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PloS One 2022Guidelines recommend patient education materials (PEMs) for low back pain (LBP), but no systematic review has assessed PEMs on their own. We investigated the... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Guidelines recommend patient education materials (PEMs) for low back pain (LBP), but no systematic review has assessed PEMs on their own. We investigated the effectiveness of PEMs on process, clinical, and health system outcomes for LBP and sciatica.
METHODS
Systematic searches were performed in MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, trial registries and grey literature through OpenGrey. We included randomized controlled trials of PEMs for LBP. Data extraction, risk of bias, and quality of evidence gradings were performed independently by two reviewers. Standardized mean differences or risk ratios and 95% confidence intervals were calculated, and effect sizes pooled using random-effects models. Analyses of acute/subacute LBP were performed separately from chronic LBP at immediate, short, medium, and long-term (6, 12, 24, and 52 weeks, respectively).
RESULTS
27 studies were identified. Compared to usual care for chronic LBP, we found moderate to low-quality evidence that PEMs improved pain intensity at immediate (SMD = -0.16 [95% CI: -0.29, -0.03]), short (SMD = -0.44 [95% CI: -0.88, 0.00]), medium (SMD = -0.53 [95% CI: -1.01, -0.05]), and long-term (SMD = -0.21 [95% CI: -0.41, -0.01]), medium-term disability (SMD = -0.32 [95% CI: -0.61, -0.03]), quality of life at short (SMD = -0.17 [95% CI: -0.30, -0.04]) and medium-term (SMD = -0.23 [95% CI: -0.41, -0.04]) and very low-quality evidence that PEMs improved global improvement ratings at immediate (SMD = -0.40 [95% CI: -0.58, -0.21]), short (SMD = -0.42 [95% CI: -0.60, -0.24]), medium (SMD = -0.46 [95% CI: -0.65, -0.28]), and long-term (SMD = -0.43 [95% CI: -0.61, -0.24]). We found very low-quality evidence that PEMs improved pain self-efficacy at immediate (SMD = -0.21 [95% CI: -0.39, -0.03]), short (SMD = -0.25 [95% CI: -0.43, -0.06]), medium (SMD = -0.23 [95% CI: -0.41, -0.05]), and long-term (SMD = -0.32 [95% CI: -0.50, -0.13]), and reduced medium-term fear-avoidance beliefs (SMD = -0.24 [95% CI: -0.43, -0.06]) and long-term stress (SMD = -0.21 [95% CI: -0.39, -0.03]). Compared to usual care for acute LBP, we found high to moderate-quality evidence that PEMs improved short-term pain intensity (SMD = -0.24 [95% CI: -0.42, -0.06]) and immediate-term quality of life (SMD = -0.24 [95% CI: -0.42, -0.07]). We found low to very low-quality evidence that PEMs increased knowledge at immediate (SMD = -0.51 [95% CI: -0.72, -0.31]), short (SMD = -0.48 [95% CI: -0.90, -0.05]), and long-term (RR = 1.28 [95% CI: 1.10, 1.49]) and pain self-efficacy at short (SMD = -0.78 [95% CI: -0.98, -0.58]) and long-term (SMD = -0.32 [95% CI: -0.52, -0.12]). We found moderate to very low-quality evidence that PEMs reduced short-term days off work (SMD = -0.35 [95% CI: -0.63, -0.08]), long-term imaging referrals (RR = 0.60 [95% CI: 0.41, 0.89]), and long-term physician visits (SMD = -0.16 [95% CI: -0.26, -0.05]). Compared to other interventions (e.g., yoga, Pilates), PEMs had no effect or were less effective for acute/subacute and chronic LBP.
CONCLUSIONS
There was a high degree of variability across outcomes and time points, but providing PEMs appears favorable to usual care as we observed many small, positive patient and system impacts for acute/subacute and chronic LBP. PEMs were generally less effective than other interventions; however, no cost effectiveness analyses were performed to weigh the relative benefits of these interventions to the likely less costly PEMs.
Topics: Acute Pain; Humans; Low Back Pain; Patient Education as Topic; Quality of Life; Sciatica
PubMed: 36223377
DOI: 10.1371/journal.pone.0274527 -
BMJ (Clinical Research Ed.) Feb 2022To assess whether percutaneous transforaminal endoscopic discectomy (PTED) is non-inferior to conventional open microdiscectomy in reduction of leg pain caused by lumbar... (Comparative Study)
Comparative Study Randomized Controlled Trial
OBJECTIVE
To assess whether percutaneous transforaminal endoscopic discectomy (PTED) is non-inferior to conventional open microdiscectomy in reduction of leg pain caused by lumbar disc herniation.
DESIGN
Multicentre randomised controlled trial with non-inferiority design.
SETTING
Four hospitals in the Netherlands.
PARTICIPANTS
613 patients aged 18-70 years with at least six weeks of radiating leg pain caused by lumbar disc herniation. The trial included a predetermined set of 125 patients receiving PTED who were the learning curve cases performed by surgeons who did not do PTED before the trial.
INTERVENTIONS
PTED (n=179) compared with open microdiscectomy (n=309).
MAIN OUTCOME MEASURES
The primary outcome was self-reported leg pain measured by a 0-100 visual analogue scale at 12 months, assuming a non-inferiority margin of 5.0. Secondary outcomes included complications, reoperations, self-reported functional status as measured with the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery. Outcomes were measured until one year after surgery and were longitudinally analysed according to the intention-to-treat principle. Patients belonging to the PTED learning curve were omitted from the primary analyses.
RESULTS
At 12 months, patients who were randomised to PTED had a statistically significantly lower visual analogue scale score for leg pain (median 7.0, interquartile range 1.0-30.0) compared with patients randomised to open microdiscectomy (16.0, 2.0-53.5) (between group difference of 7.1, 95% confidence interval 2.8 to 11.3). Blood loss was less, length of hospital admission was shorter, and timing of postoperative mobilisation was earlier in the PTED group than in the open microdiscectomy group. Secondary patient reported outcomes such as the Oswestry Disability Index, visual analogue scale for back pain, health related quality of life, and self-perceived recovery, were similarly in favour of PTED. Within one year, nine (5%) in the PTED group compared with 14 (6%) in the open microdiscectomy group had repeated surgery. Per protocol analysis and sensitivity analyses including the patients of the learning curve resulted in similar outcomes to the primary analysis.
CONCLUSIONS
PTED was non-inferior to open microdiscectomy in reduction of leg pain. PTED resulted in more favourable results for self-reported leg pain, back pain, functional status, quality of life, and recovery. These differences, however, were small and may not reach clinical relevance. PTED can be considered as an effective alternative to open microdiscectomy in treating sciatica.
TRIAL REGISTRATION
NCT02602093ClinicalTrials.gov NCT02602093.
Topics: Adolescent; Adult; Aged; Diskectomy; Endoscopy; Female; Humans; Leg; Lumbar Vertebrae; Male; Microsurgery; Middle Aged; Pain; Pain Measurement; Quality of Life; Sciatica; Self Report; Treatment Outcome; Young Adult
PubMed: 35190388
DOI: 10.1136/bmj-2021-065846 -
Arquivos de Neuro-psiquiatria Jun 2018Charles Lasègue is reputed to have described the test/sign bearing his name, but he never wrote about it and misinterpreted its mechanism. The purpose of this note is...
Charles Lasègue is reputed to have described the test/sign bearing his name, but he never wrote about it and misinterpreted its mechanism. The purpose of this note is to highlight the work of the Serbian, Laza Lazarević, who was first to present the original report of this seminal sign in sciatica and provide its appropriate pathophysiological interpretation.
Topics: Diagnostic Techniques, Neurological; France; History, 19th Century; Sciatica; Serbia
PubMed: 29972425
DOI: 10.1590/0004-282X20180050 -
Annals of Internal Medicine Jan 2021Few studies have examined primary care management for acute sciatica, including referral to physical therapy. (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Few studies have examined primary care management for acute sciatica, including referral to physical therapy.
OBJECTIVE
To evaluate whether early referral to physical therapy reduced disability more than usual care (UC) alone for patients with acute sciatica.
DESIGN
Randomized controlled clinical trial. (ClinicalTrials.gov: NCT02391350).
SETTING
2 health care systems in Salt Lake City, Utah.
PATIENTS
220 adults aged 18 to 60 years with sciatica of less than 90 days' duration who were making an initial primary care consultation.
INTERVENTION
All participants received imaging and medication at the discretion of the primary care provider before enrollment. A total of 110 participants randomly assigned to UC were provided 1 session of education, and 110 participants randomly assigned to early physical therapy (EPT) were provided 1 education session and then referred for 4 weeks of physical therapy, including exercise and manual therapy.
MEASUREMENTS
The primary outcome was the Oswestry Disability Index (OSW) score after 6 months. Secondary outcomes were pain intensity, patient-reported treatment success, health care use, and missed workdays.
RESULTS
Participants in the EPT group had greater improvement from baseline to 6 months for the primary outcome (relative difference, -5.4 points [95% CI, -9.4 to -1.3 points]; = 0.009). The OSW and several secondary outcomes favored EPT after 4 weeks. After 1 year, between-group differences favored EPT for the OSW (relative difference, -4.8 points [CI, -8.9 to -0.7 points]) and back pain intensity (relative difference, -1.0 points [CI, -1.6 to -0.4 points]). The EPT group was more likely to self-report treatment success after 1 year (45.2%) than the UC group (27.6%) (relative risk, 1.6 [CI, 1.1 to 2.4]). There were no significant differences in health care use or missed workdays.
LIMITATION
The patients and providers were unblinded, and specific physical therapy interventions responsible for effects could not be determined.
CONCLUSION
Referral from primary care to physical therapy for recent-onset sciatica improved disability and other outcomes compared with UC.
PRIMARY FUNDING SOURCE
Agency for Healthcare Research and Quality.
Topics: Acute Pain; Adolescent; Adult; Female; Humans; Low Back Pain; Male; Middle Aged; Physical Therapy Modalities; Primary Health Care; Referral and Consultation; Sciatica; Secondary Prevention; Single-Blind Method; Young Adult
PubMed: 33017565
DOI: 10.7326/M20-4187 -
BioMed Research International 2017Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle... (Review)
Review
Caudal epidural block is a commonly used technique for surgical anesthesia in children and chronic pain management in adults. It is performed by inserting a needle through the sacral hiatus to gain entrance into the sacral epidural space. Using conventional blind technique, the failure rate of caudal epidural block in adults is high even in experienced hands. This high failure rate could be attributed to anatomic variations that make locating sacral hiatus difficult. With the advent of fluoroscopy and ultrasound in guiding needle placement, the success rate of caudal epidural block has been markedly improved. Although fluoroscopy is still considered the gold standard when performing caudal epidural injection, ultrasonography has been demonstrated to be highly effective in accurately guiding the needle entering the caudal epidural space and produce comparative treatment outcome as fluoroscopy. Except intravascular and intrathecal injection, ultrasonography could be as effective as fluoroscopy in preventing complications during caudal epidural injection. The relevant anatomy and techniques in performing the caudal epidural block will be briefly reviewed in this article.
Topics: Adult; Anesthesia, Caudal; Anesthesia, Epidural; Child; Epidural Space; Humans; Injections, Epidural; Low Back Pain; Sacrococcygeal Region; Sciatica; Ultrasonography
PubMed: 28337460
DOI: 10.1155/2017/9217145 -
Frontiers in Endocrinology 2021The role of obesity in the development of dorsopathies is still unclear. In this study, we assessed the associations between body mass index (BMI) and several...
The role of obesity in the development of dorsopathies is still unclear. In this study, we assessed the associations between body mass index (BMI) and several dorsopathies including intervertebral disc degeneration (IVDD), low back pain (LBP), and sciatica by using the Mendelian randomization method. We also assessed the effect of several obesity-related traits on the same outcomes. Single-nucleotide polymorphisms associated with the exposures are extracted from summary-level datasets of previously published genome-wide association studies. Summary-level results of IVDD, LBP, and sciatica were from FinnGen. In our univariable Mendelian randomization analysis, BMI is significantly associated with increased risks of all dorsopathies including sciatica (OR = 1.33, 95% CI, 1.21-1.47, p = 5.19 × 10), LBP (OR = 1.28, 95% CI, 1.18-1.39, p = 6.60 × 10), and IVDD (OR = 1.23, 95% CI, 1.14-1.32, p = 2.48 × 10). Waist circumference, hip circumference, whole-body fat mass, fat-free mass, and fat percentage, but not waist-hip ratio, were causally associated with increased risks of IVDD and sciatica. Higher hip circumference, whole-body fat mass, fat-free mass, and fat percentage increased the risk of LBP. However, only whole-body fat-free mass remained to have a significant association with the risk of IVDD after adjusting for BMI with an odds ratio of 1.57 (95% CI, 1.32-1.86, p = 2.47 × 10). Proportions of BMI's effect on IVDD, sciatica, and LBP mediated by leisure sedentary behavior were 41.4% (95% CI, 21.8%, 64.8%), 33.8% (95% CI, 17.5%, 53.4%), and 49.7% (95% CI, 29.4%, 73.5%), respectively. This study provides evidence that high BMI has causal associations with risks of various dorsopathies. Weight control is a good measure to prevent the development of dorsopathies, especially in the obese population.
Topics: Adult; Body Mass Index; Humans; Intervertebral Disc Degeneration; Low Back Pain; Mendelian Randomization Analysis; Obesity; Polymorphism, Single Nucleotide; Sciatica; Waist Circumference; Waist-Hip Ratio
PubMed: 34956075
DOI: 10.3389/fendo.2021.740200 -
BMJ (Clinical Research Ed.) Jan 2021To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo. (Meta-Analysis)
Meta-Analysis
OBJECTIVE
To investigate the efficacy and safety of antidepressants for back and osteoarthritis pain compared with placebo.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, International Pharmaceutical Abstracts, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from inception to 15 November and updated on 12 May 2020.
ELIGIBILITY CRITERIA FOR STUDY SELECTION
Randomised controlled trials comparing the efficacy or safety, or both of any antidepressant drug with placebo (active or inert) in participants with low back or neck pain, sciatica, or hip or knee osteoarthritis.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers extracted data. Pain and disability were primary outcomes. Pain and disability scores were converted to a scale of 0 (no pain or disability) to 100 (worst pain or disability). A random effects model was used to calculate weighted mean differences and 95% confidence intervals. Safety (any adverse event, serious adverse events, and proportion of participants who withdrew from trials owing to adverse events) was a secondary outcome. Risk of bias was assessed with the Cochrane Collaboration's tool and certainty of evidence with the grading of recommendations assessment, development and evaluation (GRADE) framework.
RESULTS
33 trials (5318 participants) were included. Moderate certainty evidence showed that serotonin-noradrenaline reuptake inhibitors (SNRIs) reduced back pain (mean difference -5.30, 95% confidence interval -7.31 to -3.30) at 3-13 weeks and low certainty evidence that SNRIs reduced osteoarthritis pain (-9.72, -12.75 to -6.69) at 3-13 weeks. Very low certainty evidence showed that SNRIs reduced sciatica at two weeks or less (-18.60, -31.87 to -5.33) but not at 3-13 weeks (-17.50, -42.90 to 7.89). Low to very low certainty evidence showed that tricyclic antidepressants (TCAs) did not reduce sciatica at two weeks or less (-7.55, -18.25 to 3.15) but did at 3-13 weeks (-15.95, -31.52 to -0.39) and 3-12 months (-27.0, -36.11 to -17.89). Moderate certainty evidence showed that SNRIs reduced disability from back pain at 3-13 weeks (-3.55, -5.22 to -1.88) and disability due to osteoarthritis at two weeks or less (-5.10, -7.31 to -2.89), with low certainty evidence at 3-13 weeks (-6.07, -8.13 to -4.02). TCAs and other antidepressants did not reduce pain or disability from back pain.
CONCLUSION
Moderate certainty evidence shows that the effect of SNRIs on pain and disability scores is small and not clinically important for back pain, but a clinically important effect cannot be excluded for osteoarthritis. TCAs and SNRIs might be effective for sciatica, but the certainty of evidence ranged from low to very low.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42020158521.
Topics: Antidepressive Agents; Back Pain; Humans; Osteoarthritis; Pain Management; Sciatica; Serotonin and Noradrenaline Reuptake Inhibitors
PubMed: 33472813
DOI: 10.1136/bmj.m4825 -
BMJ Open Dec 2016Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and... (Comparative Study)
Comparative Study
OBJECTIVES
Evidence comparing the effectiveness of surgical and conservative treatment of symptomatic lumbar disc herniation is controversial. We sought to compare short-term and long-term effectiveness of surgical and conservative treatment in sciatica symptom severity and quality of life in patients with lumbar disc herniation in a routine clinical setting.
METHODS
A prospective cohort study of a routine clinical practice registry consisting of 370 patients. Outcome measures were the North American Spine Society questionnaire and the 36-Item Short-Form Health Survey to assess patient-reported back pain, physical function, neurogenic symptoms and quality of life. Primary outcomes were back pain at 6 and 12 weeks. Standard open discectomy was assessed versus conservative interventions at 6, 12, 52 and 104 weeks. We filled in missing outcome variable values with multiple imputation, accounted for repeated measures within patients with mixed-effects models and adjusted baseline group differences in relevant prognostic indicators by inverse probability of treatment weighting.
RESULTS
Surgical treatment patients reported less back pain at 6 weeks than those receiving conservative therapy (-0.97; 95% CI -1.89 to -0.09), were more likely to report ≥50% decrease in back pain symptoms from baseline to 6 weeks (48% vs 17%, risk difference: 0.34; 95% CI 0.16 to 0.47) and reported less physical function disability at 52 weeks (-3.7; 95% CI -7.4 to -0.1). The other assessments showed minimal between-group differences with CIs, including the null effect.
CONCLUSIONS
Compared with conservative therapy, surgical treatment provided faster relief from back pain symptoms in patients with lumbar disc herniation, but did not show a benefit over conservative treatment in midterm and long-term follow-up.
Topics: Activities of Daily Living; Adult; Back Pain; Conservative Treatment; Disability Evaluation; Diskectomy; Follow-Up Studies; Health Surveys; Humans; Intervertebral Disc Displacement; Longitudinal Studies; Lumbar Vertebrae; Middle Aged; Pain Management; Pain Measurement; Prospective Studies; Quality of Life; Registries; Sciatica; Surveys and Questionnaires; Treatment Outcome
PubMed: 28003290
DOI: 10.1136/bmjopen-2016-012938 -
Pain Aug 2023Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful...
Pain radiating from the spine into the leg is commonly referred to as "sciatica," "Sciatica" may include various conditions such as radicular pain or painful radiculopathy. It may be associated with significant consequences for the person living with the condition, imposing a reduced quality of life and substantial direct and indirect costs. The main challenges associated with a diagnosis of "sciatica" include those related to the inconsistent use of terminology for the diagnostic labels and the identification of neuropathic pain. These challenges hinder collective clinical and scientific understanding regarding these conditions. In this position paper, we describe the outcome of a working group commissioned by the Neuropathic Pain Special Interest Group (NeuPSIG) of the International Association for the Study of Pain (IASP) which was tasked with the following objectives: (1) to revise the use of terminology for classifying spine-related leg pain and (2) to propose a way forward on the identification of neuropathic pain in the context of spine-related leg pain. The panel recommended discouraging the term "sciatica" for use in clinical practice and research without further specification of what it entails. The term "spine-related leg pain" is proposed as an umbrella term to include the case definitions of somatic referred pain and radicular pain with and without radiculopathy. The panel proposed an adaptation of the neuropathic pain grading system in the context of spine-related leg pain to facilitate the identification of neuropathic pain and initiation of specific management in this patient population.
Topics: Humans; Radiculopathy; Leg; Quality of Life; Neuralgia; Sciatica
PubMed: 37235637
DOI: 10.1097/j.pain.0000000000002919 -
The New England Journal of Medicine May 2007Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known. (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Lumbar-disk surgery often is performed in patients who have sciatica that does not resolve within 6 weeks, but the optimal timing of surgery is not known.
METHODS
We randomly assigned 283 patients who had had severe sciatica for 6 to 12 weeks to early surgery or to prolonged conservative treatment with surgery if needed. The primary outcomes were the score on the Roland Disability Questionnaire, the score on the visual-analogue scale for leg pain, and the patient's report of perceived recovery during the first year after randomization. Repeated-measures analysis according to the intention-to-treat principle was used to estimate the outcome curves for both groups.
RESULTS
Of 141 patients assigned to undergo early surgery, 125 (89%) underwent microdiskectomy after a mean of 2.2 weeks. Of 142 patients designated for conservative treatment, 55 (39%) were treated surgically after a mean of 18.7 weeks. There was no significant overall difference in disability scores during the first year (P=0.13). Relief of leg pain was faster for patients assigned to early surgery (P<0.001). Patients assigned to early surgery also reported a faster rate of perceived recovery (hazard ratio, 1.97; 95% confidence interval, 1.72 to 2.22; P<0.001). In both groups, however, the probability of perceived recovery after 1 year of follow-up was 95%.
CONCLUSIONS
The 1-year outcomes were similar for patients assigned to early surgery and those assigned to conservative treatment with eventual surgery if needed, but the rates of pain relief and of perceived recovery were faster for those assigned to early surgery. (Current Controlled Trials number, ISRCTN26872154 [controlled-trials.com].).
Topics: Adult; Area Under Curve; Disability Evaluation; Diskectomy; Female; Humans; Intervertebral Disc Displacement; Kaplan-Meier Estimate; Lumbar Vertebrae; Male; Middle Aged; Physical Therapy Modalities; Proportional Hazards Models; Prospective Studies; Sciatica; Treatment Outcome
PubMed: 17538084
DOI: 10.1056/NEJMoa064039