Bone mineral density is not associated with incident high-intensity back pain: a 10-year cohort study in men.

Although patients believe that osteoporosis is a painful condition, health professionals assume it is painless unless a fracture occurs. The association between BMD and back pain has not been examined longitudinally in community-based adults in an unbiased population using gold-standard measures. This study aimed to examine the association between BMD and incident high-intensity back pain and/or high disability over 10 years in Australian men without high-intensity symptoms at baseline. Men with no high-intensity back pain and/or high disability attending the Geelong Osteoporosis Study at the 5-year visit (occurring between 2006-2010) (considered the baseline for the current study) were followed for 10 years (reassessed between 2016-2021). Back pain and disability were assessed using the Graded Chronic Pain Scale at both time points. At baseline, DXA was used to measure lumbar spine and total hip BMD and spinal artefacts. The relationships between BMD and incident high-intensity pain and/or high disability at follow-up were examined using binary logistic regression, adjusted for age, body mass index, depression, education, smoking, mobility, and spinal artefacts. A total of 679 participants had no to low-intensity pain and/or no to low disability at baseline. A total of 441 attended follow-up, providing back pain and disability data. Thirty-seven men developed high-intensity pain and/or high disability. No association of BMD at any site was seen with incident high-intensity pain and/or high disability. BMD was not associated with incident high-intensity pain or disability in community-based men. These data provide evidence to dispel the erroneous community-held belief that low BMD is related to back pain and disability.

Metformin for knee osteoarthritis with obesity: study protocol for a randomised, double-blind, placebo-controlled trial.

INTRODUCTION: Over half of the populations with knee osteoarthritis (OA) have obesity. These individuals have many other shared metabolic risk factors. Metformin is a safe, inexpensive, well-tolerated drug that has pleiotropic effects, including structural protection, anti-inflammatory and analgesic effects in OA, specifically the knee. The aim of this randomised, double-blind, placebo-controlled trial is to determine whether metformin reduces knee pain over 6 months in individuals with symptomatic knee OA who are overweight or obese. METHODS AND ANALYSIS: One hundred and two participants with symptomatic knee OA and overweight or obesity will be recruited from the community in Melbourne, Australia, and randomly allocated in a 1:1 ratio to receive either metformin 2 g or identical placebo daily for 6 months. The primary outcome is reduction of knee pain [assessed by 100 mm Visual Analogue Scale (VAS)] at 6 months. The secondary outcomes are OMERACT-OARSI (Outcome Measures in Rheumatology-Osteoarthritis Research Society International) responder criteria [Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain, function and participant's global assessment (VAS)] at 6 months; change in knee pain, stiffness, function using WOMAC at 6 months and quality of life at 6 months. Adverse events will be recorded. The primary analysis will be by intention to treat, including all participants in their randomised groups. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Alfred Hospital Ethics Committee (708/20) and Monash University Human Research Ethics Committee (28498). Written informed consent will be obtained from all the participants. The findings will be disseminated through peer-review publications and conference presentations. TRIAL REGISTRATION NUMBER: ACTRN12621000710820 .

Negative back beliefs are associated with increased odds of low back pain and disability: a 10-year cohort study in men.

OBJECTIVE: Although negative back beliefs are associated with high-intensity low back pain (LBP)/disability, whether they influence incident high-intensity LBP/high-disability over the long-term is unknown. This study aimed to investigate whether negative back beliefs were associated with developing high-intensity LBP and/or high-disability over 10 years in men. METHODS: Men with no or low-intensity LBP and/or disability attending the Geelong Osteoporosis Study between 2006-2010 were included. Data on age, body mass index, mobility, education, back beliefs (Back Beliefs Questionnaire), LBP and disability (Graded Chronic Pain Scale) were collected between 2006-2010. Beliefs, LBP and disability were re-assessed in 2016-2021. Binary logistic regression was used to examine the association between negative back beliefs and incident high-intensity pain and/or high-disability, adjusting for age, body mass index, mobility, and education. RESULTS: At baseline, 705 participants (mean age 53.8 years) had no or low LBP and no or low-disability; 441 (62.6%) participants completed a 10-year follow-up. Of these, 37 (8.4%) developed high-intensity pain and/or high-disability. In multivariate analyses, participants with more negative back beliefs at baseline were more likely to develop high-intensity pain and/or high-disability (Odds ratio 1.05, 95% CI 1.00-1.11). Developing more negative back beliefs was also associated with incident high-intensity pain and/or high-disability (Odds Ratio 1.20, 95% CI 1.12-1.30). CONCLUSION: In a male community-based population, negative beliefs regarding the consequences of LBP were associated with an increased likelihood of developing high-intensity pain and/or high-disability. Addressing negative back beliefs in the community may reduce the incidence of high-intensity pain and/or high-disability over 10 years in men.

High levels of back disability, not back pain, are associated with reduced physical activity across key activity domains.

BACKGROUND: Although remaining physically active is the cornerstone of management for low back pain, our understanding of the physical activity performed by those with back pain is limited. OBJECTIVES: To examine the physical activity reported by individuals with different levels of low back pain and disability across key activity domains. DESIGN: Community-based, cross-sectional study. METHODS: 542 women were recruited from a research database formed from an electoral roll and completed validated, self-report questionnaires. The amount and intensity of physical activity was reported using the International Physical Activity Questionnaire. Low back pain and disability were examined using the Graded Chronic Pain Scale. Participants were categorised into no, low or high pain and disability groups. RESULTS: Individuals who reported high disability performed 55% of the physical activity of those without disability (MET(hours/week):median(95%CI) = 27.1(13.2-41.0); 48.8(37.8-59.9),p = 0.01), including less moderate (18.0(10.4-25.6); 31.0(24.0-38.1),p = 0.007), and domestic and gardening activity (14.7(7.2-22.3); 25.7(19.8-31.7),p = 0.001). Fewer women with high disability performed vigorous (OR(95%CI) = 0.29(0.13-0.65),p = 0.002) and leisure activities (0.17(0.04-0.75),p = 0.02) compared to those with no disability. Those with low disability reported less leisure activity ((0.55(0.35-0.88),p = 0.01), but more work-related activities and active transport than individuals without disability (1.65(1.01-2.7),p = 0.04; 1.6(1.04-2.6),p = 0.03). There were no differences in activity between pain groups, with the exception of those with low intensity pain performing less leisure activity (0.51(0.30-0.88),p = 0.01). CONCLUSIONS: Individuals who reported high back disability, not back pain, were found to perform reduced physical activity, including less total, moderate, vigorous, and discretionary activity. These findings highlight the altered activity levels of people with back disability and the need to examine its impact on their health and wellbeing.

Television-viewing time and bodily pain in Australian adults with and without type 2 diabetes: 12-year prospective relationships.

BACKGROUND: Bodily pain is a common presentation in several chronic diseases, yet the influence of sedentary behaviour, common in ageing adults, is unclear. Television-viewing (TV) time is a ubiquitous leisure-time sedentary behaviour, with a potential contribution to the development of bodily pain. We examined bodily pain trajectories and the longitudinal relationships of TV time with the bodily pain severity; and further, the potential moderation of the relationships by type 2 diabetes (T2D) status. METHOD: Data were from 4099 participants (aged 35 to 65 years at baseline) in the Australian Diabetes, Obesity and Lifestyle Study (AusDiab), who took part in the follow-ups at 5 years, 12 years, or both. Bodily pain (from SF36 questionnaire: a 0 to 100 scale, where lower scores indicate more-severe pain), TV time, and T2D status [normal glucose metabolism (NGM), prediabetes, and T2D] were assessed at all three time points. Multilevel growth curve modelling used age (centred at 50 years) as the time metric, adjusting for potential confounders, including physical activity and waist circumference. RESULTS: Mean TV time increased, and bodily pain worsened (i.e., mean bodily pain score decreased) across the three time points. Those with T2D had higher TV time and more-severe bodily pain than those without T2D at all time points. In a fully adjusted model, the mean bodily pain score for those aged 50 years at baseline was 76.9(SE: 2.2) and worsened (i.e., bodily pain score decreased) significantly by 0.3(SE: 0.03) units every additional year (p <0.001). Those with initially more-severe pain had a higher rate of increase in pain severity. At any given time point, a one-hour increase in daily TV time was significantly associated with an increase in pain severity [bodily pain score decreased by 0.69 (SE: 0.17) units each additional hour; p <0.001], accounting for the growth factor (age) and confounders' effects. The association was more-pronounced in those with T2D than in those without (prediabetes or NGM), with the effect of T2D on bodily pain severity becoming more apparent as TV time increases, significantly so when TV time increased above 2.5 hours per day. CONCLUSION: Bodily pain severity increased with age in middle-aged and older Australian adults over a 12-year period, and increments in TV time predicted increased bodily pain severity at any given period, which was more pronounced in those with T2D. While increasing physical activity is a mainstay of the prevention and management of chronic health problems, these new findings highlight the potential of reducing sedentary behaviours in this context.

Antidepressants for hip and knee osteoarthritis.

BACKGROUND: Although pain is common in osteoarthritis, most people fail to achieve adequate analgesia. Increasing acknowledgement of the contribution of pain sensitisation has resulted in the investigation of medications affecting pain processing with central effects. Antidepressants contribute to pain management in other conditions where pain sensitisation is present. OBJECTIVES: To assess the benefits and harms of antidepressants for the treatment of symptomatic knee and hip osteoarthritis in adults. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search was January 2021. SELECTION CRITERIA: We included randomised controlled trials of adults with osteoarthritis that compared use of antidepressants to placebo or alternative comparator. We included trials that focused on efficacy (pain and function), treatment-related adverse effects and had documentation regarding discontinuation of participants. We excluded trials of less than six weeks of duration or had participants with concurrent mental health disorders. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Major outcomes were pain; responder rate; physical function; quality of life; and proportion of participants who withdrew due to adverse events, experienced any adverse events or had serious adverse events. Minor outcomes were proportion meeting the OARSI (Osteoarthritis Research Society International) Response Criteria, radiographic joint structure changes and proportion of participants who dropped out of the study for any reason. We used GRADE to assess certainty of evidence. MAIN RESULTS: Nine trials (2122 participants) met the inclusion criteria. Seven trials examined only knee osteoarthritis. Two also included participants with hip osteoarthritis. All trials compared antidepressants to placebo, with or without non-steroidal anti-inflammatory drugs. Trial sizes were 36 to 388 participants. Most participants were female, with mean ages of 54.5 to 65.9 years. Trial durations were 8 to 16 weeks. Six trials examined duloxetine. We combined data from nine trials in meta-analyses for knee and hip osteoarthritis. One trial was at low risk of bias in all domains. Five trials were at risk of attrition and reporting bias. High-certainty evidence found that antidepressants resulted in a clinically unimportant improvement in pain compared to placebo. Mean reduction in pain (0 to 10 scale, 0 = no pain) was 1.7 points with placebo and 2.3 points with antidepressants (mean difference (MD) -0.59, 95% confidence interval (CI) -0.88 to -0.31; 9 trials, 2122 participants). Clinical response was defined as achieving a 50% or greater reduction in 24-hour mean pain. High-certainty evidence demonstrated that 45% of participants receiving antidepressants had a clinical response compared to 28.6% receiving placebo (RR 1.55, 95% CI 1.32 to 1.82; 6 RCTs, 1904 participants). This corresponded to an absolute improvement in pain of 16% more responders with antidepressants (8.9% more to 26% more) and a number needed to treat for an additional beneficial effect (NNTB) of 6 (95% CI 4 to 11). High-certainty evidence showed that the mean improvement in function (on 0 to 100 Western Ontario and McMaster Universities Arthritis Index, 0 = best function) was 10.51 points with placebo and 16.16 points with antidepressants (MD -5.65 points, 95% CI -7.08 to -4.23; 6 RCTs, 1909 participants). This demonstrates a small, clinically unimportant response. Moderate-certainty evidence (downgraded for imprecision) showed that quality of life measured using the EuroQol 5-Dimension scale (-0.11 to 1.0, 1.0 = perfect health) improved by 0.07 points with placebo and 0.11 points with antidepressants (MD 0.04, 95% CI 0.01 to 0.07; 3 RCTs, 815 participants). This is clinically unimportant. High-certainty evidence showed that total adverse events increased in the antidepressant group (64%) compared to the placebo group (49%) (RR 1.27, 95% CI 1.15 to 1.41; 9 RCTs, 2102 participants). The number needed to treat for an additional harmful outcome (NNTH) was 7 (95% CI 5 to 11). Low-certainty evidence (downgraded twice for imprecision for very low numbers of events) found no evidence of a difference in serious adverse events between groups (RR 0.94, 95% CI 0.46 to 1.94; 9 RCTs, 2101 participants). The NNTH was 1000.  Moderate-certainty evidence (downgraded for imprecision) showed that 11% of participants receiving antidepressants withdrew from trials due to an adverse event compared to 5% receiving placebo (RR 2.15, 95% CI 1.56 to 2.97; 6 RCTs, 1977 participants). The NNTH was 17 (95% CI 10 to 35). AUTHORS' CONCLUSIONS: There is high-certainty evidence that use of antidepressants for knee osteoarthritis leads to a non-clinically important improvement in mean pain and function. However, a small number of people will have a 50% or greater important improvement in pain and function. This finding was consistent across all trials. Pain in osteoarthritis may be due to a variety of causes that differ between individuals. It may be that the cause of pain that responds to this therapy is only present in a small number of people. There is moderate-certainty evidence that antidepressants have a small positive effect on quality of life with heterogeneity between trials. High-certainty evidence indicates antidepressants result in more adverse events and moderate-certainty evidence indicates more withdrawal due to adverse events. There was little to no difference in serious adverse events (low-certainty evidence due to low numbers of events). This suggests that if antidepressants were being considered, there needs to be careful patient selection to optimise clinical benefit given the known propensity for adverse events with antidepressant use. Future trials should include alternative antidepressant agents or phenotyping of pain in people with osteoarthritis, or both.

Smartphone-Based Ecological Momentary Assessment for Collecting Pain and Function Data for Those with Low Back Pain.

Smartphone-based ecological momentary assessment (EMA) methods are widely used for data collection and monitoring in healthcare but their uptake clinically has been limited. Low back pain, a condition with limited effective treatments, has the potential to benefit from EMA. This study aimed to (i) determine the feasibility of collecting pain and function data using smartphone-based EMA, (ii) examine pain data collected using EMA compared to traditional methods, (iii) characterize individuals' progress in relation to pain and function, and (iv) investigate the appropriation of the method. Our results showed that an individual's 'pain intensity index' provided a measure of the burden of their low back pain, which differed from but complemented traditional 'change in pain intensity' measures. We found significant variations in the pain and function over the course of an individual's back pain that was not captured by the cohort's mean scores, the approach currently used as the gold standard in clinical trials. The EMA method was highly acceptable to the participants, and the Model of Technology Appropriation provided information on technology adoption. This study highlights the potential of the smartphone-based EMA method for enhancing the collection of outcome data and providing a personalized approach to the management of low back pain.

Does aerobic exercise effect pain sensitisation in individuals with musculoskeletal pain? A systematic review.

BACKGROUND: Pain sensitisation plays a major role in musculoskeletal pain. However, effective treatments are limited, and although there is growing evidence that exercise may improve pain sensitisation, the amount and type of exercise remains unclear. This systematic review examines the evidence for an effect of aerobic exercise on pain sensitisation in musculoskeletal conditions. METHODS: Systematic searches of six electronic databases were conducted. Studies were included if they examined the relationship between aerobic physical activity and pain sensitisation in individuals with chronic musculoskeletal pain, but excluding specific patient subgroups such as fibromyalgia. Risk of bias was assessed using Cochrane methods and a qualitative analysis was conducted. RESULTS: Eleven studies (seven repeated measures studies and four clinical trials) of 590 participants were included. Eight studies had low to moderate risk of bias. All 11 studies found that aerobic exercise increased pressure pain thresholds or decreased pain ratings in those with musculoskeletal pain [median (minimum, maximum) improvement in pain sensitisation: 10.6% (2.2%, 24.1%)]. In these studies, the aerobic exercise involved walking or cycling, performed at a submaximal intensity but with incremental increases, for a 4-60 min duration. Improvement in pain sensitisation occurred after one session in the observational studies and after 2-12 weeks in the clinical trials. CONCLUSIONS: These findings provide evidence that aerobic exercise reduces pain sensitisation in individuals with musculoskeletal pain. Further work is needed to determine whether this translates to improved patient outcomes, including reduced disability and greater quality of life.

Musculoskeletal pain and sedentary behaviour in occupational and non-occupational settings: a systematic review with meta-analysis.

BACKGROUND: Sedentary behaviour (SB; time spent sitting) is associated with musculoskeletal pain (MSP) conditions; however, no prior systematic review has examined these associations according to SB domains. We synthesised evidence on occupational and non-occupational SB and MSP conditions. METHODS: Guided by a PRISMA protocol, eight databases (MEDLINE, CINAHL, PsycINFO, Web of Science, Scopus, Cochrane Library, SPORTDiscus, and AMED) and three grey literature sources (Google Scholar, WorldChat, and Trove) were searched (January 1, 2000, to March 17, 2021) for original quantitative studies of adults ≥ 18 years. Clinical-condition studies were excluded. Studies' risk of bias was assessed using the QualSyst checklist. For meta-analyses, random effect inverse-variance pooled effect size was estimated; otherwise, best-evidence synthesis was used for narrative review. RESULTS: Of 178 potentially-eligible studies, 79 were included [24 general population; 55 occupational (incuding15 experimental/intervention)]; 56 studies were of high quality, with scores > 0.75. Data for 26 were meta-synthesised. For cross-sectional studies of non-occupational SB, meta-analysis showed full-day SB to be associated with low back pain [LBP - OR = 1.19(1.03 - 1.38)]. Narrative synthesis found full-day SB associations with knee pain, arthritis, and general MSP, but the evidence was insufficient on associations with neck/shoulder pain, hip pain, and upper extremities pain. Evidence of prospective associations of full-day SB with MSP conditions was insufficient. Also, there was insufficient evidence on both cross-sectional and prospective associations between leisure-time SB and MSP conditions. For occupational SB, cross-sectional studies meta-analysed indicated associations of self-reported workplace sitting with LBP [OR = 1.47(1.12 - 1.92)] and neck/shoulder pain [OR = 1.73(1.46 - 2.03)], but not with extremities pain [OR = 1.17(0.65 - 2.11)]. Best-evidence synthesis identified inconsistent findings on cross-sectional association and a probable negative prospective association of device-measured workplace sitting with LBP-intensity in tradespeople. There was cross-sectional evidence on the association of computer time with neck/shoulder pain, but insufficient evidence for LBP and general MSP. Experimental/intervention evidence indicated reduced LBP, neck/shoulder pain, and general MSP with reducing workplace sitting. CONCLUSIONS: We found cross-sectional associations of occupational and non-occupational SB with MSP conditions, with occupational SB associations being occupation dependent, however, reverse causality bias cannot be ruled out. While prospective evidence was inconclusive, reducing workplace sitting was associated with reduced MSP conditions. Future studies should emphasise prospective analyses and examining potential interactions with chronic diseases. PROTOCOL REGISTRATION: PROSPERO ID # CRD42020166412 (Amended to limit the scope).

Is antibiotic treatment effective in the management of chronic low back pain with disc herniation? Study protocol for a randomised controlled trial.

BACKGROUND: There has been immense interest and debate regarding the effectiveness of antibiotic treatment for chronic low back pain. Two randomised controlled trials have examined the efficacy of antibiotics for chronic low back pain with disc herniation and Modic changes, but have reported conflicting results. The aim of this double-blind, randomised, placebo-controlled trial is to determine the efficacy of antibiotic treatment in a broader patient subgroup of chronic low back pain with disc herniation and investigate whether the presence of Modic changes predicts response to antibiotic therapy. METHODS: One hundred and seventy individuals with chronic low back pain will be recruited through hospital and private medical and allied health clinics; advertising in national, community and social media; and posting of flyers in community locations. They will be randomly allocated to receive either amoxicillin-clavulanate (500 mg/125 mg) twice per day for 90 days or placebo. The primary outcome measure of pain intensity will be assessed using the Low Back Pain Rating scale and a 100-mm visual analogue scale at 12 months. Secondary measures of self-reported low back disability and work absence and hindrance will also be examined, and an economic analysis will be conducted. Intention-to-treat analyses will be performed. DISCUSSION: There is uncertainty about whether antibiotic treatment is effective for chronic low back pain and, if effective, which patient subgroup is most likely to respond. We will conduct a clinical trial to investigate the efficacy of antibiotics compared with placebo in individuals with chronic low back pain and a disc herniation. Our findings will provide high-quality evidence to assist in answering these questions. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12615000958583 . Registered on 11 September 2015.

Effect of low-dose amitriptyline on reducing pain in clinical knee osteoarthritis compared to benztropine: study protocol of a randomised, double blind, placebo-controlled trial.

BACKGROUND: Knee osteoarthritis is a major cause of pain and disability. Pain control is poor, with most patients remaining in moderate to severe pain. This may be because central causes of pain, a common contributor to knee pain, are not affected by current treatment strategies. Antidepressants, such as amitriptyline, have been used to treat chronic pain in other conditions. The aim of this randomised, double blind, controlled trial, is to determine whether low dose amitriptyline reduces pain in people with painful knee osteoarthritis over 3 months compared to benztropine, an active placebo. METHODS/DESIGN: One hundred and sixty people with painful radiographic knee osteoarthritis will be recruited via clinicians, local and social media advertising. Participants will be randomly allocated in a 1:1 ratio to receive either low dose amitriptyline (25 mg) or active placebo (benztropine mesylate, 1 mg) for 3 months. The primary outcome is change from baseline in knee pain (WOMAC pain subscale) at 12 weeks. Secondary outcomes include change in function (total WOMAC) and the proportion of individuals achieving a substantial response (≥ 50% reduction in pain intensity, measured by Visual Analog Scale, VAS, from no pain to worst pain imaginable, 0-100 mm) and moderate response (≥ 30% reduction in pain intensity, measured by VAS) at 12 weeks. Intention to treat analyses will be performed. Subgroup analyses will be done. DISCUSSION: This study will provide high level evidence regarding the effectiveness of low dose amitriptyline compared to benztropine in reducing pain and improving function in knee OA. This trial has the potential to provide an effective new therapeutic approach for pain management in knee osteoarthritis, with the potential of ready translation into clinical practice, as it is repurposing an old drug, which is familiar to clinicians and with a well described safety record. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry prior to recruitment commencing ( ACTRN12615000301561 , March 31, 2015, amended 14 December 2018, February 2021). Additional amendment requested 18 July 2021.

Is adiposity associated with back and lower limb pain? A systematic review.

BACKGROUND: Back and lower limb pain have a major impact on physical function and quality of life. While obesity is a modifiable risk factor for musculoskeletal pain, the role of adiposity is less clear. This systematic review aimed to examine the relationship between both adiposity and its distribution and back and lower limb pain. METHODS: A systematic search of electronic databases was conducted to identify studies that examined the association between anthropometric and/or direct measures of adiposity and site specific musculoskeletal pain. Risk of bias was assessed and a best evidence synthesis was performed. RESULTS: A total of 56 studies were identified which examined 4 pain regions, including the lower back (36 studies), hip (two studies), knee (13 studies) and foot (eight studies). 31(55%) studies were assessed as having low to moderate risk of bias. 17(30%) studies were cohort in design. The best evidence synthesis provided evidence of a relationship between central adiposity and low back and knee pain, but not hip or foot pain. There was also evidence of a longitudinal relationship between adiposity and the presence of back, knee and foot pain, as well as incident and increasing foot pain. CONCLUSIONS: This systematic review provides evidence of an association between both body fat and its central distribution and low back and knee pain, and a longitudinal relationship between adiposity and back, knee and foot pain. These results highlight the potential for targeting adiposity in the development of novel treatments at these sites.

Examining resting-state functional connectivity in key hubs of the default mode network in chronic low back pain.

OBJECTIVES: Changes in brain connectivity have been observed within the default mode network (DMN) in chronic low back pain (CLBP), however the extent of these disruptions and how they may be related to CLBP requires further examination. While studies using seed-based analysis have found disrupted functional connectivity in the medial prefrontal cortex (mPFC), a major hub of the DMN, limited studies have investigated other equally important hubs, such as the posterior cingulate cortex (PCC) in CLBP. METHODS: This preliminary study comprised 12 individuals with CLBP and 12 healthy controls who completed a resting-state functional magnetic resonance imaging (fMRI) scan. The mPFC and PCC were used as seeds to assess functional connectivity. RESULTS: Both groups displayed similar patterns of DMN connectivity, however group comparisons showed that CLBP group had reduced connectivity between the PCC and angular gyrus compared to healthy controls. An exploratory analysis examined whether the alterations observed in mPFC and PCC connectivity were related to pain catastrophizing in CLBP, but no significant associations were observed. CONCLUSIONS: These results may suggest alterations in the PCC are apparent in CLBP, however, the impact and functional role of these disruptions require further investigation.

Neural activity during cognitive reappraisal in chronic low back pain: a preliminary study.

OBJECTIVES: Chronic pain patients often report higher levels of negative emotions, suggesting reduced ability to regulate emotions effectively, however, little is known of the underlying neural cognitive mechanisms. Therefore, the aim of this study was to explore brain activity and connectivity during cognitive reappraisal in chronic low back pain (CLBP). METHODS: This study recruited 24 female participants; 12 with CLBP and 12 healthy controls. Participants completed an emotion regulation task that involved cognitive reappraisal of negative images during functional magnetic resonance imaging. The negative affect following each image and perceived success of the task were reported. Region of interest and seed-to-voxel analyses were conducted using key regions involved in cognitive reappraisal (i.e., amygdalae and dorsomedial prefrontal cortex) as seed regions. RESULTS: During the task, there were no group differences in the behavioural measures and blood oxygen level-dependent (BOLD) brain activation in the seed regions. Functional connectivity analysis showed reduced coupling between the amygdalae and dorsolateral prefrontal cortex, orbitofrontal cortex and inferior parietal cortex in the CLBP group compared to controls. Connectivity between the amygdala and inferior parietal cortex positively correlated with the percent of reduced negative affect during reappraisal in the CLBP group. CONCLUSIONS: These preliminary findings demonstrate that individuals with CLBP exhibit similar emotion regulation abilities to healthy controls at the behavioural and BOLD level. However, altered functional connectivity observed in the CLBP group may reduce effective cognitive reappraisal. These results provide evidence for the potential clinical impact of network changes in CLBP.

Rates, costs and determinants of lumbar spine imaging in population-based women born in 1973-1978: Data from the Australian Longitudinal Study on Women's Health.

OBJECTIVE: There are concerns that lumbar spine imaging represents low value care. Our aim was to examine the use of lumbar spine imaging [radiography, computed tomography (CT), magnetic resonance imaging (MRI)] over 20 years, and costs and person-level characteristics of imaging in a large cohort of Australian women. METHODS: The Australian Longitudinal Study on Women's Health (ALSWH) is a longitudinal population-based survey of women randomly selected from national health insurance scheme (Medicare) database. This study examined 13458 women born in 1973-1978 who consented to link their ALSWH and Medical Benefits Scheme records. Self-reported data on demographics, body mass index, depression, physical and mental health, and back pain were collected in each survey performed in 1996, 2000, 2003, 2006, 2009, 2012, and 2015. Data on lumbar spine imaging from 1996 to 2015 were obtained from the Medical Benefits Scheme database. RESULTS: 38.9% of women underwent some form of lumbar spine imaging over 20 years. While radiography increased from 1996 to 2011 and decreased thereafter, CT and MRI continued to increase from 1996 to 2015. In women with self-reported back pain, depression and poorer physical health were associated with imaging, with no significant differences in types of imaging. Based on imaging rates in ALSWH, the estimated costs for Australian women aged 30-39 years were AU$51,735,649 over 2011-2015. CONCLUSIONS: Lumbar spine imaging was common in population-based Australian women, with rates increasing over 20 years. Depression and poor physical health were associated with lumbar spine imaging. Raising awareness of this in clinicians is likely to result in significant cost savings if clinical guidelines are followed, with the potential of freeing resources for high value care and health outcomes.

Association between increased signal intensity at the proximal patellar tendon and patellofemoral geometry in community-based asymptomatic middle-aged adults: a cross-sectional study.

BACKGROUND: Histological and epidemiological data suggest that increased signal intensity at the proximal patellar tendon on magnetic resonance imaging is a response to tendon loading. As patellofemoral geometry is a mediator of loading, we examined the association between patellofemoral geometry and the prevalence of increased signal intensity at the patellar tendon in community-based middle-aged adults. METHODS: Two hundred-one adults aged 25-60 years in a study of obesity and musculoskeletal health had the patellar tendon assessed from magnetic resonance imaging. Increased signal intensity at the proximal patellar tendon was defined as hyper-intense regions of characteristic pattern, size and distribution on both T1- and T2-weighted sequences. Indices of patellofemoral geometry, including Insall-Salvati ratio, patellofemoral congruence angle, sulcus angle, and lateral condyle-patella angle, were measured from magnetic resonance imaging using validated methods. Binary logistic regression was used to examine the association between patellofemoral geometrical indices and the prevalence of increased signal intensity at the patellar tendon. RESULTS: The prevalence of increased signal intensity at the patellar tendon was 37.3%. A greater Insall-Salvati ratio (odds ratio 0.80, 95% confidence interval 0.66-0.97 per 0.1 change in the ratio, p = 0.02), indicative of a higher-riding patella, and a larger patellofemoral congruence angle (odds ratio 0.91, 95% confidence interval 0.85-0.98 per 5 degree change in the angle, p = 0.01), indicating a more laterally placed patella, were associated with reduced odds of increased signal intensity at the patellar tendon. Sulcus angle and lateral condyle-patella angle were not significantly associated with the odds of increased signal intensity at the patellar tendon. CONCLUSIONS: In community-based asymptomatic middle-aged adults, increased signal intensity at the patellar tendon was common and associated with Insall-Salvati ratio and patellofemoral congruence angle, suggesting a biomechanical mechanism. Such work is likely to inform tissue engineering and cell regeneration approaches to improving outcomes in those with tendon pathology.

Catastrophization, fear of movement, anxiety, and depression are associated with persistent, severe low back pain and disability.

BACKGROUND CONTEXT: Psychological characteristics are important in the development and progression of low back pain (LBP); however, their role in persistent, severe LBP is unclear. PURPOSE: To investigate the relationship between catastrophization, depression, fear of movement, and anxiety and persistent, severe LBP, and disability. STUDY DESIGN/ SETTING: One-year prospective cohort study. PATIENT SAMPLE: Participants were selected from the SpineData registry (Denmark), which enrolls individuals with LBP of 2 to 12 months duration without radiculopathy and without satisfactory response to primary intervention. OUTCOME MEASURES: Psychological characteristics, including catastrophization, depression, fear of movement, and anxiety, were examined at baseline using a validated screening questionnaire. Current, typical, and worst pain in the past 2 weeks were assessed by 11-point numeric rating scales and an average pain score was calculated. Disability was measured using the 23-item Roland-Morris Disability Questionnaire. METHODS: Participants completed baseline questionnaires on initial presentation to the Spine Center (Middelfart, Denmark), and follow-up questionnaires were sent and returned electronically. Statistical analysis involved multivariable Poisson regression to investigate the association between psychological factors and the number of episodes of severe pain or disability. This study received no direct funding. RESULTS: Of the 952 participants at baseline, 633 (63.4%) provided data 1 year later. Approximately half of the participants reported severe LBP (n=299, 47.2%, 95% confidence interval [CI] 43.3%-51.2%) or disability (n=315, 57.6%, 95% CI 53.3%-61.8%) at a minimum of one time point, and 14.9% (n=94, 95% CI 12.2%-17.9%) and 24.3% (n=133, 95% CI 20.8%-28.1%) experienced severe LBP or disability at two time points, respectively. Multivariable Poisson regression showed a relationship between catastrophization, depression, fear of movement, and anxiety and a greater number of time points with severe LBP and disability, after adjusting for age, gender, body mass index, and duration of symptoms. However, when all psychological factors were added to the regression model, only catastrophization and depression remained significantly associated. CONCLUSIONS: This study showed that persistent, severe LBP, and disability is common in a secondary care population with LBP and is associated with a variety of psychological risk factors, in particular catastrophization and depression, highlighting the importance of considering these factors in the design and evaluation of outcomes studies for LBP.

Association Between Inflammatory Biomarkers and Nonspecific Low Back Pain: A Systematic Review.

OBJECTIVES: Chronic inflammation increases the production of cytokines and activates proinflammatory pathways which may lead to nonspecific low back pain (LBP). We systematically reviewed the literature to investigate whether inflammatory biomarkers are associated with nonspecific LBP. MATERIALS AND METHODS: CINAHL, Medline, and Embase were searched between January 1946 and May 2018. MeSH terms and key words were used to identify studies examining the association between inflammatory biomarkers and LBP. Two reviewers performed the risk of bias assessment and 3 reviewers extracted data independently. Qualitative evidence synthesis was performed. RESULTS: Thirteen studies, ranging from fair to low quality, were included. Five studies examined the association between C-reactive protein (CRP)/high-sensitivity CRP and LBP; 6 studies assessed tumor necrosis factors (TNFs); 8 studies assessed interleukins (ILs); and 2 studies assessed fibrinogen. There was evidence for an association of elevated levels of CRP, TNFs, and IL-6 with LBP. There was conflicting evidence for an association between IL-1ß, fibrinogen, and LBP. DISCUSSION: Our findings support the notion of a positive association between inflammatory biomarkers and nonspecific LBP, specifically for CRP, TNFs, and IL-6. Although further high quality longitudinal studies are needed to confirm these findings and evaluate the magnitude of these associations, our findings suggest a role of inflammation in the pathogenesis of nonspecific LBP.