Massage Therapy as a Self-Management Strategy for Musculoskeletal Pain and Chronic Conditions: A Systematic Review of Feasibility and Scope.

Background: Musculoskeletal pain and chronic conditions are associated with deteriorating pain, stress, anxiety, and health-related quality of life (HR-QOL). There is emerging evidence that performing massage therapy as self-management (MTSM) is a viable approach to alleviate these symptoms across various clinical populations. However, a significant gap remains on the effectiveness and limitation of MTSM usage as no systematic review has been conducted to comprehensively evaluate and synthesize the scope, feasibility, and efficacy of MTSM. This systematic review aimed to investigate the effect of MTSM on common symptoms of musculoskeletal and chronic conditions, followed by identifying characteristics of MTSM dosage, setting, and adherence for formulating themes. Methods: A systematic review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, which involved searching seven electronic databases, including Medline (OVID), CINAHL (EBSCO), PEDro, Web of Science (Clarivate), PsycINFO (EBSCO), Google Scholar, and EMBASE (Elsevier) from inception to January 2023. Clinical studies were eligible if they included MTSM, and massage treatment was more than 50% of the intervention. The quality of studies was assessed using the Effective Public Health Practice Project Quality Assessment Tool. Target variables were extracted, including study design, participants' characteristics, outcome measures, massage dosage (duration, frequency, and timing), training setting, provider of massage training, adherence to the MTSM intervention, comparator, and key findings. Results: A total of 17 studies were evaluated and included 770 participants (female: N = 606) with musculoskeletal pain or chronic conditions. The emerged themes for MTSM utilization consisted of arthritis pain (knee, n = 3; neck, n = 1, hand, n = 2), neck and back pain (n = 4), and stress and anxiety (n = 3). Prescribed self-administered massage duration ranged from a single session to a maximum of 8-12 weeks, where 4 weeks (n = 8) was the most commonly prescribed duration. Out of 11 studies that used MTSM as a solo modality, 7 studies (41.2%) showed significant improvement in the outcome measures such as chronic neck and back pain, stress or anxiety, fatigue, quality of sleep, and HR-QOL. In addition, health benefits, including anxiety, depression, pain intensity, and pain threshold, were observed in six studies (35.3%) where MTSM was applied as a coadjuvant modality, which was combined with therapist-applied massage and physiotherapy. Conclusions: These findings support that MTSM is a viable approach to enhance the benefit of therapist-applied massage or as a solo modality for symptom management of musculoskeletal pain and chronic conditions. The review provides suggestions for design improvement, such as reporting participants' adherence to the prescribed massage regimen, that would be informative for providing a robust understanding of the magnitude or the extent to which MTSM is effective. Future studies on MTSM intervention are encouraged to use a theoretical framework and validated measures for determining and facilitating treatment fidelity.

Does manual therapy meaningfully change quantitative sensory testing and patient reported outcome measures in patients with musculoskeletal impairments related to the spine?: A 'trustworthy' systematic review and meta-analysis.

OBJECTIVES: To perform a 'trustworthy' systematic review (SR) with meta-analysis on the potential mechanisms of manual therapy used to treat spinal impairments. DESIGN: SR with meta-analysis. LITERATURE SEARCH: Articles published between January 2010 and October 2022 from CENTRAL, CINAHL, MEDLINE, PubMed, ProQuest, and PEDro. METHODS: This SR included English-language randomized clinical trials (RCTs) involving manual therapy to treat spinal impairments in adults. The primary outcome was pressure pain thresholds (PPTs). To synthesize RCTs with high confidence in estimated effects using the GRADE, RCTs with questionable prospective, external, and internal validity, and high risk of bias (RoB) were excluded. RESULTS: Following title and abstract screening, 89 full-text RCTs were reviewed. Twenty-two studies included the criteria of interest. Sixteen were not prospectively registered, two contained discussion/conclusions judged to be inconsistent with the registry, and one was rated as having a high RoB. Three studies met the inclusion criteria; heterogeneous interventions and locations for PPT testing prevented synthesis into practice recommendations. The two studies with high confidence in estimated effects had small effect sizes, and one study had confidence intervals that crossed zero for the outcome measures of interest. DISCUSSION: Standardized PPT testing, as a potential measure of centrally mediated pain, could provide clues regarding the mechanisms of manual therapy or help identify/refine research questions. CONCLUSION: High-quality RCTs could not be synthesized into strong conclusions secondary to the dissimilarity in research designs. Future research regarding quantitative sensory testing should develop RCTs with high confidence in estimated effects that can be translated into strong recommendations.

Effects of chiropractic use on medical healthcare utilization and costs in adults with back pain in Ontario, Canada from 2003 to 2018: a population-based cohort study.

BACKGROUND: Adults with back pain commonly consult chiropractors, but the impact of chiropractic use on medical utilization and costs within the Canadian health system is unclear. We assessed the association between chiropractic utilization and subsequent medical healthcare utilization and costs in a population-based cohort of Ontario adults with back pain. METHODS: We conducted a population-based cohort study that included Ontario adult respondents of the Canadian Community Health Survey (CCHS) with back pain from 2003 to 2010 (n = 29,475), followed up to 2018. The CCHS data were individually-linked to individual-level health administrative data up to 2018. Chiropractic utilization was self-reported consultation with a chiropractor in the past 12 months. We propensity score-matched adults with and without chiropractic utilization, accounting for confounders. We evaluated back pain-specific and all-cause medical utilization and costs at 1- and 5-year follow-up using negative binomial and linear (log-transformed) regression, respectively. We assessed whether sex and prior specialist consultation in the past 12 months were effect modifiers of the association. RESULTS: There were 6972 matched pairs of CCHS respondents with and without chiropractic utilization. Women with chiropractic utilization had 0.8 times lower rate of cause-specific medical visits at follow-up than those without chiropractic utilization (RR5years = 0.82, 95% CI 0.68-1.00); this association was not found in men (RR5years = 0.96, 95% CI 0.73-1.24). There were no associations between chiropractic utilization and all-cause physician visits, all-cause emergency department visits, all-cause hospitalizations, or costs. Effect modification of the association between chiropractic utilization and cause-specific utilization by prior specialist consultation was found at 1-year but not 5-year follow-up; cause-specific utilization at 1 year was lower in adults without prior specialist consultation only (RR1year = 0.74, 95% CI 0.57-0.97). CONCLUSIONS: Among adults with back pain, chiropractic use is associated with lower rates of back pain-specific utilization in women but not men over a 5-year follow-up period. Findings have implications for guiding allied healthcare delivery in the Ontario health system.

[Complementary procedures for chronic pain disorders in childhood and adolescence]. / Komplementäre Verfahren bei chronischen Schmerzerkrankungen im Kindes- und Jugendalter.

Pain that persists or recurs over a period of at least 3 months in childhood and adolescence is referred to as chronic pain. The primary localization of pain changes according to age: abdominal pain is more common at a younger age, headache is more common in adolescents and later back pain as well as muscle and joint pain. In the multimodal and interdisciplinary treatment of chronic pain, complementary procedures can expand the treatment spectrum. This article provides an overview of the existing evidence that for childhood and adolescence can at best be evaluated as readily understandable. In addition, the experiences of two children's hospitals show that complementary medicine can be used as a low-threshold and easily implemented therapy.

[Tennis Ball Massage Therapy in Clinical Nurses: Effect on Relieving Musculoskeletal Disorders and Enhancing Self-Efficacy].

BACKGROUND: Musculoskeletal disorders are a common occupational disease. The prevalence of musculoskeletal disorders among nurses is estimated at 65.1%-87.3%, with neck, shoulders, and lower back being most affected. PURPOSE: To explore the effectiveness of tennis ball massage therapy in alleviating muscle soreness and improving pain relief self-efficacy. METHODS: In this quasi-experimental, single-group, pre- and post-test study, 216 nurses in regional teaching hospitals were screened for neck, shoulder, and back pain. Based on the unit attributes, systematic random sampling was employed to recruit 36 nurses to participate in a four-week "fighting pain" intervention program. The "Pain Visual Scale" and "Pain Relief Self-efficacy Scale" were used as the assessment tools. One-way and two-way repeated measure analysis of variance, a signed ranks test, and the Friedman test were used to assess longitudinal change in the data. RESULTS: Shoulders were the most reported site of muscle pain (94.4%), followed by the neck (88.9%) and the upper back (55.6%). The locations of neck, shoulder, and back pain were interacted differently with the four measurement times (F = 2.69, p = .020). In the post hoc comparison, pain relief effectiveness was most significant in the third posttest, followed by the second. The pain relief was significantly different between the pre-test and the third post-test (t = 6.39, 8.68, 6.96, p < .001). There was a significant difference before and after the intervention of the pain relief self-efficacy (F = 53.49, p < .001). The post hoc comparison results revealed that self-efficacy was lowest at pretest and highest at the third posttest. Significant differences were observed between the pre-test and third post-test at the end of the intervention (t = -10.25, p < .001). CONCLUSIONS / IMPLICATIONS FOR PRACTICE: This study shows that tennis ball massage can improve neck, shoulder, and back pain in nurses and improve pain relief self-efficacy. Tennis ball massage is easy to implement, has no time and space restrictions, and requires no assistance to operate. This equipment can be used to effectively reduce muscle pain, improve the comfort of performing regular activities, and raise work efficiency, reducing the negative impact of muscle pain on work.

Clinician Perspectives on Referring Medicaid Back Pain Patients to Integrative and Complementary Medicine: A Qualitative Study.

Objective: To increase understanding of referral processes from primary care to integrative and complementary medicine (ICM) under an Oregon Medicaid policy that restricted opioids and expanded access to ICM for back pain patients. Methods: Four asynchronous online focus groups with 48 medical clinicians were conducted. Themes were constructed using thematic analysis. Results: Three themes were constructed related to the clinician's experience: (1) high patient receptivity to ICM, (2) difficulty finding ICM providers who accept Medicaid beneficiaries, and (3) uncertainty of the effectiveness of ICM among clinicians. Conclusions: Findings suggest that health systems expanding access to ICM for Medicaid beneficiaries may benefit from establishing and supporting linkages between clinicians and ICM providers, especially in rural areas.

Demographics of and Costs to Users of Chiropractic Services in the United States with Neck or Back Pain not Meeting Guideline-Based Minimum Treatment Frequency Thresholds.

Context: Acceptance of chiropractic services as an effective therapy for neck or back pain has been well established with randomized controlled trials (RCTs); however, there have been limited observations made on the treatment frequency patterns seen in the real world. Objective: The purpose of this study is to identify chiropractic users with neck or back pain who did not meet recommended treatment frequency guidelines and examine their demographics and chiropractic costs. Design: In this cross-sectional retrospective study, the nationally representative 2017 Medical Expenditure Panel Survey database was used. Setting: This study used nationally representative US survey data. Participants: Inclusion criteria were adults aged 18 years and older with a diagnosis of neck or back pain with one or more chiropractic visits in 2017. Outcomes Measures: Chiropractic utilization was categorized as concordant or discordant with treatment frequency guidelines; concordant was defined as 5 or more visits to a chiropractor within any 2-month time frame or at least 12 total visits during the year. Discordant was defined as circumstances not meeting concordant criteria. The groups were compared by demographics including age, sex, race, region, years of education, health insurance coverage, employment status, family income, presence of headache diagnosis, Charlson Comorbidity Index score and the presence of any limitation of physical function. Comparisons were made between the two groups using Chi-squared tests. Logistic regression was used to adjust for covariates. Results: There were 159 and 310 adults classified as concordant and discordant, respectively (weighted total: 1 849 108 [31.44%] and 4 032 541 [68.56%], with significantly different mean chiropractic costs of $2555 and $434, respectively. Significant independent predictors of discordant chiropractic utilization were race, years of education, family income and the presence of any limitation of physical function. Conclusions: Most chiropractic users with diagnosed neck or back pain were considered discordant with treatment frequency guidelines, which may indicate inefficiencies in treatment and inefficient use of healthcare resources.

Effect of Spinal Cord Burst Stimulation vs Placebo Stimulation on Disability in Patients With Chronic Radicular Pain After Lumbar Spine Surgery: A Randomized Clinical Trial.

Importance: The use of spinal cord stimulation for chronic pain after lumbar spine surgery is increasing, yet rigorous evidence of its efficacy is lacking. Objective: To investigate the efficacy of spinal cord burst stimulation, which involves the placement of an implantable pulse generator connected to electrodes with leads that travel into the epidural space posterior to the spinal cord dorsal columns, in patients with chronic radiculopathy after surgery for degenerative lumbar spine disorders. Design, Setting, and Participants: This placebo-controlled, crossover, randomized clinical trial in 50 patients was conducted at St Olavs University Hospital in Norway, with study enrollment from September 5, 2018, through April 28, 2021. The date of final follow-up was May 20, 2022. Interventions: Patients underwent two 3-month periods with spinal cord burst stimulation and two 3-month periods with placebo stimulation in a randomized order. Burst stimulation consisted of closely spaced, high-frequency electrical stimuli delivered to the spinal cord. The stimulus consisted of a 40-Hz burst mode of constant-current stimuli with 4 spikes per burst and an amplitude corresponding to 50% to 70% of the paresthesia perception threshold. Main Outcomes and Measures: The primary outcome was difference in change from baseline in the self-reported Oswestry Disability Index (ODI; range, 0 points [no disability] to 100 points [maximum disability]; the minimal clinically important difference was 10 points) score between periods with burst stimulation and placebo stimulation. The secondary outcomes were leg and back pain, quality of life, physical activity levels, and adverse events. Results: Among 50 patients who were randomized (mean age, 52.2 [SD, 9.9] years; 27 [54%] were women), 47 (94%) had at least 1 follow-up ODI score and 42 (84%) completed all stimulation randomization periods and ODI measurements. The mean ODI score at baseline was 44.7 points and the mean changes in ODI score were -10.6 points for the burst stimulation periods and -9.3 points for the placebo stimulation periods, resulting in a mean between-group difference of -1.3 points (95% CI, -3.9 to 1.3 points; P = .32). None of the prespecified secondary outcomes showed a significant difference. Nine patients (18%) experienced adverse events, including 4 (8%) who required surgical revision of the implanted system. Conclusions and Relevance: Among patients with chronic radicular pain after lumbar spine surgery, spinal cord burst stimulation, compared with placebo stimulation, after placement of a spinal cord stimulator resulted in no significant difference in the change from baseline in self-reported back pain-related disability. Trial Registration: ClinicalTrials.gov Identifier: NCT03546738.

Over Half of Clinical Trials of Mobilization and Manipulation for Patients With Low Back Pain May Have Limited Real-World Applicability: A Systematic Review of 132 Clinical Trials.

OBJECTIVE: To evaluate the existing body of trials assessing manual therapy for low back pain (LBP) to determine where it falls on the efficacyeffectiveness continuum. DESIGN: Methodology systematic review. LITERATURE SEARCH: PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), CENTRAL (Cochrane Central Register of Controlled Trials), and PEDro (Physiotherapy Evidence Database) were searched for trials published between January 1, 2000, and April 30, 2021. STUDY SELECTION CRITERIA: We included randomized clinical trials investigating joint mobilization and manipulation for adults with nonspecific LBP that were available in English. DATA SYNTHESIS: We used the Rating of Included Trials on the Efficacy-Effectiveness Spectrum (RITES) tool to score included trials across 4 domains: participant characteristics, trial setting, flexibility of intervention(s), and clinical relevance of experimental and comparison intervention(s). Proportions of trials with greater emphasis on efficacy or effectiveness were calculated for each domain. RESULTS: Of the 132 included trials, a greater proportion emphasized efficacy than effectiveness for domains participant characteristics (50% vs 38%), trial setting (71% vs 20%), and flexibility of intervention(s) (61% vs 25%). The domain clinical relevance of experimental and comparison intervention(s) had lower emphasis on efficacy (41% vs 50%). CONCLUSION: Most trials investigating manual therapy for LBP lack pragmatism across the RITES domains (ie, they emphasize efficacy). To improve real-world implementation, more research emphasizing effectiveness is needed. This could be accomplished by recruiting from more diverse participant pools, involving multiple centers that reflect common clinical practice settings, involving clinicians with a variety of backgrounds/experience, and allowing flexibility in how interventions are delivered. J Orthop Sports Phys Ther 2022;52(8):532-545. Epub: 19 June 2022. doi:10.2519/jospt.2022.10962.

Interest in Mindfulness Training for Chronic Low-Back Pain: Results from a Vignette-driven, Web-based Survey of Patients.

Objectives: Mindfulness-based stress reduction (MBSR) has been found effective for improving chronic low-back pain (cLBP). However, little data exist regarding how attractive this technique is to Americans as a therapy for cLBP. Design: Survey of randomly selected persons with cLBP. Settings/Location: Respondents were recruited from Kaiser Permanente Washington and one-time surveys were completed online. Patients: Adults 18-80 years of age with cLBP. Surveys: The study was conducted between December 2019 and August 2020. Outcome measures: The survey described an evidence-based classic MBSR course and then asked respondents about their sociodemographic characteristics, their current back pain, previous back pain treatments, behavioral risk factors for back pain, and four outcomes indicative of intention to engage in MBSR. Results: Four-hundred fifty-seven respondents completed the survey. Respondents were primarily women, white, educated, and with back pain for more than 5 years. About half had previously used a mind-body therapy for their pain. Overall, they reported moderate to high intention to try mindfulness classes and practice at home (median of 5 with 50% of the observations between 4 and 6, and 5.7, 50% of the observations between 4.3 and 6.3, respectively, on a 7-point scale). They reported a willingness to spend a median of 3 h/week learning mindfulness and 3.5 h/week practicing mindfulness techniques (for both outcomes, 50% of the respondents reported between 2 and 5 h). Few patient characteristics predicted intention to engage in MBSR, with no variable predicting all outcomes. The magnitude of the effect associated with significant predictors was small. Conclusion: Classic MBSR appealed to many survey respondents, in that they reported high interest in learning MBSR and intention to practice at home. The amount of time they reported being willing to spend learning MBSR and practicing at home is consistent with the time commitment in the original course.

Promoting the use of a self-management strategy among novice chiropractors treating individuals with spine pain: A mixed methods pilot clustered-clinical trial.

BACKGROUND: The uptake of Self-Management Support (SMS) among clinicians is suboptimal. To date, few studies have tested knowledge translation (KT) interventions to increase the application of SMS in chiropractic teaching clinics. STUDY OBJECTIVE: Evaluate the feasibility of implementing a KT intervention to promote the use of a SMS strategy among chiropractic interns, their supervisors, and individuals with spine pain compared to controls. METHODS: Mixed methods pilot clustered-clinical trial. Clusters of 16 Patient Management Teams were allocated to a complex KT intervention (online and workshop training). Primary feasibility outcomes for clinicians, interns and patients were rates of recruitment, retention, and adherence to protocol. A nominal group technique and interviews were used to seek end-users' views on the implementation process, and generate possible solutions. RESULTS: In total, 16 (84%) clinicians, 65 (26%) interns and 42 patients agreed to participate. All clinicians in the intervention group completed all KT intervention components, 23 interns (85%) completed the online training and 14 interns (51.8%) attended the workshop training. All clinicians in the intervention and seven (78%) in the control group completed all outcome measures at baseline and 6-month follow-up, while 15 (55.6%) and 23 (60.5%) interns in the intervention and control groups completed the questionnaires at baseline and 6-month follow-up, respectively. Among patients, 10 (52.6%) and 12 (52.2%) in the intervention and control groups respectively completed the questionnaires at the end of the study. Based on interview findings, solutions to improve the feasibility of conducting a full trial include: making SMS a part of the internship, changing the time of introducing the study to the interns, and having more training on SMS. CONCLUSION: Recruitment and retention of chiropractic interns and patients for a larger implementation trial in a single outpatient teaching clinic may be challenging.

Effects of a Bio-Electromagnetic Energy Regulation Blanket on Thoracolumbar Epaxial Muscle Pain in Horses.

Back pain and inflammation of the epaxial musculature is a significant problem in all equine athletes. Treatment of back pain can be challenging and often requires a multimodal approach. In humans, bio-electromagnetic energy regulation therapy (BEMER) has been reported to be effective in pain modulation. With its increased use in people comes a similar robust application in veterinary medicine unfortunately, there is unsubstantiated evidence for this type of therapy in horses. Objectives of this study were to assess analgesic responses and biomechanical outcome variables using a bio-electromagnetic energy regulation therapy blanket, and to evaluate serum biomarkers as a method to monitor the treatment effects in horses with thoracolumbar epaxial muscle pain. Cohort study of 8 horses treated for 3 consecutive days. Horses with naturally-occurring thoracolumbar epaxial muscle pain were used in this study. Objective outcome variables were recorded daily for 5 days, which included spinal evaluation, mechanical nociceptive thresholds, electromyography, kinematics, kinetics, and serum biomarkers. BEMER blanket therapy significantly improved thoracolumbar epaxial muscle nociceptive thresholds. Center of pressure displacement as a measure of postural stability was significantly improved as well as significant gains in spinal flexibility were demonstrated at study completion. A significant treatment effect was not appreciated in measures of muscle tone, ground reaction forces or serum biomarkers. Limitations include the lack of a control group and a definitive structural diagnosis of thoracolumbar epaxial muscle pain. The BEMER blanket produced significant clinical and biomechanical effects in horses with back pain.

Relação entre dor crônica nas costas, incapacidade e qualidade de vida após auriculoacupuntura e ventosaterapia e satisfação com o tratamento: estudo transversal / Relationship between chronic back pain, disability and quality of life after auriculoacupuncture and cupping therapy and satisfaction with treatment: across-sectional study / La relación entre el dolor de espalda crónico, la discapacidad y la calidad de vida después de la acupuntura auricular y la terapia con ventosas y la satisfacción con el tratamiento: un estudio transversal

OBJETIVO: avaliar a relação da intensidade da dor, incapacidade física e qualidade devida após tratamento de auriculoacupuntura e ventosaterapia com a satisfação com o tratamento, necessidade dele para controle da dor, percepção de melhora e consumo de medicação. MÉTODO: estudo transversal conduzido com 198 pessoas com dor crônica nas costas. Foram investigadas: intensidade da dor, incapacidade física, qualidade de vida, satisfação com o tratamento, necessidade da intervenção para o controle da dor, percepção de melhora e consumo de medicação. Foi realizada correlação de Spearman a 5% de significância. RESULTADOS: Houve correlações negativas de fraca magnitude da intensidade da dor e da incapacidade física com a satisfação com o tratamento, necessidade da intervenção, percepção de melhora após o tratamento e consumo de medicamentos, e correlações positivas de fraca magnitude da percepção da qualidade de vida com a satisfação com o tratamento, necessidade da intervenção, e percepção de melhora. CONCLUSÃO: A melhora da intensidade da dor, da incapacidade física e da qualidade de vida ocasionou melhor estado geral de saúde, satisfação com o tratamento e menor consumo de medicamentos entre os participantes do estudo.

OBJECTIVE: to evaluate the relationship between pain intensity, physical disability and quality of life after auriculoacupuncture and cupping therapy with satisfaction with treatment, need for it to control pain, perception of improvement and medication consumption. METHOD: cross-sectional study conducted with 198 people with chronic back pain. The following were investigated: painintensity, physical disability, quality of life, satisfaction with treatment, need for intervention to control pain, perception of improvement and medication consumption. Spearman's correlation was performed at 5% of significance. RESULTS: There were low magnitude negative correlations of pain intensity and physical disability with treatment satisfaction, need for intervention, perception of improvement after treatment and medication consumption, and low magnitude positive correlations of quality of life perception with satisfaction with treatment, need for intervention, and perception of improvement. CONCLUSION: The improvement in pain intensity, physical disability and quality of life resulted in better general health status, satisfaction with treatment and lower consumption of medication among study participants.

OBJETIVOS: evaluar la relación de la intensidad del dolor, la discapacidad física y la calidad de vida después de la acupuntura auricular y la terapia con ventosas con la satisfacción con el tratamiento, la necesidad del mismo para controlar el dolor, la percepción de mejoría y el consumo de medicamentos. MÉTODO:estudio transversal realizado con 198 personas con dolor de espalda crónico. Se investigó: la intensidad del dolor, la discapacidad física, la calidad de vida, la satisfacción con el tratamiento, la necesidad de intervención para el control del dolor, la percepción de mejoría y el consumo de medicamentos. Se realizó la correlación de Spearman al 5% de significancia. RESULTADOS: Hubo correlaciones negativas de baja magnitud de la intensidad del dolor y de la discapacidad física con la satisfacción con el tratamiento, necesidad de intervención, percepción de mejoría después del tratamiento y consumo de medicamentos, y correlacion espositivas de baja magnitud de la percepción de la calidad de vida con la satisfacción con el tratamiento, necesidad de intervención y percepción de mejora. CONCLUSIÓN: La mejora en la intensidad del dolor, la discapacidad física y la calidad de vida llevaron aun mejor estado general de salud, satisfacción con el tratamiento y menor consumo de medicamentos entre los participantes del estudio.

Cross-sectoral Analysis of 1.4 Million AOK-insured Patients with Back Pain in Baden-Württemberg - What Influence does Outpatient Specialist Care Have? / Sektorenübergreifende Rückenschmerz-Versorgungsanalyse von 1,4 Mio. AOK-Versicherten in Baden-Württemberg ­ welchen Einfluss hat die ambulante fachärztliche Versorgung?

BACKGROUND: Back pain is one of the leading causes of disability globally and the most common musculoskeletal pain in Germany. The lifetime prevalence of back pain ranges from 74% to 85%, and the point prevalence ranges from 32% to 49%. One in five individuals with statutory health insurance visits a doctor at least once a year for back pain, and 1 in 20 individuals is on sick leave at least once a year. The question as to what extent can different outpatient care concepts substantially contribute to improving care and avoiding inpatient hospital treatment has repeatedly been the subject of controversial political discussions. This study aimed to present a description of the reality of care in Baden-Württemberg (BW), Germany, based on claims data. MATERIAL AND METHODS: Anonymised routine billing data of AOK Baden-Württemberg were analysed in compliance with data protection regulations. The billing data cover the outpatient and inpatient care sectors. All AOK patients in BW who received at least one ICD10 diagnosis from their physician in the first half of 2015 were considered for the analysis. Patients with at least one diagnosis of back pain were evaluated as patients with back pain, whereby the assignment to the diagnosis group of specific or non-specific back pain was made based on the code. RESULTS: In the first half of 2015, nearly 988 925 patients with back pain were registered in the 6696 primary care clinics in BW, approximately 302 524 patients in 1172 orthopaedic clinics and 17 043 patients in 89 neurosurgical clinics. Primary care clinics reported back pain diagnosis in 34.6%, orthopaedic clinics in 51.9% and neurosurgical clinics in 78.6% of cases. Primary care clinics diagnosed a specific cause in approximately one-third of patients with back pain, orthopaedic clinics in approximately 40% of their patients and neurosurgery clinics in one in two cases. Overall, approximately 1.2% of 1.3 million patients with back pain (January to December 2015 in BW) were hospitalised. Inpatient therapy consisted of surgical therapy and conservative therapy. Nucleotomy, decompression and spondylodesis were the three most common surgical procedures performed. Pain medication and remedy prescriptions decreased pain after spinal surgery. There are significant regional differences in referral and surgery rates. The mean inpatient referral rate was 535 of 100 000 AOK insurants, and the median was 536 of 100 000 AOK insurants. The mean surgery rate among all admitted patients with back pain was 49.9%, and the median was 49.8%. CONCLUSION: The vast majority of patients with back pain are treated as outpatients. Only approximately 1.2% of all patients with back pain were treated as inpatients in 2015. Of these, approximately half underwent surgery. Spinal surgeries led to a decrease in pain medication and remedy prescription postoperatively. The three most frequent surgical procedures were 'decompression', 'excision of disc tissue' and 'spondylodesis'. There were significant regional differences.

Beneficios de la evaluación integral en adultos mayores con dolores crónicos de columna en un centro periférico del conurbano bonaerense / Benefits of the comprehensive evaluation in older adults with chronic back pain, in a peripheral medical center of the Buenos Aires suburbs

Introducción. Desde hace varios años, el abordaje de los pacientes adultos mayores que consultan por dolor crónico en un centro periférico del Hospital Italiano del conurbano bonaerense se realiza de manera integral, mediante la evaluación conjunta de una kinesióloga y un médico de familia, lo que facilita la indicación terapéutica individualizada, con la aplicación de estrategias cognitivo-conductuales. Objetivo. Documentar los resultados clínicos luego de una evaluación integral de pacientes mayores de 60 años que consultaron por dolor crónico de columna refractarios a tratamientos monodisciplinarios. Métodos. Estudio observacional, analítico tipo antes-después, prospectivo. Recolectamos variables descriptivas de los participantes al momento de la evaluación integral (demográficas, antropométricas, contextuales y clínicas) y de desenlace: dolor, calidad de vida y actividad física a los tres y seis meses, consultas no programadas y a servicio de traumatología durante ese periodo. Estimamos necesaria una muestra de 30 pacientes, pero debido a la pandemia por SARS-CoV-2finalizamos precozmente el estudio con los pacientes reclutados hasta ese momento. Resultados. Incluimos nueve participantes (edad media 66,5 años, desviación estándar 4,9; 67 % sexo femenino). Todos completaron el seguimiento a seis meses. Observamos reducción del dolor y mejoría de la calidad de vida a los seis meses (cambio en la escala visual analógica [EVA] -3, intervalo de confianza [IC] 95 % -5,1 a -0,94; cambio en el puntaje del EQ-5D-3L 0,17, IC 95 % 0,08 a 0,26, respectivamente). Conclusión. En los pacientes adultos mayores de 60 años con dolor crónico de columna no oncológico evaluados de manera integral por un médico de familia y un kinesiólogo se observó una mejoría del dolor y la calidad de vida a los seis meses de seguimiento. Debido a que el diseño no incluyó un grupo control estas diferencias no pueden atribuirse de manera fehaciente a la intervención, aunque estos hallazgos son concordantes con los de ensayos previos. (AU)

Introduction. For several years, the approach of elderly patients who consult for chronic pain in a peripheral center ofthe Hospital Italiano de Buenos Aires has been carried out in a comprehensive way, through the joint evaluation of akinesiologist and a family doctor, which facilitates individualized therapeutic indication, with the application of cognitive-behavioral strategies.Objective. To document the clinical results after the comprehensive evaluation of patients over 60 years of age whoconsulted for chronic back pain refractory to monodisciplinary treatments. Methods. Observational, analytical, before-after, prospective study. We collected descriptive variables from the participantsat the time of the comprehensive evaluation (demographic, anthropometric, contextual and clinical) and outcome variables:pain, quality of life and physical activity at three and six months, unscheduled consultations and trauma service during thatperiod. We estimate that a sample of 30 patients is necessary, but due to the SARS-CoV-2 pandemic we ended the studyearly with the patients recruited up to that time. Results. We included nine participants (mean age 66.5 years, standard deviation 4.9; 67 % female). All completed the six-month follow-up. We observed reduction in pain and improvement in quality of life at six months (change in visual analogscale [VAS] -3, 95 % confidence interval [CI] -5.1 to -0.94; change in score of the EQ-5D-3L 0.17, 95 % CI 0.08 to 0.26,respectively). Conclusion. In adult patients over 60 years of age with chronic non-cancer back pain who were comprehensively evaluatedby a family doctor and a kinesiologist, an improvement in pain and quality of life was observed at six months of follow-up. Since the design did not include a control group, these differences cannot be reliably attributed to the intervention, althoughthese findings are consistent with those of previous trials. (AU)

Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis.

OBJECTIVE: To assess the effects and reliability of sham procedures in manual therapy (MT) trials in the treatment of back pain (BP) in order to provide methodological guidance for clinical trial development. DESIGN: Systematic review and meta-analysis. METHODS AND ANALYSIS: Different databases were screened up to 20 August 2020. Randomised controlled trials involving adults affected by BP (cervical and lumbar), acute or chronic, were included.Hand contact sham treatment (ST) was compared with different MT (physiotherapy, chiropractic, osteopathy, massage, kinesiology and reflexology) and to no treatment. Primary outcomes were BP improvement, success of blinding and adverse effect (AE). Secondary outcomes were number of drop-outs. Dichotomous outcomes were analysed using risk ratio (RR), continuous using mean difference (MD), 95% CIs. The minimal clinically important difference was 30 mm changes in pain score. RESULTS: 24 trials were included involving 2019 participants. Very low evidence quality suggests clinically insignificant pain improvement in favour of MT compared with ST (MD 3.86, 95% CI 3.29 to 4.43) and no differences between ST and no treatment (MD -5.84, 95% CI -20.46 to 8.78).ST reliability shows a high percentage of correct detection by participants (ranged from 46.7% to 83.5%), spinal manipulation being the most recognised technique.Low quality of evidence suggests that AE and drop-out rates were similar between ST and MT (RR AE=0.84, 95% CI 0.55 to 1.28, RR drop-outs=0.98, 95% CI 0.77 to 1.25). A similar drop-out rate was reported for no treatment (RR=0.82, 95% 0.43 to 1.55). CONCLUSIONS: MT does not seem to have clinically relevant effect compared with ST. Similar effects were found with no treatment. The heterogeneousness of sham MT studies and the very low quality of evidence render uncertain these review findings.Future trials should develop reliable kinds of ST, similar to active treatment, to ensure participant blinding and to guarantee a proper sample size for the reliable detection of clinically meaningful treatment effects. PROSPERO REGISTRATION NUMBER: CRD42020198301.

Physician-Related Variability in the Outcomes of an Invasive Treatment for Neck and Back Pain: A Multi-Level Analysis of Data Gathered in Routine Clinical Practice.

Neuro-reflexotherapy (NRT) is a proven effective, invasive treatment for neck and back pain. To assess physician-related variability in results, data from post-implementation surveillance of 9023 patients treated within the Spanish National Health Service by 12 physicians were analyzed. Separate multi-level logistic regression models were developed for spinal pain (SP), referred pain (RP), and disability. The models included all patient-related variables predicting response to NRT and physician-related variables. The Intraclass Correlation Coefficient (ICC) and the Median Odds Ratio (MOR) were calculated. Adjusted MOR (95% CI) was 1.70 (1.47; 2.09) for SP, 1.60 (1.38; 1.99) for RP, and 1.65 (1.42; 2.03) for disability. Adjusted ICC (95%CI) values were 0.08 (0.05; 0.15) for SP, 0.07 (0.03; 0.14) for RP, and 0.08 (0.04; 0.14) for disability. In the sensitivity analysis, in which the 6920 patients treated during the physicians' training period were excluded, adjusted MOR was 1.38 (1.17; 1.98) for SP, 1.37 (1.12; 2.31) for RP, and 1.25 (1.09; 1.79) for disability, while ICCs were 0.03 (0.01; 0.14) for SP, 0.03 (0.00; 0.19) for RP, and 0.02 (0.00; 0.10) for disability. In conclusion, the variability in results obtained by different NRT-certified specialists is reasonable. This suggests that current training standards are appropriate.

Neurophysiological mechanisms of chiropractic spinal manipulation for spine pain.

Together, neck pain and back pain are the first cause of disability worldwide, accounting for more than 10% of the total years lived with disability. In this context, chiropractic care provides a safe and effective option for the management of a large proportion of these patients. Chiropractic is a healthcare profession mainly focused on the spine and the treatment of spinal disorders, including spine pain. Basic studies have examined the influence of chiropractic spinal manipulation (SM) on a variety of peripheral, spinal and supraspinal mechanisms involved in spine pain. While spinal cord mechanisms of pain inhibition contribute at least partly to the pain-relieving effects of chiropractic treatments, the evidence is weaker regarding peripheral and supraspinal mechanisms, which are important components of acute and chronic pain. This narrative review highlights the most relevant mechanisms of pain relief by SM and provides a perspective for future research on SM and spine pain, including the validation of placebo interventions that control for placebo effects and other non-specific effects that may be induced by SM. SIGNIFICANCE: Spinal manipulation inhibits back and neck pain partly through spinal segmental mechanisms and potentially through peripheral mechanisms regulating inflammatory responses. Other mechanisms remain to be clarified. Controls and placebo interventions need to be improved in order to clarify the contribution of specific and non-specific effects to pain relief by spinal manipulative therapy.

Effectiveness of electroacupuncture as a treatment for osteoporosis: A systematic review and meta-analysis.

BACKGROUND: Osteoporosis (OP) results in an increased risk of fragility fractures, representing a major public health problem. In preventing OP, complementary and alternative medicine, such as acupuncture, was recommended because of the low efficiency and side effects of medications. Recently, there is insufficient evidence on electroacupuncture as an effective therapy for OP management. Hence, we evaluated the effectiveness of electroacupuncture for OP treatment. METHODS: We conducted a systematic review and meta-analysis of clinical studies on patients with OP. Five databases (PubMed, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang) were searched from the earliest publication date to March 12, 2020. Randomized controlled trials (RCTs) were included if electroacupuncture was applied as the sole treatment or as an adjunct to other treatments compared with medications in patients with OP. The measurement outcomes included serum aminoterminal propeptide of type I procollagen (PINP) and C-telopeptide of type I collagen (CTX) levels, bone mineral density (BMD) of lumbar, and visual analog scale scores for OP-related pain. Acupoints were extracted when available. RESULTS: In total, 11 RCTs involving 731 participants were included for further meta-analysis. The meta-analysis showed that the use of electroacupuncture as a sole treatment or as an adjunct to other treatments could relieve OP-related pain compared with medications [mean difference (MD) =  -0.58, 95% confidence interval (CI); MD =  -0.97 to -0.19, P = .003, I2 = 88%; MD =  -1.47, 95% CI = -2.14 to -0.79, P < .001, I2 = 96%). Meanwhile, the results showed a favorable effect of electroacupuncture on decreasing serum beta-CTX levels. However, there were no significant differences in serum PINP levels and BMD of lumbar. Shenshu (BL23) was the most frequent acupoint stimulation among these studies. CONCLUSIONS: The application of electroacupuncture as an independent therapy or as an adjunct to other treatments might attenuate OP-related pain and serum beta-CTX levels. However, to overcome the methodological shortcomings of the existing evidence, due to a small size of samples and high risk of bias in these included RCTs, further rigorous studies are required.