Current trends in the medical treatment of neuropathic low back pain: a Swedish registry-based study of 1.7 million people.

BACKGROUND: Low back pain, a common problem worldwide, causes more global disability than any other condition and is associated with high costs to society. This observational registry-based study describes the current trends in the medical treatment of neuropathic low back pain in the Swedish region of Västra Götaland, which has a population of 1.7 million. The study aims to; (1) identify the prevalence of neuropathic low back pain within the study population; (2) to explore the patterns of medical treatment utilization, including the prevalence and distribution of opioids (OG) and analgesics specified for neuropathic low back pain (NG) and (3) to evaluate the long-term trends and changes in medical treatment practice for neuropathic low back pain over the study period. METHODS: This study includes a descriptive analysis of aggregated data extracted from the Swedish primary care registry VEGA and the pharmaceutical prescription registry Digitalis between the years 2017 and 2021. The data were stratified by year, age, gender, pharmaceutical code (ATC), and sub-diagnoses and presented as the prevalence of unique patients retrieving prescribed medication within six months before or after a registered diagnosis of neuropathic low back pain. The pharmaceutical codes were furthermore grouped into two groups depending on their mechanism of action; opioid group (OG) and neuropathic group (NG). RESULTS: In all four diagnosis groups, more patients used opioid analgesics than neuropathic analgesics. The greatest difference between the opioid group and neuropathic group was in the lumbar spinal stenosis diagnosis group (67.1% vs. 40.6%), followed by the lumbar root canal stenosis diagnosis (65.9% vs. 44.2%), the nerve root and plexus compressions in intervertebral disc disorders diagnosis (57.5% vs. 40.8%), and lumbago with sciatica diagnosis (38.4% vs. 22.7%). CONCLUSIONS: The trends suggest a general increase in the prescription rate and therefore patients' use of neuropathic analgesics for neuropathic pain associated with the studied diagnoses. However, opioid treatment remains the most common. The results indicate that the treatment for neuropathic low back pain needs to be improved.

Learning from the past to plan for the future: A scoping review of musculoskeletal clinical research in Sweden 2010-2020.

Background: The aims of this study are to 1) determine the scope of musculoskeletal (MSK)-related clinical research in Sweden; 2) collate the amount of first-tier funding received; 3) discuss strategies and infrastructure supporting future MSK clinical trials in Sweden. Methods: A systematic scoping review protocol was applied in PubMed, Scopus, and SweCRIS databases. The articles were examined, and data were extracted in multiple stages by three blinded authors. Results: The search strategy resulted in 3,025 publications from 479 Swedish-affiliated authors. Primary health care was the basis for 14% of the publications, 84% from secondary health care, and 2% from occupational health care with a similar proportional distribution of first-tier research grant financing. Approximately one in six publications were randomized controlled trials (RCTs), while the majority were of observational cohort design. The majority of publications in primary and occupational health care were related to pain disorders (51 and 67%, respectively), especially diagnosis, prognosis, and healthcare organizational-related interventions (34%) and rehabilitation (15%) with similar proportional distribution of first-tier research grant financing. In secondary health care, rheumatic inflammatory disorder-related publications were most prevalent (30%), most frequently concerning diagnosis, prognosis, and healthcare organizational-related interventions (20%), attracting approximately half of all first-tier funding. Publications related to degenerative joint disorders (25%), fractures (16%), and joint, tendon, and muscle injuries (13%) frequently concerned surgical and other orthopedic-related interventions (16, 6, and 8%, respectively). Pain disorder-related publications (10%) as well as bone health and osteoporosis-related publications (4%) most frequently concerned diagnosis, prognosis, and healthcare organizational-related interventions (5 and 3%, respectively). Conclusions: Swedish-affiliated MSK disorder research 2010-2020 was predominantly observational cohort rather than RCT based. There was skewed first-tier funding allocation considering prevalence/incidence and burden of disease. Use of infrastructure supporting register-based RCTs, placebo-controlled RCTs, and hybrid effectiveness-implementation studies on prevention and clinical intervention is important strategies for the future in all healthcare sectors.

The prevalence of diagnosed specific back pain in primary health care in Region Västra Götaland: a register study of 1.7 million inhabitants.

OBJECTIVES: To evaluate the one-year prevalence of diagnosed specific back pain in Region Västra Götaland, inhabiting 1.7 million people. DESIGNS: A retrospective register study. SETTINGS: Data from 2014 to 2019 were extracted from the VEGA register, which holds all health data from all publicly funded health care establishments in Region Västra Götaland. Aggregated data are presented as the one-year prevalence of unique individuals diagnosed with International Statistical Classification of Diseases and Related Health Problems - Tenth Revision codes representing specific back pain. SUBJECTS: All inhabitants in Region Västra Götaland. MAIN OUTCOME MEASURES: The one-year prevalence of diagnosed specific back pain stratified by age, sex, and health care level. RESULTS: In 2019, the one-year prevalence of diagnosed specific back pain in public primary health care centres was 0.82%, rehabilitation care 0.35%, and the combined increase was 156% from 2014. In specialized health care, the diagnosed prevalence during 2014-2019 has remained relatively unchanged. The prevalence was significantly higher among women in primary health care and rehabilitation care. M48.0 (spinal stenosis) and M51.1K (lumbar disc herniation with radiculopathy) were the most common sub-classifications. For M48.0, prevalence increased by age, whereas M51.1K peaked within the 45-64 years category. CONCLUSIONS: The one-year prevalence of diagnosed specific back pain in primary health care was 1.17% in 2019 and has increased since 2014. Women were diagnosed considerably more frequently than men, which is not reflected in surgical treatment prevalence.

The one-year prevalence of nonspecific back pain in public primary health care establishments among 1.7 million people in western Sweden.

AIM: The one-year prevalence of diagnosed nonspecific back pain in Sweden is not known. Thus, this observational register-based study aimed to evaluate this prevalence by using data from the Region Västra Götaland, inhabiting 1.7 million people. METHODS: Data from 2014 to 2018 were extracted from the VEGA database register. This register holds all health data from the publicly funded health care establishments in Region Västra Götaland. Aggregated data are presented as the one-year prevalence of unique individuals diagnosed with nonspecific back pain (i.e., the ICD-10 code M54). Stratification by health care level, gender, age, and M54 sub-diagnoses were made. FINDINGS: Between 2014 and 2018, the annual prevalence of diagnosed nonspecific back pain in public primary health care increased from 4.8% to 6.0% (26% increase, P < 0.001, CI 25-27%). In 2018, the one-year prevalence was 7.2% among women and 4.8% among men (50% difference, P = 0.001, CI 49-52%). The one-year prevalence increased by age, and the highest figure (11%) was seen in the age group of 80-84. Low back pain, M54.5, was the most common sub-diagnosis. The one-year prevalence was significantly higher (P < 0.001) among women in all the M54 sub-diagnoses. CONCLUSION: The one-year prevalence of diagnosed nonspecific back pain was 6% in public primary health care in 2018 and has increased since 2014. Women were diagnosed considerably more frequently than men. Publicly funded rehabilitation efforts, as well as actions focusing on the prevention of back pain, is probably money well spent.

Young elite Alpine and Mogul skiers have a higher prevalence of cam morphology than non-athletes.

PURPOSE: To investigate the prevalence of cam morphology in (1) a group of young elite Mogul and Alpine skiers compared with non-athletes and (2) between the sexes. METHOD: The hip joints of 87 subjects [n = 61 young elite skiers (29 females and 32 males) and n = 26 non-athletes (17 females and 9 males)] were examined using MRI, for measurements of the presence of cam morphology (α-angle ≥ 55). RESULTS: The skiers had a significantly higher prevalence of cam morphology compared with the non-athletes (49% vs 19%, p = 0.009). A significant difference (p < 0.001) was also found between females and males, where 22% of the females and 61% of the males had cam morphology. Among the skiers, there was also a significant difference (p < 0.001) between the sexes, where 28% of the females and 68% of the males had cam morphology. This difference between the sexes was not found in the non-athletic group. No significant differences were found between Mogul and Alpine skiers. CONCLUSION: Young male elite skiers have a higher prevalence of cam morphology of the hips compared with non-athletes. LEVEL OF EVIDENCE: II.

Adolescent elite skiers with and without cam morphology did change their hip joint range of motion with 2 years follow-up.

PURPOSE: To investigate how range of motion of the hips and the lumbar spine are affected by continued elite, alpine skiing in young subjects, with and without a magnetic resonance imaging verified cam morphology, in a 2-year follow-up study. The hypothesis is that skiers with cam morphology will show a decrease in hip joint range of motion as compared with skiers without cam, after a 2-year follow-up. METHOD: Thirty adolescent elite alpine skiers were examined at the baseline (mean age 17.3 ± 0.7 years) and after 2 years. All skiers were examined for the presence of cam morphology (α-angle > 55°) using magnetic resonance imaging at the baseline. Clinical examinations of range of motion in standing lumbar flexion and extension, supine hip flexion, internal rotation, FABER test and sitting internal rotation and external rotation were performed both at the baseline and after 2 years. RESULTS: Skiers with and without cam morphology showed a significant decrease from baseline to follow-up in both hips for supine internal rotation (right: mean - 13.3° and - 10.9° [P < 0.001]; left: mean - 7.6° [P = 0.004] and - 7.9° [P = 0.02]), sitting internal rotation (right: mean - 9.6° and - 6.3° [P < 0.001]; left: mean - 7.6° [P = 0.02] and - 3.3° [P = 0.008]) and sitting external rotation (right: mean - 16.9° and - 11.4° and left: mean - 17.9° and - 14.5° [P < 0.001]) and were shown to have an increased left hip flexion (mean + 8.4° and + 4.6° [P = 0.004]). Skiers with cam were also shown to have an increased right hip flexion (mean + 6.4° [P = 0.037]). Differences were found between cam and no-cam skiers from baseline to follow-up in the sitting internal rotation in both hips (right: mean 3.25°, left: mean 4.27° [P < 0.001]), the right hip flexion (mean 6.02° [P = 0.045]) and lumbar flexion (mean - 1.21°, [P = 0.009]). CONCLUSION: Young, elite alpine skiers with cam morphology decreased their internal rotation in sitting position as compared with skiers without the cam morphology after 2 years of continued elite skiing. LEVEL OF EVIDENCE: II.

The effect of pelvic tilt and cam on hip range of motion in young elite skiers and nonathletes.

BACKGROUND: Current knowledge of the effect of changes in posture and the way cam morphology of the hip joint may affect hip range of motion (ROM) is limited. PURPOSE: To determine the effect of changes in pelvic tilt (PT) on hip ROM and with/without the presence of cam. STUDY DESIGN: This was a cross-sectional study. MATERIALS AND METHODS: The hip ROM of 87 subjects (n=61 young elite skiers, n=26 nonathletes) was examined using a goniometer, in three different seated postures (flexed, neutral, and extended). The hips of the subjects were further subgrouped into cam and no-cam morphology, based on the magnetic resonance imaging findings in the hips. RESULTS: There was a significant correlation between the hip ROM and the seated posture in both extended and flexed postures compared with the neutral posture. There was a significant decrease in internal hip rotation when the subjects sat with an extended posture with maximum anterior PT (p<0.0001). There was a significant increase in internal hip rotation when the subjects sat with a flexed posture with maximum posterior PT (p<0.001). External rotation was significantly decreased in an extended posture with maximum anterior PT (p<0.0001), but there was no difference in flexed posture with maximum posterior PT. The hips with cam morphology had reduced internal hip rotation in all three positions, but they responded to the changes in position in a similar manner to hips without cam morphology. CONCLUSION: Dynamic changes in PT significantly influence hip ROM in young people, independent of cam or no-cam morphology.

Disc degeneration on MRI is more prevalent in young elite skiers compared to controls.

PURPOSE: Evidence-based facts regarding spine abnormalities and back pain are needed in order to develop rehabilitation programs and prevent spine injuries in young skiers. The aim therefore is to identify MRI changes in the thoraco-lumbar spine and the lifetime prevalence of back pain, as well as the association between them, in young skiers compared to non-athletes. METHODS: Seventy-five young elite alpine and mogul skiers, age range 16-20 years, were compared with 27 non-athletic controls. All subjects underwent spinal MRI and answered back pain questionnaires. RESULTS: Fifty-six percent of skiers had at least one disc Pfirrmann grade ≥3 compared to 30% of controls (p = 0.027). Schmorl's nodes (46%) and disc height reduction (37%) were significantly more prevalent in skiers compared to controls (0%) (p < 0.001). When all parameters were combined together, skiers had significantly higher rate of radiological changes than controls, 82% compared to 54% (p = 0.007). The mean number of discs with Pfirrmann grade ≥3 was 1.1 per individual in skiers (median 1, range 0-6) versus 0.6 in controls (median 0, range 0-3). There was no significant difference in lifetime prevalence of back pain between skiers (50%) and controls (44%) (n.s.). MRI abnormalities in skiers did not correlate with lifetime prevalence of back pain. Skiers had a better health perception than controls (p = 0.026). CONCLUSION: Alpine skiers have more degenerative disc changes compared to non-athletes, but these changes do not correlate with the lifetime prevalence of back pain. Lifetime prevalence of back pain is not significantly different between the groups; however, skiers report more severe pain on VAS score. LEVEL OF EVIDENCE: II.

No difference in prevalence of spine and hip pain in young Elite skiers.

PURPOSE: To investigate the prevalence between back and hip pain in young Elite skiers. METHODS: Sample group (n = 102), consisted of young Elite skiers (n = 75) and age-matched non-athletes (n = 27), all completed a three-part back and hip pain questionnaire, Oswestry Disability Index and EuroQoL to evaluate general health, activity level, back and hip pain prevalence. RESULTS: No significant differences were shown for lifetime prevalence of back pain in the skiers (50%) compared with controls (44%) (n.s.). Duration of back pain for the skiers showed (30%) > 1 year, whilst (46%) > 5 years. A significant difference was shown with increased Visual Analogue Scale back pain levels for skiers 5.3 (SD 3.1) compared with controls 2.4 (SD 1.9, p = 0.025). No significant differences were shown for lifetime prevalence of hip pain in skiers (21%) compared with controls (8%) (n.s.). CONCLUSION: Young Elite skiers are shown not to have increased lifetime prevalence for back and hip pain compared with a non-athletic control group. LEVEL OF EVIDENCE: II.

Range of Hip Joint Motion Is Correlated With MRI-Verified Cam Deformity in Adolescent Elite Skiers.

BACKGROUND: Radiologically verified cam-type femoroacetabular impingement (FAI) has been shown to correlate with reduced internal rotation, reduced passive hip flexion, and a positive anterior impingement test. PURPOSE: To validate how a clinical examination of the hip joint correlates with magnetic resonance imaging (MRI)-verified cam deformity in adolescents. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The sample group consisted of 102 adolescents with the mean age 17.7 ± 1.4 years. The hip joints were examined using MRI for measurements of the presence of cam (α-angle ≥55°) and clinically for range of motion (ROM) in both supine and sitting positions. The participants were divided into a cam and a noncam group based on the results of the MRI examination. Passive hip flexion, internal rotation, anterior impingement, and the FABER (flexion, abduction, and external rotation) test were used to test both hips in the supine position. With the participant sitting, the internal/external rotation of the hip joint was measured in 3 different positions of the pelvis (neutral, maximum anteversion, and retroversion) and lumbar spine (neutral, maximum extension, and flexion). RESULTS: Differences were found between the cam and noncam groups in terms of the anterior impingement test (right, P = .010; left, P = .006), passive supine hip flexion (right: mean, 5°; cam, 117°; noncam, 122° [P = .05]; and left: mean, 8.5°; cam, 116°; noncam, 124.5° [P = .001]), supine internal rotation (right: mean, 4.9°; cam, 24°; noncam, 29° [P = .022]; and left: mean, 4.8°; cam, 26°; noncam, 31° [P = .028]), sitting internal rotation with the pelvis and lumbar spine in neutral (right: mean, 7.95°; cam, 29°; noncam, 37° [P = .001]; and left: mean, 6.5°; cam, 31.5°; noncam, 38° [P = .006]), maximum anteversion of the pelvis and extension of the lumbar spine (right: mean, 5.2°; cam, 20°; noncam, 25° [P = .004]; and left: mean, 5.85°; cam, 20.5; noncam, 26.4° [P = .004]), and maximum retroversion of the pelvis and flexion of the spine (right: mean, 8.4°; cam, 32.5°; noncam, 41° [P = .001]; and left: mean, 6.2°; cam, 36°; noncam, 42.3° [P = .012]). The cam group had reduced ROM compared with the noncam group in all clinical ROM measures. CONCLUSION: The presence of cam deformity on MRI correlates with reduced internal rotation in the supine and sitting positions, passive supine hip flexion, and the impingement test in adolescents.

The effect of repetitive flexion and extension fatigue loading on the young porcine lumbar spine, a feasibility study of MRI and histological analyses.

BACKGROUND: The biomechanical mechanisms of failure of FSUs have been studied but the correlation of repetitive flexion and extension loadings to the initial phase of fatigue in young FSUs are still not known. The purpose of the study was to examine the fatigue results of low magnitude repetitive flexion and extension loading on porcine lumbar Functional Spinal Units (FSUs) with Magnetic Resonance Imaging (MRI) and histology. METHODS: Eight FSUs were subject to repetitive pivot flexion and eight to extension loading by a protocol of 20 000 cycles at 1 Hz with a load of 700 N. All loaded FSUs (N = 16) were examined with MRI and histology post loading. Three FSUs were examined with MRI as controls. Further three FSUs were non loaded histology controls. RESULTS: Fifteen (94%) of the loaded FSUs have decreased MRI signal in the growth zone of the superior vertebra and 12 (75%) in the inferior vertebrae. Fourteen (88%) FSUs have increased signal in the superior vertebral body. Fourteen (88%) FSUs have a reduced signal in all or any endplate. The histology morphometry displayed that the unstained parts of the epiphyseal growth zone were larger among the loaded FSUs (mean 29% vs 4%) and that the chondrocytes in the endplate and growth zones had abnormal structure and deformed extracellular matrix. CONCLUSION: Repetitive loading of young porcine FSUs in both extension and flexion causes concurrent MRI and histological changes in the growth zones and endplates, which could be a first sign of fatigue and an explanation for the disc, apophyseal and growth zone injuries seen among adolescent athletes.

The morphologic characteristics and range of motion in the hips of athletes and non-athletes.

The cam deformity may cause impingement and probably leads to osteoarthritis of the hip. The aetiology of the cam deformity is incompletely understood. Vigorous training during skeletal growth can lead to the development of cam and symptoms of femoro-acetabular impingement and subsequent osteoarthritis of the hip. The purpose of this study was to compare the radiographic characteristics and range of motion between a group of athletes and a non-athletic control group. Thirty-two male athletes (17 soccer players and 15 ice-hockey players) and thirty non-athletes, used as a control group, were examined clinically and radiographically. Hip range of motion was measured and the FADIR and FABER tests were performed. Standard radiographs of both hips were taken. The centre-edge angle, alpha angle, caput-collum-diaphysis angle, head-neck offset and Tönnis grade were registered. The athletes had a higher Tönnis grade (right P = 0.009, left P = 0.004), more pain on the FADIR test (right P = 0.006, left P = 0.001) and lower ROM in internal (right P = 0.003, left P = 0.025) and external rotation (P < 0.001). A superiorly placed cam deformity (seen on an AP pelvis view) was correlated with reduced external rotation (right P = 0.001, left P = 0.004) and mild osteoarthritis (Tönnis grade 1), (P = 0.015, left P = 0.020), while a more anteriorly placed cam deformity (seen on a modified Lauenstein view) was correlated with reduced internal rotation (right P = 0.029, left P = 0.013). A lower range of motion, more osteoarthritic changes and more pain were found in the athletes than the controls. The control group had more cam deformities than previously reported.

Prevalence of joint-related pain in the extremities and spine in five groups of top athletes.

PURPOSE: Joint-related pain conditions from the spine and extremities are common among top athletes. The frequency of back pain has, however, been studied in more detail, and the frequency of low-back pain in top athletes in different high-load sports has been reported to be as high as 85%. Sport-related pain from different joints in the extremities is, however, infrequently reported on in the literature. METHODS: Seventy-five male athletes, i.e. divers, weight-lifters, wrestlers, orienteers and ice-hockey players and 12 non-athletes (control group) were included in the study. A specific self-assessed pain-oriented questionnaire related to the cervical, thoracic and lumbar spine, as well as the various joints, i.e. shoulders, elbows, wrists, hips, knees and ankles, was filled out by the athletes and the non-athletes. RESULTS: The overall frequency of pain reported by the athletes during the last week/last year was as follows; cervical spine 35/55%; thoracic spine 22/33%; lumbar spine 50/68%; shoulder 10/21%; elbow 7/7%; wrist 7/8%; hip 15/23%; knee 22/44%; and ankle 11/25%. The corresponding values for non-athletes were cervical spine 9/36%; thoracic spine 17/33%; lumbar spine 36/50%; shoulder 0/9%; elbow 9/0%; wrist 0/0%; hip 9/16%; knee 10/9%; and ankle 0/0%. A higher percentage of athletes reported pain in almost all joint regions, but there were no statistically significant differences (n.s.), with the exception of the knees (P = 0.05). Over the last year, athletes reporting the highest pain frequency in the lumbar spine were ice-hockey players and, in the cervical spine, wrestlers and ice-hockey players. The highest levels of knee pain were found among wrestlers and ice-hockey players, whereas the highest levels for wrist pain were found among divers, hip pain among weight-lifters, orienteers and divers and ankle pain among orienteers. For the thoracic spine, shoulder and elbow regions, only minor differences were found. CONCLUSION: There was no statistically significant difference in prevalence of pain in the neck, spine and joints between top athletes in different sports or between athletes and non-athletes. However, pain in one spinal region was correlated to reported pain in other regions of the spine. Moreover, pain in the spine was also correlated to pain in the shoulders, hips and knees.

The immediate effect of repeated loading on the compressive strength of young porcine lumbar spine.

The human spine is exposed to repeated loading during daily activities and more extremely during sports. Despite this, there remains a lack of knowledge regarding the immediate effects on the spine due to this mode of loading. Age-specific spinal injury patterns has been demonstrated and this implies differences in reaction to load mode and load history The purpose of the present study was to investigate the impact of cyclic pre-loading on the biomechanical properties and fracture patterns of the adolescent spine in an experimental model. Eight functional spinal units from four young porcine spines were harvested. The functional spinal units were cyclic loaded with 20,000 cycles and then axially compressed to failure. The compression load at failure, ultimate stress and viscoelastic parameters were calculated. The functional spinal units were examined with plain radiography, computer tomography and MRI before and after the loading, and finally macroscopically and histologically. The median compression load at failure in this study was 8.3 kN (range 5.6-8.7 kN). The median deformation for all cases was 2.24 mm (range 2.30-2.7 mm) and stiffness was 3.45 N/mm (range 3.5-4.5 N/mm). A fracture was seen on radiograph in one case, on CT and macroscopically in seven, and on MRI and histologically in all eight cases. The cyclic loaded functional spinal units in the present study were not more sensitive to axial compression than non-cyclic loaded functional spinal units from young porcine. The endplate and the growth zone were the weakest part in the cyclic loaded functional spinal units. Disc signal reduction and disc height reduction was found on MRI. The E-modulus value found in this study was of the same order of magnitude as found by others using a porcine animal model.