LBP with SBT risk strata; demographic, clinical, and practice characteristics; and guideline nonconcordant processes of care. This inception cohort study was conducted alongside a multisite, pragmatic cluster randomized trial. Adult patients with acute LBP stratified by SBT risk were enrolled in 77 primary care practices in 4 regions across the United States between May 2016 and June 2018 and followed up for 6 months, with final follow-up completed by March 2019. Data analysis was conducted from January to March 2020. SBT risk strata and early LBP guideline nonconcordant processes of care (eg, receipt of opioids, imaging, and subspecialty referral). Transition from acute to chronic LBP at 6 months using the National Institutes of Health Task Force on Research Standards consensus definition of chronic LBP. Patient demographic characteristics, clinical factors, and LBP process of care were obtained via electronic medical records. Overall, 5233 patients with acute LBP (3029 [58%] women; 4353 [83%] White individuals; mean [SD] age 50.6 [16.9] years; 1788 [34%] low risk; 2152 [41%] medium risk; and 1293 [25%] high risk) were included. Overall transition rate to chronic LBP at six months was 32% (1666 patients). In a multivariable model, SBT risk stratum was positively associated with transition to chronic LBP (eg, high-risk vs low-risk groups: adjusted odds ratio [aOR], 2.45; 95% CI, 2.00-2.98; P < .001). Patient and clinical characteristics associated with transition to chronic LBP included obesity (aOR, 1.52; 95% CI, 1.28-1.80; P < .001); smoking (aOR, 1.56; 95% CI, 1.29-1.89; P < .001); severe and very severe baseline disability (aOR, 1.82; 95% CI, 1.48-2.24; P < .001 and aOR, 2.08; 95% CI, 1.60-2.68; P < .001, respectively) and diagnosed depression/anxiety (aOR, 1.66; 95% CI, 1.28-2.15; P < .001). After controlling for all other variables, patients exposed to 1, 2, or 3 nonconcordant processes of care within the first 21 days were 1.39 (95% CI, 1.21-2.32), 1.88 (95% CI, 1.53-2.32), and 2.16 (95% CI, 1.10-4.25) times more likely to develop chronic LBP compared with those with no exposure (P < .001). In this cohort study, the transition rate to chronic LBP was substantial and increased correspondingly with SBT stratum and early exposure to guideline nonconcordant care.

AbstractObjectiveTo assess whether percutaneous vertebroplasty results in more pain relief than a sham procedure in patients with acute osteoporotic compression fractures of the vertebral body.DesignRandomised, double blind, sham controlled clinical trial.SettingFour community hospitals in the Netherlands, 2011-15.Participants180 participants requiring treatment for acute osteoporotic vertebral compression fractures were randomised to either vertebroplasty (n=91) or a sham procedure (n=89).InterventionsParticipants received local subcutaneous lidocaine (lignocaine) and bupivacaine at each pedicle. The vertebroplasty group also received cementation, which was simulated in the sham procedure group.Main outcome measuresMain outcome measure was mean reduction in visual analogue scale (VAS) scores at one day, one week, and one, three, six, and 12 months. Clinically significant pain relief was defined as a decrease of 1.5 points in VAS scores from baseline. Secondary outcome measures were the differences between groups for changes in the quality of life for osteoporosis and Roland-Morris disability questionnaire scores during 12 months’ follow-up.ResultsThe mean reduction in VAS score was statistically significant in the vertebroplasty and sham procedure groups at all follow-up points after the procedure compared with baseline. The mean difference in VAS scores between groups was 0.20 (95% confidence interval −0.53 to 0.94) at baseline, −0.43 (−1.17 to 0.31) at one day, −0.11 (−0.85 to 0.63) at one week, 0.41 (−0.33 to 1.15) at one month, 0.21 (−0.54 to 0.96) at three months, 0.39 (−0.37 to 1.15) at six months, and 0.45 (−0.37 to 1.24) at 12 months. These changes in VAS scores did not, however, differ statistically significantly between the groups during 12 months’ follow-up. The results for secondary outcomes were not statistically significant. Use of analgesics (non-opioids, weak opioids, strong opioids) decreased statistically significantly in both groups at all time points, with no statistically significant differences between groups. Two adverse events occurred in the vertebroplasty group: one respiratory insufficiency and one vasovagal reaction.ConclusionsPercutaneous vertebroplasty did not result in statistically significantly greater pain relief than a sham procedure during 12 months’ follow-up among patients with acute osteoporotic vertebral compression fractures.Trial registrationClinicalTrials.gov NCT01200277.

Gait stability is the ability to deal with small perturbations that naturally occur during walking. Changes in motor control caused by pain could affect this ability. This study investigated whether nociceptive stimulation (hypertonic saline injection) in a low back (LBP) or calf (CalfP) muscle affects gait stability. Sixteen participants walked on a treadmill at 0.94ms−1 and 1.67ms−1, while thorax kinematics were recorded using 3D-motion capture. From 110 strides, stability (local divergence exponent, LDE), stride-to-stride variability and root mean squares (RMS) of thorax linear velocities were calculated along the three movement axes. At 0.94ms−1, independent of movement axes, gait stability was lower (higher LDE) and stride-to-stride variability was higher, during LBP and CalfP than no pain. This was more pronounced during CalfP, likely explained by the biomechanical function of calf muscles in gait, as supported by greater mediolateral RMS and stance time asymmetry than in LBP and no pain. At 1.67ms−1, independent of movement axes, gait stability was greater and stride-to-stride variability was smaller with LBP than no pain and CalfP, whereas CalfP was not different from no pain. Opposite effects of LBP on gait stability between speeds suggests a more protective strategy at the faster speed. Although mediolateral RMS was greater and participants had more asymmetric stance times with CalfP than LBP and no pain, limited effect of CalfP at the faster speed could relate to greater kinematic constraints and smaller effects of calf muscle activity on propulsion at this speed. In conclusion, pain effects on gait stability depend on pain location and walking speed.

Prior studies have shown that patients suffering from chronic Low Back Pain (cLBP) have impaired somatosensory processing including reduced tactile acuity, i.e. reduced ability to resolve fine spatial details with the perception of touch. The central mechanism(s) underlying reduced tactile acuity are unknown but may include changes in specific brain circuitries (e.g. neuroplasticity in the primary somatosensory cortex, S1). Furthermore, little is known about the linkage between changes in tactile acuity and the amelioration of cLBP by somatically-directed therapeutic interventions, such as acupuncture. In this longitudinal neuroimaging study, we evaluated healthy control adults (HC, N ​= ​50) and a large sample of cLBP patients (N ​= ​102) with structural brain imaging (T1-weighted MRI for Voxel-Based Morphometry, VBM; Diffusion Tensor Imaging, DTI) and tactile acuity testing using two-point discrimination threshold (2PDT) over the lower back (site of pain) and finger (control) locations. Patients were evaluated at baseline and following a 4-week course of acupuncture, with patients randomized to either verum acupuncture, two different forms of sham acupuncture (designed with or without somatosensory afference), or no-intervention usual care control. At baseline, cLBP patients demonstrated reduced acuity (greater 2PDT, P ​= ​0.01) over the low back, but not finger (P ​= ​0.29) locations compared to HC, suggesting that chronic pain affects tactile acuity specifically at body regions encoding the experience of clinical pain. At baseline, Gray Matter Volume (GMV) was elevated and Fractional Anisotropy (FA) was reduced, respectively, in the S1-back region of cLBP patients compared to controls (P ​< ​0.05). GMV in cLBP correlated with greater 2PDT-back scores (ρ ​= ​0.27, P ​= ​0.02). Following verum acupuncture, tactile acuity over the back was improved (reduced 2PDT) and greater improvements were associated with reduced S1-back GMV (ρ ​= ​0.52, P ​= ​0.03) and increased S1-back adjacent white matter FA (ρ ​= ​−0.56, P ​= ​0.01). These associations were not seen for non-verum control interventions. Thus, S1 neuroplasticity in cLBP is linked with deficits in tactile acuity and, following acupuncture therapy, may represent early mechanistic changes in somatosensory processing that track with improved tactile acuity.

PurposeTo evaluate the safety and efficacy of radiofrequency (RF) ablation of the basivertebral nerve (BVN) for the treatment of chronic low back pain (CLBP) in a Food and Drug Administration approved Investigational Device Exemption trial. The BVN has been shown to innervate endplate nociceptors which are thought to be a source of CLBP.MethodsA total of 225 patients diagnosed with CLBP were randomized to either a sham (78 patients) or treatment (147 patients) intervention. The mean age within the study was 47 years (range 25–69) and the mean baseline ODI was 42. All patients had Type I or Type II Modic changes of the treated vertebral bodies. Patients were evaluated preoperatively, and at 2 weeks, 6 weeks and 3, 6 and 12 months postoperatively. The primary endpoint was the comparative change in ODI from baseline to 3 months.ResultsAt 3 months, the average ODI in the treatment arm decreased 20.5 points, as compared to a 15.2 point decrease in the sham arm (p = 0.019, per-protocol population). A responder analysis based on ODI decrease ≥ 10 points showed that 75.6% of patients in the treatment arm as compared to 55.3% in the sham control arm exhibited a clinically meaningful improvement at 3 months.ConclusionPatients treated with RF ablation of the BVN for CLBP exhibited significantly greater improvement in ODI at 3 months and a higher responder rate than sham treated controls. BVN ablation represents a potential minimally invasive treatment for the relief of chronic low back pain.Graphical abstractThese slides can be retrieved under Electronic Supplementary Material.

The importance of incorporating lumbo-pelvic stability core and controlling motor exercises in patients with chronic low back pain (CLBP) reinforces the use of strategies to improve biopsychosocial beliefs by reducing biomedical postulations. However, clinical practice guidelines recommend multimodal approaches incorporating exercise and manual therapy (MT), and instead reject the application of kinesiotape (KT) in isolation. Therefore, the objectives of this study were to analyze the effects of 12 weeks of exercises combined with MT or KT on perceived low back pain using the visual analog scale (VAS) and muscle electric activity measured with electromyography (EMG) of the rectus abdominis and multifidus in CLBP (mild disability) and to explore the relationship between the rectus abdominis and multifidus ratios and pain perception after intervention. A blinded, 12-week randomized controlled trial (RCT) was carried out, involving three parallel groups of patients with CLBP. The study was registered at Clinicaltrial.gov and assigned the identification number NCT05544890 (19/09/22). The trial underwent an intention-to-treat analysis. The primary outcome revealed a multimodal treatment program supplemented by additional therapies such as MT and KT, resulting in significant reductions in perceived low back pain. The subjective assessment of individuals with CLBP indicated no discernible distinction between exclusive core stability exercises and control-motor training when combined with MT or KT. Notably, our findings demonstrated positive alterations in both the mean and peak EMG values of the right rectus abdominis in the exercise group, suggesting a beneficial impact on muscle activation. This study focused on assessing the activation levels of the trunk musculature, specifically the rectus abdominis (RA) and multifidus (MF), in individuals with CLBP exhibiting mild disability according to the Oswestry Disability Index. Importantly, improvements in the VAS values were observed independently of changes in muscle electrical activity.

Chronic low back pain (LBP) is a common musculoskeletal disorder and is often accompanied by functional leg length inequality (FLLI). However, little was known about the effects of gluteal muscle control training in patients with LBP and FLLI. This study was designed to investigate the effects of gluteal control training in patients with LBP and FLLI. This is a double-blinded, randomized controlled study design. Forty-eight LBP patients with FLLI were randomized to the gluteal control training (GT) (47.58 ± 9.42 years) or the regular training (RT) (47.38 ± 11.31 years) group and received allocated training for six weeks. The outcome measures were pelvic inclination (PI), ilium anterior tilt difference (IATD), FLLI, visual analogue scale (VAS), patient specific-functional scale (PSFS), Oswestry disability index (ODI), hip control ability, global rating of change scale (GRoC), and lower extremity strength and flexibility. The intervention effects were compared using two-way repeated measures analysis of variance and chi-square tests with α = 0.05. The results indicated that the GT group showed greater improvement ( P  < 0.01) in PI (1.03 ± 0.38∘ vs. 1.57 ± 0.51∘), IATD (0.68 ± 0.66∘ vs. 2.31 ± 0.66∘), FLLI (0.3 ± 0.22 vs. 0.59 ± 0.13 cm), VAS (1.41 ± 1.32 vs. 3.38 ± 1.51), hip control ability (2.20 ± 0.45 vs. 0.89 ± 0.74), GRoC at 3rd and 6th week as compared to the RT group. Hip strength and flexibility also improved more in the GT group ( P  < 0.05). In conclusion, gluteal control training was more effective in improving low back pain and dysfunctions, and should be integrated in the management plan in patients with LBP and FLLI.

Chronic low back pain (CLBP) is linked to reduced excitability in the primary motor (M1) and sensory (S1) cortices. Combining sensory-motor exercises with transcranial direct current stimulation (tDCS) to boost M1 and S1 excitability may improve treatment outcomes. This combined approach aligns with the neurophysiological mechanisms underlying CLBP and may target the neuroplastic changes induced by low back pain. This study aimed to assess whether enhancing M1 and S1 excitability via tDCS, alongside sensory-motor exercises, offers additional benefits for CLBP patients. Participants were randomly assigned to receive either real or sham tDCS alongside sensory-motor exercises. Outcome measures included pain intensity, disability level, motor control ability, amplitudes of N80 and N150, and the amplitude of motor-evoked potential (MEP) and active motor threshold (AMT) for the multifidus (MF) and transversus abdominis/internal oblique (TrA/IO) muscles. A linear mixed-effects model (LMM) analyzed group, time, and interaction effects, while Spearman's correlation assessed relationships between neurophysiological and clinical outcomes. The results showed significant reductions in pain intensity and disability levels (P < 0.001) and improved motor control (P < 0.001) in both groups. Both groups also exhibited increase in MF MEP amplitude (P = 0.042) and N150 amplitude (P = 0.028). The tDCS group demonstrated a significant decrease in AMT of MF and TrA/IO muscles (P < 0.05) and an increase in N80 amplitude (P = 0.027), with no significant changes in the control group. Additionally, the tDCS group had significantly lower AMT for the TrA/IO muscle in the post-test compared to the sham group (P = 0.001). Increased N150 amplitude was correlated with improved motor control. The findings showed that sensory-motor exercises combined with either tDCS or sham tDCS effectively reduced pain intensity, decreased disability, and improved lumbar motor control in lumbosacral radiculopathy patients. No significant differences were observed between groups, indicating no added clinical benefit from tDCS over exercises alone. However, both groups demonstrated increased N150 and MF MEP amplitudes, suggesting enhanced cortical excitability in motor and sensory regions. While clinical outcomes were similar, neurophysiological data indicate that sensory-motor exercises play a central role in boosting cortical excitability, with tDCS further amplifying this effect, as evidenced by a significant AMT reduction in MF and TrA/IO muscles and an increase in N80 amplitude.

To assess the efficacy of horticultural therapy (HT) on anterior cingulate cortex (ACC) activity and the changes in rumination and catastrophizing scores in individuals with chronic low back pain (LBP). We conducted a randomized, controlled, cross-over, 3-week pilot study (ClinicalTrials.gov Identifier: NCT04656158). The departments of physical medicine and rehabilitation (hospital grounds and occupational therapy room) and imaging research were involved. The participants were adults with non-specific chronic LBP. All participants underwent two 90-min HT sessions and two 90-min handiwork sessions per week. The activity sequence order was randomized, and the activities were separated by a wash-out period of 1 week. Each participant underwent 3 brain MRIs: before, after the first, and after the second activity. The primary outcome was the change in ACC perfusion in ml/100g/min using arterial spin labeling MRI. The secondary outcomes were the changes in self-reported rumination and catastrophizing scores after each activity compared to baseline. Sixteen participants were included: 14 women (87.5%), LBP intensity (numeric rating scale) mean (SD) 45.1 (27.2)/100, specific activity limitation (Roland Morris disability questionnaire) 9.3 (4.1)/24. Change in ACC perfusion from baseline was -0.1 (10.7), 95% CI [-5.6, 5.8] ml (blood)/100g (tissue)/min after handiwork and -0.1 (8.7), [-4.7, 4.6] after HT and did not differ between the 2 activities (p = 0.91). Change in rumination [-0.5 (4.4) after handiwork and -0.3 (2.8) after HT] and catastrophizing scores [-2 (2.8) after handiwork and -1.4 (2.3) after HT] did not differ between activities (p = 0.99 and 0.22, respectively). Limited exposure to the interventions and the sample profile (moderate levels of pain) may explain our results. Our results highlight the need for future studies using the most appropriate outcomes to determine the exact effects of nature experiences in people with chronic musculoskeletal disease.

Chronic low back pain (CLBP) is a disease with significant functional, emotional and social impact. Several interventions are proposed for its management and exercise is one of main, land-based or water-based. This study describes a randomized controlled trial that will analyze the effect of a combined aquatic and land-based exercise program compared to an aquatic-based program on pain, functional incapacity and quality of life in adults with CLBP. Additionally, it will analyze the effects of exercise cessation in the same outcomes. A blind randomized controlled trial will be developed with a 1:1 allocation ratio. Around 30 adults with mechanical CLBP will be randomly allocated in two groups. The experimental group (ALG) will complete an aquatic and land-based exercise program and control group (AG) will carry out only an aquatic program, both for 8 weeks. Participants will be assessed with Visual Analogue Scale, Oswestry Disability Index, Short-Form 36, Tampa Scale of Kinesiophobia-13 and Modified-Modified Schober Test, collected at baseline (M0), after 8 weeks (M1) and 4 weeks after the end of the intervention (M2). This study may provide a relevant contribution to understand the potential effect of a combined land and aquatic exercise program on pain, functional disability, fear of movement, quality of life and lumbar mobility. The results may provide important information for CLBP management. This trial is registered with ClinicalTrials.gov (registration number: NCT06641570; date of registration: October 14, 2024).