The Specifics of Non-specific Low Back Pain: Re-evaluating the Current Paradigm to Improve Patient Outcomes.

Low back pain (LBP) is the leading cause of pain and debility worldwide and the most frequent reason for work-related disability. Global expenditures related to LBP are staggering and amount to billions of dollars each year in the United States alone. Yet, despite the considerable healthcare resources consumed, the care provided to patients with LBP has regularly been cited as both ineffective and exorbitant. Among the myriad reasons for this suboptimal care, the current approach to evaluation and management of patients with LBP is a likely contributor and is hitherto un-investigated. Following the current methodology, over 90% of patients with LBP are provided with no specific diagnosis, are managed inconsistently, and receive no express preventative care. We believed that this approach added costs and promoted chronic unresolved pain and disability. This narrative review highlights problems with the current methodology, proposes a novel concept for categorizing patients with LBP, and recommends strategies for improvement. Stratifying patients according to the etiology, in lieu of the prospects for morbidity, the strategy proposed in this article may help ascertain the cause of patient's LBP early, consolidate treatments, permit timely preventative measures, and, as a result, may improve patient outcomes.

Acquiring guideline-enabled data driven clinical knowledge model using formally verified refined knowledge acquisition method.

BACKGROUND AND OBJECTIVE: Validation and verification are the critical requirements for the knowledge acquisition method of the clinical decision support system (CDSS). After acquiring the medical knowledge from diverse sources, the rigorous validation and formal verification process are required before creating the final knowledge model. Previously, we have proposed a hybrid knowledge acquisition method with the support of a rigorous validation process for acquiring medical knowledge from clinical practice guidelines (CPGs) and patient data for the treatment of oral cavity cancer. However, due to lack of formal verification process, it involves various inconsistencies in knowledge relevant to the formalism of knowledge, conformance to CPGs, quality of knowledge, and complexities of knowledge acquisition artifacts. METHODS: This paper presents the refined knowledge acquisition (ReKA) method, which uses the Z formal verification process. The ReKA method adopts the verification method and explores the mechanism of theorem proving using the Z notation. It enhances a hybrid knowledge acquisition method to thwart the inconsistencies using formal verification. RESULTS: ReKA adds a set of nine additional criteria to be used to have a final valid refined clinical knowledge model. These criteria ensure the validity of the final knowledge model concerning formalism of knowledge, conformance to GPGs, quality of the knowledge, usage of stringent conditions and treatment plans, and inconsistencies possibly resulting from the complexities. Evaluation, using four medical knowledge acquisition scenarios, shows that newly added knowledge in CDSS due to the additional criteria by the ReKA method always produces a valid knowledge model. The final knowledge model was also evaluated with 1229 oral cavity patient cases, which outperformed with an accuracy of 72.57% compared to a similar approach with an accuracy of 69.7%. Furthermore, the ReKA method identified a set of decision paths (about 47.8%) in the existing approach, which results in a final knowledge model with low quality, non-conformed from standard CPGs. CONCLUSION: ReKA refined the hybrid knowledge acquisition method by discovering the missing steps in the current validation process at the acquisition stage. As a formally proven method, it always yields a valid knowledge model having high quality, supporting local practices, and influenced by standard CPGs. Furthermore, the final knowledge model obtained from ReKA also preserves the performance such as the accuracy of the individual source knowledge models.

Risk of Opioid Use Disorder from Exposure to Opioids in the Perioperative Period: A Systematic Review.

Opioid use disorder, a major source of morbidity and mortality globally, is regularly linked to opioids given around the time of surgery. Perioperative period, however, is markedly heterogeneous, with the diverse providers using opioids distinctively, and the various drivers of opioid misuse at-play dissimilarly, throughout the perioperative period. The risk of opioid use disorder may, therefore, be different from opioids given at the various phases of perioperative care, and the ensuing recommendations for their use may also be dissimilar. Systematic search and analysis of the pertinent literature, following the accepted standards, showed an overall increased risk of misuse from the perioperative opioids. However, the analyzed studies had significant methodological limitations, and were constrained mainly to the out-patient phase of the perioperative period. Lacking any data, this risk, therefore, is unknown for intraoperative and postoperative recovery periods. Consequently, no firm recommendations can be extended to anesthesia providers generally managing these perioperative stages. Furthermore, with significant methodological limitations, the current recommendations for opioid use after surgery are also arbitrary. Thus, though proposals for perioperative opioid use are formulated in this article, substantive recommendations would require clear delineation of these risks, while avoiding the limitations noted in this review.

Adding Ozone to Dextrose and Somatropin for Intra-articular Knee Prolotherapy: A Randomized Single-Blinded Controlled Trial.

BACKGROUND: Prolotherapy, as an alternative therapy, has emerged as an effective treatment for chronic musculoskeletal injury, including knee osteoarthritis (OA). Several studies have mention ozone as a potential treatment for these diseases, which is based on analgesic, anti-inflammatory, and anti-oxidant. OBJECTIVES: The current study aimed to investigate the effect of adding ozone gas to hypertonic dextrose and somatropin for knee prolotherapy in patients with knee OA. For this purpose, pain, knee stiffness, and physical activity are measured. METHODS: Sixty patients with chronic knee OA were randomly assigned into two groups of DS and DSO. The DS group received intra-articular hypertonic dextrose (10 ml) plus 4 IU somatropin (4 IU), and the DSO group received 10 ml ozone 25 mcg plus intervention in the DS group. This procedure was performed three times (first, third, and fifth weeks). WOMAC score was examined during the third, fifth, and sixteenth weeks. RESULTS: The mean WOMAC score of the DS group was decreased significantly (P < 0.001) sixteen weeks after providing the intervention (before 64.9 ± 10.6, vs. after 49.2 ± 9.0). A similar decrease (P < 0.001) was observed in the DSO group (before 64.1 ± 11.3, vs. after 41.3 ± 8.0). The decrease of the WOMAC score in the third and sixteenth weeks after providing the intervention was significant in the DSO group compared to the DS group (P < 0.005). CONCLUSIONS: For patients with knee OA, prolotherapy with ozone plus hypertonic dextrose and somatropin was more effective in sedating the pain and improving the stiffness and function of the knee than dextrose and somatropin alone.

Musculoskeletal Disorders a Universal Source of Pain and Disability Misunderstood and Mismanaged: A Critical Analysis Based on the U.S. Model of Care.

Musculoskeletal disorders are the leading source of pain and disability globally but are especially prevalent in the industrialized nations including the U.S. In addition to the substantial individual suffering caused the rising monetary costs of these disorders are noteworthy. In the U.S. alone the annual costs have been estimated to be $874 billion 5.7% of the annual U.S. G.D.P. Despite these expenditures the care provided to patients with musculoskeletal disorders is highly variable and has regularly been shown to have suboptimal outcomes. The many reasons for this ineffective care include the mutable nature of the prevailing syndromes and their limited and variable understanding. The care rendered by a broad and incongruent group of providers who practice disparate methodologies and employ variable treatments. Disorderedly triage comprised of arbitrary selection of providers, care methodologies, and treatments, which is prone to a range of extraneous influences. Treatments that are unable to apprehend the causative pathological processes, which are therefore progressive, cause irreversible damage to the respective musculoskeletal structures, and result in enduring pain and disability. The overall lack of preventative care and the consequent prevalence of these disorders especially in specific work environments and with certain high-risk life styles. This article makes recommendations for better understanding, prevention, early recognition, timely employment of disease altering therapies, streamlining the existing care, and policy initiatives for waste confinement and improvement. These discernments may improve the overall quality of care provided to these patients, diminish the staggering pain and disability caused, and can reduce the immense costs incurred.

Disease-modifying Antirheumatic Drugs for the Treatment of Low Back Pain: A Systematic Review of the Literature.

Low back pain (LBP) is a common source of pain and disability, which has an enormous adverse impact on affected individuals and the community as a whole. The etiologies of LBP are protean and local inflammation contributes to the majority of these processes. Although an array of potent disease-modifying anti-rheumatic drugs (DMARDs), which are typically anti-inflammatory in character, have become clinically available only corticosteroids are routinely used for the treatment of LBP. To further investigate this potentially underutilized therapy, we reviewed the available literature to determine the role of DMARDs in the treatment of LBP. Our results show that the current DMARD use for LBP is indeed limited in scope and is characterized by isolated use and empiric selection of drugs from a range of available DMARDs. Moreover, the dose, frequency, and route of drug administration are selected arbitrarily and deviated from treatment protocols proposed for the management of other inflammatory conditions. The literature published on this topic is of low quality, and the results of the reviewed trials were inconclusive or demonstrated only short-term efficacy of these medications. Based on the findings of this review, we recommend that the future DMARD use for LBP is initially limited to patients with debilitating disease who are unresponsive to conventional treatments, and the criteria for drug selection and routes of drug administration are clearly defined and may be modeled after treatment protocols for other inflammatory conditions.

Efficacy of Pregabalin in the Treatment of Radicular Pain: Results of a Controlled Trial.

BACKGROUND: Pregabalin is commonly used to treat patients with various neuropathic pain syndromes. OBJECTIVES: The purpose of the present study was to evaluate the efficacy of pregabalin in patients with lumbar or cervical radicular pain. PATIENTS AND METHODS: A prospective, randomized, double-blind trial was conducted in 39 patients with lumbar and cervical radicular pain, who received 3 weeks of either pregabalin (n = 10) or placebo (n = 9) treatment. Baseline pain and disability were evaluated before the treatment and were re-evaluated, along with overall patient satisfaction, after the 3 weeks of treatment. RESULTS: Data on 19 of the 39 patients recruited were available for analysis. No statistically significant differences in the pain, disability, and patient satisfaction scores were found between the groups. When the individual patient scores were assessed, the placebo treatment was found to be efficacious in 4 of the 9 patients and pregabalin was effective in 2 of the 10 patients, but the difference was not statistically significant (P = 0.350). CONCLUSIONS: The present data do not suggest that pregabalin is more efficacious than placebo in the treatment of lumbar and cervical radicular pain. However, the small sample size of this study may have affected the ability to detect such a difference.

Diagnostic criteria and treatment of discogenic pain: a systematic review of recent clinical literature.

BACKGROUND CONTEXT: Pain innate to intervertebral disc, often referred to as discogenic pain, is suspected by some authors to be the major source of chronic low back and neck pain. Current management of suspected discogenic pain lacks standardized diagnosis, treatment, and terminology. PURPOSE: In an attempt to determine whether patterns existed that may facilitate standardization of care, we sought to analyze the terminologies used and the various modes of diagnosis and treatment of suspected discogenic pain. STUDY DESIGN: A systematic review of the recent literature. METHODS: A Medline search was performed using the terms degenerative disc disease, discogenic pain, internal disc disruption while using the limits of human studies, English language, and clinical trials, for the last 10 years. The search led to a total of 149 distinct citations, of which 53 articles, where the intervertebral disc itself was considered the principal source of patient's pain and was the main target of the treatment, were retained for further analysis. RESULTS: The results of this review confirm and help quantify the significant differences that existed in the terminology and all the areas of diagnosis and treatment of presumed discogenic pain. CONCLUSIONS: Our findings show that suspected discogenic pain, despite its extensive affirmation in the literature and enormous resources regularly devoted to it, currently lacks clear diagnostic criteria and uniform treatment or terminology.