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Low Back Pain A Review

Author/s: 
Aidan G. Cashin, Roger Chou, Melissa B. Weimer

Abstract
Importance Low back pain is defined as pain localized below the costal margin and above the inferior gluteal fold, with or without leg pain. Low back pain affects approximately 619 million people worldwide and is the leading cause of years lived with disability worldwide.

Observations Approximately 90% of patients presenting for care with low back pain have nonspecific low back pain, which is defined as low back pain that is not associated with specific spinal disorders (such as lumbar radiculopathy, lumbar spinal stenosis, vertebral fracture, axial spondyloarthritis, infection, or malignancy). Low back pain is classified as acute if the duration is shorter than 6 weeks, subacute if the duration is 6 to 12 weeks, and chronic when the duration is longer than 12 weeks. The age-standardized prevalence of low back pain is higher in females (9330 per 100 000) than in males (5520 per 100 000). The prevalence of low back pain increases with age, peaking at approximately 85 years. Risk factors for low back pain include obesity, depressive symptoms, occupational exposures (eg, heavy lifting), tobacco use, chronic disease (eg, diabetes), and previous low back pain. Acute nonspecific low back pain is usually self-limited, and approximately 72% of individuals recover by 12 months. Prognosis is less favorable for chronic nonspecific low back pain, but 42% of patients recover within 12 months. Initial management of patients with low back pain of any duration includes reassurance that serious underlying disease is unlikely, discussion about the expected time course of recovery, and the recommendation to remain physically active. Patients should be encouraged to continue their usual activities (including work), avoid prolonged rest, and be advised to self-manage their condition, which consists of symptom-relief strategies (such as heat application) and activity pacing (maintaining or gradually increasing usual activities and work). For patients with acute nonspecific low back pain, first-line therapies include heat application, spinal manipulation, massage, and acupuncture (typically provided by physical therapists, chiropractors, acupuncturists, and massage therapists) as well as nonsteroidal anti-inflammatory drugs (NSAIDs; such as ibuprofen) and skeletal muscle relaxants (such as cyclobenzaprine). For chronic nonspecific low back pain, first-line therapies include exercise of any type, psychological therapies (eg, cognitive behavioral therapy), or combined multidisciplinary approaches (such as pain management programs and integrated exercise and psychological care) along with spinal manipulation, massage, and acupuncture. NSAIDs should be considered as second-line therapy for chronic nonspecific low back pain.

Conclusions and Relevance Low back pain is a leading cause of disability worldwide. Acute nonspecific low back pain is often self-limited, whereas chronic nonspecific low back pain has a less favorable prognosis. For patients with acute nonspecific low back pain, first-line treatments include selected nonpharmacological therapies and medications (such as NSAIDs and skeletal muscle relaxants). For patients with chronic nonspecific low back pain, first-line treatment consists of exercise, psychological therapies (such as cognitive behavioral therapy), and combined multidisciplinary care.

Keywords 
Low Back Pain Nonspecific Low Back Pain

Tramadol versus placebo for chronic pain: a systematic review with meta-analysis and trial sequential analysis

Author/s: 
Jehad Ahmad Barkji, Mathias Maagaard, Johanne Juul Petersen, Yousef Ahmad Barakji, Emil Ørskov Ipsen, Christian Gluud, Ole Mathiesen, Janus Christian Jakobsen

Objectives The objective of our study was to assess the benefits and harms of tramadol vs placebo in adults with chronic pain.

Design The research method was a systematic review of randomised clinical trials with meta-analysis. The review followed the Trial Sequential Analysis and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Data sources The Cochrane Library, MEDLINE, Embase, Science Citation Index and BIOSIS were searched for trials published from inception to 6 February 2025.

Eligibility criteria for selecting studies Studies were eligible for inclusion if they were published and unpublished randomised clinical trials comparing tramadol vs placebo in adults with any type of chronic pain. Risk of bias was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions.

Main outcome measures The main outcome measures were pain level, adverse events, quality of life, dependence, abuse and depressive symptoms.

Results We included 19 randomised placebo-controlled clinical trials enrolling 6506 participants. All outcome results were at high risk of bias. Meta-analysis and Trial Sequential Analysis showed evidence of a beneficial effect of tramadol on chronic pain (mean difference numerical rating scale (NRS) −0.93 points; 97.5% CI −1.26 to −0.60; p<0.0001; low certainty of evidence). However, the effect size was below our predefined minimal important difference of 1.0 point on NRS. Beta binomial regression showed evidence of a harmful effect of tramadol on serious adverse events (OR 2.13; 97.5% CI 1.29 to 3.51; p=0.001; moderate certainty of evidence), mainly driven by a higher proportion of cardiac events and neoplasms. It was not possible to conduct a meta-analysis of the quality of life due to a lack of data. Meta-analysis and Trial Sequential Analysis showed that tramadol increased the risk of several non-serious adverse events including nausea (number needed to harm (NNH) 7), dizziness (NNH 8), constipation (NNH 9), and somnolence (NNH 13) (all very low certainty of evidence).

Conclusion Tramadol may have a slight effect on reducing chronic pain levels (low certainty of evidence) while likely increasing the risk of both serious (moderate certainty of evidence) and non-serious adverse events (very low certainty of evidence). The potential harms associated with tramadol use for pain management likely outweigh its limited benefits.

Keywords 
Tramadol chronic pain Adults Placebo Trial

Practical Recommendations for Minimizing Pain and Anxiety with IUD Insertion

Author/s: 
Viktoriya Ovsepyan, Petra Kelsey, Ann E Evensen

Background: Intrauterine devices (IUDs) are one of the most effective, long-lasting, and convenient contraceptive methods available in the United States. Unfortunately, the anticipated pain and anxiety associated with an IUD insertion procedure deter many people from using this contraceptive method.

Methods: A literature review was conducted on PubMed by searching the terms “IUD insertion”, “pain management”, “anxiety”, “gynecologic procedures”. The Cochrane database was also searched for reviews about pain management methods during IUD insertions. Findings were summarized using the American Academy of Family Physicians’ Strength of Recommendation Taxonomy (SORT) scale.

Results: Pharmacologic methods that can be used to reduce pain with IUD insertion include naproxen, tramadol, lidocaine paracervical blocks, 10% lidocaine spray, lidocaine-prilocaine cream, and EMLA cream. Non-pharmacologic methods for reducing pain or anxiety during gynecologic procedures include pre-insertion counseling, “verbal analgesia”, lavender aromatherapy, distraction with music or television, using Valsalva maneuver instead of tenaculum during IUD insertion, and use of heating pad during procedure.

Conclusion: Moderately effective pharmacologic and non-pharmacologic methods exist for reducing pain and anxiety with IUD insertion. These treatment methods should be offered to create a more comfortable experience for patients. Additional research is needed to determine the comparative efficacy of these methods.

Keywords 
IUD Intrauterine Devices managing pain contraception anxiety

Conservative Treatments in the Management of Acute Painful Vertebral Compression Fractures: A Systematic Review and Network Meta-Analysis

Author/s: 
Assil-Ramin Alimy, Athanasios D Anastasilakis, John J Carey, Stella D'Oronzo, Anda M Naciu, Julien Paccou, Maria P Yavropoulou, Willem F Lems, Tim Rolvien

Importance: Osteoporotic vertebral compression fractures (VCFs) frequently cause substantial pain and reduced mobility, posing a major health problem. Despite the critical need for effective pain management to restore functionality and improve patient outcomes, the value of various conservative treatments for acute VCF has not been systematically investigated.

Objective: To assess and compare different conservative treatment options in managing acute pain related to VCF.

Data sources: On May 16, 2023, 4 databases-PubMed, Embase, Scopus, and CINAHL-were searched. In addition, a gray literature search within Scopus and Embase was also conducted.

Study selection: Included studies were prospective comparative and randomized clinical trials that assessed conservative treatments for acute VCF.

Data extraction and synthesis: Data extraction and synthesis were performed by 2 authors according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Network Meta-Analyses recommendations. A frequentist graph-theoretical model and a random-effects model were applied for the meta-analysis.

Main outcomes and measures: Primary outcomes were short-term (4 weeks) pain during activity and long-term (latest available follow-up) nonspecified pain in patients with acute VCF.

Results: The study included 20 trials, encompassing 2102 patients, and evaluated various interventions for managing VCF. Calcitonin (standardized mean difference [SMD], -4.86; 95% CI, -6.87 to -2.86) and nonsteroidal anti-inflammatory drugs (NSAIDs; SMD, -3.94; 95% CI, -7.30 to -0.58) were beneficial regarding short-term pain during activity compared with placebo. For long-term nonspecific pain management, bisphosphonates were associated with inferior pain outcomes compared with daily (SMD, 1.21; 95% CI, 0.11 to 2.31) or weekly (SMD, 1.13; 95% CI, 0.05 to 2.21) administration of teriparatide, with no treatment being superior to NSAIDs. The qualitative analysis of adverse events highlighted that typical adverse events associated with these medications were observed.

Conclusions and relevance: NSAIDs and teriparatide may be the preferred treatment options for pain management in acute osteoporotic VCF. Although calcitonin also proved to be beneficial, its safety profile and potential adverse effects restrict its widespread application. The limited evidence on braces and analgesics underscores the urgent need for future research.

Keywords 
pain management Spinal Fractures acute pain pain management Compression Fractures

Review of systemic and syndromic complications of cannabis use: A review

Author/s: 
Shah, J., Fermo, O.

Purpose of review: Prescribed and non-prescribed cannabis use is common. Providers in specialties treating chronic pain – primary care, pain management, and neurology–will be coming across medical cannabis as a treatment for chronic pain, regardless of whether they are prescribers. It is important to be aware of the systemic and syndromic complications of acute and chronic cannabis use in the differential diagnosis of cardiac, cardiovascular, cerebrovascular, gastrointestinal, and psychiatric disorders.

Recent Findings: Medical cannabis is legal in 36 states. Studies have shown several potentially serious adverse effects associated with cannabis use.

Summary: Cannabis use has the potential to cause several complications that can be easily overlooked without a preexisting high index of suspicion.

Keywords 
neurology marijuana Pain managing pain complications of cannabis use

Efficacy and Safety of Nonantibiotic Outpatient Treatment in Mild Acute Diverticulitis (DINAMO-study): A Multicentre, Randomised, Open-label, Noninferiority Trial

Author/s: 
Mora-López, L., Ruiz-Edo, N., Estrada-Ferrer, O., Piñana-Campón, M. L., Labró-Ciurans, M., Escuder-Perez, J., Sales-Mallafré, R., Rebasa-Cladera, P., Navarro-Soto, S., Serra-Aracil, X.

Objective:
Mild AD can be treated safely and effectively on an outpatient basis without antibiotics.

Summary of Background Data:
In recent years, it has shown no benefit of antibiotics in the treatment of uncomplicated AD in hospitalized patients. Also, outpatient treatment of uncomplicated AD has been shown to be safe and effective.

Methods:
A Prospective, multicentre, open-label, noninferiority, randomized controlled trial, in 15 hospitals of patients consulting the emergency department with symptoms compatible with AD.

The Participants were patients with mild AD diagnosed by Computed Tomography meeting the inclusion criteria were randomly assigned to control arm (ATB-Group): classical treatment (875/125 mg/8 h amoxicillin/clavulanic acid apart from anti-inflammatory and symptomatic treatment) or experimental arm (Non-ATB-Group): experimental treatment (antiinflammatory and symptomatic treatment). Clinical controls were performed at 2, 7, 30, and 90 days.

The primary endpoint was hospital admission. Secondary endpoints included number of emergency department revisits, pain control and emergency surgery in the different arms.

Results:
Four hundred and eighty patients meeting the inclusion criteria were randomly assigned to Non-ATB-Group (n = 242) or ATB-Group (n = 238). Hospitalization rates were: ATB-Group 14/238 (5.8%) and Non-ATB-Group 8/242 (3.3%) [mean difference 2.58%, 95% confidence interval (CI) 6.32 to -1.17], confirming noninferiority margin. Revisits: ATB-Group 16/238 (6.7%) and Non-ATB-Group 17/242 (7%) (mean difference -0.3, 95% CI 4.22 to -4.83). Poor pain control at 2 days follow up: ATB-Group 13/230 (5.7%), Non-ATB-Group 5/221 (2.3%) (mean difference 3.39, 95% CI 6.96 to -0.18).

Conclusions:
Nonantibiotic outpatient treatment of mild AD is safe and effective and is not inferior to current standard treatment.

Trial registration:
ClinicalTrials.gov (NCT02785549); EU Clinical Trials Register (2016-001596-75)

AAFP Chronic Pain Management Toolkit

Chronic pain is common in the U.S., with anywhere from 11% to 40% of the adult population reporting daily pain.1 Approximately one-third of patients experiencing pain receive a pain medication.2 While the number of prescriptions for pain management have declined in recent years3, opioid misuse remains a significant public health crisis. Roughly 21-29% of patients who are prescribed opioids for chronic pain will misuse them.4

This increase leads to a rise in opioid overdoses—at least half are attributed to prescription medications—and morbidity and mortality. Numerous groups—including the AAFP, other medical societies, the National Academy of Medicine and the U.S. Congress—are emphasizing the need to improve chronic pain care.

Keywords 
RISEOK opioids chronic pain pain management Opiate Overdose

Association of Therapies With Reduced Pain and Improved Quality of Life in Patients With Fibromyalgia: A Systematic Review and Meta-analysis

Author/s: 
Mascarenhas, Rodrigo O., Souza, Mateus B., Oliveira, Murilo X., Lacerda, Ana C., Mendonca, Vanessa A., Henschke, Nicholas, Oliveira, Vinicius C.

Importance: Fibromyalgia is a chronic condition that results in a significant burden to individuals and society.

Objective: To investigate the effectiveness of therapies for reducing pain and improving quality of life (QOL) in people with fibromyalgia.

Data sources: Searches were performed in the MEDLINE, Cochrane, Embase, AMED, PsycInfo, and PEDro databases without language or date restrictions on December 11, 2018, and updated on July 15, 2020.

Study selection: All published randomized or quasi-randomized clinical trials that investigated therapies for individuals with fibromyalgia were screened for inclusion.

Data extraction and synthesis: Two reviewers independently extracted data and assessed risk of bias using the 0 to 10 PEDro scale. Effect sizes for specific therapies were pooled using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.

Main outcomes and measures: Pain intensity measured by the visual analog scale, numerical rating scales, and other valid instruments and QOL measured by the Fibromyalgia Impact Questionnaire.

Results: A total of 224 trials including 29 962 participants were included. High-quality evidence was found in favor of cognitive behavioral therapy (weighted mean difference [WMD], -0.9; 95% CI, -1.4 to -0.3) for pain in the short term and was found in favor of central nervous system depressants (WMD, -1.2 [95% CI, -1.6 to -0.8]) and antidepressants (WMD, -0.5 [95% CI, -0.7 to -0.4]) for pain in the medium term. There was also high-quality evidence in favor of antidepressants (WMD, -6.8 [95% CI, -8.5 to -5.2]) for QOL in the short term and in favor of central nervous system depressants (WMD, -8.7 [95% CI, -11.3 to -6.0]) and antidepressants (WMD, -3.5 [95% CI, -4.5 to -2.5]) in the medium term. However, these associations were small and did not exceed the minimum clinically important change (2 points on an 11-point scale for pain and 14 points on a 101-point scale for QOL). Evidence for long-term outcomes of interventions was lacking.

Conclusions and relevance: This systematic review and meta-analysis suggests that most of the currently available therapies for the management of fibromyalgia are not supported by high-quality evidence. Some therapies may reduce pain and improve QOL in the short to medium term, although the effect size of the associations might not be clinically important to patients.

Keywords 
Fibromyalgia quality of life cognitive behavioral therapy pain management

Mind-Body Therapies for Opioid-Treated Pain: A Systematic Review and Meta-analysis

Author/s: 
Garland, Eric L., Brintz, Carrie E., Hanley, Adam W., Roseen, Eric J., Atchley, Rachel M., Gaylord, Susan A., Faurot, Keturah R., Yaffe, Joanne, Fiander, Michelle, Keefe, Francis J.

Importance: Mind-body therapies (MBTs) are emerging as potential tools for addressing the opioid crisis. Knowing whether mind-body therapies may benefit patients treated with opioids for acute, procedural, and chronic pain conditions may be useful for prescribers, payers, policy makers, and patients.

Objective: To evaluate the association of MBTs with pain and opioid dose reduction in a diverse adult population with clinical pain.

Data sources: For this systematic review and meta-analysis, the MEDLINE, Embase, Emcare, CINAHL, PsycINFO, and Cochrane Library databases were searched for English-language randomized clinical trials and systematic reviews from date of inception to March 2018. Search logic included (pain OR analgesia OR opioids) AND mind-body therapies. The gray literature, ClinicalTrials.gov, and relevant bibliographies were also searched.

Study selection: Randomized clinical trials that evaluated the use of MBTs for symptom management in adults also prescribed opioids for clinical pain.

Data extraction and synthesis: Independent reviewers screened citations, extracted data, and assessed risk of bias. Meta-analyses were conducted using standardized mean differences in pain and opioid dose to obtain aggregate estimates of effect size with 95% CIs.

Main outcomes and measures: The primary outcome was pain intensity. The secondary outcomes were opioid dose, opioid misuse, opioid craving, disability, or function.

Results: Of 4212 citations reviewed, 60 reports with 6404 participants were included in the meta-analysis. Overall, MBTs were associated with pain reduction (Cohen d = -0.51; 95% CI, -0.76 to -0.26) and reduced opioid dose (Cohen d = -0.26; 95% CI, -0.44 to -0.08). Studies tested meditation (n = 5), hypnosis (n = 25), relaxation (n = 14), guided imagery (n = 7), therapeutic suggestion (n = 6), and cognitive behavioral therapy (n = 7) interventions. Moderate to large effect size improvements in pain outcomes were found for meditation (Cohen d = -0.70), hypnosis (Cohen d = -0.54), suggestion (Cohen d = -0.68), and cognitive behavioral therapy (Cohen d = -0.43) but not for other MBTs. Although most meditation (n = 4 [80%]), cognitive-behavioral therapy (n = 4 [57%]), and hypnosis (n = 12 [63%]) studies found improved opioid-related outcomes, fewer studies of suggestion, guided imagery, and relaxation reported such improvements. Most MBT studies used active or placebo controls and were judged to be at low risk of bias.

Conclusions and relevance: The findings suggest that MBTs are associated with moderate improvements in pain and small reductions in opioid dose and may be associated with therapeutic benefits for opioid-related problems, such as opioid craving and misuse. Future studies should carefully quantify opioid dosing variables to determine the association of mind-body therapies with opioid-related outcomes.

Keywords 
Mind-Body Therapies meditation hypnosis cognitive behavioral therapy pain reduction opioids Opioid Epidemic
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