Back Pain Relief: Skin Impedance Measurements Can Help Identify Trigger Points

PainRelief.com Interview with:
Giovanni Barassi PhD

Center for Physiotherapy, Rehabilitation and Reeducation
Center of Sports Medicine
“G.d’Annnunzio” University
Chieti, Italy

PainRelief.com:  What is the background for this study?

Response: Our research started with the observations made during standard clinical practice concerning the inefficiency of standard physiotherapeutic procedures used for pain relief in chronic nonspecific low back pain, a scourge of modern times, particularly in industrialized countries. Therefore, the need has arisen to search for new approaches in the evaluation and treatment of musculoskeletal problems.

Chronic low back pain is clinically manifest as the pain between rib margins and folds of the inferior gluteus muscle. It usually results from an incorrect lifestyle, typical of modern society having too little physical activity, too much psycho-physical stress, and poor management of body weight. On the background of osteopathic medicine, we developed a concept of the dysfunctional flow of body fluids as a plausible underlier of low back pain, referring by and large to spine bony structures.

It has been shown that alterations in afferent activity coming from visceral, structural, and emotional nociception converge in the same metamers of the spinal cord, resulting in information noise and jam. The final motor output of the reflex arc encompasses somatic, myofascial, and connective tissue responses, with the inevitably added influence of the autonomic nervous system. There also are studies demonstrating the importance of interpreting myofascial dysfunction, not as an isolated local phenomenon but rather as an expression of the central nervous activity. Therefore, a concept has been shaped of somatic and myofascial dysfunction, currently gaining increasing recognition among physicians, osteopaths, and physiotherapists, the professionals dealing with tissue and joint manipulation. The practical crux of the issue is the identification of the “major dysfunction” site, expressing the specific spinal information jam.

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Chiropractic Manual Therapy for Chronic Low Back Pain Relief

PainRelief.com Interview with:
Kylie Isenburg
Athinoula A. Martinos Center for Biomedical Imaging
Massachusetts General Hospital, Boston, MA

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: Chronic low back pain (cLBP) is the leading cause for disability worldwide, with a lack of efficacious non-pharmacological treatments. Back pain doesn’t just effect the back. Recent investigations using brain imaging have shown changes in brain structure and function in cLBP patients. Therefore, there is a growing interest in how different non-pharmacological therapies might impact cLBP by studying alterations in brain function that follow such therapies.

For our project, we assessed resting brain connectivity for a specific set of regions known as the Salience Network, a network involved in detection of salient information that arises from continuous sensory input. We assessed Salience network connectivity pre- and post- a single session of Manual Therapy (MT), a chiropractic manipulation technique used to treat a range of musculoskeletal disorders. We found that manual therapy reduced clinical low back pain intensity after a single-session. Additionally, assessment of two different grades of MT; Spinal Manipulation and Spinal Mobilization, suggested that Manipulation increases connectivity of the Salience Network to the Primary Motor Cortex and the Thalamus. Furthermore, the reduction in low back pain post-MT was associated with increased Salience connectivity to the lateral Prefrontal Cortex. These findings suggest modulation of sensorimotor, affective, and cognitive regions of the brain via Manual Therapy may play an important role in reducing Chronic low back pain. 

PainRelief.com: What should readers take away from your report?

Response: Our report suggests that non-pharmacological therapies, specifically Manual Therapy, can be successful in reducing chronic low back pain intensity. It also suggests that brain changes following Manual Therapy are important, and specifically that changes in Salience network connectivity to brain regions important for processing sensory, affective, and cognitive information might underly this reduction in low back pain.

Altogether this work promotes increased investigation into brain-based mechanisms by which Manual Therapy can reduce chronic low back pain.

PainRelief.com: What recommendations do you have for future research as a result of this work?

Response: Following this study, we have a better idea of what a single manual therapy session can accomplish, but assessment of the long-term effects of a series of MT sessions will be useful in allowing for a better understanding of its efficacy in treating low back pain. Additionally, clinical trials assessing manual therapy against other treatment modalities can allow for direct comparisons against the current standard of care approaches. 

Citation:

Kylie Isenburg, Ishtiaq Mawla, Marco L. Loggia, Dan-Mikael Ellingsen, Ekaterina Protsenko, Matthew H. Kowalski, David Swensen, Deanna O’Dwyer-Swensen, Robert R. Edwards, Vitaly Napadow, Norman Kettner,

Increased salience network connectivity following manual therapy is associated with reduced pain in chronic low back pain patients,
The Journal of Pain, 202

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Why is Exercise Prescribed for Low Back Pain Relief?

PainRelief.com Interview with:
Matthew Jones PhD, AEP

Lecturer
Department of Exercise Physiology, Faculty of Medicine
UNSW SYDNEY

Dr. Jones


PainRelief.com:  What is the background for this review?

Response: Bck pain is the leading cause of disability worldwide and is associated with significant individual and societal costs. Low back pain can significantly impact an individual’s ability to carry out day to day tasks. Clinical guidelines consistently recommend that people with low back pain take exercise, and there does not appear to be a type of exercise (e.g., walking, Pilates, lifting weights) that is better than another for reducing pain and improving function. Despite hundreds of studies of exercise in people with low back pain, researchers do not have a good idea of how it works. This is important, because if we know how something works, we can design more effective interventions to reduce the burden of low back pain. The aim of this review was to summarise why researchers think exercise helps people with chronic low back pain (i.e., pain persisting for longer than 3 months).

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Understanding Back Pain During Neuroendovascular Procedures

PainRelief.com Interview with:

Adnan Qureshi, MD
Zeenat Qureshi Stroke Institute
Department of Neurology
University of Missouri
Columbia, MO

Dr. Qureshi

PainRelief.com: What is the background for this study? What are the main findings?

ResponseOptimizing of patient experience is a very important goal for any procedure. Neuro Endovascular procedures are unique because most of them are performed awake to perform repeated neurological examinations during the procedure. The angiographic tables have to be made of unique stiff material to ensure X rays can pass through and any movement during procedure can distort images. We believe understanding the factors that can be improved upon given the unique settings remains an important goal of the specialty. 

Our research broadens our understanding of complications of the procedures. Previous studies have look at the risk of stroke or bleeding but not complications like back pain which are far more common.

5-Year Follow-Up of Open-Label Placebo Trial for Chronic Low Back Pain Relief

PainRelief.com Interview with:
Claudia Carvalho, PhD
Instituto Universitário de Ciências Psicológicas
Social e da Vida
Lisbon, Portugal

PainRelief.com: What is the background for this study? What are the main findings?

Response:  Some clinical trials on chronic pain have shown placebo responses that rival those of commonly prescribed first-line therapies for low back pain (LBP).  However, prescribing placebos would pose ethical problems in clinical practice.  One solution to this problem is the use of open label placebos (OLP), which are presented to patients openly as pills without active ingredients, along with a rationale indicating that because of classical conditioning of relief with active medications, the pills themselves might reduce pain. OLP has been shown effective compared to treatment-as-usual for a number of clinical conditions, including chronic LBP.  Having conducted the first clinical trial on OLP on back pain, my colleagues and I wondered whether the effects were long-lasting. To answer that question, we conducted a five-year follow-up on the patients who had received OLP for their back pain.

In our original study, patients who took OLP pills for three weeks experienced greater reduction in back pain intensity and in back pain related disability than patients that simply continued their usual treatment. Additionally, after this phase of the trial, we offered OLP to participants  in the treatment as usual group) and they also reported a significant reductions in pain and disability, together with a spontaneous decrease in the use of pain medication by participants.

In our current follow-up, we found that patients who had taken OLP for three weeks had maintained their reductions in pain and disability 5 years later. In addition, pain medication usage was reduced by 49%. This follow-up study is currently in press (https://journals.lww.com/pain/Fulltext/9000/Open_label_placebo_for_chronic_low_back_pain__a.98186.aspx)

PET Probe Pinpoints Sites of Pain Generation to Improve Pain Management

PainRelief.com Interview with:
Sandip Biswal MD
Associate Professor of Radiology
Co-Section Chief, Musculoskeletal Imaging
Director, Musculoskeletal Imaging Fellowship
Member, Molecular Imaging Program at Stanford (MIPS) and Bio-X
Department of Radiology
Stanford University School of Medicine

PainRelief.com:  What is the background for this study?
Response: Our ability to manage patients with chronic pain remains woefully inadequate. Chronic pain patients are faced with limited resources and inadequate care, and as a result, they make up the #1 disease group in the world—numbering more than heart disease, diabetes and cancer combined. Those suffering from low back pain, headache, fibromyalgia, arthritis and many other pain syndromes make up this ever-growing population. A big part of our inability to care for chronic pain patients is due to the fact that our current imaging methods for correctly identifying pain generators remain substantially inaccurate. Our ability to accurately identify the cause of a person’s pain, discomfort, inflammation or other related musculoskeletal symptom(s) using current clinical imaging approaches, such as magnetic resonance imaging (MRI), computed tomography (CT), digital radiography (x-ray) and ultrasound, is quite limited, lacks sensitivity/specificity and can even misguide treatment. As a musculoskeletal radiologist, I witness these shortcomings on a daily basis. I, for example, see firsthand how the lack of reliable diagnostic tools leads to significant misdiagnosis, mismanagement, incorrect use of opioids, unhelpful surgeries and, ultimately, therapeutic failures. We need a much better way to diagnose pain generators. 

Accordingly, our group has been developing new clinical imaging methods that pinpoint the site of pain generation using imaging probes—more specifically, positron-emission tomography (PET) tracers that specifically target “pain receptors” or “pain molecules.” These pain receptors or pain molecules are present in abundance at the site of pain generation. After injecting one of these imaging probes into a patient through the vein, we give the probe a few minutes to circulate around the body and stick to areas that have a high density of pain receptors. We can then take a picture of the patient with a special camera that will show “hot spots” on the image that signify the location of high number of pain receptors, thereby highlighting “painful” pro-inflammatory and/or pro-nociceptive tissues. With this approach, doctors and patients have information with which they can make more objective decisions about the diagnosis and treatment of one’s pain.

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Tanezumab for Chronic Low Back Pain Relief: Phase 3 study

“Tanezumab is a monoclonal antibody that is part of an investigational class of non-opioid chronic pain medications known as nerve growth factor (NGF) inhibitors.” Link

“Tanezumab 2.5 mg administered subcutaneously (SC), which is being evaluated for patients with chronic pain due to moderate-to-severe osteoarthritis (OA) who have experienced inadequate pain relief with other analgesics.” Link

Comments from Pfizer regarding the study of Tanezumab for chronic low back pain, July 21 2020.

Pfizer and Lilly made the decision to prioritize tanezumab as a potential treatment for osteoarthritis, based on an assessment of the totality of SC tanezumab data and an initial discussion with the FDA.

At this time, regulatory submissions are not planned for tanezumab in patients with moderate-to-severe chronic low back pain (CLBP), but we recognize the significant patient needs and intend to maintain an open dialogue with regulatory authorities on potential future regulatory pathways for tanezumab. Additional data analyses, and potentially further clinical study, may be required to more fully characterize tanezumab in CLBP patients.

Additional information:

Alliance announced in early March that the U.S. FDA accepted the regulatory submission for Tanezumab, a potential first-in-class treatment for patients with chronic pain due to moderate-to-severe osteoarthritis.

Citation:

Markman, John D.a,*; Bolash, Robert B.b; McAlindon, Timothy E.c; Kivitz, Alan J.d; Pombo-Suarez, Manuele; Ohtori, Seijif; Roemer, Frank W.g,h; Li, David J.i; Viktrup, Larsj; Bramson, Candacek; West, Christine R.k; Verburg, Kenneth M.k Tanezumab for chronic low back pain, PAIN: June 25, 2020 – Volume Articles in Press – Issue – doi: 10.1097/j.pain.0000000000001928

Which Back Pain Patients Get Pain Relief from Yoga?

PainRelief.com Interview with:
Eric J. Roseen, DC, MSc
Department of Family Medicine
Boston University School of Medicine
Department of Rehabilitation Science
Massachusetts General Hospital Institute of Health Professions
Boston, MA 02215

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: The Back to Health Study is a noninferiority randomized controlled trial of yoga, physical therapy, and back pain education for chronic low back pain. Participants were recruited from a SafetyNet hospital (Boston Medical Center) and seven affiliated federally-qualified community health centers. Participants reflected the population served by this health system, they were predominately low-income and non-white.

The yoga intervention consisted of 12 group-based, weekly, 75-minute, hatha yoga classes incorporating poses, relaxation and meditation exercises, yoga breathing and yoga philosophy. Thirty minutes of daily home practice was encouraged and supported with at-home yoga supplies. The physical therapy intervention consisted of 15 one-on-one 60-minute appointments over 12 weeks. During each appointment, the physical therapist utilized the Treatment-Based Classification Method and supervised aerobic exercise, while providing written instructions and supplies to continue exercises at home. The self-care intervention consisted of reading from a copy of The Back Pain Handbook, a comprehensive resource describing evidence-based self-management strategies for chronic lower back pain including stretching, strengthening, and the role of psychological and social factors. Participants received check-in calls regarding the reading every three weeks.

The main findings from the trial published in Annals of Internal Medicine found that yoga was non-inferior to physical therapy in terms of pain and function outcomes.

In this study published in Pain Medicine, we wanted to dig deeper and understand the characteristics of patients who tended to do better no matter what treatment they received (i.e., predictors) and characteristics that modified the likelihood that they would improve with a particular treatment (i.e., treatment effect modifiers). This type of information is useful to patients and clinicians who are trying to decide which type of treatment may be best for a unique individual experiencing back pain.

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Back Pain: Web-Based Self-help Intervention to Prevent Depression

PainRelief.com Interview with:

Lasse B. Sander, PhD
Institute of Psychology
Department of Rehabilitation Psychology and Psychotherapy
Albert-Ludwigs-University of Freiburg
Freiburg, Germany

Lasse B. Sander, PhD
Institute of Psychology
Department of Rehabilitation Psychology and Psychotherapy
Albert-Ludwigs-University of Freiburg
Freiburg, Germany
Dr. Sander

PainRelief.com:  What is the background for this study?  What are the main findings?

Response: People with chronic pain have a significantly increased risk of developing depression. When depression and pain collide, this is a considerable burden for those affected. In addition, pain management is made more difficult due to comorbidity.

We have known for some years now that the onset of depression can be delayed or even completely prevented by means of early psychological therapies. However, until now there has been no scalable application option available for routine healthcare.

In our study we were able to show that this can be achieved by a digital self-help intervention.

Trial of Desipramine, Cognitive Behavioral Therapy, and Placebo for Low Back Pain Relief

PainRelief.com Interview with:
Thomas Rutledge, PhD, ABPP
Staff Psychologist, VA San Diego Healthcare System
Professor of Psychiatry
UC San Diego

PainRelief.com:  What is the background for this study?

Response: The goal of this study was to combine our team’s pharmacy, psychiatry, and psychology expertise with chronic pain to conduct a rigorous, head-to-head efficacy trial. The clinical trial literature for chronic back pain is enormous. On the surface, this literature suggests that many medication and pain psychology treatments are effective by standards of statistical significance. These findings are difficult to interpret, however, because there are few trials comparing statistically effective chronic back pain treatments with active control treatments and nearly no trials randomizing patients with chronic back pain to medication versus pain psychology treatments. We hoped that our trial could offer data to help fill these gaps. Mindful of the increasing concerns about long-term opioid use for chronic pain, we also believed the study could have value by focusing on non-opioid agents (Desipramine) and cognitive behavioral therapy.