Normality Analysis of Numeric Rating Scale Scores in Patients with Chronic Axial Spine Pain Before and After Medial Branch Blocks: a Multicenter Study.

OBJECTIVE: The statistical analysis typically employed to compare pain both before and after interventions assumes scores are normally distributed. The present study evaluates whether Numeric Rating Scale (NRS), specifically the NRS-11, scores are indeed normally distributed in a clinically-relevant cohort of adults with chronic axial spine pain pre- and post-analgesic intervention. METHODS: Retrospective review from four academic medical centers of prospectively collected data from a uniform pain diary administered to consecutive patients after undergoing medial branch blocks. The pain diary assessed NRS-11 scores immediately pre-injection and at 12 different time points post-injection up to 48 hours. D'Agostino-Pearson tests were used to test normality at all time points. RESULTS: One hundred fifty pain diaries were reviewed and despite normally distributed pre-injection NRS-11 scores (K2 = 0.655, p = 0.72), all post-injection NRS-11 data was not normally distributed (K2 = 9.70- 17.62, p = 0.0001-0.008). CONCLUSIONS: Although the results of parametric analyses of NRS-11 scores are commonly reported in pain research, some properties of NRS-11 do not satisfy the assumptions required for these analyses. The data demonstrate non-normal distributions in post-intervention NRS-11 scores, thereby violating a key requisite for parametric analysis. We urge pain researchers to consider appropriate statistical analysis and reporting for non-normally distributed NRS-11 scores to ensure accurate interpretation and communication of these data. Practicing pain physicians should similarly recognize that parametric post-intervention pain score statistics may not accurately describe the data and should expect manuscripts to utilize measures of normality to justify the selected statistical methods.

Design of the COMEBACK and BACKHOME Studies, Longitudinal Cohorts for Comprehensive Deep Phenotyping of Adults with Chronic Low-Back Pain (cLBP): a part of the BACPAC Research Program.

Objective: The University of California, San Francisco (UCSF) Core Center for Patient-centric, Mechanistic Phenotyping in Chronic Low Back Pain (REACH) is one of the three NIH Back Pain Consortium (BACPAC) Research Programs Mechanistic Research Centers (MRCs). The goal of UCSF REACH is to define cLBP phenotypes and pain mechanisms that can lead to effective, personalized treatments for patients across the population. The primary objective of this research project is to address the critical need for new diagnostic and prognostic markers, and associated patient classification protocols for chronic low back pain (cLBP) treatment. Design: To meet this objective, REACH is conducting two large investigator-initiated translational research cohort studies called: The Longitudinal Clinical Cohort for Comprehensive Deep Phenotyping of Chronic Low-Back Pain (cLBP) Adults Study (comeBACK) and the Chronic Low-Back Pain (cLBP) in Adults Study (BACKHOME). Setting: comeBACK is a longitudinal multicenter in-person observational study of 450 adults with chronic low back pain designed to perform comprehensive deep phenotyping. While, the BACKHOME study is a site-less longitudinal observational e-cohort of approximately 3000 U.S. adults with cLBP. To our knowledge, BACKHOME is the largest prospective remote registry of nationwide adults with cLBP. Methods: Both the comeBACK and BACKHOME studies are collecting a robust and comprehensive set of risk factors, outcomes, and covariates in order to perform deep phenotyping of cLBP patients based on combined biopsychosocial variables to: define cLBP subtypes, establish phenotyping tools for routine clinical evaluation, and lead to improved cLBP outcomes in the future. The data from both studies will be used to establish techniques to develop a patient-centric definition of treatment success and to analyze cLBP patient traits to define clinically useful cLBP phenotypes, using a combination of traditional data analyses and deep learning methods. Conclusions: These 2 pivotal studies, in conjunction with the ancillary studies being performed in both comeBACK and BACKHOME, and the other BACPAC-consortium research projects, we will be able to address a number of diagnostic and therapeutic issues in this complex and diverse patient population with cLBP. These studies will help clarify biopsychosocial mechanisms of cLBP with the aim to provide a foundation to improve the evaluation of treatment effectiveness and to spur new avenues of therapeutic research, including personalized outcome measures that constitute a clinically meaningful treatment effect for individual cLBP patients.

Predictors of response in PROMIS-global in a chronic low back pain specialty clinic: STarTBack and chronic overlapping pain conditions.

BACKGROUND: Tools, such as the STarTBack Screening Tool (SBT), have been developed to identify risks of progressing to chronic disability in low back pain (LBP) patients in the primary care population. However, less is known about predictors of change in function after treatment in the specialty care population. OBJECTIVE: We pursued a retrospective observational cohort study involving LBP patients seen in a multidisciplinary specialty clinic to assess which features can predict change in function at follow-up. METHODS: The SBT was administered at initial visit, and a variety of patient characteristics were available in the chart including the presence of chronic overlapping pain conditions (COPCs). Patient Reported Outcomes Measurement Information System-10 (PROMIS-10) global physical health (PH) and global mental health (MH) were measured at baseline and at pragmatic time points during follow-up. Linear regression was used to estimate adjusted associations between available features and changes in PROMIS scores. RESULTS: 241 patients were followed for a mean of 17.0 ± 7.5 months. Mean baseline pain was 6.7 (SD 2.1), PROMIS-10 global MH score was 44.8 (SD 9.3), and PH score was 39.4 (SD 8.6). 29.7% were low-risk on the SBT, 41.8% were medium-risk, and 28.5% were high-risk. Mean change in MH and PH scores from baseline to the follow-up questionnaire were 0.86 (SD 8.11) and 2.39 (SD 7.52), respectively. Compared to low-risk patients, high-risk patients had a mean 4.35 points greater improvement in their MH score (p= 0.004) and a mean 3.54 points greater improvement in PH score (p= 0.006). Fewer COPCs also predicted greater improvement in MH and PH. CONCLUSIONS: SBT and the presence of COPC, which can be assessed at initial presentation to a specialty clinic, can predict change in PROMIS following treatment. Effort is needed to identify other factors that can help predict change in function after treatment in the specialty care setting.

[Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]. / Evidenzbasierte Interventionen zur Behandlung von chronischem Schmerz im unteren Rücken ­ Therapieauswahl für einen personalisierten Behandlungsansatz : Deutsche Fassung.

INTRODUCTION: Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP. OBJECTIVE: The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial. METHODS: A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered. CONCLUSION: The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Preferences for risks and benefits of treatment outcomes for chronic low back pain: Choice-based conjoint measure development and discrete choice experiment.

INTRODUCTION: Understanding individual patient preferences for chronic low back pain (cLBP) outcomes is essential for targeting available therapeutic options; yet tools to elicit patient outcome preferences are limited. OBJECTIVE: To develop and test a choice-based conjoint (CBC) measure, commonly used in behavioral economics research, to elicit what outcomes patients with cLBP want to achieve and avoid. DESIGN: We developed a survey-based CBC measure to allow patients to make risk/benefit trade-off choices between possible treatment outcomes. After extensive literature, clinician, and patient input, our measure included seven attributes: fatigue, anxiety/depression, difficulty thinking/making decisions, pain intensity, physical abilities, change in pain, and ability to enjoy life despite pain. Random-parameters logit models were used to estimate strength of preferences, and latent class analysis was used to identify patient characteristics associated with distinct preference. SETTING: Online study using the Sawtooth web-based platform. PARTICIPANTS: Two hundred eleven individuals with cLBP recruited from online advertising as well as at clinical sites across multiple academic and private institutions. INTERVENTIONS: Not applicable. RESULTS: The most valued outcome was the highest level of physical activity (ß = 1.6-1.98; p < .001), followed by avoiding cognitive difficulties (ß = -1.48; p < .001). Avoidance of severe pain was comparable to avoiding constant fatigue and near-constant depression/anxiety (ß = -0.99, -1.02); p < .001). There was an association between preferences and current pain/disability status; patients with higher pain had a stronger preference to avoid severe pain, whereas those with higher disability have stronger preferences for achieving physical activity. The latent class analysis identified two distinct groups: (1) more risk-seeking and willing to accept worse outcomes (56%); and (2) more risk-averse with a stronger preference for achieving maximum benefits (44%). CONCLUSIONS: Our study illuminated cLBP patient preferences for treatment outcomes and heterogeneity in these preferences. Patients stressed the importance of reaching high physical activity and avoiding cognitive declines, even over a desire to avoid pain. More work is needed to understand patient preferences to aid informed, shared decisions.

CAPER: patient preferences to inform nonsurgical treatment of chronic low back pain: a discrete-choice experiment.

OBJECTIVE: We developed and used a discrete-choice measure to study patient preferences with regard to the risks and benefits of nonsurgical treatments when they are making treatment selections for chronic low back pain. METHODS: "CAPER TREATMENT" (Leslie Wilson) was developed with standard choice-based conjoint procedures (discrete-choice methodology that mimics an individual's decision-making process). After expert input and pilot testing, our final measure had 7 attributes (chance of pain relief, duration of relief, physical activity changes, treatment method, treatment type, treatment time burden, and risks of treatment) with 3-4 levels each. Using Sawtooth software (Sawtooth Software, Inc., Provo, UT, USA), we created a random, full-profile, balanced-overlap experimental design. Respondents (n = 211) were recruited via an emailed online link and completed 14 choice-based conjoint choice pairs; 2 fixed questions; and demographic, clinical, and quality-of-life questions. Analysis was performed with random-parameters multinomial logit with 1000 Halton draws. RESULTS: Patients cared most about the chance of pain relief, followed closely by improving physical activity, even more than duration of pain relief. There was comparatively less concern about time commitment and risks. Gender and socioeconomic status influenced preferences, especially with relation to strength of expectations for outcomes. Patients experiencing a low level of pain (Pain, Enjoyment, and General Activity Scale [PEG], question 1, numeric rating scale score<4) had a stronger desire for maximally improved physical activity, whereas those in a high level of pain (PEG, question 1, numeric rating scale score>6) preferred both maximum and more limited activity. Highly disabled patients (Oswestry Disability Index score>40) demonstrated distinctly different preferences, placing more weight on achieving pain control and less on improving physical activity. CONCLUSIONS: Individuals with chronic low back pain were willing to trade risks and inconveniences for better pain control and physical activity. Additionally, different preference phenotypes exist, which suggests a need for clinicians to target treatments to particular patients.

The Back Pain Consortium (BACPAC) Research Program: Structure, Research Priorities, and Methods.

In 2019, the National Health Interview survey found that nearly 59% of adults reported pain some, most, or every day in the past 3 months, with 39% reporting back pain, making back pain the most prevalent source of pain, and a significant issue among adults. Often, identifying a direct, treatable cause for back pain is challenging, especially as it is often attributed to complex, multifaceted issues involving biological, psychological, and social components. Due to the difficulty in treating the true cause of chronic low back pain (cLBP), an over-reliance on opioid pain medications among cLBP patients has developed, which is associated with increased prevalence of opioid use disorder and increased risk of death. To combat the rise of opioid-related deaths, the National Institutes of Health (NIH) initiated the Helping to End Addiction Long-TermSM (HEAL) initiative, whose goal is to address the causes and treatment of opioid use disorder while also seeking to better understand, diagnose, and treat chronic pain. The NIH Back Pain Consortium (BACPAC) Research Program, a network of 14 funded entities, was launched as a part of the HEAL initiative to help address limitations surrounding the diagnosis and treatment of cLBP. This paper provides an overview of the BACPAC research program's goals and overall structure, and describes the harmonization efforts across the consortium, define its research agenda, and develop a collaborative project which utilizes the strengths of the network. The purpose of this paper is to serve as a blueprint for other consortia tasked with the advancement of pain related science.

Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach.

Introduction: Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP. Objective: The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial. Methods: A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered. Conclusion: The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Compensatory biomechanics and spinal loading during dynamic maneuvers in patients with chronic low back pain.

PURPOSE: This study explores the biomechanics underlying the sit-to-stand (STS) functional maneuver in chronic LBP patients to understand how different spinal disorders and levels of pain severity relate to unique compensatory biomechanical behaviors. This work stands to further our understanding of the relationship between spinal loading and symptoms in LBP patients. METHODS: We collected in-clinic motion data from 44 non-specific LBP (NS-LBP) and 42 spinal deformity LBP (SD-LBP) patients during routine clinical visits. An RGB-depth camera tracked 3D joint positions from the frontal view during unassisted, repeated STS maneuvers. Patient-reported outcomes (PROs) for back pain (VAS) and low back disability (ODI) were collected during the same clinical visit. RESULTS: Between patient groups, SD-LBP patients had 14.3% greater dynamic sagittal vertical alignment (dSVA) and 10.1% greater peak spine torque compared to NS-LBP patients (p < 0.001). SD-LBP patients also had 11.8% greater hip torque (p < 0.001) and 86.7% greater knee torque (p = 0.04) compared to NS-LBP patients. There were no significant differences between patient groups in regard to anterior or vertical torso velocities, but anterior and vertical torso velocities correlated with both VAS (r = - 0.38, p < 0.001) and ODI (r = - 0.29, p = 0.01). PROs did not correlate with other variables. CONCLUSION: Patients with LBP differ in movement biomechanics during an STS transfer as severity of symptoms may relate to different compensatory strategies that affect spinal loading. Further research aims to establish relationships between movement and PROs and to inform targeted rehabilitation approaches.

What does the patient with back pain want? A comparison of patient preferences and physician assumptions.

BACKGROUD CONTEXT: Low back pain can be difficult to diagnose, leaving patients frustrated and confused after medical visits. PURPOSE: To evaluate the importance of reasons for seeking care in patients with back pain, and to compare this to physicians' assumptions about these patients' reasons. STUDY DESIGN/SETTING: Prospective survey study carried out at two academic spine centers. PATIENT SAMPLE: A sum of 419 patients with back pain upon initial presentation to a spine clinic, and 198 physicians; all volunteered to complete a survey. OUTCOME MEASURES: Variance in mean values between patient and physician responders with significance determined by non-overlapping 95% confidence intervals. METHODS: Patients were asked to "rate each of the following with regard to their importance to you" (answering between 0 "not important" to 4 "extremely important"): improvement in level of pain, improvement in ability to perform daily tasks, explanation of what is causing your problem, thorough physical examination, diagnostic testing, medication, physical therapy, surgery. Physicians were asked to rate each of these "with regard to their importance to your patients." RESULTS: Patients indicated the following items were the most important (mean values): explanation of what is causing your problem (3.27), improvement in level of pain (3.48) and improvement in ability to perform daily tasks (3.31). Patients attributed the least importance and lowest scores to: surgery (1.07) and medication (1.89). Comparing the mean values to each item by patient and physician responders revealed statistically significant differences in certain items. Specifically, physicians underestimated the importance of an explanation of what is causing the problem (2.78±0.119 vs. 3.28±0.098, 95% CI) and overvalued diagnostic tests (2.64±0.120 vs. 2.30±0.147, 95% CI), medications (2.38±0.118 vs. 1.89± 0.143, 95% CI) and surgery (1.60±0.126 vs. 1.07±0.140, 95% CI). CONCLUSION: Patients did not place as much importance on diagnostic tests, medications and surgery as the physicians assumed. Physicians understand that back pain patients want improvement in both pain and function, but they underestimate the importance of an explanation for the pain.

Objective features of sedentary time and light activity differentiate people with low back pain from healthy controls: a pilot study.

BACKGROUND CONTEXT: Physical inactivity has been described as both a cause and a consequence of low back pain (LBP) largely based on self-reported measures of daily activity. A better understanding of the connections between routine physical activity and LBP may improve LBP interventions. PURPOSE: In this study, we aim to objectively characterize the free-living physical activity of people with low back pain in comparison to healthy controls using accelerometers, and we aim to derive a set of LBP-specific physical activity minutes thresholds that may be used as targets for future physical activity interventions. STUDY DESIGN: Cross-sectional. PATIENT SAMPLE: A total of 22 low back pain patients and 155 controls. OUTCOME MEASURES: Accelerometry derived physical activity measures. METHODS: Twenty-two people with LBP were compared to 155 age and gender-matched healthy controls. All subjects wore an ActiGraph accelerometer on the right hip for 7 consecutive days. Accelerometry-based physical activity features (count-per-minute CPM) were derived using Freedson's intervals and physical performance intervals. A random forest machine learning classifier was trained to classify LBP status using a leave-one-out cross-validation procedure. An interpretation algorithm, the SHapley Additive exPlanations (SHAP) algorithm was subsequently applied to assess the feature importance and to establish LBP-specific physical activity thresholds. RESULTS: The LBP group reported mild to moderate disability (average ODI=18.5). The random forest classifier identified a set of 8 features (digital biomarkers) that achieved 88.1% accuracy for distinguishing LBP from controls. All of the top distinguishing features were related to differences in the sedentary and light activity ranges (<800 CPM), whereas moderate to vigorous physical activity was not discriminative. In addition, we identified and ranked physical activity thresholds that are associated with LBP prediction that can be used in future studies of physical activity interventions for LBP. CONCLUSIONS: We describe a set of physical activity features from accelerometry data associated with LBP. All of the discriminating features were derived from the sedentary and light activity range. We also identified specific activity intensity minutes thresholds that distinguished LBP subjects from healthy controls. Future examination on the digital markers and thresholds identified through this work can be used to improve physical activity interventions for LBP treatment and prevention by allowing the development of LBP-specific physical activity guidelines.

Radiofrequency Ablation for Chronic Hip Pain: A Comprehensive, Narrative Review.

Chronic hip pain can be treated with physical therapy, oral medications, injections, and, definitively, total hip arthroplasty. Enough patients have contraindications to and refractory pain even after total hip arthroplasty, that there is a need to develop alternative managements for this disabling condition. This article examines the state of hip radiofrequency ablation literature including relevant anatomy, patient selection, and treatment outcomes.

Evaluation of human cartilage endplate composition using MRI: Spatial variation, association with adjacent disc degeneration, and in vivo repeatability.

Cartilage endplate (CEP) biochemical composition may influence disc degeneration and regeneration. However, evaluating CEP composition in patients remains a challenge. We used T2* mapping from ultrashort echo-time (UTE) magnetic resonance imaging (MRI), which is sensitive to CEP hydration, to investigate spatial variations in CEP T2* values and to determine how CEP T2* values correlate with adjacent disc degeneration. Thirteen human cadavers (56.4 ± 12.7 years) and seven volunteers (36.9 ± 10.9 years) underwent 3T MRI, including UTE and T1ρ mapping sequences. Spatial mappings of T2* values in L4-S1 CEPs were generated from UTE images and compared between subregions. In the abutting discs, mean T1ρ values in the nucleus pulposus were compared between CEPs with high vs low T2* values. To assess in vivo repeatability, precision errors in mean T2* values, and intraclass correlation coefficients (ICC) were measured from repeat scans. Results showed that CEP T2* values were highest centrally and lowest posteriorly. In the youngest individuals (<50 years), who had mild-to-moderately degenerated Pfirrmann grade II-III discs, low CEP T2* values associated with severer disc degeneration: T1ρ values were 26.7% lower in subjects with low CEP T2* values (P = .025). In older individuals, CEP T2* values did not associate with disc degeneration (P = .39-.62). Precision errors in T2* ranged from 1.7 to 2.6 ms, and reliability was good-to-excellent (ICC = 0.89-0.94). These findings suggest that deficits in CEP composition, as indicated by low T2* values, associate with severer disc degeneration during the mild-to-moderate stages. Measuring CEP T2* values with UTE MRI may clarify the role of CEP composition in patients with mild-to-moderate disc degeneration.

Variability among methods and timing of pain assessment tools for tracking improvement of lumbar stenosis patients after surgery.

BACKGROUND CONTEXT: Many different pain and functional outcomes are used to determine progress after surgical intervention for lumbar spinal stenosis (LSS); it is unknown how these different outcomes correlate, or whether timing of pain measurement is important. PURPOSE: The goal was to determine whether method and timing of pain measurement is important in the context of LSS surgical outcomes. STUDY DESIGN/SETTING: Cohort study. PATIENT SAMPLE: LSS patients (N=21). OUTCOME MEASURES: Self-report measures. METHODS: Each patient completed the 36-item Short Form, Oswestry Disability Index, and Swiss Spinal Stenosis Questionnaire 1 week presurgery and 6 months postsurgery. Objective function was measured using the Self-Paced Walking Test (SPWT). Low back and leg pain were assessed by visual analogue scale both immediately before the SPWT (prewalking pain) and at the symptom-limited endpoint (provoked pain). Pain was also assessed before and after surgery using the pain subscales of 36-item Short Form pain, Oswestry Disability Index, and Swiss Spinal Stenosis Questionnaire. RESULTS: Patients averaged 65.3 years of age with 15 being female. After surgery, all outcome measures improved significantly. Postwalking pain (provoked pain) demonstrating a strong relationship with objectively measured function (SPWT). Pain (visual analogue scale prewalk and postwalk) showed little correlation with reported changes in disability, general health or physical function. CONCLUSIONS: Our results suggest that for patients with LSS, the context of the pain measurement matters, and it is important to measure pain after walking (provoked pain). Results also suggest that when examining the relationship between pain and function, objective measures of function are preferable (eg, a walking test). Finally, given the lack of association between measures of pain, it is important to understand that each pain measure is addressing a different pain construct. Therefore, when conducting outcomes studies, it is imperative to compare the exact same pain measures across time points.

Digital Care for Chronic Musculoskeletal Pain: 10,000 Participant Longitudinal Cohort Study.

BACKGROUND: Chronic musculoskeletal pain has a vast global prevalence and economic burden. Conservative therapies are universally recommended but require patient engagement and self-management to be effective. OBJECTIVE: This study aimed to evaluate the efficacy of a 12-week digital care program (DCP) in a large population of patients with chronic knee and back pain. METHODS: A longitudinal observational study was conducted using a remote DCP available through a mobile app. Subjects participated in a 12-week multimodal DCP incorporating education, sensor-guided exercise therapy (ET), and behavioral health support with 1-on-1 remote health coaching. The primary outcome was pain measured by the visual analog scale (VAS). Secondary measures included engagement levels, program completion, program satisfaction, condition-specific pain measures, depression, anxiety, and work productivity. RESULTS: A total of 10,264 adults with either knee (n=3796) or low back (n=6468) pain for at least three months were included in the study. Participants experienced a 68.45% average improvement in VAS pain between baseline intake and 12 weeks. In all, 73.04% (7497/10,264) participants completed the DCP into the final month. In total, 78.60% (5893/7497) of program completers (7144/10,264, 69.60% of all participants) achieved minimally important change in pain. Furthermore, the number of ET sessions and coaching interactions were both positively associated with improvement in pain, suggesting that the amount of engagement influenced outcomes. Secondary outcomes included a 57.9% and 58.3% decrease in depression and anxiety scores, respectively, and 61.5% improvement in work productivity. Finally, 3 distinct clusters of pain response trajectories were identified, which could be predicted with a mean 76% accuracy using baseline measures. CONCLUSIONS: These results support the efficacy and scalability of a DCP for chronic low back and knee pain in a large, diverse, real-world population. Participants demonstrated high completion and engagement rates and a significant positive relationship between engagement and pain reduction was identified, a finding that has not been previously demonstrated in a DCP. Furthermore, the large sample size allowed for the identification of distinct pain response subgroups, which may prove beneficial in predicting recovery and tailoring future interventions. This is the first longitudinal digital health study to analyze pain outcomes in a sample of this magnitude, and it supports the prospect for DCPs to serve the overwhelming number of musculoskeletal pain sufferers worldwide.

Pain and Functional Outcomes After Sacroiliac Joint Injection with Anesthetic and Corticosteroid at Six Months, Stratified by Anesthetic Response and Physical Exam Maneuvers.

OBJECTIVE: To evaluate sacroiliac joint (SIJ) injection outcomes with local anesthetic and corticosteroid. DESIGN: Prospective cohort. SETTING: Single academic medical center. METHODS: Thirty-four patients referred for SIJ injection with a clinical diagnosis of SIJ pain underwent injections with 1:1 mixture of 2% lidocaine and triamcinolone 40 mg/mL. Pain provocation physical exam (PE) maneuvers were recorded immediately before and after injection. Outcome measures at two to four weeks and six months included pain numeric rating scale (NRS) and Oswestry Disability Index (ODI). RESULTS: For the analysis of outcomes by the overall group (not stratified by PE and/or anesthetic block), a 58.8% (95% confidence interval [CI] = +/-16.5%) ≥2 NRS reduction, a 32.4% (95% CI = +/-15.7%) ≥50% NRS reduction, and a 38.2% (95% CI = +/-16.3%) ≥30% ODI reduction were observed at two to four weeks, with similar improvements at six months. Outcomes stratified based on pre-injection PE did not reveal significant differences at either time point. The stratification based on the presence of 100% postinjection anesthetic response demonstrated a significant difference at two to four weeks for ≥50% NRS improvement. The true positive/true negative group (TP/TN) stratification demonstrated a significant difference for ≥50% NRS improvement at two to four weeks, whereas six-month outcomes for TP/TN demonstrated significant differences for ≥50% NRS and ≥30% ODI improvement. An increased injection response was observed with stratification of patients more likely to have true SIJ pain (i.e., TP), with TP/TN stratification demonstrating a 75% (95% CI = +/-30.0%) ≥2 NRS improvement and a 62.5% (95% CI = +/-33.5%) improvement of ≥50% NRS and ≥30% ODI for the TP group at two to four weeks, with similar results at six months. CONCLUSIONS: SIJ steroid injection based on referral clinical diagnosis is unlikely to demonstrate true injection efficacy, and more specific selection criteria are warranted.

Radiofrequency Ablation for Posterior Sacroiliac Joint Complex Pain: A Narrative Review.

Radiofrequency ablation (RFA) of the sacral lateral branches targets the innervation of the posterior sacroiliac ligaments and posterior portion of the sacroiliac joint, also referred to as the posterior sacroiliac joint complex. This review assesses the published evidence on local anesthetic blocks for the diagnosis of posterior sacroiliac joint complex pain and the efficacy of RFA of the sacral lateral branches as a treatment. The current evidence suggests that RFA can provide relief of pain that originates from the posterior sacroiliac joint complex, but interpretation of this literature is limited by variability in patient selection criteria, the specific nerves targeted for ablation, and the types of RFA technology and technique utilized.

Trends in steroid agent and diluent choices for epidural steroid injections: a survey of Spine Intervention Society physicians.

BACKGROUND: Epidural steroid injections (ESIs) are a frequently used treatment for refractory radicular spinal pain. ESIs, particularly transforaminal epidural steroid injections (TFESI), may provide pain relief and delay the need for surgery. Corticosteroid agent and diluent choices are known to impact the safety of ESIs. In particular, the risk of embolization with particulate corticosteroids has led to recommendations for non-particulate steroid use by the Multisociety Pain Workgroup. Additionally, there is in vitro evidence that ropivacaine can crystalize in the presence of dexamethasone, potentially creating a particulate-like injectate. Despite widespread use and known risk mitigation strategies, current practice trends related to steroid and diluent choices are unknown. OBJECTIVE: Identify the use of particulate versus non-particulate corticosteroids for epidural steroid injections in the cervical and lumbar spine, as well as local anesthetics commonly used as diluents during these procedures. METHODS: Cross-sectional survey study of 314 physician members of the Spine Interventional Society. RESULTS: 41% and 9% of providers reported using particulate corticosteroids during lumbar TFESIs and cervical TFESI, respectively. Four per cent of providers reported the use of ropivacaine in cervical TFESIs. Forty-four per cent of respondents reported using anesthetic in cervical interlaminar ESIs. 21% of providers report using high volumes (> 4.5 mL) during cervical interlaminar ESIs. CONCLUSION: Current trends, as assessed by this survey study, indicate substantial variability in steroid and diluent choice for ESIs. Patterns were identified that may impact patient safety including the continued use of particulate corticosteroids for TFESIs and the use of ropivacaine during TFESIs by a subset of respondents.

Image-Guided Sacroiliac Joint Injections: an Evidence-based Review of Best Practices and Clinical Outcomes.

Injections into the intraarticular sacroiliac joint (SIJ) are commonly done for both diagnostic and therapeutic reasons. Injection of an anesthetic can aid in the diagnosis of SIJ pain. Corticosteroids can be administered with the goal of providing a therapeutic effect. This article summarizes the literature regarding the diagnostic and therapeutic effects of these injections. It includes a review of the various imaging modalities including fluoroscopy, ultrasound, and computed tomography guidance, as well as a discussion on the prevalence data and other variables that may affect the reported outcomes.

Challenges in Diagnosing Sacroiliac Joint Pain: A Narrative Review.

Accurate diagnosis of sacroiliac joint (SIJ) pain is challenging. Diagnosis can be aided by pain referral patterns, historical features, physical examination maneuvers, and imaging. However, all of these diagnostic tools have limitations. The most reliable clinical tools may be a combination of three or more positive physical exam maneuvers, although the evidence is inconsistent even for this strategy. Intra-articular diagnostic SIJ injections are often used as the reference standard for "true" sacroiliac pain. However, such injections do not consider extra-articular sources of pain that may also exist as part of the sacroiliac joint complex. Research has established the posterior sacral ligaments as a possible source of pain, and the innervation of these ligaments has been anatomically defined. It is possible that by expanding our focus from the articular portion of the sacroiliac complex structure to both the joint and extra-capsular ligaments, advancements in clinical diagnosis and treatment will be possible.